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INTRA-CRANIAL ANEURISM

WilliamE. Humble
1875 The Lancet  
489 dependently of any mechanical cause, though they may also coexist with it. I have at present under my care a widow lady, aged about thirty, who had for years been suffering from lumbar and pelvic pain extending down the left thigh, and accompanied with lameness, dysuria, and slight uterine catarrh. The cervix uteri was congested and the os patulous, the sound penetrated five inches, and the fundus was tilted backwards. Before she consulted me she had been treated by others for retroversion
more » ... s for retroversion by mechanical expedients only, and for a long time I did the same. Every pessary-and the number was almost countless that I tried,-however well it might fit, was practically useless: before a week's time she would limp into my study in as bad a plight as ever. I need not go through the details of the case further than to add that I learned at last that she inherited gout, and, on examining, found her urine laden with uric acid. She was then treated by alkaline remedies and colchicum, sent to Vichy, and has returned with all the symptoms relieved, and, though yet necessitated to wear a Hodge's pessary, is practically free from any discomfort. With regard to active local treatment in ordinary cases of chronic inflammation and simple ulceration of the os and cervix uteri, Talleyrand's advice to a young diplomatist might be advantageously adopted by gynaecologists—" Surtout point de zele." If we trusted more to nature in such cases, I verily believe that in most instances our patients would get well sooner than if the local irritation be increased secundum artem by almost daily examinations and the repeated application of escharotics. I have, again and again, seen simple abrasions or ulcerations of the cervix uteri cured without any topical treatment whatever; and in other instances cervical ulcerations of long standing were healed, and hypertrophies of the cervix which had resisted the use of the potassa fusa, potassa cum calce, and other violent remedies which had been previously employed by bolder practitioners, were reduced by the use of a strong solution of iodine in glycerine or spirit, or nitrate of silver, corabined, of course, with constitutional treatment. In such cases, too, I always rely in great measure on the effects of emollient or medicated tepid vaginal irrigations. For this purpose the ordinary vaginal syringe is always an imperfect and useless, nay, in some cases even a dangerous instrument. I therefore always recommend the use of au irrigator such as that which I exhibited to the Obstetrical Society some time since. The instrument is very portable, can be readily used, and is capable of impelling a gentle continuous stream of plain or medicated water into the vagina for any length of time, and in any position the patient desires, without causing the least fatigue. Before considering the uses of mineral waters in cases of impaired health connected with chronic inflammation of the uterus and its appendages, we should in the first place recognise the fact that in such cases local treatment, although not to be neglected, should be subordinate to the cure of the constitutional disease which is the remote, and too commonly the undetected, cause of the local complaint. Thus, in cases of scrofulous disease of the cervix uteri, in addition to the obvious hygienic and dietetic means required by all strumous patients, the faulty state of the blood must be corrected by alteratives and tonics-cod-liver oil, small doses of metallic iodine, Blaneard's pills, and the syrup of the iodide of iron, and, above*all, by the natural chalybeate and iodated mineral waters. In like manner, in instances of uterine irritation occurring in gouty patients our treatment sh',uld be primarily directed to the diathetic predisposing cause, and not, as is too generally the case, merely to the predominant local symptoms. It is utterly impossible to cure gouty inflammation of the uterus without constitutional treatment. There is never any difficulty in inducing valetudinarian ladies to take any quantity of medicine, and, as a rule, women bear colchicum and other remedies for gout fully as well as men. But it is by no means so easy to persuade a patient suffering from gouty endometritis, who has long been treated by local measures only, conjoined with a stimulating and nutritious regimen to keep up her strength, that her disease is the result of long indulgence in a diet beyond all proportion to the wants of her system, late hours, and little active open-air exercise. Nor in such cases is the patient always disposed to thank the physician who honestly tells her-Si tibi deficiant medici, medici tibi fiant Hsec tria: mens Ireta, requies, moderata dieta." Hysteria in some form is generally associated with chronic uterine disease, and this underlies and complicates most of the symptoms for which gynaecologists are consulted. Counterfeiting every malady, acting through and upon the nervous system, attended with groundless apprehension, depression of spirits, and morbid irritability of temper, oftentimes rendering the patient herself as miserable as she renders those about her, this disease is closely allied to that graver nervous lesion which constitutes insanity, and, if unchecked, may pass into it. Local treatment, except to rectify some displacement or subdue some well-marked ovarian or uterine inflammation, is of little utility in such cases ; nor are the tonics and antispasmodics usually relied on comparable, in their therapeutical effects in restoring a hysterical woman to the mens sana in corpore sano, to the saline chalybeate water, such as Ems, Schwalbach, or Spa, provided these be used at their source. " There is," says Burton, " no better physic for a melancholy man than change of air and variety of places." And this physic we prescribe when we order our hysterical patients to any continental watering place. The use of some remote spa is something beyond the effect of the medicated water we have recommended. It necessitates what is of far greater service than any physical remedy in such cases-namely, the moral benefit of change of scene, of occupatior, and mode of living. The functions of the liver and bowels, commonly torpid in hysterical women, are stimulated by the change of living, and a sedative effect is generally produced on the hyperasstbetic condition of the patient. The changes and incidents of the journey suggest new thought, by which the patient's mind is diverted from that morbid concentration on her ailment which characterises utero-hysteric disease, and ceasing to dwell on her symptoms, they cease to exist; in other words, she is cured. The benefits derived from the use of mineral waters in the chronic diseases peculiar to women are by no means limited to the moral effects just referred to. In many of these spas we have medico-chemical agents of extraordinary therapeutic power, and in the next paper I propose to point out the special application of some of these-in the constitutional treatment of chronic inflammation of the uterus and its complications. THE rarity of cases of intra-cranial aneurism diagnosed during life induces me to forward an account of a case now under my care. And I do so at the present time, rather than wait for the ultimate issue of the case, in order to draw attention to the importance of practising auscultation of the head more frequently than we are in the habit of doing. So far as I can find, there are but two cases on record in which intra-cranial aneurism has been diagnosed during lifeone by Mr. Coe, of Bristol, in which the carotid artery was tied successfully ; and the other by Mr. Jonathan Hutchinson, who related the case at the Clinical Society on the 9th of April, 1875, and in which a spontaneous cure occurred by consolidation of the aneurism, as demonstrated by examination afterdeath from another cause. Mr. Holmes in his lectures on Aneurism refers to Mr. Coe's case, and in the same lecture relates another case of intra-cranial aneurism which was for a long time under observation, but in which auscultation was unfortunately not practised, and the disease not diagnosed during life. Mr. Holmes says :-" We know nothing at present of the diagnosis of intra-cranial aneurism, so that no treatment can as yet be directed specially to it. And, looking at the very free intercommunication of the four large trunks which ! sourish the brain, it seems unlikely that surgical measures directed to any one of them would procure the consolidation of an aneurism situated on one of its main branches." I think that a careful consideration of Mr. Coe's and Mr. Hutchinson's cases together with that I am about to relate, and the clearly defined symptoms in each of them, may perhaps lead us to look more favourably upon the possibility of diagnosing this disease within the head. Mrs. -, a lady aged forty, has had a family of several
doi:10.1016/s0140-6736(02)30582-8 fatcat:jjlk4y4w5ve7par4g4efpslxqa