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THE NEW SYDENHAM
SOCIETY.
INSTITUTED MDCCCLVIIl.
VOLUME LIX.
BIENNIAL RETROSPECT
MEDICINE, SURGERY,
AND THEIE
ALLIED SCIENCES,
FOB
1871-72.
EDITED BY
Mli. H. POWER, DR. SHEPHERD, MR. WAREN TAY,
MR. R. B. CARTER, DR. PHILLIPS,
AND
DR. T. STEVENSON,
FOS
THE NEW SYDENHAM SOCIETY.
LONDON.
MDCCCLXXIII.
V.4'
PRINTED BY
J. E. ADLAED, BARTHOLOMEW CLOSE.
CONTENTS.
I.— EEPORT ON PHYSIOLOGY.
PAGE
By Henby Powee, F.R.C.S., M.B. Loud. . . .1
II.— REPORT ON PRACTICAL MEDICINE.
By A. B. Shepheed, M.A., M.B., M.R.C.P. . 33
III.— REPORT ON SURGERY.
By Waeen Tat, F.R.C.S. . . .193
IV.— REPORT ON OPHTHALMIC MEDICINE AND
SURGERY.
By RoBEET Beijdenell Caetee> F.R.C.S. » . 887
v.— REPORT ON MIDWIEERY AND THE DISEASES OF
WOMEN AND CHILDREN.
By J. J. Philiips, M.D. Lond. . , .369
VI.- REPORT ON MEDICAL JURISPRUDENCE.
By Thomas Stevenson, M.D. Lond., M.R.C.P. . . 433
b
VI CONTENTS.
VII.— REPORT ON MATERIA MEDICA AND GENERAL
THERAPEUTICS.
rAOE
By Thomas Stevenson, M.D. Lond., M.R.C.P. . . 461
VIII.— REPORT ON PUBLIC HEALTH.
By Thomas Stevenson, M.D. Lond., M.R.C.P. . . 472
Index ........ . 497
I
EEPOET
ON THE
PROGRESS OF PHYSIOLOGY AND THE
ALLIED SCIENCES,
DURING THE TEARS 1871 AND 1872.
BY
HENRY POWER, E.R.C.S., M.B. Lond.,
EXAMINEE IN PHYSIOLOGY AND COMPAEATIVE ANATOMY IN THE TTNIVEESITY OF
LONDON ; SENIOE OPHTHALMIC SUEGEON TO ST. BAETHOLOMEW'S
HOSPITAL.
The principal treatise on physiology that has been published during
the last two years in the English language is the fourth volume of Dr.
Flint's ' Physiology of Man,' which embraces the consideration of the
nervous system, and is one of the best, as it is the most complete, ex-
positions of the state of our knowledge of nerve physiology that we
at present possess.
Dr. Bennett adds one more student's manual to those already existing,
which, besides the information usually given in such text-books, con-
tains three chapters or sections devoted to practical chemical physiology,
to practical histological physiology, and to practical experimental phy-
siology. The first of these has been written by Dr. McKendrick, and
will probably prove of much service to students.
Dr. Nichols has published a manual of physiology applied to social
and sanitary science, which, with some errors and eccentricities, contains
much thoughtful writing.
Dr. Dalton has issued a fifth edition of his * Human Physiology,' the
sections in which on the liver and on reproduction are both original
and excellent.
Dr. Rutherford has done important service by publishing a series of
lectures in the * Lancet' for 1871-72 on experimental physiology, in
which the principal facts, and the evidence supporting those facts, that
have been made out during the last few years upon the functions and
vital properties of muscle, nerve, and gland, are given with great clear-
ness and much originality.
The Sydenham Society has published a translation of the second
volume of Strieker's ' Manual of Histology,' and also the first volume
of Rindfleisch's ' Pathological Histology.'
France has produced but little. The ninth volume of Milne-
1
0
2 REPORT ON PHYSIOLOGY.
Edwards's large work on ' Comparative Physiology,' which is occupied
with the tegumentary appendages of animals, has appeared ; Claude
Bernard has published a series of lectures on " Experimental Physio-
logy," delivered at the College de Prance, and an excellent course of
forty lectures on *' Animal Heat," by the same author, is contained in
the ' Revue Scientifique.'
Germany, as usual, has been very active, her activity exhibiting itself
in the production of a multitude of papers rather than of complete works ;
some of these, however, attaining almost the size of a treatise (witness
the essay of Schmidt on '* Fibrin," in Pfliiger's ' Archiv'). These are
published in innumerable journals, rendering it difficult to obtain some,
still more difficult to find the time to run hastily through all, and almost
impossible to analyse them in such a manner as to do justice to the
valuable work and results they frequently contain. The mere record
of them would occupy the entire space allowed for this notice of
physiological progress.
An interesting lecture on "Dust and Smoke" was delivered by
Prof. Tyndall, at the E-oyal Institution, on June 9, 1871, containing
statements and detailing experiments, which have since been frequently
referred to, as showing the presence of much floating organic matter in
ordinary air, and as supporting the germ theory.
Bastian* contributes a very important work on the mode of origin of
the simplest forms of animal life, such as Bacteria, Torul®, and Vibrios.
These he believes he has demonstrated can develop without antecedent
spores in organic infusions, and even in solutions of ammoniacal salts,
which have been exposed to temperatures supposed to be sufficient to
destroy all life. Such development he terms archebiosis. He als»o
maintains that by a process of heterogenesis the higher forms of ciliated
infusoria, and even a Rotifer, may develop from the proligerous pellicle
of organic solutions.
Dr. Sandersonf corroborates Dr. Bastian's statements in various
particulars, and has satisfied himself that, following Dr. Bastian's
directions, infusions can be prepared which are not deprived by an
ebullition of from five to ten minutes of the faculty of undergoing those
chemical changes which are characterised by the presence of swarms of
Bacteria, and that the development of these organisms c^n proceed with
the greatest activity in hermetically sealed' glass vessels, from which
almost the whole of the air has been expelled by boiling.
Crace CalvertJ contends, in opposition to Dr. Bastian, that when
living bodies appear in any solution they proceed from the develop-
ment of germs introduced from without or previously present and not
killed by the temperature to which they have been exposed. He finds
that life is retained by some of the lower forms of animal life even after
exposure to a temperature of 300° P., but not of 400°. It may just be
noticed that Dr. Blake§ has found certain diatoms growing in abund-
ance in water at a temperature of 163° Pahr.
* 'The Beginnings of Life/ London, Macmillan, 2 vols., pp. 475 and 640, 1872.
t 'Nature,' Dec. 14, 20, 27, 1872.
X 'Proceed. Eoy. Soc.,' xix, 409, 1871.
§ 'Month. Mic. Journ.,' 1873, 71.
ABSORPTION. 3
Metcalfe Jolinson,* speaking of the transmutation of form in certain
Protozoa, observes that if an examination be made of some of the green
growths on moist surfaces we shall find one composed of a dust, to
which the name of Chlorococcus has been applied ; another, a green
scum on the surface of a liquid, which has received the name of Euglena ;
a third, forming patches of dark green slime, is called Oscillatoria ; a
fourth, Lingbya ; a fifth, Yaucheria ; and a sixth, Schizonema. More
detailed examination of these separately named products, and a study
of their life history, leads to the opinion that they are all stages of de-
velopment of some one common source, which he believes to be the
Monad. He has himself watched and here depicts the transformation
of Paramaecium into Vorticella, and of this into CalUdina elegans.
The truth of the doctrine of pangenesis has been put to a practical
test by Mr. F. G-alton,t by breeding from rabbits of a pure variety, into
whose circulation blood taken from other varieties had previously been
largely infused ; the results were absolutely opposed to the idea of
pangenesis, the animals continuing to maintain in their offspring the
purity of the breed.
Dr. Bree has published ' An Exposition of Fallacies in the Hypothesis
of Mr. Darwin.'
Mr. Huxley, * A Manual of the Anatomy of Vertebrated Animals.'
Dr. Ord, * Notes on Comparative Anatomy.*
ABSOEPTION.
In regard to absorption, H. Auspitz % ^as made many experiments
on the absorption of solid substances from the serous cavities, using for
this purpose starch-meal, the grains of which preliminary observations
showed to be easily recognised under the microscope when injected
into the blood. The grains were found to be taken up in their
solid form. The presence of oil or fat greatly favoured the process of
their absorption. The examination of the skin after the infrication of
starch-meal salve showed the grains to have penetrated into the tissue
of the corium, into the subcutaneous connective tissue, and into the
muscles connected therewith, but not into the fundus of the sebaceous
glands or of the hair-follicles. Neumann's § researches with mercurial
ointment showed, on the contrary, that when this was well rubbed into
the skin it penetrated into the hair-bulbs, sebaceous follicles, and, for a
short distance, into the sweat-ducts. He believes it is absorbed from
these parts after a variable length of time in the form of sublimate.
Neumann satisfied himself that rabbits absorb corrosive sublimate
through the skin after long immersion in a bath containing a small pro-
portion of that salt.
Genersich,!! in a paper on the absorption of lymph by tendons and
fasciae, shows that the action of the muscles plays an important part in
* 'Month. Mic. Journ.,' v, 222; vi, 184 and 217, 1871.
f 'Proceed. Roy. Soc.,' xix, 1871.
j 'Wiener Med. Jahrbiicher,* N. F., 187 1, iii.
§ ' Wiener Med. Wochens./ (871.
II 'Ludwig's Arbeiten/ 5 Jahrg, 1870.
4 REPORT ON PHYSIOLOGY.
causing the lymphatics of the tendons to absorb, by a kind of suction-
power, the lymph within and surrounding the muscular masses. He
ascertained the amount of lymph discharged from the thoracic duct in
a given time, both when the muscles were quiescent and when excited
to powerful and sustained action by induced currents of electricity,
and found that the proportion varied from i : 4-45 to i : 24*5 in favour
of the period when the muscles were called into play. Lesser * corro-
borates Grenersich's results, and recommends the insertion of a glass
tube into the thoracic duct of fasting dogs for the procurement of large
quantities of lymph. He obtained in this way as much as 300 c.c. of
lymph in a few hours. Haramarsten t analysed the gases of the lymph
thus obtained, and found as much as 40 per cent, of carbonic acid.
Nasse;]: investigated the circumstances that influence the flow and for-
mation of the lymph. He finds that ligature of the carotid diminishes
the rapidity of the current in the cervical lymphatics, and causes an in-
crease in the amount of water and a diminution in the amount of fibrin
in the fluid traversing them. Ligature of the veins produced opposite
effects. Irritation of the sympathetic, or rather of the vago-sympa-
th€tic, caused a diminution of the lymph current and augmentation of
the coagulability of the lymph. Section of the sympathetic had re-
markably little eff'ect.
Goltz § has demonstrated, in an interesting paper, that the nerve-
centres have a direct and considerable influence on the process of
absorption.
Popper II has investigated the mesenteric glands of dogs by means of
the chloride- of-gold method of Cohnheim and Gerlach. He finds the
capsule of the lymphatic glands contains fasciculi of non-medullated
nerve-fibres, from which nerves pass off", which penetrate into the sub-
stance of the gland, where they form a fine plexus, some of the fibres of
which are traceable into connection with the cell-elements. Here and
there were found stellate cells resembling ganglion-cells.
Dr. E. Klein and Dr. Burden Sanderson,'|[ in a paper on the normal
and pathological histology of serous membranes,^ describe the arrange-
ment of the lymphatics in them. They show how^ the lymphatics
communicate at various points, not only by true stomata, but also by
means of protoplasmic processes of the lymph-canal-cells which run to
the surface between the endothelial cells with the serous cavity. These
last they call pseudo-stomata. In a later number** of the same journal
Dr. Lavdowsky lays claim to the merit of being the original discoverer
of the true stomata, and the same histological feature was observed by
Dr. Winogradowtt in the amnion.
EohrigJJ shows that various substances, as turpentine, solution of
* • Berichte der konig. Sachs. Gesellschaft der Wissensch.,' 1871.
t Idem, 187 1.
X * Henle uud Meissner's Bericht fiir 1871,' 121.
§ ' Pfliiger's Archiv/ v, i.
II * Archives of Medicine,' v, 46.
■[[ ' Centralblatt,' Nos. 2, ^, aud 4., 1872.
** No. 17.
ft 'Rudnew's Archiv,' iii, 1871, i.
Xi 'Archiv d. Heilkunde,' 1872, xiii, 341-388.
BLOOD. 5
iodide of potassium, &c., can be absorbed througb the unbroken skin,
especially if applied under pressure.
Other papers are by Eichorst (" Ueber die Eesorption der Albuminate
im Dickdarm"), in ' Pfliiger's Archiv,' 1871, 570-662. Heiberg (*' Safe
canal system der Schleimhaiite"), in * Nordiskt Med. Archiv,' iii, 4,
and Laqueur (" Ueber die Durchgangigkeit der Hornhaut fiir Flussig-
keiten"), in ' Centralblatt,' No. 37, 1872.
BLOOD.
The most important treatise that has appeared upon the blood is that
of Preyer * on the crystals of the blood, of which the reader will find
an analysis in ' Humphry and Turner's Journal of Anatomy,' by Dr.
Butherford, and another in the ' Medico-Chirurgical Beview' for 1872.
Preyer finds haemoglobin in all vertebrates, in one mollusc (Planorbis),
two arthropods, and two worms. It is not present in echinoderms,
coelenterates, protozoa, or plants. It exists independently of the
blood in muscle. The easiest, though not the best, mode of procuring
hremoglobin-crystals is to defibrinate dogs' blood and mix it with one
and a half times its weight of cold water. After three hours add a
quarter of its volume of rectified spirit. This fluid, if left for a night
in a freezing mixture, will be found to contain crystals in the morning,
which should be washed with a little pure water. Pure hsemoglobin is
very insoluble. All the forms of its crystals belong either to the rhombic
(man, guinea-pig, and most mammals) or to the hexagonal (squirrel
and some rodents) system. All doubly refract light. Haemoglobin
gives one absorption band ; when combined with oxygen it gives two.
He gives its formula as C6()QH9g()]S'j54Pei, S3, O179. It can be broken up
into albuminoid compounds, pigments, and acids.
M. Brondgeest t found a variable number of colourless crystals in the
blood of frogs kept for some time at low temperatures. Their form
was, for the most part, prismatic, with very long lateral surfaces and
pyramidal extremities, not, therefore, agreeing with any known form of
blood-crystals. They are insoluble in water and in ether, soluble in
dilute acids and alkalies, and in a 5 per cent, solution of common salt.
They are very stable. When dried they may be kept for years un-
changed in appearance. They do not form as the blood thaws, but may
be seen in the frozen blood. They cannot be obtained from coagulated
blood. They are most abundant and best seen in animals that have
been frozen into a solid block at a temperature of 4° Cent., and then
submitted to a considerably lower temperature. Brondgeest believes
them to be derived from albumen.
Struve, of Tiflis,]: has demonstrated the presence of two colouring
matters in blood. One of them is extremely soluble in water and
alcohol, but with some difiiculty in ether, and not in acids. The ashes
contain silicic and phosphoric acids, oxide of iron, and a little alkali. It
gives a blue colour with tincture of guaiacum and turpentine. It appears
* ' Die Blut-crystalle/ Jena, 1871, 263.
t * Archiv f. Genees-en-Naturkunde,' 1870, 378.
% ' Virchow's Archiv/ Ivi, 1872, 423.
k
6 REPORT ON PHYSIOLOGY.
to be identical with Preyer's alkaline oxy-hgematin or Y. Wittich's
hcBmatin. The second kind of colouring matter forms small, dark, blue-
black, microscopic crystals, insoluble in water, alcohol, ether, chloro-
form, and acids, but readily soluble in alkalies. From it hsemin-
crystals can be readily prepar^. It appears to be identical with
Virchow's hcematoidin.
Strassburg's * experiments corroborate the statements of Pfliiger and
Zuntz that on the addition of acids to blood the hsemoglobin undergoes
oxidation and splits into hsematin and albumen.
Adolf Jarisch f gives the following as the arithmetical mean of four
careful researches on the composition of the ashes of the blood of the
dog: — Phosphoric acid anhydride i3"32 per cent., sulphuric acid anhy-
dride 4"oi, chlorine 31*43, potash 3*83, soda 42"oi, lime i'25, magnesia
0-65, oxide of iron 8-34 per cent.
i)r. J. EichardsonJ concludes, from his experiments, that the white
blood-corpuscle is a cell composed of a cell-wall with contents and a
nucleus (or nuclei), which possesses the power of voluntary amoeboid
movement, is soluble in water, but is capable of slowly imbibing that fluid
and increasing to nearly double its normal size. The cell- wall of the cor-
puscle is a membranous envelope, insoluble in water, too thin to exhibit a
double contour with a magnifying power of 1200 diameters, but firm
enough to restrict the movement of its contained granules. Its exterior
is somewhat adhesive, so that surfaces or particles coming in contact with
it are liable to become attached thereto. Some phenomena observed lend
countenance to a theory that this membrane is dotted with minute
pores, which permit delicate threads of the soft protoplasm to be ex-
truded, and the edges of which, if the projection still continues during the
amoeboid movement, are carried outwards as a sheath to all except the
extreme point of the narrow tongue-like process. The material occu-
pying the space between the capsule and the nucleus, denominated the
protoplasm of the cell (the fibro-plastin of Prof. Heynsius), is a soft,
jelly-like matter, in which the power of amoeboid motion resides. It
appears to be soluble in water and saline solutions in all proportions,
and when freely diluted loses its amoeboid power, which, however, is
regained in a majority of cases when the excess of fluid is withdrawn.
The laws by which leucocytes take up and part with liquids seem to
be simply those of the dialysis of fluids through animal membranes by
endosmosis and exosmosis, as studied by Graham, on a larger scale, in
Jurasz§ has investigated the action of bile and the biliary acids upon
the blood-corpuscles, and finds that the white corpuscles resist the
action of bile better than the red, hence the greater number of the
former in the blood of the hepatic vein.
Manassein,|| from the results of numerous comparative measure-
ments, finds that the size of the red corpuscles diminishes in septicsemic
* * Pfliiger's Archiv,' iv, 454.
t ' Strieker's Med. Jahrb./ iv, 187 1.
X Pamplilct, 1872.
§ Inaug. Dissert. Grcifswald, 187 1.
II ' Centralblatt,' No. 44, 1871.
BLOOD. 7
poisoning during exposure to a high temperature and to an atmosphere
containing an excess of carbonic acid ; whilst they enlarge under the
influence of oxygen, and by the action of agents lowering the tempera-
ture of the body, as cold, quinine, hydrocyanic acid, and alcohol.
The action of quinine upon the white corpuscles of the blood has
been studied by Geltowsky,* Kerner,t and Binz J All agree in stating
that it renders them round, darkly granular, motionless, and unexcitable.
Dr. A. Marcet§ maintains that blood is a colloid fluid, but that it
also contains 7*3 per 1000 of diffusible constituents. The proportion
of diffusible constituents in serum is 9*25, these quantities diffusing
out in twenty-four hours. The proportion of chlorine is remarkably
uniform, being 3*06 per 1000. Blood contains phosphoric anhydride
and peroxide of iron in a perfectly colloid state.
Schmidt 1 1 devotes a long paper to the consideration of the cause of
the coagulation of the blood. He considers that, besides the fibrino-
genous and the fibrinoplastic substances, a third substance or ferment
must be present ; this is generated either in the white corpuscles or in
the plasma, but not in the red corpuscles.
Schiffer % demonstrates that no coagulation of blood takes place in
the living vessels, even though considerable quantities of free fibrino-
plastic substance be injected into them.
Boll** finds that, owing to deficiency of fibrinogen, the blood of the
foetal chick does not coagulate before the twelfth or fourteenth day,
and then only imperfectly. Haemoglobin can be distinguished by the
spectroscope in the blood on the third day of incubation. Kleinff
describes the development of the earliest blood-vessels and corpuscles.
Boyd Moss]: J describes a peculiar ciliated hsematozoon, which he found
on several occasions in the blood of the Ceylon deer (Muntjac), and T.
E, Lewis§§ describes a peculiar kind of Filaria as being constantly
present in vast numbers in the blood of patients affected with Chyluria.
The views of Waller and Cohnheim respecting the origin of pus-
globules from the white corpuscles of the blood have met with an
opponent in Dr. Duval, || || who, from the results of his experiments upon
the cornea, has arrived at the conclusion that the pus-corpuscles
appearing in severe inflammation of that membrane result from the
proliferation of the plasmatic cellules of the corneal tissue, and not from
the white corpuscles.
Lostorfer^^ has published some observations on the presence of fungi
* * Practitioner,' June, 1872.
f 'Pfliiger's Archiv,' v, 27.
X ' Practitioner,' Sept. 1872.
§ 'Nature,' May 18, 1871.
II * Pfliiger's Archiv,' vi, pts. 8 and 9.
1" ' Centralblatt,' No. 10, 1872.
** ' Reichert und Dubois Reymond's Archiv,' 1870, 718.
ft ' Sitz. der Akad. der Wiss.,' Vienna, 187 1 ; and * Humphry and Turner's Journal,*
1872, 438.
J J ' Monthly Mic. Joum.,' 187 1, vi, 181.
§§ Pamphlet, 1872.
nil Brown- Sequard's 'Archives de Physiologic,* 1872, 176.
1^ ' Strieker's Jahrbiicher,' 187 1, 451 ; 1872, 96.
REPORT ON PHYSIOLOGY.
in the blood of man, showing that the germs of the sarcina ventriculi
or of a fungus which when cultivated is so closely allied to it as to b<
indistinguishable from it, exist in normal human blood. He has also
written a paper to demonstrate the presence in the blood of syphilitic
patients of peculiar corpuscles. His statements are endorsed by the
high authority of Prof. Strieker, but have met with great opposition in
Germany.*
Chalvetf gives the following analysis of the blood in scurvy : — Fibrin
4 per cent.; corpuscles 6^ — loo per looo, instead of 130 per 1000;
water 853*^, instead of 779; albumen 72-3 per 1000, instead of the
normal 687.
Laschkewitz J describes the red corpuscles in a case of Addison's
disease, large, pale, and presenting amoeboid movements.
Mosler § states that during life the blood of a highly leucaemic patient
was alkaline ; it only became acid after death.
Hoppe-Seyler || finds that white blood- or lymph-corpuscles contain
glycogen so long as they exhibit movements, but when they become
rigid they lose their glycogen and contain sugar.
Other papers on the blood-corpuscles are by E. Bay Lankester
('Quart. Journ. Mic. Sci.,' Oct. 1871), George Gulliver (idem, Jan.
1872), Braxton Hicks (idem, April, 1872), and Norris ('Transact. 8t.
And. Med. Grad. Ass.,' 187 1). Norris considers that in passing
through the capillary walls the morphological elements of the blood
obey the same physical laws as soap-bubbles. Mantegazza (' Ceutral-
blatt,' 187 1, No. 45), Hoppe-Seyler and Mieschen (" On the Chemical
Composition of Pus and Pus-corpuscles," *Mediz. Untersuchungen,'
1871, pp. 441).
Other papers are — P. Q. Brondgeest, " Over ongekleurde Kristallen
in het bleed van bevroren Kikvorschen" (on the presence of colourless
crystals in the blood of frozen frogs), in the ' Nederlandsch Archiv.
voor Genees-en-Naturkunde,' 1870, v, 378, with a plate. M. Preyer,
" Synthese des rothen Blutfarb-stofFs aus seinen Zersetzungsproducten'*
(synthesis of the red colouring matter of the blood from the products
of its disintegration), in the ' Centralblatt fiir die Medicin. Wissen-
schaft,' No. 10, 1 87 1. Exner, " On the Development of Ammonia in
Decomposing Blood," ' Sitzungsber. d. K. Akad. zu Wien,' Ixii, ii, 363.
W. Marcet, " On the Constitution of Blood and Nutrition of Tissue,"
* British Medical Journal,' June 17, 187 1.
CIRCULATION. HEART. ARTERIES.
F. W. Beneke % gives the following as the results of nearly a hun-
dred measurements of the arteries of adults:— i. The internal circum-
* See for various papers on this subject Vaida and Biesiadecki in 'Wien. Med.
Wochens.; Kobner, 'Berlin Klin. Wochens./ 1872, No. 18.
t ' Union Medicale,' 187 1, No. 121.
J 'Die rothen Blutkorperchen in einem Falle von Morbus Addisonii.'
§ ' Die Reaction des leukamischen Blutes.
II • Med. Chem. Untersuch.,' 486. v
IT • Jahrbuch. f. Kinderheilkunde,' N. P., iv, 380.
1
!1
CIRCULATION. ' 9
ference of the aorta i centimeter above the valves, maximum 588
millimeters, minimum 31*0 millimeters; difterence, 27"8 mm. 2. In-
ternal circumference of the descending thoracic aorta 12 cm. below the
origin of the left subclavian, max. 407 mm., min. 13*2 mm. ; difterence,
27*5 mm. 3. Internal circumference of the abdominal aorta 3 cm.
above the bifurcation, max. ^y^ mm., min. 13*2 mm.; dift'erence, 20*1
mm. 4. Internal circumference of the pulmonary artery 2 cm. above
the valves, max. 58*0 mm., min. 30*7 mm. ; dift'erence, 27*3 mm. The
smallest diameter of the arterial vessels was found most frequently in
cases of chronic pneumonia and tuberculosis.
Cyon and Steinmann* find that the rapidity of the current of blood
in the veins is nearly as great as in the arteries, and they describe the
conditions which lead to variation in the rapidity of the current.
Dr. Miescherf conducted experiments to determine what influence
section with preservation of certain portions of the spinal cord exercised
upon the reflex action of certain nerves arising below the lesion upon
the blood pressure. He concludes that the centripetal fibres of the
sciatic nerves capable of reflectorially increasing the blood jressure
run (in that portion of the medulla which extends between the third
lumbar nerve and the last dorsal) either entirely or principally in the
lateral white medullary columns of the cord. Again, he finds that in
the same region of the cord the centripetal fibres of the left sciatic
chiefly run in the right and in smaller proportion in the left lateral
column, and vice versa. Lastly, he shows that the fibres of this nature
coming from the lower regions of the cord, run in its outermost portion,
whilst those that enter at the higher planes run wholly or partially in
the neighbourhood of the median plane.
Ceradini,:}; T. Lauder Brunton,§ and rick,|| have investigated the
effects of heat on the action of the heart.
A. H. Garrod has published a paper on the construction and use of
a simple cardio-sphygmograph ; % and another on the mutual relations
of the apex cardiographic and the radial sphygmographic traces.**
The remarkable increase in pressure in the arterial system occurring
with stoppage of the respiration is generally accompanied by increased
vascular contraction, and MM. Dogiel and Kowalewsky ft have shown
that in curarized dogs there is also a coincident decrease in the rapidity
of the arterial current in the crural artery.
G-atzuck's observations J J made on dogs show that vensBsection,
especially from the anterior extremities, retards the mean velocity of the
current of blood in the carotid and crural arteries and their branches,
and, generally speaking, the mean pressure also falls, though it occasion-
ally remains unaltered or even augments. The quantity and rapidity
* * Bull, de I'Acad. des Sci. de St. Petersbourg,' xvi, 266.
t ' Ludwig's Arbeiten/ 5th Jahrg.
X *I1 Mecanismo delle Valvole Semilunari del Cuore,' Milano, 1871.
§ ' St. Bartholomew's Hospital Eeports/ vii, 216.
II * Pfliiger's Archiv/ v> 38.
^ * Humphry and Turner's Journal,' v, 265.
** * Proceed. Roy. Soc.,' xix, 318.
ft ' Pfliiger's Archiv,' iii, 489.
XX 'Ceutralblatt/ No. 53, 1871.
10 REPORT ON PHYSIOLOGY.
of the blood discharged powerfully influence the result. When the flow
of blcod has ceased, both the rapidity of the current and the pressure
quickly return to their normal amount. With the diminished velocity
and pressure of the blood current the frequency of the heart's beats
augments, the sounds (especially the second) are diminished in inten-
sity, and the temperature of the body falls 2° or 3° Pahr.
M. Nolet,* in investigations made to determine the nature and cause
of vascular murmurs, finds that a sound is produced even in a tube of
uniform calibre, providing the rapidity of the current be sufficiently
great. Thus, in a thick- walled tube of caoutchouc having a diameter of
about 2-3rds of an inch (1875 mm.), a bruit becomes audible when the
rapidity of the current was about five and a half feet a second (1600 —
J 700 mm.). The smaller the tube the greater the velocity required to
produce a bruit. G-reater velocity was required with metal tubes than
with caoutchouc, in consequence of their greater smoothness. The
presence of a constriction caused a bruit to become audible with greatly
diminished velocity of current, the sound being produced both before
and beyond the constriction, but chiefly beyond. The presence of a
dilatation also causes a bruit, but the velocity of the current must be
great. The larger the dilatation the greater the rapidity of current
required, hence the absence or diminution of murmur in large aneurisms.
The sound is most audible at the entrance to the dilatation, and in all
cases the bruit is due to the formation of eddies.
Dr. Mayert has investigated the action of strychnine on the blood
pressure, and finds that it immensely augments it, which he attributes
to its excitant action on the vaso-motor centre in the cerebrum, causing
contraction of the smaller arteries, and not to the tetanic convulsions
of the voluntary muscles.
Ewald HeringJ from his experiments on dogs, shows that moderate
expansion of the lungs by insufflation through a canula in the trachea,
which is then closed, causes increased rapidity of the heart's action.
He proceeds to demonstrate that this eff'ect is not due to the increased
pressure exerted upon the external surface of the heart, nor to altera-
tions in the condition of resistance in the different parts of the circula-
tion, nor to differences in the interchange of gases, nor to any dislocation
of the heart's position, but that it is effected reflectorially through the
vagi. The insufflation, he thinks, excites certain sensory fibres of the
lungs, and these stand to the cerebral centre of the inhibitory fibres of
the heart in the same relation that the fibres of the depressor nerve do
to the cerebral centre of the vaso-motor nerves. Both of these centres
are in a state of constant excitation, which is lowered by the irritation of
the above-mentioned fibres. These fibres are therefore to be regarded
as inhibitory nerves for these centres. For other papers see O.
Schmiedeberg, researches on the action of certain poisons (muscarin,
atropin, daturine) on the heart of the fi'og.§
* 'Beitrage aus dem Physiolog. Laborat. zu Leiden/ 1871.
t " Studien zur Physiologie des Herzens und der Blutgefasse," Dr. Sigmuud Mayer
m 'Strieker's Jahrbiicher,' 1872, iii.
X ' Strieker's Jahrbiicher,' 1872, 37.
§ ' Lud wig's Arbeiten,' 5th Jahrg.
RESPIRATION AND ANIMAL HEAT. 11
Eiidinger, " Ueber die Topographie der beiden Vorliofe und die
Einstrbmung des Blutes in dieselben bei den Foetus."*
Dr. G-arrodt describes a simple form of cardiograph, and gives the
results he obtained from its use.
RESPIRATION AND ANIMAL HEAT.
Dr. Boldyrew,:|: in giving the results of his researches upon the
histology of the mucous membrane of the respiratory organs, larynx, and
trachea, states, in opposition to others, that he finds mucous glands
do exist on the convexity of the cartilages, though they are much
flattened and expanded. He agrees generally with Puxy-Axos§ in
describing the mucous glands as presenting the form of small sacs, some-
times divided dichotomously. The excretory ducts are lined by columnar
epithelium, the sacculi contain an epithelium in form of the demilune
described by Griaunuzzi in the salivary glands. Boldyrew also finds
lymphatic follicles, like those forming Peyer's patches, in the mucous
membrane of the larynx.
Dr. Sikorsky, II in experiments undertaken to determine the lym-
phatics of the lungs, injected carminated ammonia into the lungs of living
cats and dogs, which were then removed from the body and frozen, the
blood-vessels in the meanwhile being injected with a blue fluid. It
was found that, in regard to the deep plexus and in the bronchia, pecu-
liar cell-like structures intervened between the ordinary columnar
epithelial cells, which were tinted red, and that, either from these
or from canals in immediate relation with them, minute vessels ran
towards the membrane, and formed a close plexus in the mucosa and
submucosa, from which larger vessels arose, that accompanied the
bronchia to the roots of the lungs. In the alveoli similar^ cells and
tubes exist, but the plexus is characterised by having many dilatations,
and the vessels proceediug from it accompany the veins.
Leichtenstern ^ publishes the results of his inquiries into the effects
of various conditions upon the volume of the expired air. He first
considers the influence of the vagi, and discusses B-osenthal's views.
His experiments agree with those of Rosenthal, and show that section
of the vagi, though it greatly diminishes the number of the respirations,
does not at once materially alter the absolute volume of air admitted,
the depth of the respiration undergoing a corresponding increase in
consequence of the excitation of the medulla oblongata by the carbonized
blood. After a time, however (some hours), the muscles become
fatigued, and cyanosis gradually sets in. He next produced a unilateral
pneumothorax ; in a weak rabbit great restlessness and dyspnoea were
produced ; forty-five minutes after, the number of the respirations was
but little above the average, and soon sank below it, clearly on account
* * Journal fiir Kinderkrankheiten,' xxix, 402.
t * Humphry and Turner's Journ. of Anat. and Phys.,' 1871, 265.
X Brown-Sequard's 'Archives de Physiologie/ 1870, 625.
§ 'Sitz. bericht. d. Wien. Akad.,' 1869.
II ' Centralblatt,' Dec. 3, 1876.
^ ' Zeitschrift fiir Biologic,' vii, 197.
12 REPORT ON PHYSIOLOGY.
of rapidly superveDing fatigue of the muscles, which ceased to respond
to the most violent excitement of the respiratory centres produced by the
cyanosed blood. In a strong rabbit similar dyspnoea occurred, but the
number of respirations rose from 32 to 48, and gradually to 77, inconse-
quence of the greater vigour of the muscles. In both rabbits the amount
of air breathed diminished to about one half, even the greater rapidity
of the respiratory movements of the stronger rabbit not compensating
for the absolutely smaller quantity inhaled. (3) In a third set of
experiments the tracheal tube was narrowed so as to diminish the
quantity of air admitted ; the number of the respirations was imme-
diately diminished, their depth was increased, but a smaller volume of air
was actually respired. (4) In another series of experiments the effect of
the abstraction of blood was investigated. These showed that, as might
have been expected, the diminution in the number of oxygen-conveying
blood-corpuscles occasioned in the first instance dyspnoea, but the same
absence of red corpuscles soon reduced the interstitial changes in the
tissues, a less supply of oxygen was needed, and consequently the respi-
ratory volume diminished. Ultimately the disintegration of the tissues
and the absorption of oxygen was so far lowered that death took place.
(5) In the fifth series Leichtenstern injected half a grain of morphia
under the skin of the back. This diminished the number of the respi-
rations as well as their depth, and, therefore, the volume of the respired
air, for the first half hour. Then the number of respirations rose, and
after a time and to a certain extent the volume inspired, though not to
the normal amount. V. Bezold thinks these effects due to lowered ex-
citability of the respiratory centre, but it may also be due to diminished
tissue change, just as occurs during sleep. Leichtenstern thinks both
causes operate. (6) The effects of section of the spinal cord between
the third and fourth cervical vertebra were examined. Tlie number and
depth of the respirations were found to be remarkably diminished ; this
is owing to diminished metamorphosis of tissue, which, again, Leich-
tenstern thinks is attributable to the paralysis of the blood-vessels and
lowered blood pressure throughout the system. (7) The effects of cold
were examined, and it was found that immediately after exposure, before
the general temperature of the body could have undergone any change,
the number and depth of the respirations underwent great increase, and
this even when the animal was wrapped up in warm cloths, showing it was
due to the excitation of the vagi in the lungs. When the cold acted for
some time, so that the general temperature sank, the number of the
respirations fell gradually below the normal amount, though their
increased depth was maintained for some time. (8) Experiments were
made on the action of heat on the volume of the respired air, and it was
found that the exposure to heat caused quickly a slight increase in the
number of the respirations, owing, probably, to excitation of the vagi in
the lungs and the cutaneous nerves ; but further augmentation of the heat
did not increase their number till it became very high, when both their
number and depth increased, apparently because high temperatures
augment tissue metamorphosis. (9) And lastly, a series of experiments
were made on the volume of the respired air after the cutaneous respira-
tion had been suppressed by coating the animal with linseed oil. Leich-
RESPIRATION AND ANIMAL HEAT. 13
tenstern corroborates the experiments of Laschkewitsch and Krieger,
that death results in these cases from cold, and the phenomena of the
respiration corresponded with those observed in cold.
Quincke and PfeifFer* show that with each inspiration the passage
of the blood through the left ventricle is accelerated.
Schifff maintains that section of the lateral columns of the cord at
the level of the first cervical nerves arrests the respiratory movements
of that side. He states also that, the lungs and vagi being removed
from the body, electrical excitation of the vagi causes contraction of the
parenchyma of the lung.
LandoisJ and Ceradini§ have experimented on the action of the heart
on the respiration. The former finds that some air is expelled with
each systole of the heart, the latter that the effect is more complicated.
The opposite investigation, viz. the action of the respiration on the cir-
culation, has been pursued by Dr. Hering.||
Experiments made in 1865 by MM. Estor and St. Pierre seemed to
show that a considerable quantity of oxygen disappears from the blood,
even whilst passing through the larger arteries. This statement is,
however, contested by MM. Mathieuand D'Urbain,^ who maintain that
there is scarcely any appreciable difference in the amount of oxygen
contained in the blood of the carotid and crural arteries ; they have,
however, found that when the difference in the size of two vessels is
very great the blood coursing through the larger one contains more
oxygen and less carbonic acid. In a second paper, in which they give
the results of their experiments on the influence of external tempera-
ture on the amount of gas contained in arterial blood, they show that
in warm-blooded animals the quantity of oxygen absorbed by the blood
varies inversely with the temperature of the air they breathe, being in-
creased in winter and diminished in summer. This is conformable
with the physical fact that the exchange of gases through a moist
animal membrane is more rapid at a low than at a high temperature.
M. Paul Bert** has studied, in the physiological laboratory of the
Sorbonne, the influence that changes in the barometric pressure exercise
on the phenomena of life. When warm-blooded animals are suddenly
exposed to air so rarefied that it will only support 15 to 18 centim. of
mercury, convulsions, followed by death, are rapidly induced, with the
appearance of bloody froth in the bronchi. If it be done by degrees,
however, they will live in a very rarefied air (12 centim.) for some
time, though all ultimately die from asphyxia. Birds cannot live at a
lower pressure than 18 centim. The lower the pressure the more
oxygen remains unexhausted.
Hermann Aubert, of Rostock,tt finds that the total amount of car-
* ' Reichert und Dubois Reymond's Archiv,' 1871.
t ' Pfliiger's Archiv,' iv, 225.
J 'Berlin Klin. Wochensch./ 1870, 9.
§ * Annali Universali,' iv, 587.
II ' Sitzungsber. der K. K. Akad. zu Wien,' Ixiv.
^ Brown-Sequard's 'Archives de Physiologie,' 1872, 190 and 304.
** 'Rev. Scient./ 2de ser., i, 166.
ft ' Pfliiger's Archiv,' vi, 1872, xi.
14 REPOUT ON PHYSIOLOGY.
bonic acid eliminated from the skin of the whole body in twenty-four
hours, at a temperature of 86° Fahr., is about 4 grammes, or 60 grains,
whilst the amount of that given off by the lungs is, perhaps, 900
grammes, or 13,500 grains.
Dr. Bernstein* remarks that no attempt has hitherto been made to
construct an apparatus approximatively resembling the conditions under
which an exchange of gases takes place in the placenta. He gives the
details and a drawing of an ingenious instrument he has constructed
with this object in view, and shows that the exchange of gases dissolved
in fluids is extremely small.
Schiff't has made many researches on the influence of artificial respira-
tion having an important bearing on the preservation of life in concus-
sion and compression of the brain and on the circulation.
Arthur Ransome,! in a paper on the mechanical conditions of the
respiratory movements in man, shows that the clavicles have more
upward than forward motion, and move less than either sternum or
ribs. The ribs move upwards more decidedly than the sternum, and
the upward dimensions of the respiratory movement of the chest, as a
whole, are sufficiently accounted for by the upward rise of the ribs, their
chord length being taken as radius, their vertebral attachments as
centres. The outward indications, as given by the stethometer, are also
probably to be accounted for by the simple radial rise of the costal
ends of the costal cartilages, the sternal articulation being taken as
centre. The extent of the forward indications may be accounted for
either on the hypothesis of the ribs becoming straightened in in-
spiration or of their being previously unbent in expiration. As regards
the actions of the intercostal muscles, the external intercostals (i) draw
the ribs upwards, (2) separate their anterior ends, (3) straighten them.
On the other hand, the action of the internal intercostals is (i) to
draw the ribs downwards, (2) to bring their anterior extremities nearer
together, (3) to bend them inwards. The diaphragm also bends in the
lower ribs.
Mr. P. Le Gros Clark § has also discussed somewhat fully the
mechanism of respiration, especially showing the importance of the
passive tension of the diaphragm.
Dr. Rattray II enters into some interesting details in regard to the
more important physiological changes induced in the human economy
by change of climate. He concludes that natives of colder climates,
and especially the young, debilitated, and diseased, should leave the
tropics, particularly during the rainy season. Even adults should
leave them if they lose flesh and strength, and frequent change to more
beneficial climates or higher altitudes is advisable for all who live
in them. He concludes also that the primary effects of great changes
of climate is on the circulation, the blood being drawn surface-ward by
heat and driven inward by cold, hence a difference in the relative
* * Ludwig's Arbeiten/ 1870, 5th Jahrgang.
t ' Centralblatt/ 1872, 756.
X 'Proceed. Roy. Soc.,* xxi, 11.
§ 'Meet. Roy. Society,' May 25, 1871.
II 'Proceed. Roy. Soc.,' 1871, xix, 295.
.. DEGLUTITION. 15
activity of the external and internal organs, the function of the skin
augmenting, those of the lungs and kidneys diminishing. The
respiration and circulation are both more languid, yet the temperature
rises about 2° F.
Gt. V. Liebig* contributes a paper on the influence exerted upon the
respiration by increased or diminished atmospheric pressure. He
finds that residence at high altitudes has a tendency to develop the
respiratory power and the strength generally, hence it is useful in all
cases of diminished elasticity. Por other papers on respiration see
Gustav Strassburg.f H. Sanders Ezn, on apnoea and dyspnoea^
L. Groldstein.§ P. Kratschmer. |1
Wolffbey^ finds the arithmetical mean of the tension of the carbonic
acid in the alveoli of the lungs to be 2' ^6, and the tension in that of the
blood to be 3-43 percent.
Cliff'ord Allbutt** has contributed a paper on the effect of exercise on
the bodily temperature, showing in opposition to M. Lortet that the
regulating power of the organism holds good under great variations of
muscular exertion, though once or twice low temperatures were noticed,
perhaps attributable to some accidental deficiency in combustion.
Eor other papers see Eansome,tt ^^^ especially Horvath.:^!
DEGLUTITION.
The subject of the nerves presiding over deglutition has been care-
fully investigated by MM. Waller and Prevost,§§ and they sum up their
results in the following words : — (i) Feeble induced currents applied
to the central extremity of one of the superior laryngeal nerves after
division cause arrest of the movements of the diaphragm in expiration,
as stated by Rosenthal, and rhythmical movements of deglutition. (2)
Movements of deglutition may be produced by irritation of the central
cut extremity (a) of the recurrent nerves ; (b) of the vagi, when the
irritation was made above the origin of the superior laryngeal nerves ;
(c) of the glosso-pharyngeal (at least in the dog and cat, but not in the
rabbit). (3) On laying open the buccal pharyngeal and laryngeal
cavities, with a view of determining what nerves excite movements of
deglutition on being irritated, and the results of dividing the several
nerves successively, they found that in rabbits (a) the glosso-pharyngeal
* * Archiv f. Klin. Med.,' viii, 445.
t ' Pfliiger's Archiv,' vi, i, 65.
X ' Maandblad voor Natuurwetenschapen,' 1870-71, 113; and * Centralblatfc,'
1871, 511.
§ " Ueber Warmdyspnoe," ' Centralblatt,' 1871, 678.
II "Ueber Reflexe von der Nasensehleimhaut auf Athmung und Kreislauf," ' Cen-
tralblatt,' 1871, 58.
^ ' Pfliiger's Archiv,' 1872, 23, " Ueber die Athmung der Lunge."
** 'Proceed. Roy. Soc.,' xix, 289, 1871.
ft " On the Organic Matter of Human Breath in Health and Disease," * Journal
of Anatomy,' 1870, No. vi.
Xt * Centralblatt,' 1872, Nos. 45, 46, and 47.
§§ * Brown-Sequard's Archives,' 1870, 185 and 323.
]6 EEPORT ON PHYSIOLOGY.
nerve exerts no reflex influence upon these movements ; (b) that the
fifth nerve animating the velum palati is the principal sensory nerve
presiding over deglutition, since after section of one of the fifths deglu-
tition could no longer be provoked by exciting the corresponding half
of the velum palati ; (c) that the superior laryngeal nerve contributes
to the reflex actions of deglutition by its sensory branches distributed
to the mucous membrane covering the glottis, the aryteno-epiglottidean
folds, the superior borders of the laryngeal cavity, and chiefly by those J
distributed over the corniculated cartilages ; (d) the recurrent nerve ■
aids in the reflex phenomena of deglutition by its sensory branches.
(4) In the cat and dog cough is often observed on electrifying the
trunk of the superior laryngeal nerve and that of the glosso-pharyngeal.
In the rabbit cough is occasionally observed on irritation of the latter
nerve.
M. Ebstein* has arrived at the conclusion that the glands of the
pyloric region of the stomach, formerly believed to secrete mucus,
really produce gastric juice like the true peptic glands, and have an
epithelial lining of the same nature. The mucus of the stomach he
believes to be formed by the cells covering the general surface.
rriedinger,t as the result of his researches on various classes of
animals, arrives at the conviction that the older views were correct, and
that, in opposition to the statements of Ebstein, the investing cells of
Heidenhain, or delomorphous cells of E-oUett, are those which really
contain and form the pepsin.
See also Gr. Schwalbe,J E,. Wiedersheim.§
Pick II regards the peptones as compounds capable of easy disintegra-
tion, and as supplying by their non-nitrogenous constituents the com-
bustible materials for the muscles and other organs, their nitrogenous
constituents being speedily eliminated from the body.
Paschutin^ demonstrates that the presence of a large quantity of the
products of the metamorphosis of starch, as, for instance, of dextrine
and grape sugar, does not interfere with the action of ptyalin on
starch.
M. Lepine** finds that a ferment capable of converting starch into
sugar is widely distributed throughout the body, the only organ in
which it appears to be totally absent being the crystalline lens. It is
most abundant in the blood, muscles, spleen, vitreous humour, testis,
and brain.
DIGESTION.
The phenomena of peristalsis have been reinvestigated by G. v.
* * Centralblatt,' 1871, No. 6, and ' Pfluger's Archiv,' iv, 1872, i.
t * Wiener Akad. Sitzber.,' Ixiv, 187 1.
X 'M. Sohultze's Archiv,' viii, 92, " Beitrage zur Kenntniss der Driisen in den
Darmwandungen, insbesondere der Brunnerschen Driisen."
§ 'Die feineren Strukturverhaltnisse der Driisen iu Muskelemagen der Vogel,'
Iiiaug. Dissert., abstract in ' Centralblatt,' 1872, 278.
II ' Pfliiger's Archiv,' v, i.
If 'Centralblatt,' 187 1, 372.
' Ludwig's Arbeiten,' 1870.
#*
DiGESTIOJf. 11
Brakel,* who maintains the existence of both peristaltic and of anti-
peristaltic movements, and states that if a loop of the intestine of a cat
be pinched a wave may be followed in both directions, travelling as far
as to the pylorus and to the ileo-csecal valve at the rate of an inch and
a half in a second. The large intestine, the ureters, and the uterus,
exhibit similar waves. H. Sanders Ezn,t in pursuing the same inves-
tigation, places the animal in water at blood heat, containing o'6 per
cent, of common salt, and opens the abdominal cavity. The intestine in
his experiments was always at rest. After a little while slight wavy
movements occurred ; mechanical excitation had little effect. Violent
movements occurred when the animal was asphyxiated, but these did
not occur if the two vagi were previously divided in the neck. Excita-
tion of the cut peripheric extremities induced contraction, commencing,
for the most part, at the lower extremity of the duodenum and the
upper end of the ileum. The right vagus induced the former, and the
left the latter. Sanders Ezn observed antiperistaltic movements in one
case of diarrhoea, but in all other cases the movements were peristaltic.
Dr. Dalton J states that he has arrived at the following conclusions
in regard to the sugar of the liver : — (i) Sugar exists in the liver, how-
ever rapidly it may have been examined after removal from the body,
even in the living animal. (2) The quantity present, under these cir-
cumstances, is at least two and a half parts per thousand. (3) The he-
patic sugar thus found does not proceed from the arterial blood circulat-
ing through the organ, but is a normal product of the tissue of the liver.
Gustav Strassburg § gives a modification of Pettenkofer's test for the
detection of the biliary acids in urine, which he states is extremely
delicate. It consists in dipping a piece of filtering paper into the urine,
to which cane sugar has previously been added, drying it, and then
dropping some concentrated sulphuric acid upon it. A beautiful violet
tint appears.
V. Lair and Masius || apply the term sterco-bilin to a new colouring
matter obtained from the feculent contents of the intestines. Its ab-
sorption band is precisely limited by the lines b and E. It is soluble
in water, alcohol and chloroform, insoluble in sulphuric ether.
A very long paper will be found in the ' Comptes Eendus' for May
29, 187 1, by M. Payen, on the substances used as food during the
siege of Paris. Amongst these blood in the form of blood-puddings,
horseflesh, the dried albumen of eggs, and preserved fruits, occupied a
prominent position.
A. Gusserow ^ shows presence of urea in liquor amnii, and passage
of iodine from stomach of mother into urine of foetus.
Eor other papers see Leube,** "Weiss, ft Maly.JJ
* 'Pfluger's Archiv,' iv, 187 1, S3' t ' Centralblatt/ 187 1, 479.
J In a paper read before the New York Academy of Medicine, June 15, 187 1.
§ ' Pflxiger'sArchiv,' iv, 10. || ' Centralblatt/ 1871,369.
% " Zur Lehre vom Stoffwechsel des Foetus," ' Archiv fiir Gynsec.,' iii, 241.
** ' Ueber die Eruahrung von Kranken durch Zuf uhr des Ernahrungs-materials per
anum.'
tt " Zur Statik des Glycogens im Thierkorper," * Sitzungsber. der Wien Akad. d.
Wissenschaft,' Ixiv, 1871.
XX "Umwandlung von Bilirubin in Harnfarbstoff," * Centralblatt,' 187 1, 847.
Z
18 EEPOB-T ON PHYSIOLOGY.
A series of researches undertaken by Gustav Meyer* on man and^
dogs, having for their object the determination of the relative value of
different kinds of bread used in Germany, namely, rye bread (Eoggen-
brod, Miinchen), white wheat bread ("Weizen-brod, Semmel), the Hors
ford-Liebig bread, and coarse rye bread (Pumpernickel), led to th(
result that, with equal weights of the dry substance, the white wheater
bread was decidedly the most nutritious of the four kinds of bread, since
under its use the smallest quantity of fsBces were excreted, whilst the
largest proportion of nitrogen was extracted in the process of digestion.
Next to the wheaten bread in nutritive value was the rye bread fer-
nented with leaven (sour dough, Sauerteig), but containing no bran.
Then followed the Horsford-Liebig bread (prepared without leaven, but
risen or made porous by the extrication of carbonic acid from the bicar-
bonate of soda and acid phosphate of lime and magnesia). And lastly,
the pumpernickel. When the question of cost came to be considered
it was quite a different matter, the white wheaten bread standing at the
bottom of the list, and the Pumpernickel and Miinich Eoggenbrod
occupying the next place.
J. Eankef has written an important pamphlet, the general purport of
which is to show that during the activity of any organ, not only is the
supply of blood to it increased, but there is a diminished supply of
blood to the remaining organs of the body, relations which he expresses
under the term ''functional interchange" (" Funktions-wechsel "), and
which have many important practical bearings.
E. A. ParkesJ has made some further experiments on the effect ol
diet and disease on the elimination of nitrogen, and shows that when
the nitrogenous food of a healthy man was reduced to one half for five
days, and he was then kept for five days more without nitrogen, he was
able on the fourth day of such deprivation to do a very hard day's
work. Non-nitrogenous diet appeared to suit him well. The pulse
became soft, but not altered in frequency.
V. Subbotin § maintains, in opposition to Parkes, Anstie, and other
English observers, that when alcohol is ingested in considerable quantity,
at least 16 per cent, is eliminated by the bowels, lungs, skin, and
kidneys.
Dr. Dupre,|| on the other hand, shows that at least an ounce of pure
alcohol may be entirely consumed in the system per diem, or, at least,
that more than this quantity must be ingested before any material
quantity is eliminated by the urine and breath.
Paalzow.^
Gen. Pleasanton, of Philadelphia, has a paper on the influence of
violet light on the growth of animals and plants.**
* *Zeitschri£t fur Biologie,' vii, 1871, i — 48.
t ' Die Blutrertheilung und der Thatigkeitswechsel dor Organe/ 8vo, 187 f.
t 'Proceed. Roy. Soc.,' xix, 187 1, 349.
§ ' Zeitschrift fiir Biologie/ vii, 4.
II "On the Elimination of Alcohol, Royal Soc," sec 'Nature,* v, 274.
^ IT "Ueber denEinfluss der Hautreize auf den Stoffwechsel." * Pflueer's Arcliiv/
IV, 492. ^
** 'Academy,* March, 1872, 95.
GLANDS. 19
GLANDS.
Hosier* finds — (i) That the spleen is not essential to life. (2)
That after its ablation other lymphatic organs discharge its functions,
especially the medulla of the bones. (3) That the spleen exerts a
direct influence on the development of the corpuscular elements of
the blood. (4) That it exerts no influence on gastric or pancreatic
digestion.
Wedi t finds from his dissections that the bloodpath of the spleen is
continuous, the blood passing from the arteries into capillaries, and
from these into veins.
Stofi" and Hasse J hold the opposite view, and maintain that the blood
IS discharged from the arteries into lacunar spaces.
Eosenstein§ suggests a new plan for determining whether urea is
formed in and by the kidneys, namely, the extirpation of one kidney
and analysis of the urine, the diet being the same. He finds that rather
more urea than normal is at once excreted by the remaining kidney,
showing that urea is not formed in and by the kidney, as it is incredible
hypertrophy of the gland tissue could take place in the course of a few
hours. II
Gscheidlen^ finds that urea is distributed through every tissue in the
body except the muscular, in which it is never present.
Dr. Salkowski**gives the following as the results of his investigations
on the elimination of alkaline salts from the body. In normal condi-
tions the urine is the channel through which by far the greater part of
the alkaline salts leave the body. The quantity of soda always exceeds
that of potash. In febrile states, however, the opposite obtains, the
quantity of potash increasing to three, four, or even seven times more
than in health. The salts of soda appear to be retained in febrile states.
In certain affections (typhus), notwithstanding free diuresis, a large
quantity of the alkaline salts are eliminated by the surface of the
intestine. In fever there is an augmented disintegration of those
tissues that contain a large excess of potash over soda.
Ustimowitsch'sft researches were undertaken on dogs which had been
kept fasting for eighteen hours. The urine was collected from the
ureters, and he found that the lowest pressure of the blood in the blood-
vessels under which urine continued to be secreted was about 50 mil-
limeters of mercury. The relative quantity of the several constituents
of the urine varies with diff'erences in the pressure of the blood in the
vessels when it is excreted, with the section of the renal nerves, and
with the resistance that the urine meets with in its discharge by the
ureters. Moreover, probably by its action on the nerves, it causes a dimi-
* ' Centralblatt/ 1871, 369.
t * Sitzungsber. der Wiener Akademie,' Ixiv, 1.
t * Centralblatt/ 1872, 753.
§ Idem, 1871, 353.
II For a good paper on the " Origin of Urea in the Animal Body," see * Academy,
Sept. I, 1872.
% Pamphlet, Leipzig, 187 1, Engelmann.
** ' CentralblatV 187 1, 289 and 774.
tt • Ludwig's Arbeiten/ 1870, $ Jahrg,
aO UEPOUT ON PHYSIOLOGt.
nution or absolute arrest of the secretion when the system is fully under
its toxic influence.
Cyon and Aladoff* corroborate Eckhard*s statement that diabetes
occurs in dogs an hour after the section of the inferior cervical or
upper dorsal ganglion. They consider it to be a phenomenon of paralysis
of certain fibres passing from the spinal cord to the ganglia, and from
thence to the ganglion stellatum through the aunulus Vieussenii. They
find vaso-motor nerves for the liver running in the annulus Vieussenii. f
KupressowJ inserted a tube into the bladder of otherwise uninjured
rabbits, and tried what height of a column of water was required to
overcome the resistance of the sphincter muscle. It amounted to
^0—60 centimeters. If, however, the spinal column were divided
between the fifth and seventh lumbar vertebrae the pressure required for
the same purpose immediately fell to 12 — 16 centimeters.
M. Decaisne§ shows from observations made during the siege of
Paris that the milk of woman has less butter, caseine, sugar, and salts,
but more albumen, than natural, when the diet is insufficient. ||
Boll has given the histology of the lachrymal glands in ' Strieker's
Manual,' Eollet^ that of the gastric glands, Schwalbe** that of the
duodenal glands, and Boldyrewff that of the laryngeal and tracheal
G-. LottJt finds that the uterine glands of the pig, cow, sheep, rabbit,
mouse, and bat, are lined with ciliated epithelium.
NEEVES.
The structure of the nerves has been specially investigated by
Eanvier§§ and Tamamschef.||||
M. Eanvier's researches were made upon nerves stained with picro-
carminate of ammonia, with perosmic acid, and with nitrate of silver.
He states that by means of these reagents he has been able to discover
the presence of annular constrictions succeeding each other at the dis-
tance of about a twenty-fifth of an inch in all nerve-fibres. The con-
striction seems to be due to a thickening of the sheath of Schwann,
and at this point the white substance or medullary sheath, but not the
cylinder axis, is interrupted. About midway between every two
constrictions is a nucleus the outer surface of which is in contact or is
* * Bull, de I'Acad. Imp. de St. Petersb./ viii, 90.
t See also Eckhard, " Uiitersuchungen iiber Hydrurie," * Beitrage zur Anatomie
und Physiologic/ vi, 53, and Maley, "Kunstliche Umwandlung von Bilirubin in
Harnfarbstofife/' 'Kolbe's Journ. f. Pract. Chem./ v, 102.
X ' Pfluger's Archiv/ 1872, 291; and ' Centralblatt,' 1872, 430. " Zur Physiologie
des Blasenschliess-muskels."
§ 'Rev. Scientif.,' 29 ser. i, 163.
II See also a lecture by J. Emerson Reynolds, * On the Chemistry of Milk/ dehvcred
before the Royal Dublin Society, May 13, 187 1 ; and Bogomoloff " On the Composition
of Milk," ' Centralblatt,' No. 40, 187 1.
•[[ * RoUett's Untersuch. aus dem Institute fiir Phys. ii Histol. in Graz.,* ii, 143.
** ' Schultze's Archiv,' viii, i, 128.
ft 'Rollett's Untersuch.,' 1871, p. 237.
it ' Untersuchungen aus dem Institute fiir Physiologic in Graz.,' 187 1, 250.
§§ Brown- Sequard's 'Archives de Physiologic,' 1872, 120.
im 'Centralblatt,' No. 38, 1872.
NEEVES. 21
actually fused with the sheath of Schwann, whilst its inner surface is
received into a kind of cup formed of the white substance of Schwann.
It would, therefore, seem that each interannular segment represents a
cell. He finds, as Frommann and Grrandry had already done before
him, that the cylinder axis under the action of nitrate of silver pre-
sents alternately light and dark striae not distantly resembling muscular
tissue.
Tamamscheff excised nerve-fibres from the sciatic or brachial plexus
and moistened them with serum. He finds that many nerve-fibres
are bound together into a fasciculus by a sheath made of flattened cells
which can be rendered visible by nitrate of silver, and which probably
belong to the lymphatic system. Shortly after removal from the body
the cylinder axis breaks up into a series of spheroidal bodies which
he terms corpuscula nervea, and vphich are capable of spontaneous
movements. They equal the red corpuscles of the blood in size.
Pure albumen undergoes changes of a similar nature.
Engelmann* calls attention to certain contractions indicated by
wrinkles in the sheaths of nerves, but not accompanied by shortening,
when the nerves are removed from a living animal and quickly sub-
mitted to the action of induction shocks whilst lying in a weak solu-
tion of common salt. No wrinkles are visible in naked axis cylinders.
Eutherfordf has investigated the varying excitability of the nerves
in various parts of their course. He argues against Pfliiger's avalanche
theory, and maintains that the excitability of any point in the trunk
of a spinal nerve, whether afi'erent or efferent, is inversely as the dis-
tance of that point from the nerve-centre.
SchlischJ finds that stretching the nerves of frogs with a weight of
forty grammes had little effect on their excitability, but when the
weight applied was greater than this the excitability rapidly diminished.
Schiff"§ has again investigated the functions of the spinal cord as a
conductor. He has satisfied himself that the posterior columns convey
tactile impressions. When divided, no other part of the column can
supply their place, and after a few days, when the disturbing conditions
have subsided, tactile sensibility is entirely and permanently lost.
Dittmar|| concludes, from his experiments on rabbits poisoned with
woorara, that a system of fibres exists in the spinal cord which, though
they do not belong to the nerve-roots, are capable of responding to the
action of direct stimuli, and can transmit the impulses thus generated
along the spinal cord to the medulla oblongata, where they undergo
reflection into motor nerves.
V. Willy^ states that it is generally admitted that the degree of
excitation of a nerve measured by the extent of contraction of the
muscle to which it is distributed augments with the length of the
segment of the nerve through which the current is transmitted after
this is closed or after it is opened. He finds, however, that this only
* 'Pfliiger's Archiv/ v, i.
It Humphry and Turner's * Journal of Anat. and Physiol.,' 1871, 329.
j * Zeitschrift fiir Biologie,' vii, iv.
§ ' Centralblatt/ 1872, 774.
1 1 *Ludwig*s Arbeiten,' 1871.
22 REPORT ON PHYSIOLOGY.
holds good for the descending current, whilst the converse obtains for
the ascending current.
An important series of researches was undertaken by Fritsch and
Hitzig* on the effects of stimulating various parts of the cerebral
hemispheres by means of the galvanic current. The skull was removed
with the exception of that part covering the superior longitudinal
sinus in dogs. The irritation of the surface of definite regions of limited
extent of one hemisphere called special groups of muscles on the
opposite side of the body into action. Thus, irritation of one spot pro-
duced contraction of the muscles of the back of the neck, another the
extensors and abductors of the fore leg, another the flexors and rotators,
others the muscles of the hind leg and of the face. The irritation pro-
ceeded principally, if not exclusively, from the positive pole.
Heidenhainf investigated the changes of temperature in the brain
resulting from excitation of the sensory nerves. He compared the
temperature of the brain with that of the aortic blood by the thermo-
electric method, and convinced himself that the brain constantly
possesses a higher temperature than arterial blood, and that this dif-
ference increases considerably on excitation of the sensory nerves.
There is a coincident fall in the temperature of the blood traversing the
aorta, vena cava, and hepatic vein ; this fall is occasioned in some way by
the medulla oblongata, since it does not occur if a section of the cord be
made just below the medulla. The fall in the temperature of the blood
is accompanied by a rise in the pressure, both in the arteries and in the
veins, and with an augmented rapidity of the blood-current in both.
He attributes the changes in the temperature of the blood to anj
increased loss of heat from the surface.
Schifff has continued his researches referred to in the last * Biennial
Beport ' on the extrication of heat during the functional activity of the
nervous centre, and shows clearly that the augmented temperature]
depends on modifications of the circulation, and is primarily due to the '
vaso-motor nerves.
Dr. Pranz Kiegel,§ after repeating the experiment of division of the
spinal cord opposite the sixth cervical vertebra and corroborating the
fact of the general fall in the temperature of the body that follows that
operation, appears to think it may in part be due to paralysis of the
vaso-motor nerves leading to dilatation of the vessels and consequent
increased evaporation and exposure of the blood to the cooling influence
of the air and radiation, but that it is chiefly due to an alDsolutely
diminished production of heat, in favour of which view he adduces
various arguments.
Eicky gives an account of a series of experiments he made on the
effects of heating and cooling the blood passing to the vaso-motor and
cardiac nerve-centres, and states that, to his surprise, he obtained only
* ' Eeichert und Dubois Reymond's Archiv/ 1870, 300.
t * Pfluger's Archiv/ iii, 504.
i Brown-Sequard's 'Archives de Physiologie,' January, March, May, and July,
1870.
§ 'Pfliiger's Archiv,' No. 12, 1872.
II Idem, V, I.
NERVES. 23
negative results, thougli when sucli changes were induced in the blood
passing to the respiratory centres very marked effects were observed.
Ludwig and Owsjannikoff*find that the vaso-motor centre extends in
the medulla oblongata from i mm. under the corpora quadrigemina to
4 or ^ mm. above the calamus scriptorius and on either side of the
middle line.
For a full abstract of Ludwig and Hafiz's paper on the vaso-motor
nerves of arteries distributed to muscles in 'Ludwig's Arbeiten,' 1870.
(See Brunton's report in 'Humphry and Turner's Journal,' 1 872, p. 229.)
These experimenters show that the vaso-motor nerves distributed to
the arteries supplying certain muscles may have a totally distinct origin
and course from the proper motor nerve of the muscle. The biceps
femoris, for example, is motorially innervated from the sacral plexus, but
its vaso-motor nerves are contained in the lumbar plexus and run with
the crural nerve, whence they pass to the branches of the femoral
artery. The vaso-motor nerves distributed to arteries supplying muscles
are easily exhausted, and when such arteries are exposed to high blood
pressure they contract powerfully.
The question of trophic nerves has been discussed by Schiefferdecker,t
Fischer, J Joseph, § and Sinitzin.||
Schiefferdecker gives the details of a series of six cases of injury of
the nerves of the upper extremity. The trophic disturbances were
atrophy of muscles, thickening and strong pigmentation of the skin, and
augmented desquamation of the epidermis. The finger-nails became
curved, like talons, with transverse ridges ; the arm covered with hair,
and there was an excessive secretion of sour sweat. The temperature
was below the normal. He attributes some of these symptoms to lesion
of certain trophic nerves, and others to disturbance in the distribution
of the blood supply. Sinitzin shows that after section of the superior
cervical ganglion of the sympathetic the conjunctiva and choroid are
capable of resisting an amount of irritation to which they would other-
wise speedily succumb. It is worthy of particular notice that Sinitzin
found the symptoms of impaired nutrition in the eye consequent upon
section of the fifth pair of nerves can be altogether abrogated by sub-
sequent ablation of the superior cervical ganglion, a strong proof that
such alterations and lesions of nutrition are not the direct result of the
nerve injury, but depend upon impaired or modified blood supply. Brown-
Sequard^ observed gangrene of the ear in rabbits after injuryfof one
corpus restiforme with hereditary influence on the young. He also
observed pulmonary haemorrhages after injury of one side of the pons.
Dr. C. "Westphal corroborates M. Brown-Sequard's statements in
regard to the artificial production of epilepsy in guinea-pigs. He finds
that this condition may be induced by slight blows on the head, and
attributes the convulsions to slight extravasations of blood which he
finds in the medulla oblongata and cervical and even dorsal portion of
the spinal cord.
r
* *Ber. d. Sachs. Gesell. der Wiss.,' 187 1, 135.
t 'Berlin Klin. Wochens./ 1871, 160. J Idem, 145.
§ * Centralblatt,' 1871, 721, || Idem, 161.
IT 'Gazette Medicale,' 1871, pp. 14 and 24.
24s REPORT ON PHYSIOLOGY.
Klein* contributes a good paper on the distribution of th6 non-
medullated nerve-fibres in the membrana nictitans. He places the
perfectly fresh membrane in a one-half per cent, solution of chloride of
gold for an hour, next cautiously transfers it to pure water, at the same
time exposing it to a bright light for some days, and then brushes off
the epithelium and mounts the specimen in glycerine. He describes
four orders of nerves, the finest, which he traces to the internal surface
of the capillaries and to the cells of the epithelial investment, are deli-
cately varicose and require a No. 9 or lo immersion lens.
Pouchett believes he has traced the finest branches of certain nerves
into the interior of the sarcodic masses forming the chromoblasts of
flat fishes where they become connected with the nucleus and pigment-
granules. Dr. BealeJ in a paper in the same journal contests this
statement.
Sch6bl§ describes the termination of the nerves in the wing of the
bat, and states that some form an extremely fine plexus, whilst others
end in tactile corpuscles in close relation with the hairs, the former
minister, he thinks, to sensations of temperature and pain, the latter
to ordinary tactile impressions.
Th. Engelmannjl gives the result of his investigations upon the inner-
vation of the contractile gland-cells of the frog. He shows that these
glands can be made to contract by direct irritation, by various kinds of
excitation applied to the peripheric extremity of the divided sciatic
nerve, and also reflectorially.
Pfliiger^ shortly discusses the objections that have been advanced
against his views respecting the mode of termination of nerves in glands.
To show the correctness of his statements he recommends the fresh
submaxillary gland of the ox or sheep to be taken and fine sections
made ; these must be at once teased out with perosmic acid sp. gr. 1003,
and covered with a thin glass in a shallow cell. In the case of the liver
sections must be made from the fresh gland and placed in watch-glasses
filled with Beale's carmine solution for fourteen days. Each sectioi
must then be washed with the above solution of perosmic acid an(
mounted.
Other papers on the nervous system are by G-. Valentin,** "Wundtjtt
Bernstein, J t J. Konig.§§
Eichardson,|||| Navratil,^^ Michael Lavdovsky.***
* ' Quart. Journ. of Microsp. Sci.,' January, 1872.
t * Monthly Microscopical Journal/ vi, 285. J Idem, vii, 45.
§ ' Archiv f. Mikroskop. Anatomic/ vii, i .
II * Pfluger's ArcMv/ iv, 187 1, 3, and v, 498.
% 'Archiv fur Physiologic/ 187 1.
** " Positive und Neg. Stromschwankungen als Zeichen gewiss. Zersetzungsstufen
der Nerv. und der Muskelmasse/' ' Zeitschrift fiir Biologic/ vii, no.
ft 'Mechanismus d. Nerven u. Nerven Centra,' Erlangen, 187 1.
Xt 'The Effects of Stimulation of Nerve and Muscle,' 187 1, Heidelberg.
§§ "The Effects of Electric Stimulation of Nerve and Muscle," ' Wien. Akad.
Sitzungsbericht/ Ixii, 537 ; and Humphry and Turner's ' Journ of Anat.,' 1872, 223.
nil " Theory of a Nervous Atmosphere," 'Med. Times and Gaz.,' i, 187 1.
•I[1" "The Functions of the Laryngeal Nerves," 'Med. Times and Gaz./ June
15. 1872-
*#* "The Termination of the Nerves in the Urinary Bladder of the Frog," 'Ceu-
tralblatt fiir die Med. Wiss.,' No. 3, 1871,
SPECIAL SENSE. — TONGUE. 25
Ihlder* finds the nerves of the tongue in birds end in a ganglion-cell.
He also describes a special form of bulb of ellipsoidal form with a
simple connective-tissue investment and transversely placed nuclei.
The nerve ends with a well-marked swelling.
E. "Wolferzf arrives at the following results from his conclusions in
regard to the innervation of the lachrymal glands : — i) The lachrymal is
the proper excito-secretory nerve of the gland. (2) The subcutaneus
malsD has the same but less energetic action. (3) After section of the
lachrymal no reflex can be excited through the fifth, but readily through
the optic. (4) Excitation of the sympathetic sometimes gives positive, '
sometimes negative results. (5) The secretion continues after section
of the lachrymal and sympathetic (paralytic secretion). (6) Poisoning
with woorara excites the secretion even after section of the lachrymal,
though less than on the opposite side.
Ph. LussanaJ adduces fresh evidence, chiefiy of a pathological nature,
in support of his views respecting the nerves ministering to the sense of
taste. These cases show that the lingual in man presides over the
gustatory sensibility of the anterior portion of the tongue, for in a
woman in whom a portion was removed by Prof. Yanzetti, sensation
was entirely abolished, though the form, colour, and nutrition of the
organ remained unimpaired. But the lingual nerve in man is composed
of the lingual proper and the chorda tympani, and there are cases of
complete paralysis of the fifth on record in which, nevertheless, the
gustatory sense was retained. On the other hand, there are cases of
paralysis of the facial in which gustatory sensibility is lost, though the
fifth is intact. Hence Lussana concludes that the sense of taste in the
anterior part of the tongue is due to the chorda tympani.
Dr. Schapringer§ finds that on contracting his tensor tympani, over
which he has voluntary control, all notes below seventy vibrations are
rendered inaudible.
Other papers on the special senses are by Dr. Swan Burnett, || E.
Masch, E. Kessel, and Prof. Eudinger.^
A most elaborate paper, entitled ' ^Etudes d' Anatomic Comparee sur
les Organes du Toucher chez divers Mammiferes, Oiseaux, Poissons et
Insectes,' by M. Jobert, is contained in the i6th vol. of the ' Annales des
Sciences Naturelles,' 1872.
At one of the meetings of the Medico- Chirurgical Society (Peb.,
1872), Dr. W. H. Broadbent read a paper on the mechanism of thought.
His theory was based partly on the results of dissection, partly on
remarkable cases of loss of speech and paralysis. He considers that the
impressions derived from the several senses are conducted by fibres
radiating from the crus cerebri and central ganglia to the convolutions
* 'Reichert und Dubois Reymond's Arcliiv,' 1870, 238. Honigschmied, "Ver-
breitung der Becherformigen Organe der Zunge/* in * Centralblatt,' No. 26, 1872.
t Inaug. dissert., Dorpat, 1871, Abstract in ' Centralblatt/ 1871, 838.
X "Sur les Nerfs du Gout," * Brown-Sequard's Archives de Physiologie/ 1872,
150 and 334.
§ 'Wien. Akad. Sitzungsber.,* Ixii; and Humphry and Turner, 1871, 401.
II "On the Functions of the Cochlea/' in the * Medical and Surgical Reporter,
Nov. 4, 7871.
% " Bewegungeu des Gehororgans," ' Centralblatt,* 187 1, 593.
28 REPORT ON PHYSIOLOGY.
of the longitudinal and Sylvian margins of the hemispheres, the inter-
vening convolutions receiving no radiating or callosal fibres. In the
former (or marginal convolutions) impressions are recognised as percep-
tions, whilst the perceptions derived from different sources are asso-
ciated together to form ideas and become the subjects of thought in the
latter (or intervening convolutions) . Now, when it is desired to express
these trains of ideas in speech, impulses are transmitted along those
medullary fibres of the brain that extend from the supreme centres to
the third left frontal convolution. In this the ideas are formulated into
words, which are intellectual symbols, the centre selecting, as it were, the
sounds appropriate to the expression of the idea. To produce the
audible expression of these sounds that centre again in its turn pro-
pagates impulses to the corpus striatum, the great co-ordinating motor
centre at the base of the brain. In order to speak, a great variety of
muscular movements have to be co-ordinated, as those of the chest,
larynx, tongue, and lips. The co-ordination is effected by the corpus
striatum, which acts upon the requisite nerve-nuclei in the medulla
oblongata. Lesions at different points of this chain of ganglia and
fibres will, of course, be followed by different effects. The sequence of
events on Dr. Broadbent's theory is — the formation of perceptions in the
marginal convolutions at the summit of the sensory tract ; the combi-
nation of these to form ideas and their employment in trains of thought
in the convolutions withdrawn from immediate relation with the outer
world; the propagation of excitations to the third left frontal convolu-
tion, leading to the selection of certain sound groups ; the co-ordination
in the corpus striatum of the muscular movements required to produce
those sounds ; and finally, the transmission of impulses from the
several nuclei of the medulla ohlongata to each individual muscle
required to be brought into play.
Ploegel* describes the fibres of the muscles of Trombidium, a species
of red spider, as composed of a number of compartments formed by the
sarcolemma on the one hand and successive transverse septa on the
other. From septum to septum the contents of each compartment are
as follows : — (i) A singly and slightly refractile substance, which becomes
slightly coloured with perosmic acid. (2) A granule which stains deeply
with perosmic acid, and with its neighbours forms a transverse layer of
granules. (3) The same as ( i). (4) The doubly and strongly refracting
substance, becoming deeply stained excepting sometimes near its centre.
(5) As (3).^ (6) As (2). (7) As (i). To which may be added (8),
the deeply tinted transverse septum itself.
Merkel'sf views as regards the structure of muscle agree in many
points with those of Floegel. He recommends for observation the
thoracic muscles of the fly or bee, and states that the phenomena of
their contraction may be distinctly seen when the fibres are immersed
in albumen. The appearances presented are — first, the terminal disks
approximate; the lateral expansion of the fibrils then occurs quite
gradually, and is accompanied by a narrowing of the part occupied by
the contractile substance. When the contraction is completed the
adjoining terminal disks are seen closely approximated ; the part occupied
* 'Max Schultze's Archiv f. Mik. Anat./ vili, 69. f Idem, 244.
SPECIAL SENSE. — TONGUE. 27
by the contractile substance, which when the muscle is at rest is only
dimly visible, becomes marked by a well-defined outline, and to super-
ficial observation the decrease in length appears to be compensated for
by the increase in breadth. This is, however, by no means the case, but
the dimly defined spot representing the position of the contractile sub-
stance has become quite disproportionally attenuated, whilst the ter-
minal disks are not, as might be expected, attenuated, biat are actually
thickened. It would hence appear that the muscular fibre has under-
gone a change in its histological character, and is not a mere shorter and
thicker body than when at rest. The change consists in this — that the
contractile substance, which in the resting fibre is accumulated around
the median disk of each muscle-element, leaves this position during con-
traction, and becomes applied to the corresponding terminal disks.
Hence, instead of each element containing as it does, during rest, an
entire transverse stria in its middle, it exhibits during contraction one
half of this stria at each end. Merkel recommends the chelsB of a crab
to be immersed in alcohol; the alcohol penetrates but slowly, and
although it causes the outer fibres to contract, the innermost ones are
dead, and therefore relaxed, before the fluid reaches them, and sections
show all the intermediate stages.
Donitz* maintains the old view of fibrils as opposed to the compart-
ment theory of the structure of muscle.
"Wagenerf admits the existence of Hensen's intermediate band, but
maintains there are from two to eight adjoining strisB, which, though
very fine, are constantly present. He describes the contraction of the
muscles of an insect in the following terms :
The anisotropal substance with Hensen's intermediate stria and the
adjoining striae shorten and approximate to one another, and then the
two isotropal striae, which at first are separated by the broad anisotropal
substance, become so closely compressed together that they are only
divided by a faint line.
DanilewskyJ shows that the quantity of albuminoid compounds in
muscle diminishes, though to an inconsiderable extent, in tetanus. The
alcoholic extract of tetanized muscle contains more nitrogen than that
of resting muscle, which from various considerations renders it evident
that during contraction there is an increased disintegration of the muscle-
substance. During contraction a phosphorized body (lecithin) is pro-
duced. "Warm alcohol withdraws from muscle exclusively the products
of its retrogressive metamorphosis.
Mohammed Hafiz remarks that the vital properties of transversely
striated muscular tissue render it a priori probable that its blood cur-
rent should present some peculiarities. Opposite conclusions might be
drawn from a consideration of the physical and chemical changes
occurring during contraction in regard to the flow of blood through the
muscles ; on physical grounds it would be natural to suppose that less
blood would traverse the tissue, whilst the larger amount of carbonic
acid eliminated would rather seem to show that more blood traversed it.
* 'Reichert und Dubois Reymond's Archiv,' 187 1, 434.
t * Sitzungsberichte der Gesell. der Gesam. Nat. zu Marburg,* 1872, 35.
% * CentralblatV No. 28, 1872.
as REPORT ON PHYSIOLOGY.
Experiments undertaken by Sczelkow, Al. Schmidt, W. Sadler, and
Genersich, in Ludwig's laboratory, are opposed to the exclusive adoption
of either of these views, and show that great variations may occur in the
rapidity of the current of blood traversing the arteries of muscles, as
well as in its pressure, quite independently of the condition of con-
traction or relaxation of those muscles themselves. These experiments
tend to show that great powers of contraction and dilatation must be
attributed to the arteries distributed to muscles, and in accordance with
this is the anatomical fact that the arteries of muscular tissue con-
tain a very well-developed circular muscular layer. Mohammed Hafiz's
researches were undertaken to ascertain the course and action of the
motor nerves supplying the arteries. Dogs and rabbits were employed
in the experiments, which were either in their natural state or poisoned
with woorara, and the following results were obtained: — (i) During
tetanic excitation of the spinal cord the circular muscular fibres of the
arteries distributed to muscles contract slightly and transiently, and
never to so great an extent as the circular fibres of the arteries dis-
tributed to the skin and abdominal viscera. The contraction, if any, is
very slight in curarized animals. (2) The nerves of the circular
muscles are very easily exhausted. This is well shown by the fact that
a wound of a muscle, provided no large artery is injured, as a rule
bleeds but little ; but severe haemorrhage occurs, under the same circum-
stances, if the spinal cord be irritated, the amount depending on the
increase of blood pressure caused by the stimulation of the cord. The
more this augments the more the arteries of the skin and the abdo-
minal viscera contract, whilst those of the muscles permit free bleeding
to take place from them, the haemorrhage lasting as long as the blood
pressure is above the normal. (3) Irritation of the spinal cord caused
distinctly observable increase in the rapidity of the current of blood
through the muscular arteries, as well as by augmented pressure, ces-
sation of the irritation being followed by diminution of the rapidity of
the current. (4) The circular muscular fibres of the arteries distributed
to muscles expand and contract independently of the nerves supplied to
them, and probably as a consequence of the direct excitability of their
own proper muscular fibres. (5) The nerves of a muscle and the
nerves of the artery supplying that muscle seem, in some instances at
least, to have a different origin. (6) From a medium condition the
muscles of the vessels may either contract or dilate ; contraction often
occurs if the vessel has been long in a state of dilatation, owing to aug-
mented pressure. It was invariably observed after irritation applied
to the spinal cord, this producing, first, temporary contraction, then
dilatation, and finally very strongly marked and persistent contraction.
The increase of pressure in the arteries distributed to muscles is, no
doubt, in part due to the contraction that occurs in the cutaneous,
abdominal, and other arteries, when the spinal cord is irritated.
Dr. Marcet observes* that muscular tissue is formed of three different
classes of substances ; the first includes those substances which constitute
the tissue proper, or the portion of flesh insoluble in the preparation of
the aqueous extract, and consisting of albumen and phosphoric anhy-
* * Nature/ May 18,
J
SPECIAL SENSE. — TONGtB. 29
dride with varying proportions of potasli and magnesia ; the second class
includes the same substances as are found in the tissue proper, and in
the same proportions relatively to the albumen present in that class,
but existing in solution and in the colloid state ; the third class includes
the same substances as are found in the two others, and, moreover, a small
quantity of chlorine and soda, which, although relatively minute, is never
absent. The constituents of this class are crystalloid, and consequently
diffusible, the phosphoric anhydride and potash being present precisely
in the proportion required to form a neutral tribasic phosphate, or a
pyrophosphate, as the formula 2KOPO5 can equally be 2KOHOPO5.
Dr. Marcet further believes that flesh contains in store a supply of
nourishment equal to about one third more than its requirements for
immediate use, this being apparently a provision of nature to allow of
muscular exercise during prolonged fasting. He maintains that the
numbers representing the excess of phosphoric anhydride and potash
in blood over the proportion of these substances in an equal volume
of serum, in the regular normal nutrition of herbivorous animals,
appear to bear to each other nearly the same relation as that which
exists between the phosphoric anhydride and potash on their way out
of muscular tissue ; and he points out that vegetables used as food for
man and animals, such as flour, potatoes, and rice, transform phos-
phoric anhydride and potash from the crystalloid or difi'usible into the
colloid or undiflusible state, and that it is only after having been thus
prepared that these substances appear to be fit to become normal con-
stituents of blood and contribute to the nutrition of flesh.
A final remark, and one which he considers to be worth consideration,
is the fact established by the whole of his investigation, that there is a
constant change of rotation in nature from crystalloids to colloids, and
from colloids to crystalloids.
Petersen,* as the result of numerous analyses of the flesh of sheep,
pigs, horses, and oxen, finds that the amount of water varies in these
different species as much as 7*36 per cent. ; calves have the most (79*29
per cent.), pigs the least (71 '93 per cent.). The proportion of nitrogen
varies but little. Thus, the fresh muscle of oxen contains 3*29 per cent,
of nitrogen, that of the pig 3*25, of the sheep 3*15, of the calf 3*18, and
of the horse 3 '48 per cent. The proportions are somewhat different if
the fat is first removed, the average for fresh meat, taking all the animals,
and the fat being removed, is s'36 per cent., which equals 15*39 for the
dry muscle also free from fat.
Dr. H. Weiskef finds that the administration of food poor in lime or
phosphoric acid, for a considerable period (six weeks), to goats produced
no appreciable change in the composition of the bones, nor was their
fragility increased. The animals, nevertheless, lost their vigour, and it
was probable that if the use of such food had been long continued
pathological appearances would have been produced. On the other
hand Dr. SubbotinJ finds that the kind of food administered to pigeons,
calves, dogs, and man, exercises a considerable influence on the amount
of haemoglobin contained in the blood, highly albuminous compounds
* * Zeitschrif t fiir Biologie,' viii, 166. f Idem, vii, 179.
X Idem, vii, 185.
30 EEPORT ON PHYSIOLOGY.
increasing its amount, pure farinaceous and other non-nitrogenous food
diminishing it. Babbits, on the average, have 8-41 per cent, of haemo-
globin, vrell-nourished dogs 13-80 per cent., man 13*16 per cent. In
anaemia and chlorosis it may fall as low as to 4*63 per cent.
Prof. Haughton,* in his lectures on animal mechanics, states that
according to his experiments the muscles of the arms of a young man
accustomed to athletic exercise are capable of raising 947 lbs. per
square inch of their sectional area. The muscles of the leg are stronger
and can lift 110*4 lbs. per square inch of sectional area ; those of the
abdomen 107 lbs. ; he takes the mean at 104 lbs. A single ounce in
weight of the muscle of the human heart will lift 25*576 lbs. through
the height of one foot in a minute.
Heidenhain,t after discussing the views of Harless, Cyon, and others,
respecting the tone of the voluntary muscles, gives the results of his
experiments, which have led him to the conclusion that the tone of
muscles is simply the expression of their healthy nutrition, and has no
relation with their nervous supply.
Nigetiet and HeppnerJ observe that Heidenhain long ago showed
that the production of acid in acting muscles augments with their
tension during contraction. They made experiments to determine
whether the same holds good for the other compounds resulting from
the metamorphosis of muscular tissue, and, adopting Helmholtz and
Eanke's mode of procedure, that is, comparing the alcoholic with the
watery extract (the latter decreasing, the former increasing, during
the period of activity), they found that in muscles under otherwise pre-
cisely similar circumstances, but of which one was weighted whilst the
other was not, the former yielded more alcoholic and less watery extract
than the other.
Dr. A. Henocque§ states the nerves supplying smooth muscular tissue
are distributed in three plexuses — (i) a basal or fundamental plexus,
containing numerous ganglia situated externally to the muscle ; (2) an
intermediate plexus ; and (3) an intra-muscular plexus, situated in the
interior of the fasciculi of smooth fibres. The terminal fibres are every-
where alike, dividing dichotomously, and ending with a slight enlarge-
ment or button, or in a punctiform manner. These swellings are situated
in different parts of the smooth muscle, often near the nucleus, or on the
surface, or between the fibres.
^ M. A. Sawickijl shows that the quantity of uric acid excreted by the
kidney is in relation with the food rather than with the amount of
exercise taken.
Dr. W. Ogle^ shows that both the right leg and right arm are used
preferentially by many animals as well as by man, and in man before any
education is commenced, Erom various observations made on right-
and left-handed individuals he has arrived at the conclusion that, like
the faculties concerned in speech, those associated with the predominance
* 'Brit. Med. Journ.,' May and June, 1871.
t * Pfliiger's Archiv," iv— x. J Idem, iii, iiAi
§ Brown-Sequard's 'Archives,' 1870, 397.
II * Pfliiger's Archiv,* 1872, vi.
TF ' Proceed, of Roy, Med. and Chir. Soc.,' vi, No. 8.
{
SPECIAL SENSE. — TONGUE. $%
of the right hand and leg are due to structural peculiarities which
are located in the left hemisphere of the brain. The greater develop-
ment of the left hemisphere he attributes to its receiving a freer supply
of blood than the right.
Oser and Schlesinger* state, as the essential result of their experi-
ments, that movements of the uterus may be induced by arrest of the
respiration, by rapid haemorrhage, and by arrest of the passage of the
blood to the brain. They found that the best animals for the purpose
of experiment vrere kittens under the influence of woorara.
Valentinf shows that the muscles of the embryo possess their true and
normal currents with negative variation on contraction long before their
development is complete, and so also nerves, which as yet do not appear
to possess a medullary sheath, possess the power of transmitting motor
impulses, and also exhibit their normal electric currents and negative
variation during activity.
Hermann J finds that living muscle offbrs very much greater resistance
to an electric current passing in a direction across the fibres than to one
transmitted along them, the proportion being as 7 to i ; in the nerves
it is as ^ to I .
Hugo Kronecker, " On the Laws of Muscular Exhaustion," in the
* Monatsberichte d. k. p. Akad. d. "Wissenschaften zu Berlin,' 1870.
rick§ " On the Change in the Elasticity of Muscle during Contrac-.
tion."
An important contribution to our knowledge of the physiological
effects of severe and protracted muscular exercise, especially in regard
to its influence on the excretion of nitrogen, has been made by Dr.
Austin Elint,|| as the result of his analysis of the food consumed and
urine passed by Mr. "Weston, during a remarkable attempt which this
pedestrian made to walk 400 miles in five consecutive days. Although
he did not accomplish this task, he succeeded in walking 317! miles in
that space of time. By the aid of several eminent physicians and
scientific men of New York, Mr. Weston was subjected to most careful
observation for five days before the walk, for the five days of the walk,
and for five days after the walk, and the results are given in a series
of carefully prepared tables. The general conclusions of Dr. Elint's
inquiry, in this case at least, are decidedly opposed to the observations
of Pick and Wislicenus and many modern experimenters, whilst they
corroborate the old view of Liebig that the elimination of nitrogen is to
a great extent a measure of the waste of the nitrogenized elements of
the tissues, and that this is increased by exercise.^
Prof. Humphry's** lectures, and still more recently published treatise
on myology, contains the results of many careful dissections of the
muscles of the Cryptobranchus Japonicus, the Uromastix spinipes,
* * Strieker's Med. Jahrbiicher,' 1872, 30.
t " Histological Researches,'* ' Zeitschrif t fur Biologie,' vii, J871, 105.
j * Pfliiger's Archiv/ part vi, 1872.
§ "Ueber die Aenderung der Elasticitat des Muskels wahrend der Zuckung,
* Pfliiger's Archiv,' 1 8 7 1, 30 1 .
I
II Pamphlet reprinted from the ' New York Med. Journ.' for June, 1871,91,
•fr See an abstract in * Amer. Journ. of Med. Sci.,* Jan., 1872,
** ' British Med. Journ.,' 1872.
3^ liUPClRT ON PHYSIOLOGY.
Lepidosiren annectens, Dog-fish, Ceratodus, and Pseudopus, with an
able exposition of the general relations and arrangements of the muscles
in vertebrate animals.
Franz Hofi'man* discusses and answers affirmatively the question
whether fat supplied in the food enters directly into the fat-cells, to be
stored up in them.
The following references to various papers that were analysed for
this Eeport, but which were excluded by the limited space accorded to
it, may, perhaps, prove useful to some readers.
HISTOLOGY.
Bizzozero, "Beitrage zur Kenntniss der sogenannten endogenen
Zellenbildung."t — Gr. V. Ciaccio, 'Nuove Eicherche suU'interna tessi-
tura dei Tendini.' Bologna, 1872. Pamphlet. — Dr. M. Lipsky, " Ueber
die entziindlichen Veranderungen des Epithels der Harn-kanalchen." J —
Dr. Adickes, "Zur Histologie des Bindegewebes." Inaug. Dissert.,
1872. — Ranvier, "Des Elements Cellulaires des Tendons et du Tissue
conjonctif lache (tissue cellulaire)."§ — Boll, " Untersuchungen iiber
den Ban und die Entwickelung der (5ewebe."|| — Mitchell Bruce, " On
the Structure of Tendon."^— MM. Philipeaux et A. Yulpian, " Sur
le mode d'accroissement des os longs."** — Dr. Stretzoff, " Beitrage zur
normalen Knochenbildung."tt — Dr. Heitzmann, " Studien am Knochen
und Knorpel."{t — Dr. "W. Elemming, " Ueber Bildung. und Eiickbil-
dung der Eettzelle imBindegeweben."§§ — V.Ebner," Ueber die Anfange
der Speichel-gange in den Alveolen den Speicheldriisen."|||| — E. Kyber,
* Untersuchungen iiber den Lymphatischen Apparat in der Milz,' viii,
568. — Dr. Dudukaloff, "Beitrage zur Kenntniss des Verwachsungs
processes unterbundener Gefasse."^^ — Dr. Durante, " Untersuchungen
uber die Organisation des Thrombus."*** — Y. Brunn, "Ein Beitrag
zur Kenntniss des feineren Baues und der Entwickluugsgeschichte der
Nebennieren."ttt — Th. Eimer, " Ueber dei Nerven-endigungen in der
Haut der Kuhzitze." JJJ — J. Schobl, " Das Ausser Ohr des Igels als
Tastorgan,"§§§ — E. Eindfleisch, "Zur Kenntniss der Nerven Endi-
gung in den Hirnrinde."|||||| — A. K. v. Ajtai, " Ein Beitrag zur Kennt-
niss der Greschmacksorgane."^^^ — Dr. E. Elin, " Zur Kenntniss der
feineren Nerven der Mundhohlenschleimhaut." **** — J. Grottstein,
" Ueber den fein. Ban und die Entwickelung der Gehorschnecke der
Saugethiere und des Menschen."tttt — Dr. Nuel, " Beitrag zur Kennt-
ness der Saugethier schnecke." {Jt{
* " Der Uebergang von Nahrungsfett in die Zellen des Tliierkorpers," * Zeitschrif t
f. Biologie,' viii, 153. t ' Strieker's Jahrbiicher,' 1872, 160.
X In idem, 155. § Brown-Sequard's 'Archives de Physiologic/ 1869, 471.
II 'Max Schultze's Archiv. fiir Microscop. Anat.,' vii, 275.
it ' Quarterly Journal of Microscop. Science/ April, 1872.
** Brown-Sequard's * Archives de Physiologie,' 1870,531.
tt ' Centralblatt/ 1872, 449. JJ ' Strieker's Jahrbiicher/ ii, 339.
§§ 'Schultze's Archiv,' vii, 1871, 32. |||| Idem, viii, 481.
•[[1" 'Strieker's 'Med. Jahrb./ 1872, 150. *** In idem, 143.
ttt 'Schultze's Archiv, viii, 618. JJJ Idem, viii, 643.
§§§ Idem, viii, 295. |||||| Idem, viii, 453. %^% Idem, viii, 465.
**## Idem, vii, 1871, 382. ffff Idem, viii, 145. JJJJ Idem, viii, 200.
REPORT ON PRACTICAL MEDICINE,
A. B. SHEPHERD, M.A., M.B., M.E.C.R,
ASSISTANT- PHYSICIAN TO ST. MAET'S HOSPITAL, ETC.
A. Diseases of the General System.
Inflammation and Suppuration.
In the course of the past two years the Vienna school seems almost
to have monopolised the subject of iniiammation. Heiberg ('Wien.
Med. Jahrb.,' 187 1, 7) has made numerous experiments on the process
which takes place in the regeneration of the epithelium of the cornea in
frogs, fowls, and white rats. He finds, after scraping off the epithelium
from the centre of the cornea with a knife, that the process of new
growth is complete in three days, and sometimes, in birds and mammals,
even earlier. From the observations of Strieker and Norris, those
writers had already come to the conclusion that, in the inflamed cornea
of the frog, the corpuscles might be transformed during the inflamma-
tory process into amoeboid cells. Hansen (ib., 212) carried out the
same experiments on the cornea of rabbits and cats, and finds that hand-
in-hand with the appearance of young cells the corneal corpuscles change
their form, and at last entirely disappear, while their nuclei undergo
division.
Carmalt and Strieker (ib., 428) set up inflammation in the cornea of
frogs and rabbits by passing a string through the centre of the cornea
and through the sclerotic, and give the results of their observations
on the formation of the blood-vessels, which in the former animals took
place in from thirteen to fifteen days, and in the latter from five to eight,
after the string was introduced.
Grenersich (ib., i) thinks, from his experiments, that the so-called
fixed corneal cells correspond to true spaces, which communicate by
branching canals, and in which the wandering cells can move.
Durante's experiments (ib., 321) were made in reference to (i) the
physiological nutrition of the walls of vessels, (2) the change taking
place pathologically and anatomically during the process of acute in-
flammation in them, and (3) the relation between the inner tunic and
* In a large number of cases I have been compelled to omit abstracts of papers.
As far as possible I have preserved those of foreign origin, and have included those
English ones which may be most easily referred to in the bibliography at the end of
each subject. Unless stated otherwise, the references are to volumes and pages. A
table of the errata in the last report will be found at the end of this. — A. B. S.
5
34 REPORT ON PRACTICAL MEDICINE.
the blood in ligatured portions of vein. He finds that the endothe-
lium, the muscle-cells, and the connective-tissue corpuscles, all take part
in the proliferation which occurs in inflammation of the wall of the
vein ; and in reference to the third point, the blood in the ligatured
portion remained fluid as long as no changes took place in the endothe-
lium, but coagulated immediately the latter became inflamed.
Samuel has made numerous experiments into the results obtained
by the injection of various secretions, &c. A reference to his papers
will be found below.
Griiterbock (* Arch, f Klin. Chip.,' xiii, 240) answers the remarks
made by Grussenbauer (ib., xii, 811) on his former work regarding
the more delicate processes which take place in the healing of wounds
in the cornea by primary intention.
Bizzozero (' &az. Med. Ital. Lomb.,' 1871, 62) calls attention to the
fact, already observed by Buhl, Eemak, Eberth, and others, that in pus,
especially when it has been taken from an epithelial or epidermal sur-
face, certain large bodies may be seen enclosing a nucleus, and some-
times a very large number of cells, unlike the pus-cells, either in tlieir
appearance or chemical reaction. He opposes the endogenous develop-
ment of these cells, as put forward by the above writers. In the puru-
lent contents, mixed with blood, of the anterior chamber of the eye, he
has found large cells containing red blood-cells.
Duval ('Arch. d. Phys.,' 1872, iv, 168) strongly opposes Cohnheim's
views as to the origin of pus. He holds that the " plasmatic cells" of
the cornea do not remain fixed, but undergo hypertrophy and prolifera-
tion, and that the appearances of cells having passed through the blood-
vessels in the mesentery is due to the mechanical rupture of lym-
phatic sacs in the operation of withdrawing the membrane from the
abdomen.
Norris ('ProcRoy. Soc.,* xiv, ^^6) concludes — i. Both white and
red corpuscles pass out of the vessels through apertures, which can
neither be seen before their ingress into, or after their egress from,
the vessel- wall, but only during the period of transit. 2. An essen-
tially primary step in the process is that the corpuscles shall adhere, or,
more properly, cohere, to the wall of the vessel. 3. These cohering
corpuscles shall subsequently be subjected to pressure from within.
V. Mosengeil, " Beobachtungen iiber ortlicbe Warme-Entwickelung bei Entziin-
dungen," 'Arch. f. Klin. Chir.' xiii, 70. Samuel, "Die Subcutane Wirkung der
Secrete," ' Centralbl.,' 1871, 433. Id., " Die ortlicbe Wirkung des Eiters und der
putriden Stoffe," ib., 305. Id., " Putrides Gift in den Sputis," ib. 435. Id., "Die
Localisirung der Entziindungen," ib., 692. Giiterbock, " Untersucliungen iiber
SehnenentziJndung," * Wieu. Med. Jahrb., 1871, 22. Lang, " Untersucbungen iiber die
ersten Stadien der Knochenentzunduug," ib., 34. Hutob, " Untersucbungen iiber
Knorpelentziindung," ib., 399. Yeo, " Untersucbungen iiber die Structur entziindeter
Lyiuphdrtisen," ib., 30. Parsons, " Catarrhal Inflammation," ' Brit. Med. Journ.,'
1871, i, 473. Flemming, "Ueber Veranderungen der Fettzelle bei Atrophic und
Entziindung," 'Virch. Arch.,' lii, 568. Bizzozero, "Saggio di Studio sulla cosidetta
endogenesi del Pus," ' Gaz. Med. Lomb.,' 1872, 33 j Mays, "The Pathology of Inflam-
mation," 'New York Med. Journ.,' xvi, 155.
CONTAGION AND INFECTION. 35
Contagion and Infection.
Chauveau (' Compt. Eend.,' Ixxiii, ii6; ' Gaz. des. Hop.,* 1871, p.
181) had already (see last *Bienn. Rep.,' p. ^^) shown that the con-
tagious property in poisonous fluids consists of solid particles held in
suspension by them. His experiments were made in the three following
sets : —
I. If a poisonous fluid capable by injection under the epidermis of pro-
ducing a well-marked and circumscribed local lesion of the skin be mixed
with a large quantity of water ; and if this fresh solution be employed
1 for inoculation, the lesion is either not produced at all, or it is produced
I with exactly the same characters. In a certain number of inoculations,
I all made under exactly the same conditions, a greater or less number
I were unsuccessful according to the degree of dilution of the fluid,
i 2. The solution having been washed and filtered, and the corpuscles
thus separated, inoculation with the precipitate was successful, while
, with the filtrate it failed ; consequently, the solid particles alone,
I i. e. without serum, possess the property of contagion.
' 3. If a poisonous liquid be covered with a layer of distilled water,
I the substance in solution in the former is rapidly diffused. Inocula-
i tion with this water gives negative results.
Chauveau has attempted to prove that the same holds good for air :
1 that poisonous substances are not dissolved in it, but suspended in it in
! the form of small particles. The poisonous substance was put into a
I capsule standing on a flat disk of glass and covered with a small bell
glass or cylinder. The whole was ])laced on a sand bath heated to
! 40° C. (104° F.). The evaporated fluid was condensed on the walls of
j the cylinder, the condensation being furthered by moistening the latter
I with ether. He made the experiments chiefly with variola and sheep-
' pox, always with the same result, that inoculation with the distilled
fluid had no effect. He also repeated the experiments with the poison
of epizootic typhus (cattle plague ?) with the same negative results,
bfiving inoculated with the water extracted from fluids supposed to he
extremely virulent, e.g. the tears, the discharge from the nose, and
the matters from the diarrhoea stools.
In another and a very long paper (' Graz. Heb.,' 187 1, viii, 638) the
i same writer concludes from numerous experiments that small organisms
i do not occur either in the blood or in the pathological products of infec-
Itious disease. The experiments were made with fresh lymph and the
blood and pus of variola, the sheep-pox, glanders, and cattle plague. The
specific poison of an infectious disease resides in its cell-elements. In
summing up the paper he lays down that—
Among contagious diseases there is a large class of maladies properly
called parasitic, due to the presence and the multiplication of minute
animals and vegetables (trichinae ; psorosperms of the silkworm, &c.).
These are not to be placed among the virulent or poisonous.
Another class is composed of the septic diseases, which ought to be
looked upon as produced by the rapid multiplication in the blood
of fermenting proto-organisms, by whose decomposition more or less
severe poisoning is set up.
36 REPORT ON PRACTICAL MEDICINE.
Lastly, tbere is a class, the subject of his present paper, which com-
prehends the poisonous affections, distinguished from the preceding by
the fact that their intimate cause is to be found only in the granular
protoplasm of the new formations.
Sanderson ('Thirteenth Rep. Med. Off. Privy Coun.,' app. p. 48, and
* Quart. Journ. of Micr. Science,' xi, 323), assisted by Ferrier, has
further investigated the conditions under which microzymes (bacteria)
are developed in various solutions, and in organic tissues and liquids.
The experiments are given in full, and lead to the following conclusions:
whereas fungi (torula, &c.) may be transmitted from one solution to
another by means of the air, such is not the case with microzymes ; there
is no developmental connection between the two, and their apparent
association is one of mere juxtaposition. If proper precautions, boiling
the solution, e.g. Pasteur's, and rinsing the vessel with boiling water,
are taken, the solution may be exposed for a length of time in an open
vessel, without any development in it of bacteria, while there will occur
a free growth of penicillium. If a drop of ordinary distilled water be
added to the solution used, bacteria will be developed in abundance ; |
but such development will not follow if the distilled water be pre-
viously boiled.
The same writer (* Nature,' 1873, Jan. 9) relates minutely fifteen
experiments made in his presence by Bastian with infusions of hay and
turnip. He is content to have established, at all events, to his owa
satisfaction, " that by following Bastian's directions, infusions can be
prepared which are not deprived by an ebullition of from five to ten
minutes, of the faculty of undergoing those chemical changes which
are characterised by the presence of swarms of bacteria, and that the
development of these organisms can proceed with the greatest activity
in hermetically sealed glass vessels, from which almost the whole o3
the air has been expelled by boiling."
Lostorfer (* Wien. Med. Jahrb.,' 1871,451) has developed organisms
resembling sarcina ventriculi from the blood of several healthy persons
He insists that they are not introduced from without, and triei
to support his view by reference to cases recorded by Virchowj
Zenker, and Cohnheim, as to the occurrence of sarcinae in tht
lungs.
Ferrier ('Brit. Med. Journ.,' 1872, i, 98) has found sarcinae in thf
blood of man, rabbits, cats, dogs, and frogs, drawn from the carotii:
vessels, and placed under a temperature of 100° P. He agrees wit!
Lostorfer as to the presence of numerous refractive granules, singl*
or in pairs, from which sarcinsB are developed ; and he finds that thi
vaccine particles constantly seen in fresh lymph multiply under a cul
tivation, and assume the characters of sarcinse, with which he holds thee
to be identical.
Bastian (ib., 123) holds that the blood is not the only source c
sarcinse, as Ferrier is disposed to think ; nor does he look upon sarcin
as a living organism. One of the essential conditions for its occui
rence seems to be the presence of a phosphate in the fluid in whic
it is to form.
Nepveu (' Gaz. Med.,' 1872, 32) has found bacteria {B. punctatur,
CONTAGION AND INFECTION. 37
Ehrenb.) in the blood of four patients affected with erysipelas, and
remarks on the diffusion of the poison.
Bennet (J. Henry) illustrates, from his own personal history ('Lancet,'
1 87 1, ii, 537), the fact stated by Paget, that poisonous fluids can exerb
their influence on the body by imbibition through the skin without any
breach of continuity. On several occasions the poison, from post-
mortem and uterine examinations, seemed to pass down a hair into a
hair-bulb ; at any rate, a hair was always in the centre of the painful
spot. Erysipelas of the arm and chest followed, with considerable con-
stitutional disturbance.
In a lecture on "Dust and Disease" ('Brit. Med. Journ.,' 187 1, i,
661), Tyndall, after some experiments and observations on the polari-
sation of light by fine dust, by the sky and the coarser particles of
smoke, referred to the theory as to the parasitic character of contagious
disease. He believes strongly in the use of a respirator in infectious
places. In one constructed for him the air enters the mouth through
cotton wool, and by a light valve, which is lifted by respiration, the
expired breath passing out by a second valve.
Liveing ('Brit. Med. Journ.,' 1871, ii, ^6^) holds that the poison of
contagious diseases is an organised poison, each organic particle of
which must have a definite period of existence, and then die a natural
death, only able to propagate its species during a comparatively short
period of its existence. Allowing the difficulty of proving the same for
the malarial poison, he yet thinks that its vegetable origin is shown by
the facts of the localisation of this poison to certain districts, of the
necessary condition of a certain elevation of temperature for its de-
velopment, and of the apparent incompatibility of its coexistence with
the central part of well-populated towns. It seems as if the congre-
gating together of inhabited houses eft'ectually excludes the virus. He
illustrates this statement from Eome. Here the central part of the
city is perfectly free, at all seasons of the year, from malarial poison,
though it abounds in a concentrated form almost within a stone's throw
of those spots which are perfectly healthy.
Eimer, " Ueber die Ei- oder Kugelformigen sogenannten Psorospermien der Wirbel-
thiere, Ein Beitrag zur EntwickeUmgs-geschichte der Gregariuen und zur Kerintniss
dieser Parasiten als Krankheitsursache," Wurzbiirg. Bastian, " Epidemic and Specific
Contagious Diseases," ' Brit. Med. Journ.i' 1871, ii, 400. Id., " The Modes of Oj igin of
Lowest Organisms ; including a Discussion of the Experiments of M. Pasteur, and a
reply to some statements by Professors Huxley and Tyndall," London and New York,
1871. Condie, "Immunity from the Action of Morbific Agents" (effects of revac-
cination), ' Amer. Journ. Med. Sci.,' Ixi, 124. Hallier, " Die Parasiten der Infections-
krankheiten," 'Zeitschr. f. Parasitenkunde," iii, 157. Weigert, "Ueber Bacterien
in der Pockenhaut," ' Centralbl.,' 1871, 609. Lex, "Ueber Fermentwirkung der-
liacterien," ib., 1872, 291. Waldeyer and Cohn, " Uber Bacterien und Vibrionen,"
' lierl. Klin. Woch,' 1871, 532. Manassein (M.), " Beitriige zur Kenntniss der
Hc'fe und zur Lehre von der Alkoholischen Gahrung," Stuttgart. Manassein (W.),
" Ueber die Beziehungen der Bacterien zum Penicillium glaucum und iiber den Einfluss
einiger Stoffe auf die Entwickelung dieses letzteren," Stuttgart. Sanderson, " On
Leucocytes," 'Med. Times and Gaz.,' 1871, i, i. Marcet, "An Experimental Enquiry
into the Constitution of the Blood, and the Nutrition of Muscular Tissue," ' Proc.
Boy. Soc.,' xiv, 465. Jarisch, " Untersuchungen iiber die anorganischen Bestand-
theile des Blutes," ' Wien. Med. Jahrb./ 187 1, 425. Ranse, " Du role des Microzoaires,
et des Microphytes dans le Genese, F]^volution, et la Propagation des Maladies,"
Paris, 1870, pp. J 24.
38 REPORT ON PRA.CTICAL MEDICINE.
Inoculahility of Tubercle. Tuberculosis ?
Paraskeva and Zallonis (' Gaz. Med.,' 1872, 197) give the results of
five experiments on rabbits, which confirm Villemin's researches. Tu-
bercular matter mixed with the food, or inoculated, provoked deposits of
the same kind in the lungs. In a sixth experiment on a fisherman, who
was suffering from gangrene of the great toe, dependent on obliteration
of the femoral artery, they inoculated him with tuberculous matter in
the upper part of his thigh. He died thirty-seven days later, and
tubercles were discovered in his lungs and liver. Kanse, who transmits
the notes of these cases, rightly insists on the frequency with which
" tubercles" are found unexpectedly at post-mortem examinations.
Bifli and Yerga (" Nuovi tentativi d'inoculazione del tubercolo grigio,"
' Gaz. Med. Lomb.,' 1871, 272), working in the Veterinary College at
Milan, inoculated two mules, a cow, two sheep, and two dogs, with grey
tubercle taken from human subjects, which was rubbed up in water and
injected hypodermically. The place at which the fluid was introduced
became inflamed and (edematous. The cow was killed two months, the
other animals three months after the operation, but not a trace of
tubercle was found in either of them. Sangalli seems to have obtained
the same negative results in his experiments on twelve mice.
Papillon, Nicol, and Laveran (''Recherches experimentalea sur
Tinoculation de la tuberculose," ' Gaz. des Hop.,' 1871, 342) have re-
peated the experiments of Cohnheim and Frankel on rabbits and guinea-
pigs. The results agree with those obtained by these observers, by
Colin, Vulpian, Clark, Lebert, Empis, Fox, Sanderson, and Walden-
burg,and distinctly contradict the idea defended by Villemin as to the
specific nature of tubercle. Cheesy matter is in all their cases, they
think, the first starting-point of the general tuberculosis. The lymph -
glands in the neighbourhood of the original wound were always the firt^t
to undergo the cheesy change. They have never been able to produce
an eruption of tubercles on serous membranes.
Bogolowsky ('*Beitrag zur Impfung mit tuberkulosen Massen,"
* Centralbl.,' 1871,97) made parallel experiments on rabbits with so-
called tuberculous pus, cheesy matter, and miliary tubercle. Both sets
had symptoms of fever : the latter ceased after a few days in those
inoculated with poisoned serum ; in the rest symptoms of inflammation
followed, resulting generally in death. The most frequent appearances
found were purulent bronchitis, with circumscribed purulent deposits in
the lungs, and sometimes in the liver.
Crisp ('Path. Soc. Trans.,' xxiii, 312) vaccinated eight hens twice,
and subsequently inoculated them with smallpox matter. Eive died
in the course of the year, and presented, post-mortem, the appearances
of general tuberculosis.
Goodhart's experiments (' Edin. Journ,,' xvii, 305) on guinea pigs
and rabbits do not add much to what has already been shown in the
inoculation of tubercle by former observers. Nor do the cases he has
recorded as occurring in the human subject throw any further light on
the presence, together, of miliary tuberculosis and cheesy deposits or
pus, whatever views may be held as to the connection between the two.
TEMPERATURE AND FEVER. 39
The elevehth case, that of a man whose affection seems to have been
probably phthisis ex haemoptysi, is imperfect. Yet the author relies
upon this case as a typical example of a class " made up of all cases of
acute tuberculosis, where no existing cause in the shape of pus can be
discovered." He thinks that all chronic pneumonic changes consist in
part of adenoid formation.
Birch- Hirschfeld ('Arch. d. Heilk.,' xii, 501) records eight cases of
miliary tuberculosis occurring after typhoid fever, with a full description
of the microscopical appearances found ; and another case of the same
affection (ib. 556) following epididymitis in a soldier aged 24.
Mandl, " Du Tubercule compare a quelques autres Produits pathologiques," * Bull.
(le I'Acad. de Med.,' xxxv, 823. Fonssagrives, " Du role de I'Element inflammatoire
dans le Production des Tubercules pulmonaires," ib., 827. Klein, "Quelques Con-
siderations sur la Tuberculose," * These de Strasbourg,' 1870. Moxon, "Inflammation
and Tubercle," 'Med. Times and Gaz.,' 187 1, i, 64 and 153.
Tem'perature and Fever.
Pilz (' Jahrb. f. Kinderheilk.,' iv, 414) finds that the temperatures taken
in the rectum of healthy children almost confirm the fact found also in
adults : that the temperature rises from the first hours of the morning
towards noon, reaches its highest in the first hours of the afternoon,
and then in the evening begins to sink again. As a rule the elevation
is not continuous but interrupted. The greatest rise occurs in the
hours from 7 to 8, or even up to 9 a.m. The fall of the temperature
begins as Finlayson had already shown (see last ' Bien. Rep.') almost
alw*«ys at six, seldom at seven in the evening. This fall is generally
more sudden than in adults ; the difference in temperature amounts
in the first hour sometimes to i*i°. The night temperatures, which
are incomplete, agree with those given by ]^'inlayson.
Manassein (' Pfliiger s Archiv,' iv, 283) subjected rabbits to swinging,
the swing making from twenty-eight to thirty double vibrations in the
minute. In all cases the temperature fell : its maximum fall being 1*2° C,
its minimum 0*3*^ C, and its mean o"66° C. The effect was distinct in
fifteen minutes, and lasted from half an hour to two hours. The
tendency to sleep was very marked. The animals were closely enveloped
in wool before swinging, to prevent any fallacy in the experiment of
mere depression of temperature from renewal of the air ; parallel expe-
riments with and without wool are given. As a more practical experi-
ment he injected decomposing matter into rabbits, thus causing pyrexia,
ajid by swinging them afterwards, reduced their temperature even to
the normal degree.
From experiments made on 174 different animals the same writer
(' Centralbl.,' 1871, 689) concludes that circumstances that increase the
temperature of the body diminish the size of the red blood-cells, as
for instance septicaemic poisoning, exposure to a high temperature, or
in closure in a space surcharged with carbonic acid ; while on the other
hand breathing oxygen, exposure of the whole body to cold, the
administration of hydrochlorate of quinine, hydrocyanic acid, and
alcohol, which lower the temperature, cause also an increase in the size
40 REPORT ON PRACTICAL MEDICINE.
of the red cells. Hydrochlorate of morphia formed an exception, causing
diminution of temperature, and of the size of the red cells. This is to be
explained probably by the inhibitory influence this drug exerts on the
respiration (carbonic acid poisoning). Lastly, acute anaemia (blood-
letting from an artery) causes increase in the size of the cells.
In a more or less popular paper on the *' Effect of Exercise upon the
Bodily Temperature" ('Alpine Journ.,' 1871, May), AUbutt thinks
that in his own case two depressions of temperature — one during a
descent, the other during a gentle ascent of lower slopes — were due to
lack of fuel. He thinks that with a full and assimilating stomach, good
heart and lungs, a warm-blooded animal is not liable to lose the balance
of his forces during wholesome exertion. He thinks that the thermo-
meter is the best test of the latter in different persons. From his own
case he concludes that hard exercise in a mountainous district accele-
rates the morning rise, carrying it '2° or "3° above the average level of
health ; that it also favours an earlier occurrence of the evening fall, if
the exertion be ended, carrying it '1° or, perhaps, '2° below usual
night level ; and that any depression during exertion signifies either
deficiency of food or inefficiency of internal work (and see ' Proc.
Boy. Soc.,' xix, 289).
Mignot (" L'abaissment de la temperature comme signe de mort ;"
* Gaz. Hebdom.,' 1871, 676), after remarking that Laborde had asserted
that the temperature during life never fell below 30° C. (86° F.), allows
his observation to be right as far as it has reference to adults. The
researches of E-oger, Hervieux and Mignot himself, show that in newly-
born children, whether affected or not with sclerema, death was pre-
ceded by a period of gradually increasing depression of temperature,
the thermometer descending sometimes as low as 23° C. (41*4° E.). He
concludes that a depression of 5° below the normal carries with it a fatal
prognosis. He thinks that the fact may be useful in determining death,
and suggests that a line should be marked on tliermometers made on
purpose, at 30° and 21°; and that no certificate of death should be
given till the axillary temperature has been proved to have fallen as
low as the first number in adults and the second in the newly born.
Liebermeister, Virchow, and Senator indulge in a discussion on tem-
perature and the means of regulating it : the references to their papers
may be found below.
Pudzinowitsch (' Centralbl.,' 1871, 2n) gives the results of twelve
experiments on the relation of the cutaneous perspiration to temperature
in febrile conditions, without any certain conclusions.
Vergely (* Gaz. Hebdom.,' 1871, 489) gives a case of intense
headache, accompanied by elevation of temperature. A girl, aged 21,
had complained for two or three months of pain in the head, attacking
her at first at intervals, but constant for several days before her admis-
sion into hospital. The whole head was aff'ected, but especially the
supra-orbital and temporal regions. She complained also of pain in the
lumbar region. Her pulse was 90 ; but there was nothing abnormal
in her general state otherwise. The temperature during the first five
days reached 39-8° C. {10 f -6 E.) and 40° C. (104° E.), and was accom-
panied by irregular and frequent pulse. On the cessation of the head-
TEMPERATURE AND FEVER. 41
ache after seventeen days, the morning temperature was 35*4°
(95*7° -^'Oj ^^^ the evening 37*2° (989° ¥.). His remarks on the cause
of the elevation of temperature are scarcely precise.
Murchison, writing on the " period of incubation of typhus, relapsing
fever, and enteric fever" (' St. Thorn. Hosp. Eep.,' ii, 23) conclu ies that,
1, the period of incubation of typhus varies in duration in different
cases, in a large proportion of tliem being about twelve days, rarely, if
ever, exceeding three weeks, and occasionally being entirely absent, the
symptoms in the last case commencing almost at the instant of expo-
sure to the poison ; that, 2, the period of incubation of relapsing fever
is more variable, and, on the whole, shorter than that of typhus, a latent
period also not occurring in some cases ; that, 3, the period of incubation
of enteric fever is most commonly about two weeks, though it may be less,
not exceeding one or two days. He suggests that the period of incu-
bation may vary according as the poison is introduced by the alimentary
canal or by the lungs.
Begbie (' Edin. Journ.,' xviii, 249) calls attention to the " swelled leg
of fevers." He first sketches the history of the affection from its earliest
notice by Burke and Cheyne, in 1821, to the present time, and shows
that a swelling of the lower extremity different from ordinary oedema
or anasarca has been recognised by various writers as occurring in
the advanced stages of typhus and typhoid fevers. It has never been
described as a sequela of relapsing fever. From a general view of cases
recorded by others, and those observed by himself, he considers himself
warranted in classifying them as follows : — i, cases dependent on vas-
cular obstruction (a) venous or (5) lymphatic ; 2, cases in which in-
flammation of the areolar tissue exists. He gives shortly cases in illus-
tration of these three varieties, and refers in conclusion to the treat-
ment, which consists in rest, bandaging, anodyne fomentations, the ap-
plication of leeches, a general dietetic regulation, and the careful
watching of any complications which may arise.
Liebermeister, " Zur Lehre von der Warmeregulirung," 'Virch. Arch.,' Hi, 123.
Virchow, "Wirkung kalter Bader und Warmeregulirung," ib., ib., 133. Lieber-
imeister, *' Wirkung kalter Bader j" (i) " Ein Brief an den Herausgeber ;" (2) "Ant-
wort des Herausgebers," ib., ib., 432. Senator, "Kritisches iiber die Lehre von der
Warmeregulirung," ib., liii, iii. Liebermeister, "Nochmals zur Lehre von der
Warmeregulirung," ib., ib., 434. Id., " Untei'suchungen uber die quantitativeu
Veranderungen der Kohlerisaure-production beim Menschen " (second article), ' Deut.
Arch./ viii, 153. Silujanoff, "Zur Pieberlehre (Experiments on the changes in
quantity of Carbonic Acid, Nitrogen, and Chlorine, in artificially induced Fever),"
* Virch. Arch.,' Iii, 327. Manassein, " Chemische Beitrage zur Fieberlehre," ' Cen-
tralbl.,' 1871, 852. Decaisne, " De la Temperature chez I'Enfant Malade," ' Gaz.
Med.,' 1871, 197. Havvkes, "Observations on the Temperature of the Insane,"
'Lancet,* 1872, i, 429. Demarquay, "Modifications imprimees a la Tempei'ature
Animale par Ies grands Traumatismes," ' Gaz. des Hop.,' 187 1, p. 373. Redard,
*' De I'Abaissement de la Temperature dans Ies grands Traumatismes par Armes k
Feu," 'Arch. Gen.,' 1872,1, 29, and ' Gaz. des Hop.,' 1872, ^s- Bourneville, " Abaisse-
ment de la Temperature rectale chez un Homme expose au froid exterieur," 'Gaz.
Med.,' 1872, 8, and 'Gaz. des H6p.,' 1872, 34. Peter, " Des Temperatures elevees
excessives dans Ies Maladies," ' Gaz. Hebd.,' 1872, ix, p. 54, 84 (and see correspond-
ence between him and Jaccoud, ib., 72). Riegel, ' Ueber den Einflnss der Curare auf
die Korpertemperatur," ' Centralbl.,' 1871, 402. Senator, " Ueber Warmebildung
uud Stoffwechsel im gesunden und fieberhaften Zustande," ib., 737. Gatzuck, " Ueber
42 REPORT ON PRACTICAL MEDICINE.
den Einfluss der Blutentleerung auf die Circulation und dieTeraperatur des Korpers,"
ib., 833. Ogle, " On the Temperature in certain Affections of the Nervous System,
but especially in Tetanus ; with Observations and Notes on the Influence of Remedies
upon the Temperature of the Body," 'Clin. Soc. Trans.,' 1872, v, 71. Nunneley,
" On the Modifications produced in the Temperature of the Body by the local
application of Cold and Heat," 'Med.-Chir. Trans.,' liv, 303. Gee, "On the Heat of
the Body," 'Brit. Med. Journ.,' 187 1, i, 271, &c. Bradley, "Effect of EK>cking on
Temperature," ib., ii, 725. Squire, "Observations on the Temperature of the Body
in Health and Disease," ib. i, 32. Wilks, " The Use and Abuse of the term ' Fever,' "
•Lancet,' 187 1, i, 10. Jessett, "Cold Water Treatment of Fevers," ib., ii, 655.
Winternitz, "Der Einfluss von Warmeentziehungen auf die Warme production,"
Wien. Med. Jahrb.,' 187 r, 180, and ' Wien. Med. Woch.,' 187 1, 170.
Infection from Poison of Animals.
Terry, " Wasp-stings (two cases, one of a lady stung in the mouth, the other swell-
ing of a leg from foot to knee, from sting in the calf)," ' Brit. Med. Journ.,' 1871,
ii, 255. Drury, "Wasp-stings" (seven cases, with treatment), ib., 351. "Death
from the Sting of a Bee" (female, a3t. 55), 'Lancet,' 1872, ii, 135. Posada-Arango,
" Le Poison de Rainette des sauvages du Choco," ' Arch, de Med. Nav.,' xvi, 203. Id.,
"Note sur les Scorpions de la Columbia," ib., ib., 213. Fayrer, "On the Action of
the Cobra Poison," ' Edin. Journ.,' xvi, 623. Anderson, " On the Use of the Bromide
of Potassium in Rattlesnake Bites," * Amer. Journ. Med. Sci.,' Ixiii, 366. Wright,
"On the Katipo or Poisonous Spider of New Zealand," 'Med.-Chir. Rev.,' xlviii, 227.
Hydrophohia.
In a preliminary article on the pathology of hydrophobia Rudnew
(' Centralbl.,' 1871,321) asserts that the presence of foreign bodies,
straw, hairs, &c., is not, as is generally assumed, an indication of the
disease ; that it is by no means constant, and is not a diagnostic sign.
He has examined microscopically all the organs in the bodies of dogs
which died from or were killed during an attack of rabies. He holds
that it, like almost all other infectious diseases, is connected with a pro-
found disturbance of all the important organs. He confines himself
in this article to the kidneys ; in all his cases there was a highly deve-
loped parenchymatous inflammation ; the peculiarity of which was that
both cortical and pyramidal portions were alike affected, presenting
all the conditions necessary for the production of uraemia. He thinks
it extremely probable that the latter may be the cause of many of the
symptoms. A second peculiarity was the degenerative character of the
nephritis ; in the most advanced and fatal stage of the disease the
urinary tubules were completely bare of epithelium, and filled with a
granular, fatty, degenerated material.
Allbutt showed to the Pathological Society ('Lancet,' 1872, i, 82 ;
*Path. Soc. Trans.,' xxiii, 17) microscopic specimens from the cerebral
convolutions, the central ganglia, the medulla oblongata, and the cord,
from two cases of hydrophobia. The same morbid conditions, in dif-
ferent degrees, were found throughout : — i, evidences of great vascular
congestion with transudation into the surrounding tissues ; 2, haemor-
rhages of various size, with apparent fibrous exudation ; 3, small gaps
due to disintegration of nerve-strands. The spleen was enlarged in
both cases.
McGill, "Two Cases of Hydrophobia," • Lancet,' 187 1, i, 5^7. Sainter, "Chloral
in Hydrophobia," ib., 1872, i, 537. Elder, "Cases of Hydrophobia, with remarks,"
MENINGITIS CEREBRO-SPINALIS. 43
'Brit. Med. .Tourn.,' 1871, ii, 642. Fothergill, "Case of Hydrophobia, Death,
Remarks," ib., ii, 264. Ellis, " Two Cases of Hydrophobia treated by Hydrate of
Chloral," ib., i, 474. Brumwell, " Case of Hydrophobia following the Bite of a Cat,"
ih., ii, 434. Lafoiit, " Observation d'uu cas de rage " (five months after bite of mad
dog, premonitory symptoms two days, well-marked hydrophobia, and death twenty-
four hours later), ' Gaz. des Hop.,' 1871, 542. Plass, "Zwei Falle von Lyssa" (with
autopsies), ' Berl. Klin. Woch.,' 1871, 217. Auchenthaler, "Ein Fall von Lyssa" (in
girl, set. 6 years, from bite of cat, two months' incubation, autopsy), ' Jahrb. f.
Kinderkr.,' 1871, p. 222. Verri, "II Cloralio nell'Idrofobia," 'Annali Univ. diMed.,'
vol. 218, p. 340.
Sal/ Fever.
"Waters ('Brit. Med. Journ.,' 1872, i, 4) gives his experience of hay.
fever as it attacks himself. He found in very hot dry summers he was
free from the affection, while he suffered from it most in warm and
moist weather. One of his symptoms was insomnia, marked by a
peculiar periodicity ; no matter what time he went to bed he could get
no sleep before half-past three or four o'clock ; after that time he slept
soundly till seven or eight.
Grueneau de Mussy (' Sur la Ehino-bronchite spasmodique ou fi^vre
de foin ;' * Gaz. Hebd.,' 1872, ix, 9) insists on its relation to gout. He
thinks that hay fever represents a process taking place upon the mucous
membrane of the nose and bronchi, akin to certain eruptions observed
on the skin of gouty patients. In support of his view he gives ten
cases where individuals who had either had gout themselves, or in whose
families gouty affections were frequent, were attacked with hay fever
regularly every summer, the attacks alternating in part with the attacks
of gout. Several times afterwards anexanthem, an urticaria or a pity-
riasis appeared on the head, and extended to the cavities of the nose
and mouth.
Ferber (' Arch, de Heilk.,' xii, 555), in referring to Helmholtz's ex-
perience (see last ' Biennial E.ep.,' 51), finds the same good effects from
the employment of a solution of quinine, but is inclined to look upon
the affection not as due to the presence of parasites, but as a neurosis
of the vagus allied to whooping-cough.
Thompson, "Notes of a Lecture on Hay Fever," 'Brit. Med. Journ.,' 187 1, i, 58.
Feargus, " Treatment of Hay Fever by Sulphurous Acid," ib., ib., 90,
Dengue {^Breahbone Fever ; Bheumatic Scarlatina).
Poggio, " La Calentura roja observada en sus apariciones epidemicas de los anos
1865 y 1867, Madrid, 187 1 (for review and full abstracts from this work see 'Arch,
de Med. Nav.,' xvi, 146, and 'Med.-Chir. Rev.,' 1872, January, p. 151). "The
Epidemic of Dengue at Aden, 'Lancet,' 187 1, ii, 652. Vauvray, "La Dengue a
Port- Said et a Aden," ' Arch, de Med. Nav.,' xvii, p. 75.
Meningitis Cerehro-spinalis.
Eulenberg (*' Ueber Meningitis Cerebro-spinalis in Regierungsbezirke
Koln ;" ' Berl. Klin. Woch.,' 1871, 6^) writes on the spread of cerebro-
spinal meningitis in the district of Cologne during the autumn and
winter of 1865. The affection was of a truly epidemic character ; in
all there were forty-two cases of it, presenting the general symptoms
44 REPORT ON PRACTICAL MEDICINE.
and course of the disease. Whether it be possible to divide it into
several forms, as has been proposed (inflammatory, abortive, apoplectic
and paralytic), remains undecided. The author thinks that the
variations in the course of the disease should be referred partly to the
influence of individual constitutions and tendencies, partly to pre-
vailing affections C' constitutio anni" of Sydenham. — Bep.). He calls
attention to the unmistakable presence, in all the cases observed, of a
rheumatic cause and the coincidence of the epidemic with the com-
paratively frequent occurrence of "rheumatic tetanus." The treat-
ment consisted of attention to the individual case, local bleedings, cold
applications to the head, and the employment of calomel or narcotics
as the case demanded.
Kotsonopulos (" Bericht iiber die in Nauplia im Anfange des Jahres
1869 aufgetretene Meningitis cerebro-spinalis epidemica ;" *Virch.
Arch.,' lii, 65) gives an account of an epidemic of this aff"ection which
broke out in Greece in the winter of 1868-69. Nauplia was attacked
earliest and most violently. The first cases were diagnosed as those of
pernicious malarial fever, or simple meningitis. After tracing the
spread of the disease, the writer describes its symptoms and course ; the
aff'ections of the joints frequently preceding the meningeal symptoms ;
the injection of the conjunctivae and eyelids at the commencement of the
disease, noticed in almost all cases ; the remittent or intermittent cha-
racter of the disease; the furious delirium, which drove the patients
not only from their beds but into the street. Generally speaking, the
disease set in suddenly without any prodromal symptoms. The arti-
cular pains were almost always present, generally attacking the wrist
or knee-joint, or both at the same time. The pain was increased by
pressure, the joint was swollen and sometimes red, and fluctuation
could be detected. The joint affection began sometimes before the
meningeal symptoms, or on the second or third day, and continued
throughout the attack. The tetanic cramp of the muscles of the neck
and back was a characteristic and, so to speak, a pathognomonic
symptoms. Clonic cramps and convulsions occurred in young children.
Paralysis of any kind, with the exceptions of blepharoptosis and stra-
bismus occurred rarely. Other symptoms on the part of the different
organs are given in full. In almost all cases the aflfection was ushered
in by a rigor of varying length and intensity, which often recurred in an
intermittent form. But little light is thrown on the etiology of the
disease or on its treatment. Of ninety-three persons attacked the
greater number, twenty-six, were between the ages of ten and twenty
years, and of these the largest number between ten and fifteen. The
author concludes that it is a specific infectious disease, not allied,
as some assert, to typhoid and malarial affections.
Eussell refers (' New York Med. Journ.,' xv, 302) to the occurrence
of seven cases of spinal meningitis, in New York, within three days ;
three proved fatal.
Jahrb. f. Kinderheilk.,' v, 109. Alix, "Epidemie de Meuiugite Cerebrospinale
YELLOW FEVER. 45
* Gaz. des Hop.,' 1871,417. Clouston, "Case of Cerebrospinal Meningitis" (in insane
patient, autopsy), 'Journ. Ment. Sci.,' xvii, 225. Dowse, "Cerebrospinal Menin-
gitis with Myelitis of the Cord" (woman, set. 60, autopsy), 'Lancet,' 1872, i, 756.
Tempini, " Un caso sporadico e fulminante di Meningite Cerebrospinale " (girl, mt.
II years, with autopsy), ' Gaz. Med. Ital. Lombard,* 1872, 237. Habershon, " Disease
of the Aortic Valves, Ulceration of the Valves; Acute Cerebrospinal Meningitis;
Ossified Aneurismal sac at the Commencement of the Aortic Valves " (man, aet. 45),
' Guy's Hosp. Rep.,' N. S., xvii, 440.
Intermittent Fever.
Boisseau ('Gaz. Hebd.,' 1871, 200) records a case of transitory
aphasia accompanying an attack of intermittent fever. The patient, a
soldier, set. 21, had suffered from the latter affection in 1866, while in
Cochin China. The attacks recurred every three or four days, while he
was in Belgium, after the battle of Sedan, and again in 187 1. At this
latter period, without any paralysis of the face or limbs, the attacks
were accompanied by an aphasia which returned at regular intervals.
The same thing had happened during the former attacks of ague.
Bazin (' Gaz. desHop.,' 1871, 286) gives a case of intra-uterine ague.
The mother was suffering from tertian ague at the time of her confine-
ment, and gave birth to a female child during one of the attacks. Nearly
a month later, and for some time afterwards, the child had regularly
every night attacks of coldness and paleness, yawned, and stretched its
limbs, and a little later became red and burning hot, its respiration
increasing in frequency ; it then fell into a sleepy condition, during
which it refused the breast ; towards morning the heat left it, and it
again resought its natural food. At the same time there was great
enlargement of the spleen and oedema of the feet, face, eyelids, &c. He
calls attention to the latter, which he considers a great aid in the
diagnosis of ague in young children (!).
Longhi, " Delia Malaria e delle Febri Intermittente," 'Gaz. Med. Lomb.,' 1872,
253. Gait, "Description of an Epidemic Malarial Colic which prevailed at Iquitos,
Peru, in the autumn of 1871," 'Amer. Jour. Med. Sci.,' Ixiii (1872), 368. Senator,
" Ueber die Beziehungen zwischen Febris Intermittens und Recurrens," * Berl. Klin.
Woch.,' 1871, 379 (abstracted under latter fever). Curschmann, " Bemerkungcn
ijber die Behandlung des Wechselfiebers mit Carbolsaure," 'Deut. Arch.,' ix. 120.
Biebuyck, " Note pour servir a I'Histoire de la Fievre Intermittente en Mexique,"
•Rec. de Mem. de Med. Milit.,' xxvi, 60. Donaud, "De I'iode contre la Fievre
Intermittente," ' Gaz. Hebd.,' 187 1, 434. Pasta e Rotondi, "Sulla virtu Medicamen-
tosa del Citrato di Chiniodina," 'Annal. Univ. di Med.,' vol. 218, p. 609. Roy,
"On the Therapeutical Action of Quinine on Malaria," 'Lancet,' 187 1, i, 245. Gee,
"The Urinary Phosphates in Ague," 'St. Barth. Hosp. Rep.,' viii (1872), 32.
Yellow Fever.
Munro (*Edin. Journ.,* xvii, 201) gives some notes on cases of yellow
fever, which occurred between September, 1868, and January, 1870, in
the usually very healthy island of St. Kitt's. All the evidence he has
been able to collect inclines him strongly to the correctness of the
" infection theory," though he does not reject the idea that it can also
originate de novo. He believes, indeed, that the first of the cases he
gives probably arose in this way, the atmospheric and bad hygienic con-
ditions which surrounded it acting as causes. The first case was that
46 REPORT ON PRACTICAL MEDICINE.
of a boy, set. 7, who, two weeks before he was attacked, had been brought
to the town of Basseterre from Grrenada, at which place, so far as the
author could discover, there was no yellow fever at the time. Fresh
cases occurred in the neighbourhood of the house ia which this patieut
died. The disease spread gradually from house to house and from place
to place round the whole island. One hundred and eight people in all
were attacked, of whom forty-four, or 407 per cent., died. Europeans,
and especially those just come out, seemed most susceptible ; then the
Portuguese, nearly all natives of Madeira. Munro thinks that a
" faecal cause" for the disease may be found in the fact that the
greater part of the town of Basseterre had been destroyed by fire in
July, 1867, which, by burning down the privies, left their pits open,
the necessary atmospheric conditions for the production of the fever
not occurring till fifteen months later. He gives an account of a
number of the cases and tables of the rainfall, barometric pressure,
&c.
Sullivan, in his " Notes on the Yellow Fever, as observed at Havana
in 1870" (* Med. Times and G-az.,' 1871, i, 304), gives a very full account
of its different forms, its symptoms, and its treatment. He remarks
that in fatal cases jaundice is as certain after death as albuminuria
during life. He draws attention to the means of diagnosing between
the true black vomit and deep-coloured bile; linen steeped in the
former gives a. bistre tres trancMe ; in bile, a green or deep yellow. As
to the nature of yellow fever, he considers it a pestilential one, having
two distinct phases — one of reaction against the infectious poison, con-
stituting sometimes the entire malady, and very like an infectious fever ;
the other, of depression or adynamic ataxia, counterfeiting nervous
haemorrhagic putrid fevers.
Hiron (ib., 1871, ii, 124) gives a long and more or less confused
account of the epidemic of yellow fever in the River Plate districts in
1870 and 1871. It had already shown itself at Ascension in the
summer of 1869-70, and in April of the latter year had appeared at
Buenos Ayres. As far as could be discovered it had been imported into
both places from Eio Janeiro, but did not spread far at the time.
During the next summer it broke out in both places and at Corrieutes.
Buenos Ayres has a population of about 1 80,000. Of these, 1 00,000
fled at the beginning of the outbreak ; of those that remained three
fourths sickened and one fourth died. There seems no doubt that the
disease was imported from Brazil, most probably aided by insufficient
quarantine arrangements. Both Monte Video and Kosario, at which
places quarantine was carefully observed, were free from the disease.
The writer discusses the effect of the atmospheric conditions. The
Italian part of the population, who are the poorest, and inhabit the worst
quarters of Buenos Ayres, suffered most, and the affection was especially
fatal among children. The post-mortem appearances and the symp-
toms are similar to those already recorded, and, as far as treatment is
concerned, the writer agrees with Sullivan.
Eulenberg (' Berl. Klin. Woch.,' 1871, 174) writes on the epidemic
of yellow fever in Eio Janeiro during the years 1869 and 1870. The
summers of these years and of 1 868 had been marked by great dryness
CHOLERA. 47
and absence of storms, and the soil-water stood extraordinarily-
deep ; at the same time the epidemic was preceded, as in former
years, by an epidemic of Dengue, which Nageli and others look
upon only as an aborted form of yellow fever. As usually is the case,
the poorest and filthiest inhabitants suffered most, the epidemic spread-
ing rapidly among the suspected coal-ships in the harbour ; 599 patients
were treated in hospital between Feb. 4 and March 18, 1870, and of
these 99 (i7"8 per cent.) died.
The 'Pall Mall Gazette' gives (Feb. 2, 1872, 5 [765]) the following :
— " In an interesting report, lately issued by the health officer of the
port of Charleston, South Carolina, the cause of yellow fever in that
city is traced to putrefying organic matter. It appears that the soil on
which the city stands is sandy and porous, and consequently well cal-
culated to conceal poisonous gases, and that the sewerage is altogether
defective. Last year, when the epidemic raged more severely among
the coloured residents than it had been known to do previously for thirty
years, the health officer shows that during the five hot months, from
May I to Sept. 25, only one vessel arrived in port having a case of sick-
ness on board, and that case was not yellow fever. The disease, there-
fore, could not have been imported. Further than this the health
officer states that the condition of the atmosphere last year was like that
of 1850, when there was another terrible outbreak of yellow fever as it
is possible to find in two diff'erent seasons. In both instances Charles-
ton was exposed for weeks to intense heat, and this was followed by a
deluge of rain."
Johnston, " Report on the Epidemic Fever at Trinidad, 1869," 'Army Med. Rep.
for 1869, xi, 363. "Report on Outbreak of Yellow Fever at Mandeville, Jamaica,"
lb., 389. Ullersperger, "Das gelbe Fieber in Valencia," * Deut. Klin.,' 187 1, 117.
" Yellow Fever in Buenos Ayres," ' New York Med. Journ.,' xiv. 1 1 1. Bailey, " The
Nature and Treatment of Yellow Fever," ib., xv, 44. Anderson, " Yellow Fever as it
occurred in Wilmington, North Caroliua, from 1800 to 1872," ib. xvi, 225.
¥
Cholera.
Botkin (' Berl. Klin. Woch.,' 187 1, 389) gives very full observa-
tions, made with reference to the symptoms and treatment of cholera
on twenty-three male cases in hospital in St. Petersburg. The ob-
servations were made during the March and April of 187 1. Of the
twenty- three, on admittance into hospital, the temperature was below
normal in twelve, and of these four died ; in seven it was high, and in
the rest normal. After entering into the state of the various organs
and secretions and the treatment (with large doses of quinine), he gives
his opinion that the cholera process is not the result of a local effect of
the cholera-poison, but the expression of an infection of all the fluids
of the body. One of his assistants, Dr. Popofi", injected the fresh vomit
of cholera patients into the veins of dogs, and obtained a condition re-
sembling the clinical condition of cholera, together with characteristic
changes in the intestinal canal. The disease, according to Botkin, may-
be fatal without any profuse diarrhoea, and it is inconsistent to refer the
cyanosis, the dyspnoea, the cramps, &c., to the loss of fluid and thicken-
ing of the blood. He uses quinine on the principle of its employment in
48 REPORT ON PRACTICAL MEDICINE.
similar infectious diseases, and looks upon it as a prophylactic as well.
He holds that in the mode of its development and propagation, in its
clinical and anatomical aspects, cholera approaches, on the one side, the
typhoid, and on the other the malarial affections ; that just as these two
fevers show various modifications in different epidemics, so also types
of cholera occur, which can by no means be summed up by the ordinary
names of cholera, diarrhoea, and cholerine ; that he and other physicians
in St. Petersburg noticed, during the epidemic of the preceding winter,
numerous cases of an affection which presented symptoms peculiar to
the cholera process, such as diarrhoea, sickness, small pulse, sometimes
profuse sweating, pain and enlargement of liver and spleen, scanty
secretion of urine, which was sometimes albuminous, and during con-
valescence herpes labialis, epistaxis, catarrh of the nose, throat, and
bronchi, tendency to diarrhoea, &c. This type was observed in persons
of all classes and ages, attacking in many families several individuals ; it
was at first sporadic, but was propagated in an epidemic form a short time
before the outbreak of the cholera. He has never noticed that these cases
became cases of cholera, but all cholera patients admitted into hospital
had suffered for several days with prodromal symptoms, which more or
less corresponded with the affection described. He believes he is jus-
tified in concluding that this is an independent affection allied to the
cholera process ; that it is the result of the action of a cholera poison,
probably modified by external influences ; that this modified poison bears
somewhat the same relation to the true cholera virus as that of bilious
typhoid does to that of recurrent fever, or that of abortive typhoid to
the true typhoid fever ; and he inclines to the view that the cases noticed
by previous writers of gastric and intermittent fevers prevailing during
or after epidemics of cholera belong to this form of the affection, in
which should be recognised a modification of the cholera infection, an
abortive form of the disease. His treatment of these "abortive" cases
consisted in the administration of pills containing carbolic acid and
quinine.
Paterson (' Med. Times and Gaz.,' 1872, i, 473) has made experiments
on dogs, rabbits, and mice, with the rice-water stools of cholera patients,
in the condition of deep collapse. Some of the experiments were
made with the fresh matter, others with the cholera matter in a state
of fermentation. No result was obtained in any case.
Lawson (ib., 1871, ii, 15) gives some very interesting observations
on outbreaks of cholera in ships at sea, which, as he has before laid
down, have for their cause the " Pandemic waves" which " travel uni-
formly from south to north according to definite law."
Wittcke (' Zeitschr. f Epidemiol.,' iii, 204) gives a sketch of the
epidemic of cholera in 1866 at Erfurt, whither it was introduced from
Berlin. It broke out on the 23rd July, and was extinguished by Nov. 15.
It was the most extensive epidemic that ever broke out in that district,
and though it attacked a less number of persons than the epidemic of
1850, the mortality was greater. In the latter year 3819 were at-
tacked, of whom 13 12 died; in 1866, 1539 died out of 26';o cases.
Striking proofs were obtained of its contagion by individuals or in-
fected objects. According to Wittcke, Pettenkoffer'a views as to the
CHOLERA. 49
relation of certain conditions of subsoil water to cholera were not sup-
ported by this epidemic ,nor did the directions given by him as to the
disinfection of latrines, &c., prove more efficacious. The affection
visited several places which had been perfectly free, and spared others
which had suffered, in former years.
Moore translates (' Brit. Med. Chir. Rev.,' xlviii, 462) a paper by
Schleisner, on the cholera in Copenhagen in 1866. Thirty cases of
cliolerine, suspicious diarrhoea, and cholera remained on board ship in
the roadstead, of whom two died ; sixty-one, of whom six died, were
admitted into the hospital. In the city itself only four cases occurred,
of which the first died. This immunity of the city, to the port of
which 2233 ships arrived between May and December from infected
localities, was due to the stringent measures adopted. These the author
gives at length — strict quarantine ; daily inspection of the ships for the
first three days of their stay in harbour ; strict regulations as to lodg-
ing-houses and inns, as regarded the reception of seafarers, &c. ; the
formation of a cholera hospital in an isolated position near the harbour ;
disinfection of all latrines ; special supervision of the city itself by the
sanitary police ; and of all institutions, orphan houses, schools, &c., by
the medical officer of health ; and the removal of the occupants of such
houses as might be first attacked by cholera.
Thompson gives a report (' Army Med. Eep.' for 1869, xi, 392) on an
epidemic of cholera at Thayetmyo, British Burmah, in 1869. A portion
of the 76th regiment was stationed there from February, 1868, to April,
1869. At the end of the latter month cholera, which had not appeared
before, broke out in a coolie village. In May, it attacked a barrack in
which the married soldiers lived, and spread rapidly, till they were re-
moved to a more elevated and easily isolated spot, when no further
cases occurred.
Fauvel ('Bull, de I'Acad. de Med.,' xxxvi, 599), read before the
Academy some notes on cholera, in which he sketches its march in Europe.
In Russia, where it never entirely disappeared since its importation in
1865, it was still epidemic, at the end of 1869, in several provinces in
the centre and the west. It gradually diminished, till it seemed to
have disappeared about the middle of 1870. In July of that year it
again broke out at Taganrog and Rostow, spread along the sliores of
the Black Sea by Kertch, Odessa, and Poli, from whence it was propa-
gated inwards to the transcaucasian provinces. The rapid extension
along the coast coincided as usual with the arrival of travellers from
affected parts. It was by no means severe and ceased again at the end
of September. In the early part of that month a few cases occurred in
St. Petersburg, where it reappeared in February, 187 1, and was regularly
epidemic. In May it also broke out in Moscow and the neighbouring
provinces ; next month at Wilna, at Sulwalki, not far from Koenigsberg,
and at Riga ; at Nijni-Nowgorod, and Kazan ; and in the south again
at Taganrog, where it raged with especial violence, 1 1,942 people being
attacked between June 12 and July 22, of whom 4489 died (ib., 694).
At the end of July (1871) it appeared at Kcenigsberg (ib., 983) ; in
August successively at Dantzig, Stettin, Berlin, on the 19th at Posen, and
on the 29th at Frankfort- on-the- Oder, and almost at the same time at
4
50 REPORT ON PRACTICAL MEDICINE.
Hamburg and Altona, on the Elbe. These places were the most westward
limit, as Frankfort, &c., were the most southern, of the cholera in 1871.
At Koenigsberg 2635 were attacked, and 1204 died. In spite of rigorous
quarantine measures, the disease extended also in the south-east. In
September, 1871, fatal cases occurred in a village on the Bosphorus,
and at the end of the month in Constantinople, where 112 died in six
days. It also appeared at Gralatz. In a further communication (loc. cit.,
1872, series 2, i, ^74), Fauvel resumes his sketch, with especial refer-
ence to the outbreak of cholera at Mecca and Medina (Feb., 1872).
Barnier (' Arch, de Med. Navale,' xvi, 190) publishes a note on an
epidemic in September and November, 1870, in the island of Nossi-Be,
in lat. i5'5° south. It was brought by a negro from Madagascar, where
cholera was present, on 15th Septem^r, to the village of Ambanourou.
Next day four people who had been in contact with him, died ; and the
affection spread rapidly. The village, the position of which made it easy,
was isolated by land and sea ; but the quarantine arrangements were
broken, and the disease was propagated to Ankarankel and to Hellville,
but owing to the strict arrangements did not become general. It was
most fatal among the Caffirs, 168 dying out of 204 attacked. Among 200
Indians there were but three cases and one death. Barnier thinks that
the idea that this poison is propagated by the air is radically false ; and
that, however saturated with contagion the air may be in a towjji where
cholera is raging, it entirely loses its deleterious action in a distance of
less than a kilometer from the place.
Pellarin (' Graz. Hebdom.,' 187 1, ^^^) gives shortly his experience of
an epidemic of cholera in Guadeloupe and other islands of the Antilles,
far surpassing in violence any seen in Europe. Nothing was to be
noticed as far as atmospheric or even the local hygienic conditions was
observed. Nor was the epidemic preceded by any analogous or pre-
monitory affections ; and he concludes that the history of insular epi-
demics proves that they are directly and always preceded by the intro-
duction into the island either of patients suffering from the disorder,
or articles impregnated with the contagious principle. Mediate or mias-
matic contagion is the only mode of propagation of cholera in islands.
EoUeston (* Lancet,' 187 1, ii, 339) protests against the theory that
water is the ordinary vehicle, and, so far, the sole cause of cholera.*
On the other hand, Dr. Eenzy (" Water Theory of Cholera," ' Med.
Times and Graz.,' 1871, i, 411 ; 'Lancet,' 1871, ii, 449, 623; 'Brit.
Med. Journ.,' 1871, ii, 626) finds fault with Eolleston, Cunningham,
and V. Pettenkofer, and attempts to uphold his favourite theory.
Schlomann (' Berl. Klin. Woch.,' 1871, 43 1) found very great success
in the cholera epidemic of i866, in Texas, from the employment of
quinine combined with opium. Eeichard (ib., 408), in the epidemic at
Eiga in 1871, found chloral hydrate give good results. Eothe (ib.,
348 from the employment of carbolic acid in the diarrhoea of infants
and in sporadic cases of cholera, thinks it will be of great use
in cases of the epidemic disease. Forster (ib. 446) advocates the
* The different abstracts given in this report sufficiently confirm this protest,
which it would be well for others beside the writer of a "leading London political
paper " to lay to heart. — A. B. S.
CHOLERA. 51
burning of straw in places occupied by cholera patients, the burning
to be followed by free ventilation, and the ashes to be employed to
disinfect the vessels used for the reception of the stools. He recom-
mends the evacuation after a certain time of the rooms in which
patients have been, especially if the peculiar smell of burning does
not exist, and a fresh burning and ventilation to be carried out. He
had followed out these measures in the war of 1866.
Pfeiffer, " Die Cholera in Thiiringen und Sachsen wahrend dei* dritten Cholera-
Invasion, 1865-67," Jena. Zehnder, "Bericht iiber die Cholera- Epidemie des
Jahres, 1867," Zurich. Marsicani, "Sur le Cholera de 1869 en Russie," 'Gaz. Med.,*
1871, 194. Cunningham, "Report on Cholera in the Bengal Presidency," 'Seventh
Ann. Rep. of the Sanitary Commissioner with the Government of India, 1870,' Cal-
cutta, 1871. Cornish, "Cholera in Southern India: a Record of the Progress of
Cholera in 1870, &c.," Madras, 1871. Sing, "Hindu View of Cholera," London, 1871.
Fitzgerald, "Epidemic Cholera," London, 187 1. (For review of these four last books,
see 'Ediu. Med. Journ.,' xvii, 929.) "The Cholera Outbreak at Secunderabad,"
'Lancet,' 187 1, ii, 98. Christie, "On Cholera Epidemics in East Africa," ib., i, 113.
Id., Additional Notes on the same, ib., 1872, i, 573. Carpenter, "The Causation of
Cholera," ib., 1871, ii, 771. Sedgwick, "On the Initial Pathology of Cholera with
reference to Treatment," ib., ii, 393. Id., " On some Physiological Errors connected
with Cholera," ib., 507 (cf. Johnson on this paper, ib., 547,806, and Sedgwick's
answer, ib., 902). Id., " On Temporary Glycosuria as a seqnel of Cholera," ' Med.-
Chir. Trans.,' liv, 63. Carpenter, "Quasi Cholera," 'Lancet,' 187 1, ii, 426. Lowndes,
"On the Treatment of Cholera," ib., 319. Rickards, "Case of Cholerine difficult
to distinguish from Asiatic Cholera," ib., 290. Cornish, " The Cholera at Secun-
derabad in May, 187 1," ' Med. Times and Gaz.,' 1871, ii, 591. French, " On the pro-
bable Cause of the Post-mortem Muscular Contractions in Cholera, and on the Philo-
sophical Treatment of that Disease," ib., i, 688. Chapman, " Cholera Poisons," ib.,
1872, i, 355. Jenkins, "A Chapter in the History of Cholera," ib., 608. Radcliffe,
"The Prospects of Cholera," ib., 499. Patterson, "Treatment of Cholera by Subcu-
taneous Injection of Morphia," ib., 95. Watson, "Lecture on the Diffusion, Patho-
logy, and Treatment of Asiatic Cholera," 'Brit. Med. Journ.,' 1871, ii, 141. Murray,
" Cholera, its Diffusion, Prophylaxis, Symptoms, and Treatment," ib., 175. John-
son, ^'The Pathology and Treatment of Cholera," ib., 197. Jones, "Suggestions for
the Employment of Nitrite of Amyl in the Collapse and Cramps of Cholera," ib., 378.
Foote, " Case of Sporadic Cholera, extreme Collapse, Recovery under Eliminative
Treatment," ib., 352. Martin, "Intemperance and Cholera," ib., 198. Munro,
" Suggestion as to the use of Calabar Bean in Cholera Asiatica," * Edin. Journ.,' xvii,
327. Budd, "Cholera and Disinfection. Asiatic Cholera in Bristol in 1866,"
London. Peters, " On the Origin and Travels of Asiatic Cholera," ' New York Med.
Journ.,' xiv, 113. Tholozan, "Origine nouvelle du Cholera Asiatique, ou Debut et
Developpement en Europe d'une grande Epidemie Cholerique," Paris, 1871. Id.,
" Duree du Cholera Asiatique en Europe et en Amerique, ou persistance des causes
productrices des Epidemics Choleriques hors de I'lnde," 'Gaz^Hebd.,' 1871, 671, &c.
Grimaud, "Resultats des Observations faites sur les dernieres Epidemics Choleriques,**
' Compt. Rend.,' Ixii, 158. Foley, " Le Cholera chez les autres et chez nous ; nouvelle
etude Geographique et Biographique, Medicale, &c.," Paris. Netter, " Du Traitement
de Cholera par I'Administration, coup sur coup, d'enormes quantites de boissons
aqueuses" (20 litres et plus dans les 24 heures), 'Gaz. des Hop.,' 1872, 915. Sain-
mont, "Note sur la Nature et sur le Traitement du Cholera," ib., 11 30. De Pietra,
" Trattato Pratico sul Cholera," Palermo. Pacini, " SuU'ultimo Stadio di Colera
Asiatico, o Studio di Morte appareute dei Colerosi," Florence, 1871. Schneider,
" Cholera in Soerabaya auf Java," Berlin, 1871. Lew in, " Bericht iiber die Erkrart-
jkungen an der Asiat. Cholera zu Berlin in Jahre 1871," ' Deut. Klin.,' 1871, 411.
Focke, " Die Cholera und die Desinfectionsmittel," ib., 329. Pfeiffer, " IJnter-
suchungen iiber den Einfluss der Bodenwarme auf die Verbreitung und den Verlauf
der Cholera," * Zeitsch. f. Biol.,' vii, 263. Hallier, " Versuch iiber den Einfluss
ier Cholera-Reiswasserstiihle auf den Reis," ' Zeitschr. f. Parasitenkuude,' ii, 65.
52 REPORT ON PRACTICAL MEDICINE.
Weisbach, « Beschrankte Cholera-Erkrankungen in der Berliner Charite im Jahre
187 1," ' Virch. Arch.,' Iv, 249. V. Kaczowski, " Bericht iiber die Cholera- Epidemic
des Jahres 1866, in Posen," ' Berl. Klin. Woch./ 1872, 15. Nedsvetski, " Zur Mikro-
graphie der Cholera," * Centralbl.,' 1872, 233.
Enteric {Typhoid') Fever.
Heschl (' Wien. Med. Woch.,' 1871, No. 34) is convinced that the
capillaries and muscles of the intestinal canal are infiltrated in the same
way as the follicles and the sub-mucous tissue, and to this cause he
refers the deeper degenerative changes which lead to perforation.
He describes in full the microscopic changes found, both in the capil-
laries and the longitudinal layer of the intestines : in both the nuclei
are enlarged, and in different stages of proliferation.
Murchison (' Path. Soc. Trans.,' xxii, 144) describes the changes
found in the intestine of a man, 8Bt. 24, whose bowels had been consti-
pated throughout, and who died of haemorrhage on the twenty-seventh
day of the enteric fever. The haemorrhage did not seem to have pro-
ceeded from one ulcer in particular, but to have been due to a fungating
condition of the morbid material in many of Peyer's patches nearest to
the caecum, corresponding to which were dark-red spongy excrescences
firmly attached to the subjacent ulcerated surface.
Maclagan (* Edin. Journ.,' xvi, 865) writes a long paper on the
intestinal lesion of enteric fever, and in an appendix gives notes of
thirteen cases. He briefly summarises his facts as follows. The in-
testinal lesion of enteric fever is specific in character, and may termi-
nate in resolution or ulceration. When it goes on to ulceration there
are two sets of lesions, primary and secondary, the former an essential
part of the disease, the latter accidental, and the result of the inocula-
tion of healthy glands by discharges coming from the former. The
relative frequency of these two lesions varies in different cases. The
extent of the primary lesions bears a direct relation to the severity of
the attack, while that of the secondary does not do so, as they are more
likely to predominate in cases in which the general symptoms are mild
and the primary lesions few. One primary lesion is sufiScient to pro-
duce, directly or indirectly, many secondary. The discharges do not
necessarily inoculate every gland over which they pass ; the longer they
remain in contact with a gland, the more likely is it to suffer. The
higher up in the intestines the primary lesions are situated, the more
numerous, cceteris paribus, will be the secondary. Fatal abdominal
symptoms are more often the result of secondary than of primary
lesions. E«lapses are caused by a reabsorption of the poison into the
system, probably by one or more absorbent glands which escaped during
the primary attack. Constipation is to be regarded as a source of
ultimate danger. No one suffering from enteric fever should go more
than two days without a stool.
Allbutt C Brit. Med. Journ.,' 1871, i, 547) draws attention to cases
occurring in practice, in which the patient, without the existence oi
any organic disease, loses flesh till he becomes a living skeleton. He
thinks this marasmus may be often traced to a prior attack of enteric
fever. He gives six cases which bear more or less upon this view ; and
ENTERIC (typhoid) FEVER. 53
believes that the innutrition consists in the lack of digestive powers over
fats. In the absence of any pathological proof at present, he refers the
cause to a permanent degeneration of the mesenteric glands.
Gueniot (' Gaz. des Hop.,' 1871, 301) records a case of hsematoma
of the rectus abdominal muscle in a man of 22 recovering from typhoid
fever.
Kraft- Ebing (' Deut. Arch.,' viii, 613) gives two cases of suppuration
in muscles after typhoid fever. The first was that of a man, set. 24,
convalescent from typhoid, in whom a fluctuating tumour appeared,
corresponding to the same rectus muscle. The writer believes that
there was here a rupture of the degenerated muscle, followed by
haemorrhagic infiltration ; that the latter set up inflammation going on
to suppuration ; and that had not incision been made through the skin,
&c., the pus might easily have found its way into the peritoneal cavity.
In the second case, a man, set. 22, died of pneumonia on the forty-
third day of a severe typhoid fever. At the autopsy the whole left
psoas muscle, from an inch from its origin down to Poupart's ligament,
was changed into a tumour, which on being opened gave exit to ill-smell-
ing pus, mingled with blood, blood-clots, fibres and cell-tissue. The in-
ternal iliac and a portion of the transverse abdominal muscle were also
of a yellowish -red colour, and contained partly fluid, partly clotted
blood. The microscopical examination of all these muscles showed the
fibres infiltrated with a cloudy, granular, highly refracting material,
the striations partly destroyed, no amyloid degeneration, or rupture
(Bruchspalten). The author concludes that suppuration may occur in
typhoid fever, from haemorrhage into muscles, and that this depends,
as Zenker has shown, from antecedent degenerative changes in the
^bres.
Clement (* Lyon Med.,* viii, 649) records a case of typhoid fever in
a man, set. 22, followed by complete right facial paralysis, with paralysis
of the orbicularis and loss of electrical contractility ; paralysis of the
sensory portion of the trigeminal, the glosso-pharyngeal, auditory,
hypoglossal and olfactory nerves ; and paralysis both of movement and
sensation in the liaibs. He refers the origin of the lesion to the
medulla oblongata.
Gluge (' Bull, de I'Acad. Med. Belg.,' v, 613) records the following
as a rare termination of typhoid fever. A boy, set. 6 years, convalescent
from the disease, was attacked a month after its commencement with
peritonitis, and very considerable purulent eff'usion, which made its way
out by the umbilicus. The child recovered and the opening had closed
a month later.
Latham ('Lancet,' iSyijii, 81) concludes from his own experience
(i) that almost invariably the disease (typhoid fever) proceeds from a
special poison contained in the alvine excreta. (2) That this poison is
directly introduced into the alimentary canal, either in the food, or,
most generally, in the water drunk. (3) That it is not yet proved
that the poison is contained in, or is disseminated by, the exhalations
from drains, privies, &c., or that it can be absorbed into the system
through breathing air contaminated with such exhalations. He
describes an outbreak of typhoid fever at Harston, near Cambridge,
54 REPORT ON PRACTICAL MEDICINE.
and suggests, (i) tliat every evacuation, as soon as passed, should be
disinfected with carbolic acid. (2) That no surface-well water or
pump-water, whether boiled or not, should be used in a district where
there are any cases of typhoid fever, but that all drinking water should
be obtained from some spring not liable to contagion. He points out
the importance of not giving solid food till the temperature of the
patient at 8 a.m. and 6 p.m. has remained, for two days at least, about
the normal point, when we may be sure the ulcers have healed.
In a long " Inquiry into the causes of Typhoid Fever, as it occurs in
Massachusetts" (' Second Annual Eeport of State Board of Health of
Massachusetts,' 1871, p. no), it is concluded that " it is exceedingly
probable that a rich and fertile soil on which decompositionable sub-
stances are retained near the surface by any cause, whether a clay
subsoil, or a ledge of rock, or a protracted drought, is a soil favorable
to the production of this special disease."
N. Eatcliffe (' Lancet,' 1871, i, 760), inquiring into the outbreak of
fever at New Barnet, found the sewage arrangements of the road, in
which individuals were attacked, two of them fatally, to consist of four
large cesspools for thirty or forty houses, or more. Two of these cess-
pools w^ere open and two covered, the two open ones receiving the
overflow from the latter, the fetid sewage ultimately finding its way by
open trenches into the river Lea.
Mayo ('Med. Times and Gaz.,' i87i,ii, 492) describes an arrange-
ment of the same kind in a village near Oxford, in which an epidemic
of typhoid fever had broken out. The inhabitants seem to be most
filthy in all their habits. At the back of a house where the worst cases
occurred ran a ditch into which the people of the hamlet threw all their
slops. The drinking water of this cottage was obtained from a pump
opposite. A drain, made of rough stones, brought the slops from two
other cottages, and passed close to this pump, the distance from the
centre of the pump (which stood over its well) to the middle line of
the drain being two feet six inches.
Lissauer ('Virch. Arch.,' liii, 266) gives his experience of the anti-
pyretic (cold water) and the expectant treatment of typhoid, during the
late campaign, at Metz, Compiegne, and Eouen. Under the former he
lost 6 out of 97 (i. e. 6* 18 per cent.), and under the latter 1 1 out of 46
{i.e. 23*91 per cent). At Rouen, from the unhealthy position of the
hospital, 5 out of 13, treated on the expectant plan, died. The cases
treated with cold water were severe throughout ; those treated on the
other plan were in great quantity lighter cases, so that the averages
of mortality under the two can scarcely be compared. The bath was
employed three times a day in those cases only in which the tempera-
ture rose above 41° C. (105-8° F.). In the majority of cases two baths
in the day were sufiicient, especially if combined with large doses of
quinine. He gives the temperatures of six cases in full, together witb
a chart of each.
The cold-water treatment is also supported by Bohm and Michel, and
by Binz and others, reference to whose papers will be found below.
Scholz ('Deut. Arch.,' ix, 176) gives the results of the cold-water
treatment of typhoid in 125 cases (82 males and 43 women). Of these
ENTERIC (typhoid) FEVER. 55
five (four men and a woman) died. The patients were of all ages,
between lo and 50 years. The temperature of the bath was according
to age, 50° — 68° F. (io° — 20° C), and the period of immersion five to
ten minutes, with the addition afterwards of cold applications. Drugs
were given but rarely : castor oil in constipation, the tinct. ferri per-
chlor. in haemorrhage from the intestines. The latter contra-indicates
immersion in cold water, on account of the absolute rest necessary for
the patient, but not the use of cold applications. The paper contains a
full account of the sequelae noticed, and the author adds that he has
found the cold-water treatment most successful in the acute infectious
diseases (scarlet fever, measles, diphtheria, erysipelas).
Popper (' Oestr. Zeitsch. f. Heilk.,' No. i) obtains the same good
results from this treatment. Of twenty cases of typhoid, one only
died. The body was only half immersed in cold water for ten to Mteen
minutes, the rest of the body sprinkled with it, and cold compresses
used afterwards. The bath was employed twice a day.
Liebermeister, "Notiz betreffend die Epidemie in Andelfingen vom Jabre 1839,"
* Deut. Arch.,' ix, 245. Virchow, " Kriegstyphus und Ruhr," *Virch. Arch.,' lii, 1
(abstracted under typhus). Heine, " Ueber die Behandlung der Blattern und des
Abdominal-typhus," ib., liv, 217. Weiser, "Zur Hydrotherapie des Ileotyphus,"
* Wien. Med. Woch.,' 1871, No. 22. Bohm and Michel, " Beobachtungen uber die
Kaltwasser-behandlung des Abdominal-typhus im Kriege," ' Deut. Arch.,' viii, 596.
Billiard, " Traitement abortif de la Fievre Typhoide par I'emploi du Seigle Ergote,
' Bull, de I'Acad de Med. de Paris,' No. 35, p. 845. Morache, " De I'emploi de la
Creasote a Tinterieur dans le Traitement de la Fievre Typhoide," ' Gaz. des Hop.,*
1871,394. Temoin, " Sur le Traitement de la Fievre Typhoide," 'Bull. Gen. de
Therap.,' 82, 128. Leube, " Mittheilungen iiber die Typhus-Epidemie in der
Festung Ulm im Winter 1870-71, und ihre Behandlung im dortigen Barackenspitale,"
' Deut. Arch.,' viii, 583. Holzner, " Epidemische Erkrankungen in der Praparenden-
Schule zu Freysing im Juli, 1870," * Zeitschr. f. Biol.,' vii, 306. V. Pettenkofer,
" Typhus und Cholera und Grundwasser im Ziirich," ib., vii, 86. Wohlrab, " Einige
Falle von Verbreitung des Typhus Abdominalis durch das Wasser," ' Arch. d. Heilk.,
xii, 134. Pfeifer, "Statistik der Typhus- Abteilung aus dem Reserve- Lazareth
Weimar," 'Berl. Klin. Woch.,' 187 1, 105. Schonheyder, "Beitrag zu einer
Charakteristik iiber den Typhus bei der Cernirungsarmee vor Paris," ib., 103.
Strube, " Beitrag zur Nosologic der wahrend der Belagerung von Paris bei der
Maasarmee beobachteten Typhus Epidemie," ib., 355. Finckelnburg, " Ueber das
Auftreten der Dysenteric und des Typhus unter der Belagerungsarmee vor Metz,"
ib., 369. Hjalteln, " Pythogenic Fever in Reykjavik during the Summer of 187 1,'*
* Edin. Journ.,' xvii, 710. Fergus, "On the Sanitary Aspect of the Sewage Question,
with Remarks on a little noticed cause of Typhoid Fever and other Zymotics,' ib. ib.,
717. Taylor, "Notes of a Recent Epidemic of Typhoid Fever, and its Mode of
Propagation," ib., xviii, 1 24. Galton, " Perforation of the Bowel in Typhoid Fever
through a Diverticulum Ilei" (boy, set. 12), ' Path. Soc. Trans.,' xxiii, 103. Maclagan,
"The Bowel- Lesion in Typhoid Fever, its Nature and Treatment, * Lancet,^ 1872, i,
75. Id., " The Convalescence from Typhoid Fever," ib., 536. Rolleston, " On
Typhoid or Enteric Fever in Indian Gaols," &c., ib., 1871, i, 7. DeRenzy, "The
Dry-earth System of Conservancy," ib., 287. Id., " On the Extinction of Typhoid
Fever in the Millbank Prison by the disuse of the Thames Water," ib., 1872, i, 787.
IHnz, "The Antipyretic Treatment of Typhoid Fever at the Seat of War," ib., 1871,
i, 147. Andrew, " A Case of Typhoid Fever complicated by Hsematuria and Prostatic
Al)scess, leading to Extravasation of Urine" (man, set. 35, autopsy), ib., ii, 712. Sutton,
" Case of Typhoid Fever with High Temperature, the bath unsuccessful, large doses
of quinine quickly followed by a fall of temperature" (woman, set. 22), ib., 1872, i,
46. Hayden, " Typhoid Fever, Ursemia, Death," 'Brit. Med. Journ.,' 1871, i, 63^
Nunn, " Suppuration of Knee-joint, Typhoid Fever, Pysemia, Death," ib., 532.
56 REPORT ON PRACTICAL MEDICINE.
Kemp. " Latent Typhoid FeverJJlceration, Peritonitis, Death" (hoy, aet. 1 6), ib, ii, 1 14.
Hogg, •♦ Enteric Fever" (Statistical), 'Med. Times and Gaz.,' 1871, ii, 752. Orton,
"Typhoid Fever" (history of outbreak at Newcastle-under-Lyme, in December,! 871),
ib., 1872, i, 459. Wunderlich, " Ueber Darmblutungen bei Typhus Abdominalis
uiiter der Kaltwasserbehandlung," * Arch. d. Heilk.,' xiii, 481.
Typhus.
Yirchow C* Contagiositat dis Fleckfiebers ;" 'Virch. Arch.,' liii, 134),
from observations of the cases of typhus occurring in Berlin in 187 1,
is more convinced that it is introduced and propagated by direct con-
tagion, and does not arise spontaneously. Of the 15 cases observed the
exanthem appeared on the third day in two, and on the second day in
two also after the first rigor : in several cases the gastric disturbance
was so great as to suggest cholerine, especially as mucous " cholera-
fungi" were found in the evacuations (!). He comes to no definite
conclusion as to the period of incubation. In one case the facts seem
to point to the possibility of infection in the last stage.
In another article (' Kriegstyphus und Ruhr.,' ib. lii, 1) the same
author writes on the so-called " war typhus." He holds that it includes
both typhus and typhoid. As diagnostic of typhus he calls attention
to the early appearance of a roseolous or measly eruption, generally
thickly and widely spread, especially over the face and flexor surfaces of
the hands and feet. Petechias were almost absent in the majority of
cases of typhus, and frequent in those of typhoid. In the latter the
eruption was scanty and limited to the upper part of the abdomen and
the lower part of the thorax, and only exceptionally general. In relaps-
ing fever Virchow has met sometimes with hsemorrhagic petechias, but
never a true exanthem. He asserts that the diarrhoea of typhoid is not
dependent upon follicular ulceration, but upon the concurrent catarrh
of the intestine ; that stress should be laid, not upon the ulcer but the
so-called medullary infiltration of the follicle, inasmuch has no ulcera-
tion need occur in some cases, and the so-called typhoid scab represents
only a cheesy metamorphosis of the infiltrated elements, followed by
thickening and loosening, and in this way a secondary ulcer of the
mucous membrane. He draws attention to the fact that both in the
American and the Franco- Germanic war true typhus was extremely
rare, while typhoid showed itself in the later stages only of the miseries
produced, and then gradually increased in extent and severity.
Lyons ('Lancet,' 1871, i, 708, 743) opposes the view of Kolleston,
stated in a paper on " Typhoid or Enteric Fever in Indian Gaols" (ib.,
i, 7), and holds that typhus does prevail in India, and the epidemic of
fever in Eawul Pindee gaols in 1869 (as also that in 1867), was typhus
and not enteric or remittent fever. Chuckerbutty (* Ind. Ann. of Med.
Sci.,' 1867, No. 21, p. 107, and 1864, No. 18, p. 122), recorded 32 cases
of the disease. Other medical officers have seen typhus in the villages
and elsewhere on the north-west frontier. Between January and May
of 1869, <^6^ cases of typhoid, occurred at Eawul Pindee, of which 84
were fatal. He holds that there can be no doubt of its contagiousness,
and that typhus does and must occur under the conditions that will
generate it in Europe or other temperate regions.
Campbell (ib., i, 408) gives a case, with autopsy, in a man aet. 30,
RELAPSING FEVER. 57
which he prefers to look upon as one of acute petechial typhus rather
than of cerebro-spinal raeningitis.
Relapsing Fever.
Tennent (' Glasgow Med. Journ.,' n. s., iii, ^^s) gives at some length
an analysis of 352 cases of relapsing fever admitted into the Grlasgow
Tever Hospital between March 16 and Oct. 20, 1870. Six of these
cases (17 per cent.) died ; one, a man, set. 45, became affected with
paraplegia; a child, set. 9 months, had severe convulsions; the other
four died from syncope, the typical form of death in this affection. In
three of these four cases, however, there was already existing a chronic
disease (mitral obstruction ; granular kidneys ; bronchitis). Experience
seems to show that relapsing fever very rarely proves fatal to healthy
persons. The post-mortem examination of one of these three cases
showed the presence in the spleen, which weighed g^ oz., of three
fluctuating tumours containing sanious fluid, and disorganisation of the
spleen tissue.
Charteris (ib., 347) draws attention to " Post-febrile Ophthalmia" as
a result of some cases of relapsing fever. It seems to have been first
observed in Dublin in 1826, and in Glasgow in 1843 and 1844. The
ophthalmoscopic examination of one case out of 20 showed the vitreous
somewhat turbid, with black flocculi floating in it. The optic disc was
indistinct, the retinal vessels congested, and the retina of a dull greyish
tint. The pathology of the aftection is obscure. Notes of these cases
are given.
Eobinson ('Lancet,' 187 1, i, 644) gives an account of the outbreak
of relapsing fever, at Leeds, in 1870. The first case seems to have oc-
curred on March 31. Out of 361 cases coming under notice, there had
been in 219 previous communication with infected persons. Privation
due to the dissolute habits of tlie patients themselves or their parents,
existed in 261 instances. Typhus was said to have attacked the family
of the first patient simultaneously with the relapsing fever, and typhoid
was epidemic throughout the period during which relapsing fever pre-
vailed. The mortality from the three diseases in Leeds during 1870 was
as follows : Prom relapsing tever (July — October), 13 ; from typhus,
131, the highest numbers being from May to October; from enteric
fever, 182, the highest between July and November.
After drawing attention to the fact that former writers had remarked
on the relations between intermittent and relapsing fever, Senator
('Berl. Klin. Woch.,' 1871, 379) gives his own experience of an
epidemic in Berlin in 1870, which beside numerous cases of intermittent
and recurrent fever, presented also some case of a character between
the two. The patients seemed to be affected at first with true recur-
rent fever, which later on, and not only during the course of convales-
cence» yielded to one of a regular intermittent type. He gives six
cases, and concludes that (i) intermittent fever supervenes in the
course of a recurrent fever, at any rate, after the first attack ; (2) it
may appear during convalescence from the latter; (3) and that it is
sometimes observed at the end of epidemics of recurrent fever, in dis-
58 HEPOUT OK PRACTICAL MEDICINE.
tricts which were formerly free from it. And these facts lead him to
believe that recurrent fever sets up a special liability to malarial poison-
ing. At the same time there is no relationship between the two affec-
tions ; on the contrary, the fact that one infectious malady is no safe-
guard against another, proves that the two are perfectly distinct.
Eelapsing fever again made its appearance in London, in November,
1872 ('Lancet,' 1872, ii, 895), attacking eight cases, all in the same
family— three brothers aged 21, 19, and 3, the mother aged 40, and
four sisters aged 16, 12, 7, and ^. ' ;
Insolatio (Sunstrolce).
Thin ('Edin. Journ.,' xvi, 780) describes a number of cases of sun-
stroke met with in Shanghai in 1866, at a time when the thermometer
registered 96° Fahr. in the shade. He thinks the attack is not to be
attributed to great heat alone, but to the glare of the sun, and probably
to an atmosphere charged with electricity. All the cases could be directly
traced to exposure to the sun's rays falling on the head or the nape of
the neck. The symptoms varied extremely : in the worst case complete
coma was followed by speedy death ; in others the coma lasted only a
few hours, and was succeeded by complete recovery ; in other cases a
temporary paraplegia was a common sequela. Sometimes the attack
could scarcely be distinguished from the commencement of a continued
fever. He thinks that the affection is due to paralysis of the vasomotor
nerves of the head, and in some cases of the spinal cord as well.
Macdonald ('Lancet,* 1871, ii, 289) gives two cases of sunstroke in
men aged 6^ and 34, the first one fatal. His remarks on the cases sup-
port Thin's views as to the causation of the affection, both attacks
having occurred between 6 and 7 p.m., not at the hottest part of the
day, but at a time when the air appeared dry, rarefied, and full of
electricity.
Clapham (ib., 1872, i, 464) publishes the " particulars of a case of
sunstroke recorded by the patient" (the writer).
The Acute Exanthemata,
Hofmann (' Zeitschr. f. Parasitenkunde,' iii, 105), in a paper on the
rational treatment of the acute exanthems, especially measles and
scarlet fever, after stating that it would consist in the removal of the
causes of these diseases, the contagious nature of which, as Hallier has
clearly shown, consists in the presence of true fungi, considers that the
latter must be rendered harmless by the administration of remedies
capable of killing them, or that they must be eliminated from the body
as soon as possible. The former plan — that employed by Binz in
typhus (typhoid?) — is impossible in scarlet fever and measles. Hof-
mann, therefore, employs the second method, and following Steinfacher,
envelopes the patient in sheets wrung out of cold water, and surrounded
by a woollen cover or dry sheet. The entire nervous system is in this
way powerfully excited, heat withdrawn from the bodv, and when the
temperatures of the body and cloth are equalised, a more or less profuse
sweating occurs as a result of the hypersemia of the skin. On this
THE ACUTE EXANTHEMATA. 59
increased excretion Steinfacher laid great stress, contending tliat it
eliminated the special poison. To prove the latter position, Hofmann
sent the sweat of a child affected with measles, and treated in this way,
to Hallier, who reported the abundant presence in it of micrococcus.
Hofmann has used this plan in numerous cases of scarlet fever and
measles, even where the patients were comatose. He found that not
only were the febrile symptoms rapidly diminished, but that the con-
valescence of the patient was quicker than under other treatment. His
own method is as follows : — In slight cases, where the temperature in
ano does not exceed 40° C, and when the brain is clear, he envelopes
the patient, from the axilla to the hips, in the wet cloth, which is kept
on for one or two hours ; fresh cloths are applied till the temperature
falls to 38° or 38*5° C, which generally occurs in from 2 to 4 days. He
then orders a warm bath daily to promote desquamation, and the con-
valescence is complete in about eight days. In severer cases, when
the temperature is over 48° C, and the patient comatose, he recom-
mends the whole body to be enveloped for fifteen or thirty minutes ;
the cloths to be renewed after one or two hours. Later on the cloths
are left on for one or two hours, twice or three times daily. After
removing the cloths the whole body is sponged with cold water, or if
the comatose symptoms are well marked, the patient is put into a bath
of lukewarm water, and cold water poured over him till slight shivering
is produced; and he is then placed in bed. The whole process is
repeated whenever the temperature rises. Careful observation of indi-
vidual cases can alone determine the temperature of the wet cloths, the
frequency with which they should be applied, and other minor points.
Ballot (' Med. Times and Gaz.,' 187 1, 510) gives some tables showing
the number of deaths in Rotterdam from smallpox, scarlet fever and
measles, from 1778 to 1811, and from 181^ to 1870. He finds during
that period that
1. Epidemics of smallpox were slightly diminishing.
2. Those of scarlatina also diminished and were almost disappearing
from the table.
3. Those of measles were always increasing.
Eleischmann ('Jahrb. f. Kinderheilk,' iv, 174) gives statistics of
the mortality of scarlet fever. As combinations of two exanthems he
found scarlet fever and vaccinia ; scarlet fever and smallpox ; scarlet
fever and varicella ; scarlet fever and measles. He considers the in-
cubation of measles to be three days. The same writer (ib., 166) gives
an account of an epidemic in the children's hospital at Vienna, of
scarlet fever occurring during variola. Five children between the ages
of three and a half and eleven years, one in the pustular stage of
smallpox, the other in that of decrustation, were found to have a re-
currence of high temperature (105-8° F,), which remained high from two
to four days, and in the favourable cases fell. With this were pains in
the neck, swelling of the tonsils and mouth. In one case the tongue
was very injected and red. Soon after appeared an eruption like that
of scarlet fever, either diff*used over the whole body or limited to certain
parts, as the breast and abdomen. In one case which recovered it was
bluish red. Haemorrhagic rings surrounded the still present pustules
60 REPORT ON PRACTICAL MEDICINE.
of smallpox. The disappearance of the eruption was followed by a
lamellar scaling ; in the hsemorrhagic case the scales were an inch
square. No sequelae were observed. Two of the children died, one of
very acute nephritis, while tlie eruption still existed, the other, a weak
child of three and a half years, from febrile exhaustion.
Auchenthaler (ib., 220) gives a case of coincidence of measles and
smallpox in a boy of thirteen.
Brunton (' Griasg. Med. Journ.,' iv, 27) records the following cases
of combined eruptive disease; measles and smallpox in a pregnant
woman of twenty-nine; scarlet fever and smallpox in a woman of
forty-one, followed by death ; scarlet fever and varicella in a patient of
four years.
Sansom, " Case of probable coexistence of Scarlatina and Variola " (female, set.
31, with chart of temperature), 'Brit. Med. Journ.,' 1871,1,395. Musket, "Con-
currence of Scarlatiua and Varicella" (child, aet. 3 years), ib., 1872, i, 71.
Scarlet Fever.
Carpenter (' Lancet,' 187 1, i, no) holds that scarlet fever may and
often does arise de novo ; that it results from incipient decomposition
of the blood of vertebrate animals, either healthy or diseased, under
the influence of certain conditions of temperature, magnetic state and
moisture ; that the poison is probably more virulent when produced
from diseased material ; and that some of the granules contained in
blood undergo a certain corpuscular degeneration, and are the exciting
agents in the production of the fever, by altering the character of the
natural zymosis which is said to be always proceeding within the body.
He attempts to support this theory by the histories of various outbreaks
of scarlet fever in localities, houses, schools, &c., in the neighbourhood
of places where slaughterhouse refuse was stored or used lor manure.
He believes that the disease would be shorn of its fatal tendency if
blood were kept out of the sewers, &c., in fact, if all sanitary regula-
tions were enforced. The paper contains an analysis of the preva-
lence of scarlet fever in Croydon during the last twenty-two years.*
Huber (' Deut. Arch.,' viii, 422)] observed during an epidemic of
scarlet fever in 1869 a hsematoma in the neck of a child, aet. 6. It
appeared as an oval, indistinctly fluctuating tumour, of the size of a
hen's egg, in the left cervical region, corresponding to the course of
the glands. It had presented itself ten days after the commencement
of the scarlet fever, and had become rapidly larger during the last two
days under the use of poultices. He looked upon it as an abscess,
opened it, and evacuated about a handful of pretty firm clot, the re-
moval of which was followed by a strong arterial blood stream ; the
case ended fatally. He refers to another case of the same kind, which
had a more fortunate result. He thinks that a haematoma may be
diagnosed from an abscess by the rapid increase of the former in a
relatively short time, and by the comparatively greater hardness and
indistinct fluctuation of the tumour.
* There is an odd coincidence between the letters used in this paper and those
employed in Pettenkofer's resume of his writings on cholera (' Zeitschr. f. Biol.,'
Bd. V, 295), A. B. S.
SCATILET FEVER. 61
J. Harley (*Med.-Chir. Trans.,' Iv (1872), 103 ; 'Brit. Med. Journ.,'
T871, ii, 740) writes on the morbid anatomy of scarlatina and the rela-
tion between enteric and scarlet fevers. He gives notes of twenty-
eight cases, the majority of which died on days ranging consecutively
from the third to the fifteenth day, and the remainder on the 17th,
20th, 29th, 33rd, 41st, and 69th days. More or less albuminoid or
fatty degeneration of the kidneys existed in six cases, and in these
death occurred on the 15th, 17th, 20th, 29th, 41st, and 69th days re-
spectively. In the rest these organs were healthy. The pathological
changes common, with a few exceptions (depending on the time of the
disease), to all, were — i. The formation of fibrinous clots in the heart
and great vessels during a pyrexial state, at any period of the disease —
the commonest cause of death during the early stage of scarlet fever. 2.
Marked derangement of the hepatic function as shown by the deteriora-
tion of thebile. 3. General inflammation of the lymphatic system of glands
(ordinary lymphatic glands, tonsils, and solitary glands of the tongue,
spleen, mesenteric, solitary, &c.). From these pathological conditions
he thinks that '■'■ fehrh lymphatica is the appropriate scientific definition
of scarlatina^'' and he asserts that from this view one general conclu-
sion as to the connection of scarlet fever and enteric fever is inevitable,
viz, that the pathological changes accompanying an attack of scarlet
fever include all those of the first stage of enteric fever, and are so far
identical with them. Whence it follows that the transition from the
former disease to the latter is nothing more than a natural pathological
sequence, readily determined by any cause which may increase the
intestinal irritation. The writer gives six cases of the coexistence of
enteric and scarlet fevers, and proposes the term " abdominal scarla-
tina," already suggested to his own mind in writing the article on
" Enteric] Fever," in Eeynolds' ' System of Medicine,' " as the appro-
priate definition of a disease which every intelligent practitioner will
sooner or later meet with." (The report of the discussion on this
paper will be found in the * Brit. Med. Journ.' as above.)
Kelly and Nowlan (' Brit. Med. Journ.,' 1871, i, 342) record a case
of severe scarlet fever in a girl, set. 3 years, in whom an abscess was
formed under the angle of the right jaw, extending down the neck
and spreading over the clavicle. This opened spontaneously, and the
whole clavicle came away, necrosed only at the acromial end. The
patient recovered with unimpaired movement of the arm (I). (' Path.
Soc.,' Dublin).
Meynet ('Lyon. Med.,' viii, 124) records the occurrence of scarlet
fever in a child only fifteen days old.
Marcbioli, " Sopra di una Epidemia di Scarlattina," * Gaz. Med. Lombard/ i872»
109. Barclay, " Observations on Scarlet Fever, especially with reference to its
epidemic character," 'St. George's Hosp. Rep.,' v, 167. Copeman, "On Scarlet
Fever," ib., 55. Chappie, " Scarlet Fever in India," ' Lancet,' iSyi.ii, 188. Crocker,
"Iron in Scarlatina," 'Brit. Med. Journ,,' 187 1, ii, 255. Pyle, "On the Contagion
of Scarlatina and Smallpox," ib., 34. Aldis, " Scarlet Fever for Ten Years
(i860 — 1870) in the Parish of St. George," London. Hutchinson, "Case of Renal
Retinitis, with peculiar History as to Scarlet Fever," 'Lancet,' 187 1, i, 479.
Gueneau de Mussy, "Sur quelques formes graves de Scarlatina" (three cases),
*Gaz. des Hop.,' 1871, 305. Langier, "Note sur la Rechute dans la Fievre Scar-
latine," *Gaz. Uebd.,' 1871, 545.
62 REPORT ON PRACTICAL MEDICINE.
Measles {Morhilli) and Rotheln {Rubeola).
Eoss (' Edin. Journ.,' xvii, 981) gives a case of rotheln occurring in a
man, aged 27. He defines the affection as " scarlet fever combined with
catarrh, the catarrh being coexistent and coetaneous \yith the entrance of
the scarlet fever virus into the body of the patient, the symptoms of
the catarrh at once showing themselves and aggravating what is usually
the period of incubation in scarlet fever." His reasons are founded on
the similarity of the rash and the period of incubation (in rotheln, 4
days; in scarlet fever, 3 days, with an invasion period of one day).
Dunlop ('Lancet,' 1871, ii, 464) gives an account of an epidemic of
rotheln occurring during the summer months of 1871 at St. Helier's,
differing in no particulars from the affection as generally described.
Fleischmann (" Zur Eothelnfrage," ' Wien. Med. Woch.,' 1871,
No. 30), describes the symptoms given by various writers as charac-
teristic of rotheln. He thinks that many of the so-called transitional
or mixed forms may be explained by the simultaneous course of two
acute exanthems (scarlet fever and measles) in the same patient. From
his own observations he looks upon Thomas's " large spotted" type of
rotheln as an urticaria (erythema urticatum) ; the " small spotted" type
he considers to be a specific affection, in which he seems to lay stress
on the absence of the eruption from the face, the absence of peeling and
the rapid fall of temperature.
Jaccoud, " De quelques Complications et Suites de la Roageole," * Gaz. des H6p./
1871, 73. Vezien, "Rapport sur un Epidemic de Rougeole qui a regne pendani
les mois de Fevrier, Mars, Avril, et Mai a Dunkerque," ' Rec. de Mem. de Med.
Milit.,' xxvii p. 300.
Variola and Varicella.
It is impossible to do more than pick out a few from the revy
numerous papers published on variola during the two years past ; the
bibliography of the affection might be prolonged indefinitely from bot h
French and English papers.*
Clemens (' Deut. Klin.,' 187 1, 281) describes the case of a girl aged
21, in w^hom the eruption was extremely thick on the left half of the
body, and only small on the right half, especially the right face. On
the third day of the eruption red spots appeared on the right face and
arm, on the fifth day these had become large vesicles of pemphigus.
One only was visible on the right leg. These vesicles did not originate
in aborted smallpox pustules ; they were smooth, filled with yellowish
serum, and healed without leaving a scar.
Simon (' Arch. f.Derm.,' iii. 242), supplementing his former account of
the prodromal exauthem of smallpox (see last ' Eeport,' p. 77), gives
several cases in which it was present. From these it is evident that it
sometimes appears as the very earliest symptom, so that it is possible to
diagnose the coming affection in a patient who exhibits little or no
fever, and few or no subjective pains. The first symptom was a sensa-
tion of heat or itching of the abdomen. He refers the characteristic seat
of this eruption to the axilla, and the inner and front part of the upper
* Capt. Butler gives a good report (" The Great Lone Land," London, 1872, App.,
•p. 317) of the epidemics of small-pox among the Indians of the Missouri and
'Saskatchewan, especially during the years 1869-70. — A. 13. S.
VARIOLA. AND VARICELLA. 63
arm (the triangle of the upper arm). He answers generally in the affirma-
tive the question whether this eruption is entirely pathognomonic of
a coming variola ; but he gives two cases in which, though it was
present, the latter affection did not occur, and these he looks upon as
cases of variola sine variolis. As to its nature, he places the exanthem
in the same category as other vasomotor neuroses of the prodromal stage.
Gubler and Laborde (' Gaz. des. Hop.,' 1871, 529) describe some of
the nervine symptoms of variola. Frequently there was paralysis of
motion and sensationjn the lower extremities ; paralysis of the bladder
at the commencement and end of the affection, sometimes with cystalgia.
In two cases there was aphasia in a young woman at the beginning of
a slight attack, and in a soldier on the second day of the eruption.
Both cases recovered, in both the movements of the tongue were
unaffected, the intelligence was perfect, and the patients referred to the
throat, which was not abnormally affected, as the cause of the aphasia.
Cartaz (' Lyon Med.,' viii, 200) gives the results of an examination
of the brain in 106 cases of smallpox, of w^hich 49 were varioloid, and
13 haemorrhagic. Of the other 44 albumen was present in one out of
12 men, and in six out of 32 women. It was present in all the
haBmorrhagic cases. He holds that the albuminuria occurs in the con-
valescing stage of smallpox, and in the majority of cases lasts only a
few days.
Eommelaere (' Bull, de I'Acad. de Med. de Belg.,* v. 214) writes on
the relation between variola and varicella. According to him the poison
of variola exhibits itself in three different clinical types — variola,
varioloid, and varicella ; persons exposed to the contagion of varicella
may take variola; and he advises that on an outbreak of varicella
recourse should be had to the precautions employed against variola
(re-vaccination, isolation, &c.). He enters into the pathological changes
found in smallpox. In the cases examined by him there were pustules
on the respiratory tract, the vocal cords, near the pylorus, and in the
large intestine ; enlargement of the solitary glands, spleen and mesen-
teric glands, and Beyer's patches ; extravasation in the liver, kidneys,
ovaries, bladder and pericardium, &c. ; fatty degeneration of the liver
and of the heart muscle.
Vulpian (' Bull, de I'Acad. de Med.,' xxxvi, 912) discusses the mode
of formation and structure of the pustules in smallpox.
Weigert (' Centralbl.,' 1871, 108) has found bacteria in the skin of
several patients suffering from smallpox.
"Wyss (' Arch. f. Derm.,' iii, 529) has studied fully the anatomy of
the extravasations in haemorrhagic smallpox, and purpura variolosa
(haemorrhagic smallpox without pustules). The hair and sweat glands
seem to be unaffected in both diseases. In the early stages of smallpox
he finds that the papules are formed not only by distension of the cells
of the epidermis, but also by oedema of the papillae.
According to Huchard (Arch. Gen. de Med,,' xvii, 348), death
in smallpox is due either to septicaemia or asphyxia. In the latter case
the pustules may be found extending from the pharynx and larynx,
throughout the respiratory tract, as far as the finest bronchi.
Eevillout (' Gaz. des Hop.,' 1871, 274) prevents the occurrence of
64 REPORT Ox\ PRACTICAL MEDICINE.
smallpox scars by opening the pustules with a needle dipped in nitrate
of silver. He gives the case of a lady on whose face he opened all the
pustules but two ; cicatrices were left by these two only.
Fox, " The Mortality from Smallpox in regard to Sex and Age," * Med. Times and
Gaz./ 1871, i, 538. Bieganze, "II Vajuolo Epidemico uel 1870 — 1871 in Milano," *Gaz.
Med. Ital. Lomb.,' 1871, 221, 1872, 133. DcH'Acqua, " Cenni sul Vajuolo e sulla
Vaccinazione in Milano," ib., 25. Poppelauer, " Keminiscenzen aus den hiesigen
Stadtischen Pockenheil-Anstalten," ' Berl. Klin. Woch.,' 187 1, 276. Paul, "La
Variole consideree suivant les Sexes, les Ages, et les Saisons," * Union Med.,' xi,
229. Grieve, "An Analysis of 800 Cases of Smallpox," *Lancet,' 1871, i, 371.
Yarrow, " Report of Cases of Smallpox admitted into St. Luke's Workhouse," ib., i,
606. Adams, " An instance of the Introduction and Propagation of Smallpox in a
Community, and its Eradication by Stringent Sanitary Measures," ' Med. Times and
Gaz.,' 1871, i, 125, Jones, "On the Recent Outbreak of Smallpox at St. George's
Hospital," *St. George's Hosp. Rep./ xiv, 229. Brouardel, " Des conditions do Con-
tagion et de Propagation de la Variole," ' Union Med.,' xi, 240. Andhoui, " Reflexions
sur la Nature des Varioles observes aux Ambidances de Grenelles pendant le Siege de
Paris," * Gaz. Hebd.,' 1871, 180. Giustiniano, "L'Epidemia Variuolosa del 1871 in
Carpi di Modena," 'Ann. Univ. di Med.,' vol. 218, p. 137. Hjaltelin, " Smallpox Im-
ported into Iceland by French Fishing-vessels, stamped out by Quarantine and Sul-
phurous Fumigations," ' Brit. Med. Journ.,' 1871, ii, 519, Grieve, "Case of Hseraor-
rhagic Smallpox, with remarks," ib., 465. Gaskoin, " Antiseptic Treatment of Small-
pox," ib., 1872, i, 4. Biiumler, " The Use of Baths in Smallpox," ib., ib., 45.
Barlow, " On the Exclusion of Light in the Treatment of Smallpox," * Lancet,'
1871, ii, 9. Collie, "Lecture on Smallpox," ib., 423. Jones, "Propagation
of Smallpox," ib., 28. Gayton, " Haemorrhagic Smallpox associated with Teta-
nus" (boy, set. 17, autopsy), ib., 1872, i, 187. Cheves, "Haemorrhagic Variola"
(two cases, one autopsy), ib., 101. Ducat, "A Case of Malignant Smallpox,"
ib., 791. Aikman, "A Suggestion as to the Causes and Treatment of the Ha3-
morrhagic Type of Smallpox," * Glasg. Med. Journ.,' iv, 52. Wohlrab, " Ein Fall
von Varioloiden mit partieller Encephalitis im Gefolge," ' Arch. d. Heilk.,' xiii,
512. Geissler, " Einige Bemerkungen iiber Pocken und Vaccination," ib., 545.
Schwenniger, " Kurze Notiz Uber die VVirkung des Chinins in dem Prodromalstadium
der Variola," ib., 577. Briquet, " Sur la Variole," ' Bull, de I'Acad. de Med.,' xxxvi,
858. Gueneau de Mussy, " Lemons Cliniques sur la Variole," ' Gaz. des Hop.,' I87i»
37. Desnos et Huchard, "Des Complications Cardiaques dans la Variole, et notam-
ment de la Myocardite Varioleuse," ' L'Union Med.,' xi, 145 (and cf. * Bull.Gen. de
Therap.,' T. 80, 385.) Lavise, "Variole, Developpement de Vesico-pustules dans
le Pharynx, le Larynx, et les Bronches, Mort, Necropsie," ' Press. Med. Beige.,' 1871,
loi. Netter, "Les Ferments Variolique et Vaccinale," * Gaz. des Hop.,' 1871, 569.
Divet, " De I'Action Combinee de I'Alcool et de I'Opium dans le Traitement de la
Variole Hemorrhagique," ib., 505. Heine " Ueber die Behandlung der Blattern und
Abdominal Typhus," ' Virch. Arch.,' liv, 195. Eisenschitz, " Die Variola- Varicellen-
frage," ' Jahrb. f. Kinderheilk.,' iv, 205. Fleischmann, "Ueber Varicella und
Varicellen-Impfungeu," Arch. f. Derm.,' iii, 497.
Syphilis.
Lostorfer* (" Ueber die Moglichkeit der Diagnose der Syphilis
mittelst der Mikroskopischen Blutuntersuchung," * Wien. Med. Jahrb.,'
1872, 96, and included under a paper by other writers, * Arch. f.
Derm. u. Syph.,* iv, 115) describes certain corpuscles to be found in
the blood of syphilitic patients, and not in others. He thinks that their
development is materially affected by temperature, and gives thirteen
cases in which the corpuscles were present in all stages of the aftection.
He purposely says nothing definite as to their origin, or as to their being
* The 'Lancet,' 1872, i. 868, has a summary of Lostcrfer's work.
SYPHILIS. 65
infecting organisms. The two papers contain discussions in which "Wedl,
Strieker, &c., took part. The latter adds a note, in which lie says that,
on sending certain test-specimens to Lostorfer, the presence or absence
of syphilis was pretty generally diagnosed. Wedl, who elsewhere
('Allg. Wien. Med. Zeit.,' 1872, 46) makes fun of the whole subject,
declares that he has for some time found the said corpuscles in healthy
as well as in syphilitic blood, and looks upon them as fat-cells. Vajda
("Lostorfer 'sche Syphiliskorperchen," *Wien. Med. Woch.,' 1872,
s. 172) improved on Lostorter's method by keeping the blood con-
tinuously in a moist chamber. His observations were made on the
blood of thirty-five patients. He describes the corpuscles at length,
and concludes that they occur in syphilitic, leuchsemic, and carcinoma-
tous blood more frequently than in healthy ; that they are sometimes
absent in syphilitic blood ; that they are made up of an albuminoid
(s. 200), probably a compound of phloretic acid,* with some combina-
tion of an amide, and that they are neither vegetable organisms nor
fat-cells. Biesiadecki (" Ueber die Lostorfer 'schen Korperchen," ib.,
g. 172) comes to almost the same conclusions, and says that his colleague
Stopczanski looked upon Lostorfer's corpuscles as granules of para-
globulin.
Owen E,ees ('Guy's Hosp. Hep.,' 1872, 250) considers that the fol-
lowing symptoms especially aid the diagnosis in cases of cerebral
disease having a syphilitic origin, (i) The paralytic seizure is gener-
ally the immediate result of some violent exertion, or of some long-
continued muscular effort carried on to fatigue, and the collapse is often
so great as to threaten immediate dissolution. (2) The hemiplegic or
paraplegic symptoms are very irregular in character ; the right arm and
leg may be paralysed, the latter scarcely affected, while the left leg has
lost motor power ; or there may be hemiplegia of one side and anses-
thesia of the other; or loss of sensation may affect only one limb,
generally the arm. (3) Pain in the head and tenderness of scalp are
scarcely ever wanting. (4) Aphonia has been observed in many cases
in the early stage. He believes strongly that mercurial treatment is
essential to the removal of the gummous deposits, and gives three cases
— one with autopsy— in illustration of his view, which he states as fol-
lows : — Syphilitic deposits may, like various forms of malignant disease,
be present in the brain-substance, without producing symptoms, or
only slightly incommoding the patient. An exciting cause may inter-
vene and induce inflammation, which results in deposits made up of the
ordinary components of the blood. These are easily absorbed by the
iodide of potassium ; the symptoms disappear and the patient is con-
sidered perfectly cured. But the original syphilitic deposit still
remains unabsorbed, and a recurrence is imminent, unless recourse be
had to mercurial treatment, in order to effect the removal of the
gummous mass.
Oser (' Arch. f. Derm, und Syph.,' iii, 27) describes three cases of
extensive syphilitic ulceration of the small intestine. The first was
* Phloretic acid is the product of Phloritzin, a substance which occurs in the bark
of the apple and other fruit trees, the composition of which is given by Strecker as
C49Hcv.0,n + 4Aq.— A. B. S.
6Q REPORT ON PRACTICAL MEDICINE.
that of a man, set. 51, who about six months before death became
greatly emaciated. He presented psoriasis palmaris, plaques muqueuses,
and glandular changes, but his digestion was pretty good. He died
suddenly, and the autopsy showed a greyish-red infiltration of all the
intestinal layers, extending from the lower part of the jejunum to the
cgecal valve. In the middle of the infiltration was a polygonal ulcer,
parallel with the length of the intestine, its base formed by the sub-
mucous tissue, and with well-defined edges. The peritoneum covering
it was injected and (edematous, and contained dilated lymph-vessels.
Under the microscope were found numerous round, partly fatty cells.
The writer enters into the differentiation between this syphilitic affec-
tion, tuberculosis of the intestines, typhoid, and leuchaBmia. The two
other cases were those of newborn children, and gave the same micro-
scopic appearances as the first.
Simon (ib., iii, 537) quotes the views of several authors on the fol-
lowing questions : — whether deposits in the liver (gummata) are so far
characteristic of syphilis, that without any further history, or the
presence of any constitutional affection, the disease may be recognised ;
and whether there are cases in which hereditary syphilis may lie latent
for years, even up to puberty, before it is developed. In opposition to
Dittrich, who answers both questions in the aflRrmative, the author con-
siders them still unsettled. He gives two cases, from his own ex-
perience, as matter for the discussion of these points.
Bradley ('Brit. Med. Journ.,' 1871, i, 116) gives the case of a child,
four months old, in whom a syphilitic eruption was accompanied by the
presence of albumen in the urine. There was no history of scarlet
fever. The eruption and the albumen both yielded to mercurial treat-
ment. He found, later, albumen present in two out of twenty cases of
hereditary syphilis, and infers that syphilis may be a cause of granular
or waxy kidney ; and that the chronic albuminuria resulting from these
changes should be treated with small doses of mercury.
Lane, " Clinical Records of the Therapeutic Value of Iodine in the Treatment of
Syphilis/' 'Lancet,' 1871, i, 267. Berkeley Hill, "Clinical Records of the Therapeutic
Value of Iodine in the Treatment of Syphilis," ib., i, 305. Buzzard, " Clinical Records
of the Therapeutic Value of Iodine in the Treatment of Syphilitic Nervous Affections,"
ib., i, 339, Lee, "On Contagion (Syphilitic)," ib., i, 472. Berkeley Hill, "Early
Syphilis," ib., ii, 599. Fox (Tilbury), " Primary Sore on the Lip of a Child," ib., i,
536. Hutchinson, "Report on Vaccino-SyphUis," ib., ii, 143. Spencer Watson,
" Ptosis, Mydriasis, and Hypersemia, with Anaesthesia of the left side of the Face, in
a Syphilitic Patient" (female, ait. 22), ib., ib., ii, 676. Jeaffreson, "Syphilitic Ptosis
and Paraplegia," ib., 1872, i, 252. Pollock, " Case of Paralysis in a Syphilitic Sub-
ject treated by large doses of Iodide of Potassium: cure," ib., ib., i, 255. Dowse,
" Syphilitic Growth of right Cerebral Hemisphere " (woman, set. ^-i, autopsy), ib., ib.,
i, 539. Fairlie Clarke,* * Case of Icthyosis Linguae " (in a syphilitic subject, male,
set. 38), ib., 1872, i, 648. Lockhart Clarke, " Case of Syphilitic Disease of the Brain,
complete paralysis of right arm, partial paralysis of right leg, aphasia" (male, set. 47),
ib., i, 677. Bristowe, " Softening of the Brain following Syphilis, death" (male, aet.
23 : thickening of membranes and of right posterior cerebral artery, the latter occu-
pied for an inch of its length by a cylinder of adherent fibrine, softening of anterior
part of left optic thalamus, left crus cerebri, and posterior part of outer wall of right
ventricle), 'Lancet,' 1872, i, 826. Hulke, "Syphilitic Stricture of Rectum, &c."
(woman, set. 25, with autopsy), ib., ii, 79. Venning, "The Modern Treatment of
Syphilis," based on the evidence adduced before the Committee appointed to inquire
PELLAGRA. 67
into the Pathology and Treatment of the Venereal Disease, published in 1867," *St.
George's Hosp. Rep.,' v, 77. Caspari, "Ueber die subcutanen Sublimat-Injectionen
bei Syphilis," 'Deutsche Klin,,' 1871, 21. V. Sigmund, "Zur Beurtheilung
der Subkutanen Sublimat-Injectionen gegen Syphilis," ' Wien. Med. Woch.,' 187 1,
No. 36 and 37. Id., "Ueber die Beschneidung bei Syphilis der Vorhaut und Eickel,"
ib., No. 21. Schwimmer, " Casuistische Mittheilungen aus dem Gebiete der Syphilis,"
ib.. No. 45. Hill, "The Iodides of Ammonium and Sodium in Syphilis," * Brit. Med.
Journ,,' 187 J, ii, 724. Parker, "The Modern Treatment of Syphilitic Diseases,"
London, 5th ed. Chorin, " Ueber den Nutzen der Schwefel-Thermen zur Ermbgli-
chung einer Mercuriellen Syphilis-cur," 'Arch. f. Derm, und Syph.,' iii, 109. Pick,
"Einige Bemerkungen zum offenen Brief des Dr. Chorin' s," ib., ib., iii. Llunggren,
" Ueber Syphilis des Gehirns und Nervensystems," * Arch. f. Derm. u. Syph.,' 187 1, Bd.
iii, 8. ^3^, 509 ; 1 782, Bd. iv, s. 254. " Ueber die Unterscheidbarkeit des Blutes Syphi-
litischer :" — I. Strieker, " Beitrage zur Pathologie des Blutes ; II. Kobner, " Unter-
suchungen iiber die Unmoglichkeit der Diagnose der Syphilis mittelst der Mikro-
skopischen Blut-untersuchung," 'Arch. f. Derm. u. Syph.,' 1872, B. iv, 275, 293, and
'Wien. Med. Jahrb.,' 1872, 96. Hennig, "Erhebte Lues, Muskelleiden," 'Jahrb.
f. Kinderkr.,' 187 1, p. 320. Schuster, "Bemerkungen iiber die Art der Einwirkung der
Aachener Schwefelthermen bei Hydrargyrose und bei Syphilis," ' Berl. Klin. Woch.,'
1872, 164. Paliard, "Chancre a siege insolite," 'Lyon Med.,' ix, 37. Hutchinson,
" Report on two cases in which Syphilis was communicated in the practice of Vacci-
nation," 'Med.-Chir. Trans.,' xxxvi, 317. Id., "Syphilis from a scratch on the hand
made by striking the knuckle against an opponent's tooth," * Brit. Med. Journ.,'
1872, i, 14. Fox (T.), " Unusual form of Eruption in a Child, attributed to Syphilis :
mercurial treatment : cure," ib., 1871, i, 613. Stokes, " Syphilitic Laryngitis : trache-
otomy twice, recovery " (woman, set. 30), ib., ib., 339. James, " Syphilitic Diseases of
the Throat," 'Med. Press and Circ.,' 1872, i, 28. Bradley, "Notes on Syphilis, with
an Appendix on the Unity of the Syphilitic Poison," London, 1872.
JPella^ra.
Gemma (" Delle dermopatie Pellagrosa," * Annal. Univ. di Med.,'
ecxvii, 31) describes the skin aiFections occurring in pellagra, dividing
them into the transitory ones, showing themselves in the spring time,
and the chronic, which have a regular or irregular course. The first
are nearly always of the erythematous type, running on into the
wrongly so-called erysipelas pellagrosum. The eruption appears most
frequently on the backs of the hands, spreading from thence over a
j large part of the forearm, sometimes on the backs of the feet, the face,
and the upper parts of the breast, all of them places exposed to the
I sun. The skin is more or less reddened and swollen, and the afiection
': may last from a few days to some months. With the increased tempe-
Irature at the commencement of summer the condition of the parts
j affected undergoes certain changes. Itching is never present. After
I the eruption has lasted some time the hand has a white shining appear-
ance, desquamation commences in large scales, the skin below appears
atrophied, has a white cicatrised look, and feels velvety. Sometimes
the erythema comes out in patches, or in papules closely crowded to-
gether, and here and there confluent. More advanced stages are met
with in which the redness is much deeper, and the patient complains of
the burning pain, though in many cases of the worst kind cutaneous
isensation is abolished. Large vesicles and pustules occur, succeeded
by scabs and by desquamation, and by a pigmentation lasting a longer
or shorter time. In other cases, again, the vesicles stand so thick
.together that the affection deserves the name of eczema pellagrosum.
68 REPORT ON PRACTICAL MEDICINE.
The treatment of tlie lighter cases consists in keeping the parts affected
from the sun, and in the severer to apply, night and morning, an oint-
ment composed of olive oil, laurel water, and acetate of lead.
In the chronic forms of the eruption occur— (i) Branny desqua-
mation or larger scaling of the epidermis, taking place not only as a
consequence of an antecedent erythema on the exposed parts, but
on the covered portions of the body also, sometimes extending over
the whole of the latter, and consisting in an hypertrophy of the
rete mucosum, in which the nails also take part. (2) Pigmentation
of the skin (Lentigo or Chloasma), remaining for several years.
(3) Cracks in it, extending to the rete mucosum. (4) An anaemic or
sallow appearance. (5) Livid spots on the lower extremities, noticed
only in women. (6) (Edema of the skin. (7) A livid colour of the
lips, already noticed by Strambio in cases of pellagra. (8) A shagreen
roughness, accompanied by atrophy of the skin. (9) Purpura haemor-
rhagica, with the symptoms, in some cases, of the haemorrhagic diathesis.
(10) Lichen miliformis. (11) Separation of the epithelium of the
mucous membrane of the tongue and mouth, in the worst and latest
stages of the disease, generally accompanied by diarrhoea pellagrosa.
(12) Onychogryphosis, partly spurious, from disappearance of the fat
under the bed of the nail, and partly true, from hyperplasia of the
latter. (13) Atrophy of the skin, accompanying general atrophy, in
the last stages of the affection.
Maas (*Berl. Klin. Woch.,' 1871, ^6^) gives two cases of so-called
sporadic pellagra occurring in children, set. 13 and 15, whose parents
presented the history of syphilis.
Gemma ("La pellagra dei lattanti e dei bambini," ' Gaz. Med.
Lomb.,' 1 87 1, 349) describes this affection as it occurs in young chil-
dren and in children at the breast. They present a roughness of the skin,
especially on theforearms and cheeks, with a brownish colour, deepen-
ing as they grow older, dry and generally livid lips, watery eyes, slight
oedema of the lower eyelid, a red or pale tongue, with enlarged papillae.
In addition to symptoms of general innutrition, catarrh of the bronchi,
diarrhoea, &c., there is a peculiar form of dyspnoea, something like that
of asthmatic patients, vulgarly called bellowing (mantesament) or
wheezing (buffament) by the Lombard women. There may be sleep-
lessness or a lethargy, out of which it is difficult to rouse them. In
one case the author noticed symptoms resembling the delirium pella-
grosum of adults. The general cause seems to be hereditariness, and,
beyond doubt, feeding with maize. The treatment consists of half-
gramme doses of chloride of iron in the course of the day, as long as
diarrhoea continues, and afterwards arseniate of quinine, cod-liver oil,
warm baths with chloride of sodium, animal food, with omission of the
maize. Eighteen clinical cases are given in illustration.
Other papers are—
Billod, " Traite de la Pellagre, d'apres des Observations recueillies en Italie et en
France," Paris, 1870. Balardini, "Progress! della questione della Pellagre dopo
I'anno 1855 ^^ Italia e in Francia, e conclusioni sulla etiologia, suUa profilassi
et sulla cura di tale malattia," ' Ann. Univ. di Med.,' ccxvii, 70. Gemma, " SuU'
Arsenico nella Cura della Pellagra," ib., ccxv, 564. Strina, "Casi di Pellagra
LEUCH^MIA. 69
curata col metodo Lombroso in Tornaco," ib., ccxvi, 559. Strambio, "Intorno alia
cura della Pellagra," ib., 17. Cristina, "Pellagra con Tuberculosi curata coll' Acido
Arsenicoso," ib., 190. Manzini and Dotti, "Dell Arsenico nella Cura della Pellagra
e della Pa^zia," ib. 69 ; and see a very long paper by Lussana (" Sulla Cause della
Pellagra), ib., 1872, 351, with discussions on the same by Balardini (ib., 189) and
Lombroso (ib., 221, 351). Lombroso, " Studi Clinici ed Esperimentale sulla Pellagra,"
Bologna, 1871.
Leuchcemia.
Salkowski ('Yirch. ArcH.,' 1, 174, and Hi, 58) has made some curious
clinical researches into Neumann's case of uncomplicated leuchsemia
lienalis (cf. Neumann, * Arch. d. Heilk.,' xi, i). In his last communica-
tion he gives the following analyses of the urine ; its quantity varied,
in the course of ten days, between 560 and 1440 cubic cm. The
proportion of urea varied between io"42 and 27*2 grms., averaging
19*358 grms. The proportion of uric acid varied between "646 and
2*085 ; its mean ii'ioS. Its proportion to the uric acid was i : 17*4,
showing marked increase in the amount of the latter. A little albumen
was always present. There was no lactic acid ; slight traces of formic
and other volatile acids. The author, in conclusion, draws atten-
tion to the fact that Leyden has several times tried galvano-punc-
ture of the spleen, with the only result of causing its temporary
enlargement.
Eeincke (' Centralbl.,' 1871, 222) gives the appearances found post-
mortem in a patient suffering from advanced leuchaemia lienalis. The
retina was beset with numerous small haemorrhages, increasing in
number towards the periphery. These were rounded and prominent,
and present in all the layers of the retina. Eed globules occupied
generally the outer portion, and white cells almost alone their centres.
The optic nerve was normal. He considers that there is, in these cases,
a simple extravasation of leuchsemic blood, and does not agree with
Leber in looking upon them as lymphatic new growths.
Wood (' Amer. Journ. of Med. Science,' Ixii, 373), in a paper on the
"Eelations of Leucocythsemia and Pseudoleuksemia," desires to show that
there is a " third form" of the latter disease, a splenic variety, which he
thinks has been formerly described under the names of tumours of the
spleen, splenic cachexia, &c., and he gives the following case, which
he holds is sufficient to prove the point. A man, set. 30, serving in
the army in Virginia during the rebellion, had suffered severely from
camp-diarrhoea or dysentery. In 1870 he was taken with a dragging
and heavy pain in the back and left side, believed for the next two
months to be rheumatism. During the succeeding two months he
rapidly lost flesh and strength, and in August came under observation.
He was then very thin and weak, though able to walk ; the skin was
pale, the abdomen enlarged, spleen and liver extremely so, with slight
oedema of legs ; there was no increase in the white cells. In October
he died. The spleen, at the autopsy, was eight inches long, five and
three quarters broad, and nearly four thick ; the liver was also much
enlarged; the lymphatics of the thorax, abdomen, and axilla were much
increased in size. The writer proceeds to discuss the question whether
there is any change in the marrow of the bones peculiar to leucocy-
70 REPORT ON PRACTICAL MEDICINE.
thsDmia, and gives three other cases, which presented hyperplasia of the
medullary cells.
Waldeyer, "Diffuse Hyperplasia des Knochenmarkes, Leukamie," ' Virch, Arcli.,'
lii, 305. Neumann, "Kernhaltige Blut-zellen bei Leukamie undbei Neugeborenen,"
* Arch. d. Heilk.,* xii, 187. Id., " Ein neuer Fall von Leukaemia mit Erkrankung des
Knochenmarkes," ib., xiii, 48 1 . Mosler, " Die Pathologic und Therapie der Leukamie,"
Berlin, 1872, 283 (reviewed * Deut. Arch.,' ix, 359). Eames, "Case of Leucocythaemia,"
'Dubl. Journ.,' li, 388; 'Brit. Med. Journ.,' 1871, i, 653. Ward, "Leukaemia Lym-
phatica" (man, set. 24, with autopsy), 'Lancet,' 1872, i, 577. Patchett, "Leucocy-
thaemia, great hypertrophy of spleen, constant deposit of uric acid in urine " (woman,
aet. 23, death from fractured base of skull, autopsy), ib., ib., 682.
Microcyth emia.
Under the term Microcythemia, Vanlair and Masius (' Bull, de 1' Acad.
Med. Beige,' v, 515) describe a morbid state characterised by the
presence in the blood, in considerable numbers, of red cells (microcytes),
distinct from the ordinary blood-cells. One case, that of a young
woman attacked soon after her first confinement, is given in full, and
the paper, which enters at great length into the symptoms, the exami-
nation of the blood and urine, &c., seems to be based upon this case.
The symptoms are described as pains over the epigastrium and spleen,
hypertrophy of the latter, atrophy of the liver, remittent jaundice, tem-
porary aphonia, and paralysis of the limbs. A sister of the patient
was said to have presented the same train of symptoms some years
previously.
Troyressive Muscular Atrophy ; Pseudo-Muscular Sypertrophy.
Martini (" Zur Kenntniss des Atrophia Musculorum Lipomatosa,"
* Centralbl.,' 1871, 641) has examined the muscles of a patient who
died of this affection, both in. the fresh state and after hardening in
chromic acid. He observed in the striated substance round or oval
fissures, at first small, which either had a central position, singly or
in pairs, or were distributed over the transverse section of the primitive
bundle to the number of ten or twelve. The fissures increased from
atrophy of the striated substance or the unchanged septa, till at last
tubular fibres, analogous to the muscles of insects, were formed. Their
contents consisted of a homogeneous protoplasmic mass (serous, as
opposed to simple atrophy). This observation disposes of the view that
in progressive lipomatosis no other change takes place but increase or
decrease in thickness of the muscular fibres. The same change (serous
or tubular atrophy) is found to take place in other cases, in which the
muscles become atrophied through pressure of new and growing tissue
(fat, sarcoma).
Eulenburg (* Virch. Arch.,* liii, 361) records three cases, in which the
affection first showed itself in three sisters successively in the eighth
year of their age. They were the only children of healthy parents, who
do not seem to have presented any hereditary aifection, and were them-
selves quite well up to this period. He gives a full account of the cases,
and compares with them the report by Meryon (' Graz. des Hop.,' 1854,
No. 127) of the occurrence of the affection in four brothers, and another,
MUSCULAR ATROPHY. 71
by his own father (*Deut. Klin.,' 1856), in two brothers. He believes
that the pathological origin of the disease must be looked for in some
congenitally defective formation of the central nervous system, probably
in the cells of the grey substance of the spinal cord.
Vogt (' Berl. Klin. Woch.,' 1871, 26^) contributes a case of progressive
muscular atrophy. The patient, a man, had lived a hard life, and had
suffered from ague and a severe attack of typhoid. The disease had
not made any advance for the last year and a half The treatment con-
sisted of good nutrition. He gives a summary of seventeen cases occur-
ring in the period 1863-71. Of these, thirteen were men, two women,
and two children. He refers the origin of the affection to severe labour
in the majority of cases, to exposure to cold and wet, and in two cases
to typhoid and ague. Generally speaking, the muscles of the ball of
the thumb were first affected, then the deltoid, biceps, triceps, &c. The
same rule seems to hold for the frequency with which these muscles
are attacked separately. The abdominal muscles and the diaphragm
were not affected in any case. No case improved; one only was
stationary.
Grombault ('Arch, de Physiol.,' 1872, iv, ^09) publishes a case of pro-
gressive muscular atrophy, accompanied by glosso-labio-laryngeal
paralysis, in a woman, aet. 58, under the care of Charcot. The autopsy
showed pigmentary degeneration of the nerve-cells of the hypo-glossal
nucleus in the medulla oblongata, &c., sclerosis of the anterior pyramids
and antero -lateral columns ; disorganisation of the anterior grey sub-
stance in parts, yellowish colour of the muscles of the face and upper
extremities, many of the fibres having lost their transverse striae and
undergone granular degeneration. The case confirmed the connection
already pointed out by Charcot, between rigid contraction of the joints,
which existed in this case, and sclerosis of the lateral columns of the
cord (and see 'Gaz. Med.,' 1872, 641).
Knoll (' "Wien. Med. Jahrb.,' 1872, s. i) describes a case of paralysis
pseudo-hypertrophica in a boy aged 13 years. He was the only child of
healthy parents, and no history could be obtained of any former affection.
The muscles of the lower extremities and the lower portion of the trunk
as high up as the last rib, were much enlarged, while those of the upper
part were of the normal size, and especially showed no signs of atrophy.
The apparently hypertrophied muscles were not weak and flabby, as
other observers have noticed, but tough and hard. This condition was
explained by the microscopical examination of a portion of muscle
excised from the left gastrocnemius. The muscle fibres were found to
be separated by broad tracts of fibrous connective tissue, poor in cells,
and interpersed with fine nuclei. This interstitial tissue contained no
fat, either in the form of cells or drops. The fibres themselves showed
marked differences in their diameter. The majority of them were of
moderately normal calibre ; some were less than the normal, others
again exceeded it considerably. No relation could be made out between
their size and that of the masses of interlying connective tissue. The
transverse and longitudinal striation of the fibres was well preserved,
but delicate, and the distance between the former unusually small.
Separate fibres, especially the thicker ones, often split up into two equal
72 REPORT ON PRACTICAL MEDICINE.
parts. (To show that these appearances were not due to any mode of
preparation, he made various comparative researches on muscle from a
boy who had died of acute inflammation of the lungs.)
The muscles examined showed no granular or fatty appearance. He
refers to other investigations in cases of progressive muscular atrophy,
in which a simple, non-fatty degeneration of the fibres has been found,
and he thinks that upon these grounds a sharp distinction between the
two forms of disease can be drawn. He believes that the connective-
tissue induration of the muscle represents an earlier stage of the affec-
tion ; that the fatty infiltration of the muscles, like the lipomatosis
occurring after the division of nerves, is one stage of the same patho-
logical disease. But the development of fat is no essential symptom of
the affection, and Duchenne's name of paralysis pseudo-hypertrophica
is, therefore, still the most convenient. The aff*ected muscles reacted
with a weak induction-current as healthy ones : with a strong current,
only feebly, and without power of locomotion. A long disquisition
succeeds on the contractions occurring in paralysis pseudo-hypertro-
phica, and on the secretion of urea. As to whether the disease be a
primary affection of the muscles, or due to an affection of the central
nervous system, he thinks cannot as yet be decided.
Duchenne (' Gaz. des Hop.,' 1872, 634) publishes a note on the patho-
logical anatomy of pseudo-hypertrophic paralysis in five more cases,
which only confirm his former researches.
Barth, " Beitrage zur Kenntniss der Atrophia Musculorum Lipomatosa *' (man, aet.
44, autopsy), 'Arch. d. Heilk,' xii, 121. Tillaux, " Atrophie Musculaire Consecutive
aux Congelations," 'Bull. Gen. de Therap.,' t. 80, p. 226. Banks, "On Progressive
Muscular Atrophy*' (three cases, one death, autopsy incomplete), ' Brit. Med. Journ./
1871, i, 2. Pepper, "Clinical Lecture on a case of Progressive Muscular Atrophy,"
'Philadelph. Med. Times,' 1871, i. No. 18 (quoted in * Centralbl.,' 1871). Auerbach,
" Eiri Fall von wahren Muskelhypertrophie " (man, a;t. 21), * Virch. Arch.,' liii, 234.
Down, " Case of Paralysis, with apparent Muscular Hypertrophy," * Trans. Patli.
Soc.,' xxi, 24. Id., " Case of Pseudo-hypertrophic Paralysis," ib., 29. Chapot-Duvert,
" Atrophie Musculaire Progressive, guerison au moyen des courants continus," * Bull.
Gen. de Therap.,' t. Ixxi, 134. Orsi, " Cenno sull' Ipermegalia Muscolare, Paralitica,
Progressiva, e Storia Clinica di uno caso della stessa," 'Gaz. Med. Lomb.,' 1872, 117.
Butlin, " Condition of the Muscle in Pseudo-Hypertrophic Muscular Paralysis," * St.
Barth. Hosp. Rep.,' viii (1872), 124. Greenhow, "Case of Progressive Muscular
Atrophy," 'Clin. Soc. Trans.,' v (1872), 210. Davidson, "On Pseudo-Hypertrophic
Muscular Paralysis " (three cases, with photographs, &c.), ' Glasg. Med. Journ.,' iv,
289.
Diabetes,
Zimmer (" Die Nachste Ursache des Diabetes Mellitus ;" * Deut.
Klin.,' 1871, 41) quotes the experiments of Bernard, Pavy, &c., to show
that the production of sugar from glycogen is increased in the liver by
great congestion, in the muscles by contraction, and in the whole body
by large venesections. The mode of working in all these cases he finds
in the larger amount of water acting as a ferment upon the glycogen of
the different organs. The same process-occurs in artificial diabetes, only
in larger amount and for a longer time. In Bernard's experiment of
pricking the floor of the fourth ventricle, in division of the splanchnic
nerve, in destruction of the upper cervical ganglion, or extirpation of
DIABETES EHEUMATISM. 73
the solar ganglion (Klebs), the same result occurs. In all there is
paralysis of the contractile elements of the blood-vessels in tlie liver ;
and in all these he sees tlie same action of the water, the same fermen-
tation of the glycogen, the same swelling of tlie liver cells, which he
believes to be at the bottom of what may be distinguished as two forms
of artificial diabetes, the one produced by paralysis of the vessels, the
other by changes in the nutrition of the cells, of the liver. In the same
way he explains the occurrence of diabetes in men. In autopsies of these
cases the liver is frequently found filled with blood.
Salinger (' Beitrag. zur Diagnose des Diabetes Mellitus,' ib., 306)
holds that the nature of a disease is identical with its seat in any given
organ to which it may be referred, and, therefore, the mucous mem-
brane of the digestive organs is the original seat of diabetes. So long
as arterial blood contains no sugar, none can be abstracted by any of
the organs, nor, consequently, taken up by the veins or lymphatics.
If, however, sugar be found in the vena cava and right ventricle, it
must have entered by the thoracic duct and the capillaries of the
small intestine ; consequently the intestinal mucous membrane is the
only seat of the formation of sugar (!).
Kratschmer (' Wien. Med. Woch.,' 1871, No. 8) concludes from his
researches into the action of opium and morphia in diabetes, that
patients affected with this disease easily bear large doses of opium ; and
that not only is the secretion of sugar considerably diminished by the
drug, but even arrested for a shorter or longer period. The same result
follows the use of morphia.
Donkin, " The Skim-milk Treatment of Diabetes and Bright's Disease, with Clinica
Observations on the Symptoms and Pathology of these Affections," London, 187 1,
pp.317. Bouchardat, " Eaux de Vals dans la Glycosurie," ' Gaz. des Hop.,' 1872,
421. Duboue, "De TOdeur Acide de I'Haleine comme signe Diagnostique du Dia-
bete," ib., 802. Salomon, " Geschichte der Glycosurie von Hippokrates bis zuni
Anfauge des 19 Jahrhunderts," *Deut. Arch.,' viii, 489. Sedgwick, " On Temporary
Glycosuria as a sequel of Cholera," 'Med.-Chir. Trans.,' liv, 63. Nicol, "Case of
Diabetes Mellitus under Milk-treatment: death" (boy, set. 15, the autopsy showed
slight atheroma of the aortic valves and aorta, fatty liver and (probably) kidneys,
slight milkiness of the arachnoid, other organs normal), 'Brit. Med. Journ.,' 187 1, ii,
64. Smith, "Case of Acute Diabetes, with Clinical Eemarks " (boy, set. i6, no
autopsy), ib., ib., 728. Donkin, " Further Observations on the Skim-milk Treatment
of Diabetes Mellitus," 'Lancet,' 187 1, i, 603. Pyle, " Cases (two) of Diabetes," ib.,
1872, i, 718. Balfour, "On the Treatment of Diabetes by Lactic Acid " (seven cases),
* Edin. Journ.,' xvii, 533. Gueneau de Mussy, " Etudes sur la Traitement de la
Polyurie," * Gaz. des Hop.,' 187 1, 389.
Rheumatism.
Ferber (' Arch. d. Heilk.,' xii, 80) gives the further history and
autopsy of a boy whose case he had already recorded (see last ^ Report,'
p. 99). The patient suff'ered from joint-affection, chorea and heart
disease. The attacks of rheumatism were repeated frequently, accom-
panied by a cluster of enlarged cervical glands, such as occurs in spinal
meningitis. The brain and spinal cord were not examined ; the pericar-
dium* was completely adherent ; the valves were deficient, and the
muscle fatty. He gives a case of the same kind still under treatment.
The patient was a boy of two years and eight months, whose father
74 EEPORT ON PRACTICAL MEDICINE.
had had rheumatism, and whose grandfather had suffered from convul-
sions and paralysis. In May and September of 1 868 the child had had
two attacks of eclampsia. In April, 1869, there was swelling of both his
feet, with fever. This was followed by choreic movement of the hands
and face, and head symptoms. By the end of May the child was com-
pletely well. The same attack occurred a year later, and at this time
a rasping murmur was heard over the heart, disappearing soon after-
wards. The patient was well again by the middle of May. The author
looks upon this case as one, not of simple articular rheumatism, but of
meningeal affection.
Andrew (' Clin. Soc. Trans.,' v. 229) gives the case of a boy, aet. 16,
in whom a wide daily range of temperature in rheumatism was asso-
ciated with disease of the heart, vegetations on the mitral valve, and
infarction of the spleen.
Handfield Jones ('Lancet,' 1871, ii, 6^6) gives a summary of five
cases of acute rheumatism, treated with drugs. He concludes that the
affection has no fixed period of continuance, but is on the contrary subject
to very considerable variations. These, he thinks, depend on the quality
of the individual system, by which also the choice of remedies should
be guided. He gives alkalies in cases where the urine and sweat are
acid ; where the pulse is small and the patient weak they are injurious ;
in such cases quinine in full doses is very often of great service.
Blisters, which are valuable agents in relieving pain, do not curtail the
course of the disease ; in some cases they add to the nervous irritabi-
lity. Purgatives should always be given at the outset, and when the
tongue is foul, &c. The subcutaneous injection of atropia is generally
the best remedy for the pain.
Foster (' Brit. Med. Jour.,' 187 1, ii, 722) gives an account of articular
pains, resembling in all particulars those of rheumatic fever, observed
in two diabetic patients, to whom lactic acid had been administered.
Esmarch (*Berl. Klin. "Woch.,' 187 1, 422) employs ice continuously
till all the symptoms of acute rheumatism have disappeared. He
records four cases in which it was used with the very best results. He
lays stress on the difference between this employment of ice and cold
applications, asserting that the latter may, from the continual change of
cold and warmth, make the affection worse.
Roth (' Virch. Arch.,' liv, 375) gives an account, with plates, of the
autopsy of a pig, six months old, which eight days before death was
seized with loss of appetite, and symptoms resembling those of so-
called malignant erysipelas. The free edges of the tricuspid were
thickened ; vegetations were present on the other three sets of valves ;
both hip-joints, the right knee, and left shoulder-joint had increased
fluid, and thickened and hyperaemic synovial membranes. He concludes
from the alterations found, that this was a case of recurrent valvular
endocarditis combined with recent inflammation of the joints.*
Fox, " On the Treatment of Hyperpyrexia, as illustrated in Acute Articular Rheu-
matism by means of the External Application of Cold," London, 187 1, pp. 78.
Anderson, "Cerebral Rheumatism" (3 cases, no marked post-mortem appearances),
* Brit. Med. Journ.,' 1871, i, 529. Gillard, "The Treatment of Acute Rheumatism.
* Might this not be a case of pyaemia ? — A. B. S.
SCURVY — RICKETS. 75
by Morphia Injection," ib., ib., ii8. Ridge, "On Rheumatism," 'Mod. Times' and
Gaz.,' 187 1, ii, 185. Moxon, " Case of Cerebral Rheumatism treated by Cold Bath"
(man, aet. 23, highest temperature 106-2°, recovery), ib., ib., 243. Sutton, " Case of
Rheumatic Fever with Moderately High Temperature, successfully treated by Baths "
(girl, set. 16, first attack, mitral systolic bruit, highest temperature, io4-4°), 'Lancet/
1872, i, 46. Ogle, "Severe Case of Acute Rheumatic Fever" (man, set. 23), ib.,
1871, i, 445. Id., " Several Cases of Rheumatic Fever," ib., ib., 682. Silver, "Case
of Rheumatism treated with Veratrum Viride," ib., ib., 193. Weber, "A Case of
Hyperpyrexia (heatstroke) in Rheumatic Fever, successfully treated by Cold Baths
and Affusions," 'Clin. Soc. Trans.,' v (1872), 136. Russell, "Case of Rheumatic
Pericarditis and Pleurisy (girl, set. 12, affected with chorea); "A Case of Double
Pleurisy" (boy, set. 15), each with very slight rheumatic development, 'Med. Times
and Gaz.,' 1872, i, 487. Fox, " Case of Acute Rheumatism, Death" (negro, aet. 27,
autopsy, highest temperature io5'3°), 'Glasgow Med. Journ.,' iv, 403. Southey,
"Acute Rheumatism with Cerebral Symptoms and High Temperature (i05'5°) treated
unsuccessfully by Cold Affusion" (man, set. 35, autopsy), 'Lancet,' 1872, ii, 562.
Russell, " Death from Obstruction of the Pulmonary Artery in the course of Peri-
carditis occurring during the fifth attack of Acute Rheumatism," ib., ib., 707.
Scurvy ; Purpura, Sfc.
The greater number of writers on scurvy during the last two years
are to be found among the French, who seem to have had good reasons
to observe the affection during and after the late war, at Paris and
elsewhere.
Hayem (' Graz. Hebd.,' viii, 227) gives a sketch of the affection based
on forty cases ; he recognises a primary and secondary form, the latter
occurring after typhus, tuberculosis, &c. He also gives a note of eight
autopsies (and see *Graz. Med.,' 1871, 127, ib., 157).
Chalvet (' Union Med.,' t. xii, p. 525) finds the blood of scorbutic
patients is more fluid and paler than normal, resolving itself into an ex-
tremely dense, small clot, with an unwonted amount of serum. Becquerel
and Rodin had found an increase in the number of red cells ; but Chalvet
finds the reverse. The amount of water and albumen is increased.
Legroux, " Le Scorbut," 'Gaz. Hebd.,' viii, 97. Verneuil, " Du Scorbut Compli-
quent les Lesions Traumatiques," ib., 149. Bucquoy, " Le Scorbut a I'Hopital Cochin
pendant le Siege de Paris," ib. 321. Lasegue, " L'^Spidemie de Scorbut dans les
Prisons de la Seine et a I'Hopital de la Pitie," 'Arch. Gen.,' xviii, 5. Leven,
"Une ^pidemie de Scorbut Observee a I'Hopital Militaire d'lvry pendant le Siege
de Paris," 'Gaz. Med.,' 1871, 431. Laboulbene, " Sur I'Examen Microscopique
du sang dans le Scorbut Observe a Paris en 1871," 'Compt. Rend.,' Ixxii, 411.
Poncet, "Observation d'Hemophilie : autopsie" (boy, set. 16), 'Rev, Med.,' 1872, i,
41. Legg, "Four Cases of Haemophilia," 'St. Barth. Hosp. Rep.,' vii, 23. Ward,
"Case of Purpuric Fever" (with autopsy), 'Lancet,' 1871, i, 647. Id., "Seven Cases
of Scurvy," ib., ii, 397. Brigstocke, "Cases of Hsemophilia," 'Brit. Med. Journ.,'
1872, ii, 122.
Rickets.
Eitchie ('Med. Times and Gaz.,' 1871, i, 9) observed the morning
and evening temperature of eleven children affected with uncomplicated
rickets for eight days. The bulb was placed in the rectum for five
minutes between 9 and 10 a.m. and p.m. The ages of the children
ranged between 10 months and 3 years. The mean result thus
obtained was 99*13° ^. for the morning and 97*44° for the evening.
Fleischmann (' Wien. Med. Woch.,' 187 1, No. 50) treats of rachitis
76 REPORT ON PRACTICAL MEDICINE.
with especial reference to the pause in the development of the teeth.
On the average a month, to a month and a half, occurs between the
appearance of the several incisors, and two, to two and a half months,
between that of the several canine and back teeth ; so that the twenty
milk teeth are appearing up to the end of the second year. Generally
after the eruption of the incisors, between them and the first back
teeth, the first symptom of rickets is shown in the cessation of the
tooth development. This is followed by the other symptoms, and the
later teeth are cut before they are fully formed.
Grunhut and Jay, " Three Cases of Rachitis in Children," * Amer. Journ. of Obstet.,
&c.,' 1871 (August), p. 317. Parry, " Rachitis" (case of coloured boy, set. 9 months,
with autopsy), 'Amer. Journ. Med. Sci.,' Ixi, 427. Id., "Observations on tho
Frequency and Symptoms of Rachitis, with the Results of the Author's Clinical
Experience," ib., Ixiii, 17,
AddisorCs disease.
Laschkewitsch publishes (' Wien. Med. Jahrb.,' 187 1, 425) the follow-
ing : — A strong and well-nourished man of 45 suft'ered from excessive
weakness, palpitation, dyspnoea and headache. He was extremely anaemic,
the mucous membrane of his lips, &c., livid, his hands and feet oedema-
tous. His red blood-corpuscles were found to be paler and larger than
normal, and underwent certain changes of form, becoming club or worm-
shaped. Processes were protruded from them and again retracted.
Lastly they broke up into fragments. The addition of weak acetic acid
accelerated the phenomena. Heat and electricity made no difference.
The patient's condition improved in the course of a month under tonics ;
the numerical proportion of the red cells increased ; they became
intensely coloured, but still retained the capability of undergoing change
in form. Three months later the patient returned with bronze colour-
ation of the face, neck, nipples, scrotum, &c.
Tuckwell ('St. Earth. Hosp. Eep.,' 1871, 73) gives a case of
Addison's disease in a woman set. 31, with a full account of the post-
mortem examination and the microscopic appearances found in the
capsules. The latter were enlarged, hard and nodulated, on section
toughly fibrous, with a dull white surface studded with small bright yellow
spots. There was very great increase of connective tissue about the
supra-renal plexus, the semi-lunar ganglion, and great splanchnic
nerve. He opposes at length the views of Rossbach,* and in his con-
clusion on the nature and pathology of this disease agrees with those of
most English writers on the subject.
Payne ('Path. Soc. Trans.,' xxii, 281) records a case of Addison's
disease in a man set. 32, in whom the softened and broken-down
capsules were accompanied by a sooty colour of the genitals only, at
any rate to any perceptible degree, and by a deposit of pigment in the
connective-tissue cells of the pia mater covering the medulla oblongata
and first two or three inches of the medulla spinalis.
Gilliam, " Identity of Addison's Disease and Degeneration of the Gastric Tubules,"
*Phil. Med. Surg. Rep.,' 1871, xxiv, 473. Churchill, "Effects of Ether Spray upon
the Skin in Addison's Disease," 'Path. Soc. Trans.,' xxii, 3 1 7. Quain and Silver,
* Cf. last Biennial Report,' p. 87.
ANIMAL PARASITES. 77
♦' Addison's Disease^' (man, set. 24, capsules cretified), ib., 280. Finlayson, " On a Case
(f Addison's Disease " (man, set. ^^), * Glasgow Med. Journ.,' iii, 433. Marshall,
" Case of Bronzed Skin, chronic disease of the membranes of the brain, perforation
of the skull, abcesses of the scalp, death " (male, at. 63, autopsy), ib., iv, 355. Moore,
'• Case of Bronzed Skin without Disease of the Suprarenal Capsules," ' Dubl. Quart.
Journ.,' li, 80. Russell, " Hereditary Bronze Colour of the Skin simulating Addison's
Disease,^' *Med. Times and Gaz.,' 1871, i, 57. Nicholson, "Addison's Disease"
(l)oy, set. 14, autopsy), 'Brit. Med. Journ.,' 1872, ii, 121. Merkel, *' Ein Fall von
Bronce-Haut ohne Nebenuieren-erkrankung," * Deut. Arch.,' x, 205.
Exophthalmic GoUre.
Galezowski ("Etude sur le goitre Exophthialinique," 'Gaz. des.
]Iop.,' 1 871, 42^) gives a general sketch of the affection, claiming for
Demours the first description of it in 181 8. He considers the affection
to be a nervine one, accompanying lesion of the sympathetic nerve,
such as Lancereaux and Peter found in one case in the hypertrophy
and hypersBmia of the inferior cervical ganglion. He thinks the pro-
I trusion of the eye is due to the contraction of the small muscles in
I Tenon's capsule, supplied by that nerve.
Emmert (" Historische notiz iiber Morbus Basedowi, nebst lieferat
iiber 20 selbst beobachtete Falle dieser Krankheit," * Arch. f.
Ophthal.,' xvii, 203) gives the first description to an Englishman (' Col-
lections from the unpublished writings of the late C. H. Parry,' 182^).
Meyer ('Berl. Klin. Woch.,' 1872, 468) gives four cases of this
affection in females in which good results were obtained by galvanizing
the cervical sympathetic.
Hutchinson, "Cases of Basedow's Disease" (four females), 'Lancet,' 1872, i,
538. Patchett, " Exophthalmic Goitre, unusual severity of symptoms, ulcer of
coruea, cured" (woman, set. 27), ib., ib., 827.
I Animal Parasites.
Udhe (* Yirch. Arch.,' Iii, 439) gives a table showing that of 87,111
I pigs killed in the duchy of Brunswick, from Easter 1868 to 1869, six
ionly were found to have trichinae. Petri (ib., 440) gives another table
iof all the pigs (5688) slaughtered at Hostock in 1870 : one only was
found affected (cf. last 'Eeport').
In the * Second Annual Eeport of State Board of Health in Massa-
chusetts' (1871) may be found (p. 46) a report on " Trichina Disease
I in Massachusetts." The history and symptoms of the affection are
I given, and an account of outbreaks of it in 1870, one in Saxonville and
the other in Lowell. In the first, three out of a family of six, who had
'eaten underdone fresh fried pork, were attacked, two boys, set. 14 and
19, and their sister set. 17. The eldest boy died with symptoms of
(typhoid fever. In the second case — badly reported — a mother and four
children ate portions of raw smoked ham {i. e. not even slightly cooked,
as the father took it) and became affected. Living trichinae were
found in fragments of the ham examined. As to prevention — a tem-
iperature of 150° to 160° E. is fatal to the trichina. Pickling may and
does probably render the pork harmless, smoking does not. Uncooked
pork muscle, i. e. the lean portion (for trichinae are not harboured in
the fat), can never be eaten with safety.
78 REPORT ON PRACTICAL MEDICINE.
Kittel (*Wien. Med. Zeitung,' 1871, 254) describes an epidemic of
trichina disease at Libau in Saxony. Over 90 people were attacked
with very severe symptoms after eating the flesh of a diseased pig, and
sausages made from it. He calls especial attention to the symptoms
observed in the eyes. The patients had a peculiarly fixed stare, with,
at any rate at first, perfectly free movement of the eyeball. The latter
decreased as other symptoms of the presence of the trichinaB in the
muscles of the eye showed themselves. Simultaneously occurred obsti-
nate mydriasis, which the author refers to paralysis of the third nerve ,
(the short root of the ciliary ganglion). 1
Maurer (" Eine Trichinosisgruppe aus Bay em," * Deut. Arch.,' viii,
368) gives an account of an outbreak of trichinosis, rare in the south
of Germany, at Erlangen. Almost all the cases could be traced to one
butcher's shop. One patient, already aflfected with phthisis, died ; and
the post-mortem inspection proved the presence of trichinae.
Zenker ("Zur Lehre von der Trichinenkrankheit," ib., 387) puts
together the above case of Maurer's with other autopsies of cases of
trichinosis occurring in Bavaria (three in Wiirzburg, and two in
Erlangen). In opposition to the vulgar opinion, he holds that the
rarity of the aff'ection is due to the small quantity of raw flesh eaten, not
to the rare occurrence of affected pigs. The latter is contradicted by the
frequent occurrence of trichinae in rats. In opposition, too, to the
views of Leuckart, Pagenstecker, and others, he considers these
animals as affected secondarily, and as a consequence of affected pigs in
the same neighbourhood. Erom materials gathered in Saxony, Bavaria,
"Wiirtemberg, and Austria, he deduces certain averages as to the fre-
quency of trichinae in rats. At the same time he sees no reason to
doubt the truth of KUhn's observations, that these trichinous rats are
eaten by pigs.* Tlie author concludes by giving certain veterinary
advice which may conduce to the prevention of trichinosis among rats.
Eeeb (' Rec. de M^m. de M6d.,' xxvii, 31) gives two cases of hy-
datids of the brain, the first in a boy aet. 5 years, in whom the most
marked symptoms were a left-sided chorea, and affections of the sight
accompanied by dilated, uncontracting pupils, and atrophy of the optic
nerve. A prominence was gradually developed on the right parietal
bone, becoming soft and pulsatile, then gradually disappeared. Later
on the tumour again appeared, increased in size, with fluctuating con-
tents. It was twice punctured, seventy -two grammes of liquid being
removed the first time, and seventy the second. Convulsions of a
tetanic character set in some time before death. At the autopsy were
found three communicating cysts, one subcutaneous, the second
between the bone and the dura mater, and the third, larger, in the
* The taste of these animals is as varied as that of the higher ones who devour
them. The pigs of Estremadura are said to eat locusts ; and, according to Ford
('Murray's Handbook for Spain/ 1869, part ii, p. 176), the Duke of Arcos shut up
his pigs in places abounding in vipers, on which they fattened. Of " ces petits
jambons vermeils" the Due de St. Simon (' Mem./ xx, 30) writes with infinite gusto,
" Ces jambons ont un parfum si admirable, un gout si releve et si vivifiant, qu'on
est surpris ; il est impossible de rien manger si exquis." Cobbold (* Brit. Med. Journ.,'
i87i,ii, 394) draws attention to another entozoon {Stephanurus dentatus) found in
the hogs of America and Australia. — A. B. S.
DISEASES OF THE NERVOUS SYSTEM. 79
posterior lobe of the right hemisphere, surrounded by a thin layer
only of brain substance. This further communicated with the lateral
and middle ventricles, and terminated in a vast pouch in the posterior
lobe of the left hemisphere. Numerous hydatids were found through-
out the cavities. The whole brain, including the central ganglia, was
more or less softened. The second case is that of a boy, set. i8, who
after frequent attacks of intermittent fever suffered from acute supra-
orbital neuralgia. Hemiplegia, followed by coma, occurred, and four
days later he died. Post-mortem, the whole right hemisphere was found
to be destroyed by a large cyst filled with hydatids. As in the former
case, it was surrounded by a thin layer of brain substance, but was
compressed by the skull bones.
Zuber ('Gaz. des Hop.,' 1872, 730) records the occurrence of two
hydatid cysts in the lung of a man, aged 22. The symptoms were those
of acute tuberculosis. Eupture of one sac took place into the pleura
and was followed by death.
Hirschberg (' Berl. Klin. Woch.,' 1872) removed cysticerci from the
eye of a woman and of a boy.
The ' Lyon Med.' (x, 341) quotes a case recorded by Armour
('Detroit E-eview of Med.'), in which portions of taenia solium were
passed by a child three days old.
Dickinson, "Three Cases of Trichiniasis after Eating Home-fed Pork," 'Brit.
Med. Journ./ 1871, i, 446. Huber, "Einige Notizen iiber Echinococcus Multilocu-
laris," *Virch. Arch.,' liv, 269. Froramann, " Zur Casuistik der Trichiniasis,'' ib.,
liii, 501. Fagge and Durham, "On the Electrolytic Treatment of Hydatid Tumours
of the Liver," 'Med.-Chir. Trans.,' liv, 1. Giraud-Teulon, ** Cysticercus Ladrique
(C. cellulosae) dans le corps vitre," 'Gaz. des Hop.,' 1872, 12. Surmay, "Tenia Mul-
tiple," ib., 900. Leidy, " Taenia caused by the use of Raw Beef (T. medio-canellata),"
'Amer. Journ. Med. Sci.,' Ixii, 293. Preston, "A Lumbricus discharged through an
Abscess about the Hip-joint" (boy, set. 13), 'Lancet,' 1872, ii, 777. Welch, "The
presence of an Encysted Echinorhynchus in Man," ib., ib., 703.
Vegetable Parasites.
Richter (*Zeitschr. f. Parasitenk.,' iii, i) finds, on examining the
central portion of warts, an extremely large number of micrococci in
and between the epithelial cells, and on placing them in a solution of
ammonia and sugar obtains numerous and largely branched mycelia.
Hallier ("Des Parasiten des Infections Krankheiten," 'Zeitschr. f.
Parasitenk.,' ib., 157) publishes the results of his experiments on the
faeces of sheep which died of foot-and-mouth disease.
Tuckwell (' St. Barth. Hosp. Eep.,' viii, i2j) writes on the ringworm
of cattle and its communicability to man.
B. Diseases of the Nervous System.
Hysteria,
Charcot (' Gaz. des Hop.,' 1871, ^^6) gives a lecture on two cases of
hysterical contraction of the limbs, one, a woman aged 40, representing
the hemiplegic type, the other, a girl aged 21, representing the paraplegic
type of the afiection.
80 REPORT ON PRACTICAL MEDICINE.
Jamieson ('Edin. Journ.,' xvii, 29) gives a case of "trance" in an
hysterical girl, aged 16 years.
'in a clinical lecture on supposed cases of hysteria, EuUer ('Brit.
Med. Journ.,' 1871, ii, 610) draws attention to the necessity of noting
carefully all the symptoms, and mentions two cases of supposed
hypochondriasis or hysteria, in which the symptoms during life, and the
immediate cause of death, were due in one case to abscess of the brain,
in the other to a small aneurism causing erosion of the spine.
Tilt (ib., ib., 690) attacks the views with regard to hysteria held " by
men who own they know nothing about diseases of women ; " quotes
the opinion of Chambers, Eussell Reynolds, and Handfield Jones, &c.,
and thinks that to understand rightly hysteria, catalepsy and epilepsy,
"the diseases of the ganglionic nervous system" should be studied.
Rosenthal ("Ueber vasomotorische Innervationsstorungen bei Hy-
steric," '"Wien. Med. Zeitg.,' 187 1, 182) records a fresh case of
analgesia with no loss of the sense of touch, in an hysterical girl. He
refers to the fact that in hysterical patients the anaesthesia and analgesia
are regularly distributed according to^the limits of cutaneous nerve-terri-
tories established by Voigt, and gives an interesting case illustrating
certain changes in the vasomotor system. A young woman, aged 23,
had suffered from hysterical and cataleptic attacks which had ceased
for two years, but returned again in consequence of a blow which set
up inflammation in the left mamma. These attacks were accompanied
by a fall in the temperature of the hands from 93*9° F. to 87°, and in
the pulse from 72 to 65 ; by paleness and coldness of the fingers and
nails ; loss of consciousness and convulsions. The attack lasted from
a quarter to half an hour. On the return of consciousness the pulse
and temperature rose again ; there was positive, as well as subjective,
feeling of warmth, redness of the nails, and cutaneous perspiration.
The time just before these attacks was marked by hyperaesthesia, which
was rarely noticed on days which were free from them ; it was present
in various parts of the trunk, more frequently on the left than the right
side ; sometimes in the left upper and right lower extremity. At the
onset and termination of the attack there was anaesthesia. Reflex
movement could be excited in the hands and fingers, while the patient
was still unconscious, and her pupils not acting, and were sure signs of
her soon coming to herself. Morphia injections were employed, and
recovery was complete on the return of the catamenia after their absence
for several months.
Ferguson (' Lancet,' 1872, ii, 78) records a case of hysteria in a young
girl, from whom loi pins and needles were removed from the arms and
legs.
Hodges, " Hysterical Closure of Right Eyelids cured by Galvanism," * Lancet,'
1871, i, 378. Bazin, "Observation d'Apbasie Hysterique" (in a pregnant woman!),
* Gaz. des Hop / 1871, 446. Corlieu, " Anesthesie Musculaire et Cutanee Occasionnee
par un Refroidissement, ou Nevrose Cataleptiforme Hemiplegique," * L'Union Med./
xii, 376. Waleher, "Observation de Nevrose Cataleptiforme simulee," ib., ib., 436.
Kraft-Ebing, " Ein Beitrag zur Erkennung und Bebandlung der Hysterischeu Lah-
mungen" (hysterical paraplegia cured by electricity), 'Berl. Klin. Woch.,' 1871,
529. Silver, " Hysterical Ptosis," 'Lancet,' 1872, ii, 117. Aitchison, "A Case of
Feigned Disease," 'Brit. Med. Journ.,' 1872, ii, 120. Foss, "Notes of a Fatal Case
of Hysteria " (girl, set. 19, autopsy), ib., il)., 9.
CHOREA. 81
Chorea.
Handfield Jones ('Med. Press and Circ.,' 1872, i, 24) records fiye
eases of chorea ; in one girl set. 7 years, and two, set. 13, in each of
whom the aifection lasted six weeks ; in a girl of 18, in whom its dura-
tion was doubtful, and in whom there was a curious mingling of motor
and mental disorders; and in one boy set. 10 years, in whom its dura-
tion was about eleven weeks. These cases illustrate the following
points, (i) The tendency of chorea proper — motor centre disorder —
to be attended with an analogous state of the emotional or of the intel-
lectual centres ; (2) its liability to occur in a modified form, and to be
complicated with quasi-epileptic attacks ; (3) the absence of rheumatism
or definite endocarditis in alJ the cases ; (4) the varying duration and
causation of chorea; (5) the certainty that the same remedy is not
suitable to all cases ; (6) the increased excretion of urinary solids which
not unfrequently occurs in chorea.
Butlin communicates to the * Lancet' (1871, ii, ^76, 606) twelve
cases of chorea in children between the ages of 7 and 10 years, treated
with sulphate of zinc.
Gray and Tuckwell (ib., ii, 778) give a series of eighteen cases, six
under the observation of the former, and twelve under that of the latter.
In none of these was any special treatment adopted from the first onset
to the complete disappearance of the symptoms, calculated to influence
the nervous system. Good diet, the better hygienic conditions of the
infirmary, and peppermint water were the only means employed. The
cases show well how remarkably chorea is liable to vary in its duration.
The most protracted case in Gray's list lasted twenty weeks, the
shortest six weeks ; the longest of Tuck well's cases seventeen weeks,
the shortest six weeks. The average duration of Gray's six cases is ten
w eeks and one day ; of Tuckwell's twelve cases, ten weeks and three
days. These averages have a remarkable identity with the results obtained
by the use of various drugs. Gray finds the average of seven cases,
taken at random, and treated with arsenic, steel, &c., to be ten weeks
^nd two days. The mean duration of eight cases treated in succession
by Tuckwell with arsenic in gradually increasing doses, after Begbie's
plan, was ten weeks and six days ; the longest case lasting sixteen, the
shortest seven weeks. Hillier puts the mean duration of thirty cases
at " about ten weeks." See gives sixty-nine days as the average dura-
tion of 1 1 7 cases.
Buzzard ('Brit. Med. Journ,,' 1872, i, 342) showed to the Clinical
Society a female set. 25, with atrophy of the right side of her face,
ifter chorea.
Spender, " Two Cases of Severe Chorea rapidly Cured by Arsenic,'* ' Brit. Med.
lourn.,' 187 1, ii, 429. Andrews, " Case of Chorea with Mitral Regurgitation, treated
lyConium" (boy, a^t. 12), ib., i, 612. Lane, "Chorea arising from a blow," ib.,
1S72, i, 525. Sawyer, "Chorea following Acute Rheumatism," ib., ib., 527. Ogle,
■ Three Cases of Chorea (two girls, aet. 14 and 19, and a boy, set. 18), ' Lancet,' 1871,
i, 541. Dickinson, " On Chorea," ib., i, 504. Hughlings Jackson, ** Remarks on a
Ji'.se of Chorea in a Dog," ib., 1872, i, 148. Radcliffe, " Case of Clonic Spasms,
)ccurring only when the patient (girl, aet. 21) attempts to stand," ib., ib.
6
82 KEPORT ON PRACTICAL MEDICINE.
Epilepsy.
Brown-Sequard (' Arch, de Physiol.,' 1872, iv, 204) has arrested the
fits of epilepsy which have been provoked in guinea-pigs, by section of
a portion of the spinal cord, or of the sciatic nerve, by irritating
the throat or larynx by carbonic acid gas. The strength of the
gas must be such as to be almost insupportable by the experimenter,
and must be injected with a certain amount of force. Injection of the
gas simply into the nose of the animal is insufficient, though the case
may be different in the human subject. The author has also verified
the experiments of Rosenthal, that pulmonary insufflation arrests the
epileptic attacks provoked by strychnine. At the same time he looks
upon the explanation given as absolutely false, and thinks the arrest to
be due not to superoxygenation of the blood, but to the mechanical
irritation of the air upon the branches of the vagus distributed to the
bronchi, and to the nerves of the diaphragm. The same results followed
the same experiments made on pigeons and a duck.
The same writer (' G-az. Med.,' 1872, 466) communicates to the
Societe de Biologic the experiments he has made to determine the path
followed by irritation, which has been set up by section of the sciatic
nerve, in order to reach the upper part of the spinal cord, and produce
attacks of epilepsy. Section of the nerve, high up, and especially
removal of the nerve, constantly produce epilepsy. But section of the
cord immediately above the origin of the nerve does not do so. This
unexpected fact makes him think that the epileptic symptoms are not
due to section of fibres of the sciatic, but rather to section of fibres of
the sympathetic contained in the sciatic nerve. He therefore attempted
to divide the Hlaments of the sympathetic passing to the sciatic, but the ■
task was difficult, and the results transient. On the other hand, section ;
of the last dorsal and first lumbar roots, which furnish sympathetic!
filaments to the sciatic, did produce epilepsy. He thinks, therefore, i
that artificially produced epilepsy is probably due to section of the]
sympathetic nerve.
Westphal (' Berl. Klin. Woch.,' 187 1, 448) has repeated and confirmed
the experiments made by Brown-Sequard on guinea-pigs with reference
to the artificial production of epilepsy (see last 'Report,' 107).
Another interesting and new fact is shown by these experiments — that
a blow on the head may set up in guinea-pigs the same epileptiform
condition as direct injury to the cord, or section of the sciatic nerve.
Immediately or soon after the blow an attack of general convulsion, or
a series of attacks, occur. At this time there is no "epileptogenic^"
zone of skin, by irritating which even slightly general convulsions may
be provoked ; four or five weeks later, however, a cutaneous zone may
be found, irritation of which provokes at first certain reflex movements,
and later the epileptiform attacks. This zone has the same position-
near the angle of the lower jaw — as in Brown-Sequard's experiments,
and its local sensibility is diminished. The epileptiform condition lasts
from one and a half to two or more months, and gradually disappears.
A female guinea-pig, which had been rendered epileptic by a blow, gave
birth to two young ones, in whom, on irritating the " epileptogenic
EPILEPSY. 83
zone," incomplete but well-marked convulsions could be provoked. In
all the experiments the same lesion was found, in the medulla oblongata,
or upper cervical region of the cord, small hseraorrhages, generally into
the sac of the spinal dura mater, less frequently at the base of the
brain. According to Brown-Sequard, the essential lesion is more pro-
bably that in the spinal cord than the medulla oblongata. Whether
this spinal-cord-epilepsy, produced artificially in guinea-pigs, occurs in
the human subject, cannot be decided at present. He refers to some-
thing resembling the " epileptogenous zone " in some cases of epilepsy
in men.
In the discussion which followed the reading of this paper (ibid.,
6i6), V. Langenbeck remarked that epileptic convulsions do sometimes
occur in the human subject after injuries, especially injuries to the
head, and related a case of the kind occurring in a man set. 44. (And
see discussions in the 'Societe de Biol.,' ' Gaz. Med.,' 1872, 641.)
Martin ('Wien. Med. Ztng.,' 1871, No. 53) gives a case of epileptic
fits in a man who had had an injury to the lower part of the thigh ; the
fits disappeared on the removal of some loose bone.
The 'Lancet' (1871, i, ^^6) quotes the opinion of Vance, of New
York, that two well-marked groups of epilepsy may be formed in accord-
ance with the appearances found with the ophthalmoscope ; the one
characterised by hyperaemia, the other by ansBmia of the retina. " As
the brain is anaemic during sleep, it is natural to suppose that the
occurrence of sleep would be a predisposing cause of the fits in the
anaemic form, whilst in the congestive form they would-be most likely
to take place during the day." Bromide of potassium and depletion
are, according to him, indicated in the congestive form ; quinine, iron,
and strychnia in the anaemic.
iLutz (' Berl. Klin. Woch.,' 1871, 212) employed bromide of potassium
in ten cases ; in three patients no attacks occurred after six months ;
in two others the cure was longer ; five were still under treatment. He
began with one to three grains, daily increased to ten to twenty grains.
He found it successful in a case of nocturnal incontinence in a girl of
1 8, and in nervous headache. He thinks that he found the best results
from a combination of the drug with bromide of ammonium.
Magnan, "Epilepsie Absinthique," 'Compt. Rend.,' Ixxiii, 341. Bussiere, " De la
auerison des Necroses Convulsives, du meilleur mode d'administration du Bromure
le Potassium," * Gaz. des Hop.,' 187 1, 501 (three cases of convulsive neurosis,
•ured with the Syrup of H. Mure.). Huppert, " Ein Fall von Balkenmangel bei
•inem Epileptischen Idioten," 'Arch. d. Heilk.,' xii, 243. Auerbach, "Ueber Be-
landlung der Epilepsie, nebst Krankenvorstellung," 'Berl. Klin. Woch.,' 187 1,
|22. Handfield Jones, "Epilepsy and other Nervous Affections resulting from
:he Excessive Use of Alcohol," 'Practitioner," Feb., 1872. Ramsay, "Case of
Kpileptic Mania," ' New York Med. Journ.,' xiv, 280. Ogle, " Case of Epilepsy
uid Hemiplegia, probably Syphilitic" (woman, set. ^^^), 'Lancet,' 187 1, ii, 540.
lackson, "Cases of Epilepsy," ib., i, 376. Id., "Case of Epileptiform Seizure begin-
ling in the Right Hand," 'Med, Times and Gaz.,' 1872, ii, 767. Tyrell, "On
be Treatment of Epilepsy," ib., 187 1, i, 36. Dickson, "Remarkable Cases of 'Le
'utit Mai,'" ib., 1872, ii, 183. Id., ib., 1871, ii, 183. Id., "On the Nature of
he condition called Epilepsy," 'Lancet,' 1872, ii, 251. Murray, "Epileptiform
Seizures of Fifty Years' standing, relieved by Bromide of Potassium," ib., i, 539.
^loir, " Remarks on a Case of Epilepsy and Delirium Tremens," ib., ib., 464. Lane,
84 REPORT ON PRACTICAL MEDICINE.
" Injury of the Head, followed by Delirium, Epileptiform Convulsions, and Aphasia"
(man, aet. 27), 'Brit. Med. Journ.,' 1872, ii, 97.
Hemiplegia and Aphasia.
Perroud ('Lyon Med.,' viii, 65) attempts to verify by statistics
Brown-Sequard's assertion that the left hemisphere is the centre of in-
tellectual and animal life, the right that of organic life. The number
of hemiplegic patients observed by himself being too small for his pur-
pose, he presses into service a note of Charcot, pubHshed in the ' Journal
de Physiologic,' in 1868, containing the history of 27 cases of hemi-
plegia, in which death occurred in the course of a few days after tlie
sudden attack. They were all complicated with bedsore of the thigh of
the paralysed side, and this "lesion of nutrition" depended, in 16, on
lesion of the right hemisphere (sores on the left side), and in 11 on
lesion of the left (sores on the right side). Perroud gives an analysis
of 70 cases of chronic hemiplegia observed by himself during the last
four years, in 32 right-sided, 38 left-sided. Of the former, 24 had no
trouble of nutrition, 8, i. e.one fourth of the cases, had. Of the latter,
26 had none, and 12, i. e. one third of the cases, had.
Pieber (' Klinische Studien iiber die Brown-Sequard'sche Spinal-
lahmung," ' Wien Med. Zeitg.,' 1871, i66, &c.) records four cases of
spinal hemiplegia, with muscular paralysis on one side and ansBsthesia
on the opposite side. He thinks these cases are more common than is
generally supposed, and as overlooked when, as is often the case, sen-
sation returns, while the paresis remains. He gives (ib., 175) a tabular
arrangement of the four cases.
Verneuil gives (' Bull. del'Acad. de Med.,' Jan. 1871) an account of
the case of a man, aet. 46, in whom, after being thrown from a cart,
only numerous contusions could be found, but who presented symptoms
of violent delirium, right hemiplegia, and cerebral compression. He
died fifteen days later, and the autopsy showed complete rupture of the
two internal coats of the left carotid, with a clot in its canal, extending
into the branches of the Sylvian artery. There was extensive softening
of almost the whole middle lobe.
Broadbent ('Med.-Chir. Trans.,' Iv, 145) has published an important
paper on the cerebral mechanism of speech and thought. His object
has been, by means of the light thrown upon cerebral physiology by
cases of loss or derangement of speech, to construct a theory of the
subject stated, and to connect this with the facts of cerebral structure, \
so far as they are at present known. The paper opens with ten cases, \
the autopsies of which are given as fully as the histories of all. These |j
cases, so far as they bear on the question, are entirely corroborative of ;
the view which assigns a close functional relation with articulate speech *
to that part of the upper edge of the fissure of Sylvius which forms the 1
posterior end of the third frontal convolution of the left hemisphere, j
The writer criticises cases which may seem to bear on the other side of
the question, and states that this part of the hemisphere is not the seat
of a "faculty of language," but simply a part of the nervous or cell-
and-fibre mechanism, by means of which speech is accomplished, which
mechanism may be damaged elsewhere, above or below this particular
HEMIPLEGIA AND APHASIA. 85
node. In the cases distinguished by Baatian, Hughlings Jackson, "W".
Ogle, Sanders, &c., as amnesic or amnemonic, and ataxic or aphasic,
the lesion has occurred at different points. Broadbent quotes his
eighth case in illustration. Here, while the object seen no longer
evoked the appropriate name, the name and the object presented to-
gether were recognised as pertaining to one another ; the channel
between the visual centre and the mind (the intellectual centre) was
interrupted. The same condition occurs in severance of the auditory
jierceptive centre from the intellectual centre. Spoken words have lost
their meaning to the patient, and he will have no idea whether he is
saying what he wishes or not. Both as to mental condition and seat of
It sion these cases would be different from amnesic and aphasic cases.
The author states at some length the result of his own observations on
the course and distribution of the fibres in the cerebral hemispheres,
lie enumerates the convolutions which have no direct communication
with the cms, central ganglia, or corpus callosum, the said convolutions
being latest in order of development, and constituting the difference
between the human and quadrumanous brain, " withdrawn, so to speak,
from the outer world," and "receiving the raw material of thought
from the convolutions on which sensory impressions impinge, and em-
ploying for the transmission outwards of the volitional product those
convolutions which are in communication with the motor ganglia and
tract." He adopts, with modification, the theory of Bastian (" On the
IMuscular Sense and on the Physiology of Thinking," 'Brit. Med. Journ.,'
iS6g, May), giving it an important extension, and applying it to the
tacts of cerebral structure. After considering the two distinct aspects
iti which words may be considered — i, as motor processes, 2, as intel-
lectual symbols — and expressly stating that reading and writing have
been kept out of sight for the sake of clearness, and the mechanism of
tliought as sufficiently explained in the consideration of that of speech,
he gives the following as a resume of his theory :
(i) Words, as remembered sounds, will be represented by cell-groups
at the summit of the receptive side of the nervous system, which, for
reasons given, is supposed to be situated in the marginal convolutions
of the hemispheres.
(2) From these cell-groups, when definitely formed, impressions will
be transmitted to a cell-area in the superadded convolutions, to which
also impressions conveying to the mind the various properties of ob-
jects indicated by the words will be transmitted ; all these impressions
are associated, and the word is employed as the symbol for the result-
ing idea of the object.
(3) Almost simultaneously motor cells in the corpus striatum are
grouped for the production of articulate words, under the guidance of the
remembered sound, in response to efforts at imitation, which are at first
more or less parrot-like. The cell-groups for spoken words once formed
are, however, employed almost exclusively in intellectual expression.
(4) The receptive cell-groups for remembered sounds will be found
in the marginal convolutions of the two hemispheres, which are symme-
trically associated by the corpus callosum, and the cell-groups for spoken
sounds will be found in the two corpora striata ; but the absence of
bb REPORT ON PRACTICAL MEDICINE. j
commissural connection between the superadded convolutions of the
two hemispheres permits of the predominant, if not exclusive, educa-
tion of the left hemisphere for the verbal expression of the product of
intellectual action, as has been revealed by pathology. This is an
eiferent process, and does not imply the exclusive use of the hemisphere
in thought.
(5) The outlet for intellectual expression in spoken words, which are
motor acts, is necessarily in some part of the marginal convolutions in
relation by fibres with the corpus striatum, and pathology has shown
the point to be the left third frontal gyrus.
(6) The left third gyrus being the outlet for expression, the left
corpus striatum necessarily takes the lead in the production of spoken
words, but a way round exists, probably, from the left to the right
third frontal gyrus by the corpus callosum. Thus, speech, though tem-
porarily embarrassed by damage to the left corpus striatum, is reco-
vered ; whereas, if the cortex of the left third frontal convolution is
damaged, or its fibres, both to corpus striatum and corpus callosum, cut
through, speech, having no other outlet, is lost.
Bristowe ('Brit. Med. Journ./ 1871, i, 122) read a paper on cases
illustrative of the various forms of impairment or loss of the power of
speech. Considering aphasia under three heads, he gave first four
examples of that form which is due to a mental defect, independent of
any affection of the organs of speech (amnesia, amnestic aphasia). All
these four cases had hemiplegia of the right side. Though in these
cases the lesion was on the left side of the cerebrum, he yet affirms, with
Trousseau, that aphasia in some instances is obviously the result of
disease of the right hemisphere, and holds that the dependence of
aphasia on disease of a particular convolution, whether on the right or
left side, is at present very far from certain. As an illustration of the
second form of aphasia, in which the patient, without any mental defect,
or paralysis of the organs of speech, loses the power of speech
absolutely, he gave a case in which he had succeeded in teach-
ing a person to speak (cf. ' Trans. Clin. Soc.,' iii, 92). He thinks
that cases of this kind lead to the conclusion that speech, when
once acquired, is a purely reflex phenomenon, similar to the acts
of deglutition and respiration ; that there is some ganglionic centre
intermediate between the cerebrum (which thinks and wills), and the
nuclei of the motor nerve of the fifth, the portio dura, and the hypo-
glossal nerves, and that aphasia is due in these cases to disease of this
co'ordinating centre. The third form was illustrated by a case in which
the nerves of speech were paralysed, either from disease affecting ■
some of the trunks, or their nuclei of origin.
Samt (•* Zur Aphasiefrage ; " 'Arch. f. Psych.,' iii, 751) gives the
post-mortem appearances found in the brains of two aphasics. He con-
cludes with the assertion that it is impossible at present to localise the
centre of speech, and idle to discuss the possibility of its unilateral seat.
Hammond (' New York Med. Rec.,' vi, i) defines aphasia as " a !
condition produced by an affection of the brain by which the idea of
language, or of its expression, is impaired." He then gives a brief
summary of the literary history of the affection, from 1798, when
HEMIPLEGIA AND APHASIA. 87
Cricliton described it, to the latest period. He rejects the theories of
Dax and Broca, and believes ** that the organ of language is situated in
both hemispheres, and in that part which is nourished by the middle
cerebral artery ; and that while the more frequent occurrence of right
liemiplegia, in connection with aphasia, is in great part the result of the
anatomical arrangement of the arteries, which favours embolism on that
side, there is strong evidence to show that the left side of the brain is
more intimately connected with the faculty of speech than the right."
Histories of fourteen cases of aphasia, which had come under his obser-
vation, follow ; and from these he concludes that in all of which
liemiplegia formed a feature, the aphasia was of the ataxic form, while
when there was no hemiplegia, the aphasia was amnesic. In the one
the individual was deprived of speech, because he could not co-ordinate
the muscles used in articulation ; in the other, because he had lost the
memory of words. He thinks that this point has not been noted before,
and that the phenomena indicate very clearly the seat of the lesion and
the physiology of the parts involved. When the grey matter of the
lobes, which presides over the idea of language and hence over the
memory of words, is alone involved, there is no hemiplegia, and no diffi-
culty of articulation. If the corpus striatum, or some other part of the
motor tract is attacked, the lesion is followed by hemiplegia and ataxic
a[)hasia; and if amnesic aphasia is also present, the hemisphere is like-
wise involved.
Bristowe (' Path. Soc. Trans.,' xxiii, 21) records the case of a woman,
at. 48, in whom the left corpus striatum with the brain substance
between it and the island of Reil was entirely destroyed by a clot. Dur-
ing life she had complete motor hemiplegia, temporary aphemia, and
ishght amnesia.
Baginsky (' Berl. Klin. Woch.,' 1871, 428) records two cases of
aphasia, in men set. respectively 42 and 40, in consequence of disease
oi the kidneys, and discusses at some length the relation of the two
diseases, and especially the anatomical seats of the aphasic lesion.
Simon (' Casuistische Beitrage zur Lehre von der Aphasie,' ib.,
537) writes a very interesting paper with cases of the affection. He
allows that the lesion is to be found in the third frontal convolution,
though not always on the left side, and thinks that the faculty of speech
probably resides in both, though we are in the habit of using only the
left. His last case is that of a man who was thrown with his horse,
and, attempting to get into his saddle again, was found to have complete
aphasia, and a small wound in the head. Death followed later from
meningitis, and a splinter of bone was found impinging on the third
left convolution, with softening of this end of the third convolution, and
tlie island of Reil.
Hughlings Jackson ('Lancet,' 1872, i, 72) gives a minute report of
the case of a healthy girl, set. 17, in whom a right-sided convulsion was
followed by defect of speech, from which she recovered. The convul-
sions did not resemble those which occur in hysterical women, and was
like those occurring in brain disease ; and he infers that there must
have been some pathological process, as yet unknown, in the region of
the corpus striatum.
88 REPORT ON PRACTICAL MEDICINE.
The same author (ib., 1871, ii, 430) reports two cases of the power of
singing existing in two aphasic boys of the ages of ten and eight years.
Bacon (ib., 488) reports the case of an idiot boy, aet. 12, with strong
family history of physical degeneration, who, scarcely able to use a
single word, has a certain capacity of humming tunes.
Down (ib., 1871, i, 852) records the case of a man set. 28, who had
right-sided hemiplegia, with unaffected speech, and an aortic obstruc-
tive murmur. A week later he became speechless, and two days after-
wards died. The autopsy showed, in addition to the aortic disease, a
softened cavity of irregular shape, and of about the size of a hazel nut,
in the anterior lobe of the left side of the brain.
Nicol, "Shfting and Recurring partial Hemiplegia in a Patient suffering from
Bright's Disease" (man, aet. 30), 'Lancet,' 1871,11,397. Ogle, "Case of Epilepsy
and Hemiplegia, probably syphilitic " (woman, 88t. ^^), ib., 540. Id., " Hemiplegia,
probably from softening of Embolic Origin" (woman, aet. 45), ib., ib. Clark, " Peri-
pheral Hemiplegia" (man, aet. 30), ib., 1872, i, 254. Owen, "Epileptic Hemiplegia"
(girl, aet. 17), ib., ib., ii, 744. Heaton, "Alternating Hemiplegia, with Clinical
Remarks," *Brit. Med. Jcmrn.,' 1871, ii, 498. H. Jackson, " Hemiplegia in Patients
the subjects of Congenital Syphilis," ib., 1872, i, 526..^ Bristowe, " Reflex (?) Hemi-
plegia," ib., ib., 610. Lockhart Clarke, " Incomplete Hemiplegia of the Right Side
with partial Aphasia," ib., ib., 638. Ogle, " On Dextral Preeminence," * Med.-Chir.
Trans.,' liv, 279. Wrany, •' Hemiplegie und Aphasia mit Hemichorea in Folge von
Endocarditis," Oesterr, ' Jahrb. f. Paediatrik,' 1872, i, 12 (see under Dis. of Circula-
tion). Greeuhow, " Plugging of the Left Anterior and Right Middle Cerebral
Arteries, Extensive Disease of the Frontal Lobe of the Left Hemisphere, and
Softening of a Patch of Cerebral Substance in the Centre of the Right Hemisphere of
the Brain, aortic valves incompetent and studded with fibrinous vegetations, mitral
stenosis, aphasia. Hemiplegia, first of Right and subsequently of Left Side" (female,
aet. 27), 'Path. Soc. Trans.,' xxiii, 18. Robertson, "Observation on Aphasia, with
Cases," • Glas. Med. Journ.,' iii, 229. Anderson, "Clinical Memoranda," No. i (case
of aphasia with right hemiplegia, recovery), ib., iii, 446. Obernier showed a patient
suffering from aphasia, ' Berl. Klin. Woch.,' 1871,321. Sharpe, " Case of Amnemonic
Aphasia," ' Ainer. Journ. Med. Sci.,' Ixi, 589. Druitt, "Clinical Notes of the Varieties
of Imperfect Speech produced by Brain Disease," * Med. Times and Gaz.,' 1871, i, 34.
Lush, " Well-marked Aphasia without Paralysis, recovery," ib., ii, 523. Dalton, " On
Apha.sia" (discussion of Hammond's paper), 'New York Med. Rec.,' vi, 19. Proust,
" De I'Aphasie," 'Arch. Gener. de Med.,' xix, 147. Glover, " Uncomplicated Aphasia,"
*Brit. Med. Journ.,* 187 1, ii, 684. H. Jackson, "Voluntary and Automatic Move-
ments," ib., ib., 641. McCarthy, " Fracture of the Skull in Broca's Region, Paralysis
of the Right Side, loss of power of speech, death, autopsy " (clot occupying portion of
frontal lobe, corresponding to the interior and posterior part of the frontal convolu-
tions, and very closely bordering on the central lobe, diseased blood-vessels), * Lancet,'
1872, ii, 706.
HypercestJiesia and Neuralgia.
Anstie, " Neuralgia and the diseases that resemble it," London, 1871. Althau$,
"On Neuritis of the Brachial Plexus," 'Med.-Chir. Trans.,' liv, 145. Chapman,
" Observations on Dr. C. B. Radcliffe's Theory of the Genesis of Pain,'' ' Med. Times !
and Gaz.,' 187 1, ii, 765. Anstie, "On the Pathological and Therapeutical Relations
of Asthma, Angina Pectoris, and Gastralgia," 'Brit. Med. Journ.,' 187 1, ii, 550.
Id., " A Case of Neuralgia of all Three Branches of the Fifth Nerve," ib., ib., 684.
Handfield Jones, "Clinical Lecture on Hyperaesthesia," ib., ib., 369. Hold«i, ]
" Some Notes on Neuralgia and its Treatment," ib., i, 639. Smith, '' Galvanism in '
Neuralgia," ib., 1872, i, 139. Wilks, "On Sick Headache," ib., ib., 8. "Report on
the Treatment of Sick Headache," ib., 12, &c. Chapman, "The Pathology and
Treatment of Neuralgia and its Kindred Disorders," ' Lancet,' 1872, i, 151. Porcher,
NEURALGIA. MENINGITIS, ETC. 89
" ( 'outributions to the Clinical History of Hyp'evaestbesia," ' Amer. Jonrn. Med. Sci.,'
i\i. 105, Cleborne, "Headache," 'New York Med. Rec.,' vi, 309. Meiere, "Ti-eat-
iiiciit of Sciatica," ib., 1 75. Nothnagel, "Schmerz und cutane Sensibilitats-Storungen,"
' \' reb. Arch./ Hv., 121. Peter, Nevralgie Diapbragmatique et faits Morbides Con-
iit'xes," 'Arch. Gen. de Med., xvii, 303. Sorbets, " Deux cas de Nevralgie Cervico-
brachiale Nocturne, ' Gaz. des Hop.,' 187 1, 566. Senne, " De la Migraine," 'Union
Med.,' xi, 423.
Meningitis ; Sydrocephalus ; Hcemorrliage,
A writer in the ' Graz. Med.' (1871, 412, &c.), on the treatment and
])rophylaxis of tubercular meningitis, says that in a practice of thirty
years he has seen between eighty and ninety cases, and in that time
counts two as recovering from the confirmed disease.
Fleming (' Brit. Med. Journ.,' 1871, 443) thinks he had to deal with
a case of unequivocal tubercular meningitis in a girl set. i\^ recovery
from which may have been due to the use of iodide of potassium.
MacSwiney (ib., 1872, ^39) exhibited a specimen showing tubercle
over the projecting portions of the cerebral convolutions, taken from a
boy, 8Bt. 15, who five weeks before had become suddenly incoherent.
An epileptiform convulsion followed in a few minutes, and occurred
again ten days later. There was dull, persistent pain in the head,
general anaesthesia, a quick pulse, and sluggish, dilated pupils.
Sperling (' Centralb.,' 1871, 448) has made injections between the
dura mater and the arachnoid over the convexity of the brain in rabbits
with the following results : — Eight days after the injection of fresh
blood it began to be organized into a connective-tissue membrane,
which was complete after two to three weeks. After the latter period
new blood-vessels were found in the new membrane, which agreed in all
characters with the membrane of pachymeningitis. The organization
of the blood occurred over the convexity of the brain, on the inner sur-
face of the dura mater, without any adhesions to the arachnoid. The
formation of the new membrane was due to the organization of the
fibrin contained in the blood. That this was so was shown by the fact
110 new formation was found after the injection of defibrinated blood,
which was completely reabsorbed. Injections of iodine and other irri-
tating fluids was not followed by any new formation. In some cases
the dura mater was found thickened, in others there was pus.
Arndt (' Virch. Arch.,' lii, 42) records two cases of so-called hydro-
cephalus externus, due to the accumulation of serum between the dura
mater and the arachnoid. This accumulation was the result of " chronic
internal pachymeningitis," causing the formation of thick and tough
false membranes, which bound down the dura mater. This afi'ection
is not to be confounded with Hygroma of the dura mater.
Thompson (' Brit. Med. Journ.,' 1871, ii, 154) records the occurrence
of intracranial osteophytes in a servant girl, set. 23, with dilatation of
the ventricles and increased fluid, amounting to seven ounces, and soft-
ening of the white substance. No tubercles were present anywhere.
Bierbaum, " Pathologiscbe Physiologie der Meningitis Tuberculosa," ' Deut. Klin.,'
1871, 261. Id., Semiotisch-diagnostische Analyse der Erscbeinungen bei der Menin-
gitis tuberculosa," ' Journ. f. Kinderkr.,' Ivi. 324. Neureutter, " Fractura
Cranii Sanata, Pachymeningitis interna chronica, Hydrocephalus und Tuberculosis
90 REPORT ON PRACTICAL MEDICINE.
liei einem li Jahre alten Knaben," 'Oesterr. Jahrb. f. Psediatrik/ 1872, i, 123.
Broadbent, "Cases of Acute Cerebral Disease, with Autopsies" (1, Sero- purulent
effusion into ventricles of brain, obscure symptoms ; 2, Basic tubercular meningitis),
' Med. Times and Gaz.,' 1871, ii, 376. Heller, " Ein Fall von Hydrocephalus Exter-
nus,", ' Deut, Arch.,' x, 207. Gant, " Case of Apoplexy Treated by Venesection,*'
'Lancet, 1871, ii, 577. Hughlings Jackson, "Remarks on the Difficulties in the
Diagnosis of the Causes of Apoplexy," ib., 1872,!, 505. Whitcombe, "Meningeal
Apoplexy " (male, a3t. 51), * Brit. Med. Jouru.,' 1872, i, 27. Foot, "Apoplexy, Ex-
travasation of Blood at the Base of the Brain, Cylindroid Aneurism of Fourth Stage
of Vertebral Artery (male, set. 60), ib., ib., 424. Rittmann, " Die Vorliinfer der
Apoplexie und Syncope/' * Wien. Med. Ztg.,' 1871, 60. Stille, "Simple Acute
Meningitis" (man with chronic tubercular phthisis, death from coma and collapse,
no tubercles, only injection of meninges, with pus and lymph on pia mater of con-
vexity of brain), ' Amer. Journ. Med. Sci.,' Ixi, 419. Buttenwiesen, "Function und
Adspiration eines Chronischen Hydrocephalus mittelst der Spritze von Bresgen,'*
' Deut. Arch.,' x, 301. Schmid, " Zur Differentialdiagnose von Apoplexie und Embolie
des Gehirus," ib., 305. Korber, " Des Cheyne-Stokes'sche Respirations-Phanomen
bei einem an Meningitis Tuberculosa leidenden 9 Monatlichen Knaben " (no autopsy),
ib., 600.
The OpTitlialmoscope in Diseases of the Nervous System.
Boucliut (' Gaz. des Hop.,' 1871, 97) gives the following as seen in
cases of acute affection of the brain and spinal cord.
Optic hyperaernia and venous stases in the retina, coinciding with
congestion of the meninges or thrombosis of the sinuses.
Optic neuritis, with or without exudation, the result of meningo-
encephalitis.
Papillary oedema diagnostic of cerebral compression.
Tubercles of the choroid always accompanied by tubercles of the
meninges or the viscera.
He gives three cases with autopsies :
1. Girl, set. 2 ; tubercular meningitis and general tuberculosis ;
during life almost entire disappearance of the optic papilla, which pre-
sented a uniform red colouration masking its outline ; dilatation of the
retinal veins ; no choroidal tubercle.
2. Girl, set. 8 ; double optic neuritis and miliary tubercles of the
choroid ; general tuberculosis.
3. Girl, aet. 3 : atrophy of both optic nerves, as seen with the oph-
thalmoscope ; a tubercle (scrofulous tumour, — Eep.) of the cerebellum,
the size of a hen's egg, and two the size of nuts, at the surface of the
right cerebral hemisphere ; enormous quantity of fluid in the lateral
ventricles ; no miliary tubercles anywhere. ;
Socin (" Beitrag zur Lehre von den Sehstorungen bei Meningitis ;*' !
'Deut. Arch.,' viii, 476) records two cases, in a man, aet. 31, and ai
female, aet. 37, in whom, suffering with meningeal symptoms, the same'
sort of appearances in the optic disc were observed as in children withj
tubercular meningitis. i
Broadbent (' Path. Soc. Trans.,' xxiii, 216) records a case of dropsy!
of the sheath of the optic nerve in meningitis. The patient, a girl,
aet. 19, had complained of headache for a fortnight. She had vomited,
lay in a state of torpor with her eyes half closed, the pupils large and
sluggish, the right rather larger than the left. She had well-marked
taches cerehrales. The optic discs were well defined, of a dusky pink
ABSCESS OF THE BRAIN, ETC. 91
colour, striated by vessels, and liad a white spot in tlie centre. The
retinal veins were large, the arteries small. She died thirty-six hours
after her admission. The autopsy showed turbid fluid with translucent
granulations about the interpeduncular space ; injection of the pia
iiuiter, optic commissure and tracts. The nerves presented large super-
ficial vessels along their entire length. Close to the eyeball they swelled
out into a kind of bulb, due to distension of the outer sheath of the
optic nerve by fluid. There were no tubercles in any of the other
organs.
, Friinkel, " Weitere Beobaclitung von Tuberkeln der Chorioidea " (girl, set. 6,
general miliary tuberculosis, tubercle observed in the choroid five months or so before
ideath), 'Berl. Klin. Woch.,' 1872,4. Manz, "Ueber Seh-nerven Erkrankung bei
Gchirnleiden" (Hydrops vaginae n. optic), *Deut. Arch.,' ix, 338. Hughlings Jack-
son, " Remarks on the Routine Use of the Ophthalmoscope in Brain Disease,*'
' Liincet,' 1872, ii, 525. Bouchut, "Du Diagnostic de I'Hydrocephalie par I'Ophthal-
nioscope," *Gaz. des Hop.,' 1872, 345.
Abscess of the Brain ; Softening; JEmbolism ; Tumours.
Taylor ('Brit. Med. Journ.,' 1871, ii, 527) found the left vertebral
artery completely filled by an embolic clot, in a man set. 68, who two
months before his death had fallen so as to injure his chest. He com-
})iained of numbness of the right arm and leg, but had perfect motion.
He had also paralysis of the glosso-pharyngeal nerve.
Jastrowitz ('Arch. f. Psych.,' ii, 389, and iii, 162) has studied the
hereditary character of nervous diseases, taking as his starting-point the
occurrence, pointed out by Yirchow, of a diffuse encephalitis in new-
born children. In the two years preceding his article he examined the
brains of a large number of children who had died with head symptoms
(tetanus, trismus, &c.). The result in all the cases showed an encepha-
litis agreeing completely with Yirchow's description ; hypersemia of the
meninges and white substance, comparative paleness of the cortical
Isubstance, whitish-yellow spots in the white substance corresponding to
iplaces in which the fatty change was most advanced in the cells of the
(neuroglia. He gives a full account of the changes found ; the spinal
jcord was scarcely, if at all, affected. To decide the question whether
ithis so-called encephalitis was a pathological condition, he then ex-
amined the brains of apparently healthy newborn children, who had
died from other causes. Of 80 which he examined, 7 were foetuses
of five to seven months, 37 children from that period to the age of one
(extra-uterine) week ; 12 from one week to five months ; 4 from five to
nine months; 5 from nine months to three years. All the :^'] children
presented the changes described in the brain. In foetuses the fatty
'degeneration of the cerebral substance was general ; in children it was
partial. The first child that presented no change in its brain was five
months old. !From these and further premises, for the study of which
the original article must be referred to, he concludes that this fatty
'metamorphosis in the brain is a normal process, consisting in changes
in the young cells of the neuroglia. He discusses at some length the
etiology of the affection.
Elam ( Lancet,' 1871, i, 747) gives a table of the chief differences
Ii
92 REPORT ON PRACTICAL MEDICINE.
between general and partial acute idiopathic cerebritia. He considers
tlie diagnosis of the disease not difficult. It differs from the apoplectic
form of softening, in the absence of aphasia and paralysis, as well as
other general features of progress ; from the convulsive form, in the
absence of epileptiform attacks at the beginning, and the greater con-
stancy and duration of the convulsions when they do occur ; from the
delirious form, by the mode of invasion which is never by delirium, and
by the less marked character of this symptom throughout.
Eleischmann (' Wien. Med. Woch.,' 187 1, No. 6, &c.) records a case
of cerebral tubercle in a boy set. 2 years. The tubercle had commenced
in the left thalamus, as a hard, rough, cheesy mass, which extended
into the left cerebral crus ; here it had completely destroyed the fibres
of the inner surface. The symptoms were exactly those described by
Afanasieff (ibid., 1870, No. 9) in section of one cerebral crus. They
were partial paralysis of the left oculo-motor nerve ; dilatation of the
pupil, which was unaffected by light ; paralysis of some of the facial
muscles of the trunk and extremities of the right side; tremor of the
right hand ; increased cutaneous sensibility of the right side, with the
exception of the head ; ophthalmia ; hyperaemia of the retina, choroid,
and optic disc of the left eye ; incapacity of retaining stools or urine ;
abnormal fluctuations in temperature.
Cordier (* Lyon Med.,' viii, 583) records the case of a boy of 12,
suffering from caries of the ribs and empyema, in whom three quarters
of the left cerebellar lobe had been destroyed by a "tuberculous"
{i. e. " scrofulous,"' — liep.) tumour, without giving rise to any
symptoms.
Hughlings Jaekson (' Brit. Med. Journ.,' 1871, ii, 528) publishes a
case of tumour of the middle lobe of the cerebellum in a boy set. 5.
The tumour was a " tuberculous" one, of the size of a billiard ball.
The diagnosis was grounded on (i) the enlargement of the head, with-
out any evidence of rickets ; (2) blindness (double optic neuritis) ; and
(3) a reeling gait. Perhaps of the three the last was of most value
though by itself it would only point to a tumour under the tentoriuu).
li'rom time to time the boy had convulsive seizures of a tonic charactei-.
during which he was conscious.
Broadbent (*Brit. Med. Journ.,' 1872, i, 476, 622) related to the
Clinical Society the history of two cases, in one of which there were
two tumours just beneath the floor of the fourth ventricle, near the
median line— one in the lower half of the pons, the other near the
lower end of the ventricle. The patient was a man set. 46, whose
symptoms during life were slight weakness of the right limbs, marked
paralysis of the left side of the face, not involving the orbicularis oculi ;
lateral deviation of both eyes to the right, with double loss ef vision ;
loss of sensation over the area of the right trigeminus ; difficulty of
deglutition and indistinct articulation. In the second case, a man a?t.
6^, gliomatous tumours were found in the occipital lobe, and iu the
posterior ascending parietal convolution of the right hemisphere. He
had convulsion and paralysis of the left half of the body.
Hutchinson (ibid., 185) writes on a case of supposed cerebral tumour
in a man aet. 27, alive at the time of writing.
TUMOURS OF BRAIN. \)6
Evans (ibid., 1872, i, ^66) refers to the occurrence of an hydatid cyst
protruding from the under surface of the cerebellum in a boy set. 17,
who in addition to rheumatic endocarditis had headache, dimness of
vision, and a staggering gait.
PuUar (ibid., 312) records a case of the same kind in a girl set. 4.
The cyst, the size of a pigeon's egg, lay upon the crus cerebelli of the
left side. She had periodical headache, tremors of the limbs, and later
was in a semi-unconscious state, from which she was easily roused.
(And see this Eeport, under " Animal Parasites.")
Jane way and Teakle (' New York Med. Eecord,' vi, 403) give a
description of tumours attached to the dura mater.
Edes (' Amer. Journ. of Med. Sci.,' Ixi, 87) gives three cases of morbid
growth connected with the nervous system, all occurring in women,
whose ages respectively were 83, 60, and 71. In the first there was a
gliomatous tumour of the cerebrum ; in the second a round-celled sar-
coma of the cerebellum ; and in the third there was sarcoma of the
semilunar ganglion of the sympathetic, varying in character from a
cellular to a fibrous structure.
Reynaud, "Accidents Cerebraux Survenus Consecutivement a une Tumeur blanche
Cervicale, mort et autopsie" (boy, at. 17), ' Lyon Med.,' viii, 265. Fagge, " Embolism
of the Left Middle Cerebral Artery of more than six weeks' standing, yellow
induration of the corpus striatum, with surrounding white softening" (woman, set.
25, right hemiplegia with aphasia), 'Path. Soc. Trans.,' xxii, 13. King, "Aneurism
of the Aorta associated with Fracture of the First Rib, and Embolism of Middle
Cerebral Artery," ib., xxiii, 70. Haslewood, " A Case of Disease of Right Internal
Ear, and resulting Abscess in the Brain" (male, set. 40), 'Lancet,' 1872, i. Broad-
bent, " Disease of Temporal Bone, abscess in temporo-sphenoidal lobe of brain opening
into ventricle, prolonged suppuration in ventricles," *Med. Times and Gaz.,' 1871, ii,
377. Draper "Abcess of Brain, Aphasia," 'New York Med. tJaz.,' July, 1871, 76.
Blanquique, ' Tumeur de la Glande Pineale, epanchement abondant, hernies du cer-
veau a travers la dure mere," 'Gaz. Hebd.,' viii, 532. Broadbent, "Tumour in Left
Half of Floor of Fourth Ventricle, with Tumour in Cerebellum " (gliomatous, girl,
set. 2), 'Brit. Med. Journ.,' 1871, ii, 710. Wilkinson, "Malignant Disease (glioma)
of the Eye, Brain, and Cranium" (boy, set. 2 J), 'Trans. Path. Soc.,' xxiii, 220.
Arnott, " Scrofulous Tumours in Brain and Testicle, from a case in which the elbow-
joint had been excised two years previously," ib., 5. Hawkes, " Case of Tumour of
the Brain, apparently of the Nature of Encephaloid Cancer," ib., 32. Stocks,
Tumour of Brain" (medullary, man, set. 22), 'Brit. Med. Journ.,' 1872, i, 137.
Thomas, "Cerebral Tumour" (degenerated dermoid cyst?), ib., ib., 457. Lydull,
"A Case of Bony Tumour in the Substance of the Brain" (woman, set. 56), 'Lancet,'
1872, ii, 524. Manning, "Two Cases of Medullary Cancer of the Brain" (men, ait.
60 and 50, with autopsies), ib,, 187 1, ii, 321. Deane, " Case of Ossific Deposit under
the Dura Mater (man, set. 22, autopsy), ib., 1872, i, 147.
Spinal Affections.
Hallopeau ("Etude sur les Myelitis Chroniques diffuses," ' Arch.
Gen. de Med.,' xviii, 277, &c., xix, 60, &c.,) gives the following classi-
fication of the different forms of chronic myelitis. It is scarcely
possible to abstract the article with justice.
94
REPORT ON PRACTICAL MEDICINE.
'■ Of the grey sub- f Pro<rressive mnscnlar atrophy,
stance. \ Infantile paralysis.
Parenchy-
matous.
Diffused.
Of the white sub-
stance.
f In disseminated "]
patches.
General.
•i. Peripheral (mye- \
lo-meningitis).
Round the epen- |
dyma(central). J
Posterior.
Anterior.
Primitive (progressive locomotor
ataxy).
Secondary (ascending degenera-
tion in cases of compression of
^ the cord, partial myelitis, &c.).
Primitive (Charcot's cases).
Secondary (descending degenera-
tion in cases in which the motor
fibres are injured, either in their
spinal or cerebral portions).
These may involve the cord throughout its
length, or occupy a portion only more or
less extensive.
"With Vulpian he considers the first stage to be irritation and inflam-
mation of the nerve- elements, e.g. the nerve-tubes in tabes dorsaHs,
the spinal ganglion-cells in muscular atrophy. The greater number of
patients affected with diffuse myelitis are persons under the age of 40.
Exposure to cold, and paralysis of muscles from over-use and over-
fatigue, are frequent causes ; others are wounds, alcoholism, syphilis,
tumours, severe fevers, the puerperal state, malaria, caries of the ver-
tebrae, inflammation of the meninges, and parenchymatous scleroses.
Diffuse myelitis is constantly found in paralysis of the insane, and it
has been observed in chorea and in tetanus. It is almost always partial
at its first commencement, and spreads gradually. The parts where
the inflammation takes place are swollen, the meninges injected and
thickened; the medullary tissue at first softened, then hard and
shrivelled, containing abnormal spaces, generally filled with serous
fluid. The interstitial myelitis is essentially characterised by the pro-
liferation of the cells and nuclei of the neuroglia. The inflammation
in central myelitis is accompanied by proliferation of the cellular ele-
ments of the central canal. The roots of the nerves, especially the ante-
rior ones, are often found atrophied ; more rarely there has been observed
a true sclerosis of the peripheral nerves (hyperplasia of the connective
tissue with atrophy of the nerve- fibres). In cases where the grey substance
is affected the muscles are atrophied. These changes in the latter in con-
nection with diffuse myelitis have for twenty years been described by
Duchenne as " general spinal paralysis." Generally the affection begins
suddenly with pains in the dorsal region, from which they extend to the
limbs and thoracic walls, presenting at times exacerbations, cramps, and
peripheric contractions. Sometimes, however, these pains are absent.
A remarkable irregularity is shown by the malady in its evolution, with
alternations of amelioration and aggravation. Two forms, descending
and ascending, may be distinguished according to whether the upper
or lower extremities are first paralysed, though no law can be laid down
SPINAL AFEECTIONS. 95
a^ to the order of succession in the attacked limbs. Electrical contrac-
tility is diminished or abolished in the affected muscles, very soon after
the onset of the paralysis, and they are usually the seat of the same
ilbrillar contractions observed in progressive muscular atrophy. After
the general sketch of the disease, he proceeds to discuss the different
varieties of it, and its diagnosis, giving some cases in illustration. The
article concludes at last (xix, 191) with its treatment.
Charcot (" Des troubles trophiques musculaires consecutifs aux lesions
de la moelle epiniere et du bulbe rachidien," ' Gaz. des Hop.,' 187 1, 458)
divides irritative spinal lesions into two groups. In the first, the nu-
trition of the muscles is not directly modified; and the pathological
change is limited to the white substance, or, at most, to the region of
the anterior horns, leaving the multipolar cells untouched. This is
the case in a more or less degree in the diff'erent forms of sclerosis.
The second group comprehends the affections of the spinal cord in
which the nutrition of the muscles is aff'ected to a greater or less extent.
This group is again subdivided. The first division contains those
atfections which occur as deposits, or diffused, acute or subacute, of
both white and grey substance, but especially of the latter. They are
usually followed by profound disturbance of the electrical contractility,
and rapid muscular atrophy ; as seen in acute myelitis, in spinal apo-
})lexy, and in certain cases of fracture and dislocation of the vertebral
column, which produce irritation of the cord, partial at first, but
having a tendency to become general. In the second subdivision the
lesions are limited to the grey substance of the anterior horns, where
they are very circumscribed to oval patches of motor cells. Here the
neuroglia is more opaque and thickened (inflamed), and the nerve-cells
are in different degrees of atrophy. The latter are the starting-point
of the lesion. Infantile spinal paralysis (ib., 46^) is the most perfect
type of this subdivision ; and it is very probable that in this disease a
subacute process of irritation attacks all at once a large number of
nerve-cells, and deprives them suddenly of their motor functions. Pro-
yressive muscular atrophy presents the chronic and gradual form of the
same change. He recognises two forms of the affection ; one, proto-
pathic, in which the nerve-cell tissue is primary ; the other sympto-
matic, in which it is secondary, the former causing a much more fatal
])rognosis. The spinal paralysis of adults and general spinal paralysis
(Duchenne), the pathology of which is less known, are probably due to
the same kind of change in the motor nerve-cells.
As to muscular lesions resulting from affections of the medulla
oblongata, but little work has been done. Still, judging from labio-
laryngeal paralysis, &c., it is probable that the motor ganglia of the
floor of the fourth ventricle are the seats of change.
Bourneville, "Hemorrhagie de la Moelle ^Spiniere," 'Gaz. Med./ 187 1, No. 40.
Peter, " Meningo-myelite," 'Gaz. des Hop.,' 1871, 461. Clement, " Amyotropie
St'condaire " (case of a man, not dead, with symptoms of what Jaccoud describes as
" Progressive nervous atrophy," but which the author refers to acute spinal menin-
gitis), 'Lyon Med.,* viii, 504. Tihbits, "Case of Myelitis" (man, set. 22, autopsy),
' Med. Times and Gaz.,' 1871, i, 537. Frommann, " Ein Fall von Wirbelcaries und
Degeneration des Riickenmarks" (man, set. 58, with autopsy and plate), ' Virch. Arch.,'
96 REPORT ON PRACTICAL MEDICINE.
liv, 42. Westphal, " Ueber eia Eigenthumliches Verhalten Secundarer Degeneration
des Ruckenmarks " (with plate), * Arcli. f. Psych.,' ii, 374. Schiile, " Weiterer Beitrag
zur Hirn-Ruckenmarks-Sclerose," * Deut. Arch.,' viii, 223. Kelp, " Hirnsklerose," ib.,
X, 224. Buchwald, " Ueber Multiple Sklerose des Hirns und Ruckenmarks," ib., 478.
Otto, " Casuistischer Beitrag zu Multiplen Sklerose des Hirns und Ruckenmarks," ib.,
531. Ebstein, "Sclerosis MeduUae Spinalis at oblongatse als Sectionsbeiund bei einen
Palle von Sprach- und Coordinationsstorung in Armen und Beiuen in Folge von
Typhus Abdominalis," ib., 595.
Infantile Paralysis.
Damaschino andEoger (' G-az. Med.,' 1871, 457) commence their long
paper by tracing the history of the affection and the suggestions made
by different authors as to its cause. Heine (1840) and Duchenne (i 855)
referred its origin to the spinal cord, though they had no pathological
evidence of disease in the latter. Bouchut placed the anatomical seat
of the lesion in the muscles, and the disease among the muscular
paralyses (myogeniques). Cornil in 1863, and with Laborde in the fol-
lowing year, gave the result of their anatomical investigations, and the
later writer recorded a second case also ; their example was followed by
Prevost and Vulpian in 1865, Olivier in 1869, Charcot and Joffroy in
1870, and in this last year also Parrot and Joffroy. Damaschino and
Eoger themselves had opportunities of a full examination of three cases
in 1868, 1869, and 1871, of which they now give full reports. The
first case was that of a boy aged two years, who for two months had
suffered with paralysis of the left arm with atrophy of the deltoid — a
consequence of hemiplegia occurring after dysentery. Paraplegia
set in during measles, of which last affection the child died. The
second case was observed in a boy ddt. 2^ years, who for six months
had had paraplegia, with atrophy and deformity of the left leg, less
marked in the right. He also died of measles. The third case was that
of a boy of 3 years, who had paraplegia and paralysis of the muscles of
the left back for thirteen months before he died of broncho-pneumonia.
The symptoms during life and the pathological appearances were similar
in all three cases. The changes in the muscles were of the ordinary
character, consisting of fatty and fibroid degeneration of the fibrillse.
In the spinal cord the writers found the same lesions of the grey sub-
stance and the anterior and lateral columns, differing, in the three cases,
only in its seat ; in the first case, in two places, the cervical and lumbar
enlargements; in the second, chiefly in the latter position; and in
the third case, in the same region, but on both sides. The mic-
roscope revealed changes in the vessels, thickened walls, prolife-
ration of their nuclei, atrophy of the ganglion-cells and their pro-
cesses, as well as of the nerve-fibres. There was also thickening of the
connective tissue (sclerosis), especially marked in the third case. These
facts lead the authors (ib., 578) to the conclusions that the lesion of the
spinal cord is essential and primary, and that the pathological appear-
ances found justify their use of the term " spinal infantile paralysis"
("paralysie spinale de I'enfance"). The lesion they consider to be a
myelitis, especially of the anterior grey substance, of which the atrophy
of the nerves and muscles is the consequence.
PARALTfSIS AGITANS. 97
Rinecker (' Berl. Klin. Wocli.,' 1871, 627) gives the autopsies of two
cases, which differ but little from the preceding. In the second of the
two the anterior and lateral columns, as well as the nerve fibres and
ganglia, were atrophied, and in both the peripheral nerves.
Eosenthal (' Centralbl.,' 1872, 176, quoted from ' Oestr. Zeitschr. f.
prakt. Heilkunde,' 1871, No. 52) contributes a paper towards the clinical
and anatomical knowledge of spinal infantile paralysis. French writers (cf.
Centralbl.,' 1870, 540) had especially called attention to the atrophy
and malformation of the anterior horns of the spinal cord in this
affection. Eosenthal, instead of looking upon the atrophy of the nerve-
cells as the primary cause, considers the dilatation and thickening of
the vessels, which he has observed, and which are the signs of an active
participation of the latter, as a pathological process which results further
in secondary growths and destruction of the grey substance. In oppo-
sition to Dachenne, Eosenthal finds that the motor power of paralysed
muscles improves without any return of excitability by faradisation or
galvanism. If within the first six or nine months from the commence-
ment of the affection the electrical excitability be completely lost, the
prognosis is not lor that reason unfavourable.*
Hitzi^ u. Jiii-gensen, "Zur Therapie der Kinderlahmung," 'Deut. Arch./ ix, 330.
Barwell, "Infantile Paralysis and its resulting Deformities," 'Lancet/ 1872, i, 249,
&c. Vulpian, " Anatomic Pathologique de la Paralysie Infantile/' * Gaz. Med./
1872, 9. Ball, "De la Paralysie Infantile/' * Gaz. des Hop./ 1872, 185. Simon,
"Eine besondere Form der Kinderlahmung durch encephalo-malacische Heerde/'
* Virch. Arch.,' lii, 103.
Paralysis Agitans.
Murchison and Cayley (' Path. Soc. Trans.,' xxii, 24) give the details
of a case of paralysis agitans, the spinal cord of which the latter
examined, after hardening in chromic acid, and staining with carmine.
T. The cortical or connective tissue layer of the cord appeared thick-
ened, and presented an increased number of nuclei. 2. Irregular tracts
and patches of connective tissue, thickly nucleated, passed from the
cortical layer into the substance of the cord, the reticulum of which was
I much thickened. These patches were most frequently met with near
jthe exit of the posterior roots of the nerves, which themselves did not
i appear altered. 3. The place of the central canal was an oval tract,
crowded with cells of various shapes and sizes, the majority having the
character of leucocytes, none presenting the character of the normal
epithelium of the canal. This oval tract occupied not only the site of
jthe canal itself, but also that of the surrounding central substantia
Igelatinosa. 4. The capillaries of the grey matter, and to a less extent
:the white, were distended with blood ; and here and there were small
points of extravasation. 5. Through the whole cord, chiefly in the grey
matter, were small deposits composed of leucocytes or exudation cells.
The first three changes were due to a chronic, the last two to an acute,
process.
Jeffrey's account of the morbid changes in these cases (' G-az. dea
* In abstracting this paper Bernhardt remarks, "Damaschino also observed in two
cases of essential infantile paralysis marked changes in the vessels of the anterior
horns, and both he and Duchenne seem inclined to look upon these changes as the
original affection" (cf. Duchenne, * Elect. Local,' 1872, p. 409).
7
98 EEPORT ON PRACTICAL MEDICINE.
Hop.,' 1871, 602) is very similar. In all there was proliferation of the
epithelium completely filling up the central canal ; great proliferation of
nuclei in the neighbourhood of the ependyma ; pigmentation of the
nerve-cells, especially those of Clarke's columna vesiculosa ; and a large
quantity of amyloid corpuscles. In the third case there was a sclerotic
patch of connective tissue in the neighbourhood of the pons with
dilated vessels. The conclusion to which the writer comes is that the
seat of the lesion in paralysis agitans is to be looked for in the cord.
All three cases occurred in women.
Chvostek, " Encephalitis der Gebilde des r. Ammonshorns mit dem Ausgang in
Sclerose, Paralysis agitans der linksseitiger Extremitaten " (man, set. 44), * Wien. Med.
Woch.,' 1871, No. 37. Bastian, "A Case of Paralysis Agitans " (man, aet. 51), 'Brit.
Med. Journ.,'1871, ii, 698. '
Locomotor Ataxy.
G-reenhow and Cay ley (' Path. Soc. Trans.,' xxii, 14) record a case of
locomotor ataxy in a man SBt. 57, with a microscopical examination of 1
the cord, showing atrophy of the posterior columns.
Pollard, " Locomotor Ataxy, commencing suddenly, and disappearing under treat-
ment, with remarks" (man, a)t. 64), 'Lancet,' 1872, i, 431. Althaus, "On the Pain
of Ataxy and its Relief," 'Brit. Med. Journ.,' 1871, i, 502. Spillmann, "Traitement
de I'Ataxie Locomotrice,*' ' Gaz. Hebd.,* viii, 369.
Tetanus.
Clifford-AUbutt publishes ('Path. Soc. Trans.,' xxii, 27) short notes
of four cases of tetanus, with an examination of the spinal cord in all.
Lockhart Clarke and Dickinson report on the same specimen, and the
pathological results are as follows: — i. Diminution of consistence of
various degrees and situation in the cord. 2. Haemorrhage in two of
them, visible to the naked eye. On microscopical examination:
1 . Grreat distension of the blood-vessels in both white and grey matter,
with occasional exudation and disintegration of tissue around them.
2. Isolated patches of disintegration of various shapes and sizes in both
grey and white matter ; and in the grey matter, numerous vacuities
having, on transverse section, circular or oval outlines, and resulting
from disintegration of the nerve-fibres. Clifford- Allbutt strongly urges
neurotomy as a remedial process in tetanus.
Joff'roy (' G-az. Med.,' 1871, 74) gives the microscopical examination of
the cord, pons, nerves and muscles, from a case of traumatic tetanus.
Tetanus has been treated with injections of chloral hydrate of
morphia by Aron (' Gaz. Hebd.,' vii, No. 34) ; by Demarquay with
injections of morphia solution ('Bull. G-en. de Therap.,' t. 81, 299;
' Gaz. des Hop.,' 1871, 458) ; by Nankivell (' Med. Times and Gaz.,'
187 1, i, 246), Miles (' Brit. Med. Journ.' 187 1, i, 278), Tyrrell (* Lancet,'
1 87 1, i, 154), Lawrence (ib., 303), Croft (ib., ii, 60,6) and others, with
chloral hydrate; by Poster (ib., i, 572) with this drug and nitrite of
amyl; and by Pergusson ('Edin. Journ.,' xviii, 37) with chloral and
bromide of potassium.
Kussmaul, "Ueber rheumatischen Tetanus und rbeumatische tonische Krampfe,
welche mit Albuminuric verlaufen," 'Berl. Klin. Woch.,' 1871,458. Id., "Ueber
eine Abortive Form des Tetanus," ' Dent. Arch.,' xi, i. Vogel, " Tetanus Rheumaticus
mit Glykosurie," ib., x, 103. Koenig, "Das Gesicht des Tetanischen, eine Klinische
LEAD POISONING. 99
Studie, 'Arch. d. Heilk,' xii, 549. Maccall, "Tetany/' ' Glasg. Med. Journ.,' iii, 459.
I^hick, "Notes of a Fatal Case of Tetanus Treated by the Calabar Bean," ' Brit. Med.
Journ.,' 1871, i, 220. Dearden, "Notes of a Case of Idiopathic Tetanus, recovery"
(man, aet. 25), 'Lancet,' 1872, i, 321.
Lead Poisoning.
Kussmaul and Maier (* Deut. Arch.,' ix, 233) give the following
case : — A man, get. 35, a house painter, had suffered for several years
from chronic lead poisoning, showing itself in an anaemic (bluish-yellow)
colour, emaciation, dyspnoea, constipation, and abdominal pain, and
towards the end of life in attacks of colic, with dyspnoea and slow
pulse. During the second attack, which ended fatally, and was accom-
panied by jaundice, he was constipated, and vomited matter richly
tinged with bile ; this was followed by profuse diarrhoea, and later by
: collapse. The temperature was only slightly above the normal at any
time. He had no paralysis or brain-symptoms. The following is a
summary of the appearances observed at the autopsy : general and
. , great emaciation, marked rigor mortis of the muscles and heart nine-
1 1 teen hours after death ; a certain amount of jaundice ; great distension
' jof the stomach ; chronic catarrh of the mucous membrane of the
|stomach, intestines, and ductus choledochus ; fatty degeneration of the
'glands of the stomach ; slight fatty change of the muscular walls of
the stomach, especially at the pylorus ; atrophy of the mucous mem-
brane of the jejunum, ileum, and upper part of the colon, in which
both the stroma and glands shared ; atrophy of the intestinal villi, the
glands of Lieberkiihn, the solitary glands, and Peyer's patches ;
marked development of the submucous tissue of the stomach, and
even more so of that of the intestines, from proliferation of the areolar
tissue, and thickening of the sheaths of the vessels ; this was shown
^'Specially in the smaller arteries in the narrowing of their calibre,
laused by the large amount of fat-cells deposited in the distended net-
ftork of this layer; fatty degeneration of the muscles of the intes-
dnes, especially in the small intestine ; pigmental degeneration (pig-
Jiental atrophy) of the muscular fibres of the heart. The brain, espe-
nally its cortical substance, showed slight periarteritis ; there was
oroliferation and sclerosis of the connective-tissue septa of the small
i;anglia of the sympathetic, especially the coeliac and cervical ; these
glands were hard, the circulation in them affected, and their nerve-cell
elements diminished. The authors consider that the changes found in
;he absorbent apparatus account for the chronic dyspepsia, the anaemic
colour, and the malnutrition of the patient, and contrast their case, in
ts different bearings, with those recorded by Tanquerel des Planches
md others.
HoUis (*Brit. Med. Journ.,' 1871, ii, 9) gives the case of a looking-
jlass silverer, aet. 26, in whom mercurial and chronic lead poisoning
ppear to have existed side by side. The origin of the lead is found in
he tinfoil used in silvering.
Garrod (' Lancet,' 1872, i, i), in a clinical lecture on lead poisoning,
;ives a remarkable case of the disease in a gentleman, the cause of
rhich was traced to the presence in the snuff, which the patient took
100 REPORT ON PRACTICAL MEDICINE.
largely, of particles of lead. He thinks that the mixture of the snuff
containing certain of its soluble salts acts slowly on the lead case in
which the snuff is packed. The patient had lived for many years in
Calcutta, where other cases of the same kind had been observed.
Other papers on nervous diseases are —
Laycock, " On the Influence of the Nervous System on Diseases of the Organs and
Tissues," 'Med. Times and Gaz./ 1871, i, 31, &c. Durrant, " On Vertigo as a Symp-
tom," 'Brit. Med. Journ./ 1871, i, 88. Gueneau de Mussy, "^fitudes sur la Sensibility
Reflexe," 'Gaz. Hebd.,' 187 1, 344. Mantegazza, ' Dell'azione del dolore sulla Di-
gestione e sulla Nutrizione," 'Gaz. Med. Ital.,' Lomb., 1871, 45. Hammond, "A
Treatise on Diseases of the Nervous System," 2nd edit.. New York, 1872. Eulen-
hurg, " Lehrbuch der Functionellen Nervenkrankheiten auf Physiologischer Basis,'*
Berlin, 1871. Handfield Jones, "Cases of Neurotic Disorder with unduly large
Urinary Secretion," ' Med. Times and Gaz.,' 187 1, i, 13. Ogle, " Two Cases illustrating
the Diagnosis between apparent and real Intracranial Disease," 'Lancet,' 1871, i, 853.
Moxon, "A Case of Intracranial Disease cured by Iodide of Potassium," ib., ii, 851.
Fieber, " Ueber eine noch nicht beschriebene Form von Anomalie der Bewegungsbe-
schrankung," 'Wien. Med. Woch.,' 187 1, No. 41. Anderson, "Rare Form of Spinal
Irritation," * Glasg. Med. Journ.,' iii, 31. Hutchins, ''Spinal Irritation," 'New
York Med. Rec.,' vi, 1871, Oct. 2. Feinberg, "Ueber Reflexlahmungen : eine ex-
perimentelle Studie," * Berl. Klin. Woch.,' 1871, 491. Bumke, "Ueber Reflex-
lahmung" (two cases of traumatic paralysis), * Virch. Arch.,' Iii, 442. Burow, ' Die
Parese der animalen Nerven," 'Berl. Klin. Woch.,' 187 1, 600. Ogle, (i) "Some-
what unusual form of Paralysis" (woman, aet. 39, paralysis of extremities, affected
speech, twitching of muscles of face, intelligence intact, white atrophy of optic nerve) j
(2) " Paraplegia in a Boy, at. 7, connected with Curvature of the upper part of the
Dorsal Region of the Spine;" (3) " Paraplegia of some standing, suddenly becoming
worse," 'Med. Times and Gaz.,' 187 1, i, 39. Reincke, "Ein Fall von Paralysis
Ascendens Acuta" (man, aet. ^^), ' Deut. Klin.,' 1871, 210. Bernhardt, " Beitrag
zur Lehre von der Acuten Allgemeinen Paralyse" (man, aet. 29), ' Berl. Klin. Woch.,*
1871, 561. Chalvet, "Paralysie Ascendante Aigiie" (man, set. 27), 'Gaz. des
Hop.,' 187 1, 369. Barwinkle, "Ueber ein prognosticli wichtiges Symptom der
traumat. Lahmungen," ' Arch. d. Heilkunde,' xii, 336. Westphal, " Zwei Falle von
Armlahmungen nach Luxation des Oberarmkopfes/' 'Berl. Klin. Woch.,' 1871,52.
Bernhardt, " Beitrag zur diffcrentiellen Diagnose der Radialsparalysen," ' Virch.
Arch.,' liv, 267. Panas, "De la Ca\ise reelle de la Paralysie reputee Rhumatismale
du nerf radial," ' Bull, de I'Acad. de Med.,' xxxvi, 963. Althaus, " On Neuritis of
the Brachial Plexus," 'Med.-Chir. Trans.,' liv, 145. Kraft- Ebiug, "Ueber Druck-
lahmung von Arm-nerven durch Kriickengebrauch," ' Deut. Arch.,' ix, 125. Wilt-
shire, "Facial Paralysis from Fright," 'Lancet,' 187 1, i, 231. Russell, "Three Cases
of local Paralysis ; in two accompanying disease of the central organs of the nervous
system ; in the third, connected with tremor — Question of syphilis as a cause," ' Med.
Times and Gaz,' 1871, i, 219. Carpenter, "Cases of Muscular Anaesthesia" (two fe-
males, aet. 26 and 28), 'Lancet,' 1871, ii, 779. Leyden, "Ueber Progressive Bulbar-
Paralyse," ' Arch. f. Psych.,' ii, 643. Cheadle, " Labio-glosso-laryngeal Paralysis,'*
'St. Georg. Hosp. Rep.,' v, 123. Silver, "On a Case of Retrogressive Labio-glosso-
laryngeal Paralysis," ' Brit. Med. Journ,,' 187 1, i, 430. H. Morris, " Venous Vascular
Tumour of Cerebrum," 'Path. Soc. Trans.,' xxii, 22. Bosisio, "Storia di un Tumore
Cancroso del Cervelletto," 'Ann. Univ. di Med.,' vol. 215. Clapton, "Atrophy of the
Cerebellum " (woman, aet. ^^, sexual functions normal), ' Path. Soc. Trans.,' xxii, 20.
Fleischmann, "Ueber einige zufallige Befunde bei Gehirnverletzungen," 'Jahrb. f.
Kinderheilk.,' iv, 283. Moxon, "Pathological Facts indicative of the Conveyance of
Disease by Disordered Nerves," 'Lancet,' 187 1, i, 819. Fischer, "Ueber Trophische
Storungen nach Nervenverletzungen an der Extremitaten," ' Berl. Klin. Woch.,' 1871,
145. Schiefferdecker, "Trophische Storungen nach peripherischen Verletzungen,"
ib., 160. Clarke, "A Case of Unilateral Atrophy of the Tongue," ' Med.-Chir. Trans.,'
Iv, 91. Molliere, "Note pour servir a I'Histoire de la Pathologic du nerf Olfactif,"
' Lyon Med.,' viii, 385. Noyes, " Paralysis of the Fifth Cerebral Nerve," 'New York
Med. Rec.,' vi, 231. Seeligmiiller, "Ein Fall von Lahmung des Accessorius Willisii,""
(EDEMA GLOTTIDIS, LARYNGISMUS,, ETC. 101
' Arch. f. Psych.,' iii, 433. Beck, " Spindle-celled Sarcoma connected with the Pos-
terior Tibial Nerve," 'Trans. Path. Soc,,' xxii, 18. Emminghaus, "Ueber halbseitiger
(iesichtsatrophie," 'Dent. Arch,,' xi, 96. Haudfield Jones, "Epilepsy and other
Nervous Affections resulting from the Excessive Use of Alcohol," 'Practitioner,' 1872,
Feb. Wilks, "Alcoholic Paraplegia," 'Lancet,' 1872, i, 320. Lockhart Clarke,
'' Alcoholic Paresis and Paraplegia," ib., 427. Moxon, "A Case of Paraplegia lasting
five years, electrical anaesthesia, question of malingering" (boy, set. 18), ib., ii, 7.
]^enedikt, " Nekroscopischer Bef und bei einem geheilten Fall von Paraplegic,"
' Wien. Med. Woch.,' 1872, No. i, &c. Gray, " Sudden Decrease in the Frequency of
t])e Pulse during Disease as a sign of approaching Cerebral Complication," 'Brit.
Med. Journ.,' 187 1, ii, 94. Mitchell, "On the Growth of the Nails as a Prognostic
Judication in Cerebral Paralysis" (two cases), ' Amer. Journ. Med. Sci.,' Ixi, 420.
JCdes, "Morbid Growths connected with the Nervous System ; Cerebrum, Cerebellum,
and Semilunar Ganglion of the Sympathetic," ib., 87. Meade, "Extensive Deposit of
Lymph on Serous Membranes (of brain in boy, set. 6 years, with fractured parietal
l)one, &c.) in nineteen hours," ' Lancet,' 1871, ii, 13. Dowse, " Cerebro-spinal Arach-
nitis, with Cerebral Disturbance " (woman, aet. 25, autopsy), ib., 1872, ii, 9. Charpy,
" De la Definition Anatomique et Physiologique de la Paralysie Generale," ' Lyon
Med.,' ix, 78. Howden, "An Analysis of the Post-mortem Appearances in 235 Insane
Persons," * Journ. Ment. Sci.,' 187 1,' 84. Wright, "Insanity Dependent on Consti-
tutional Syphilis," 'Edin. Journ,,' xvii, 1095. West, "On some Disorders of the
Nervous System in Childhood," 'Lumleian Lectures,' 1871. Tigri, "Sulle Anomalie
e sulle Malattie del Cervello e parti annesse, come causa prossima della alienazione
nientale ; resultanze degli studi anatomici eseguiti nel corso di' 20 anni, publicati per
guida del dissettore di queste necroscopie," ' Ann. Univ. di Med.,' ccxvi, 523. Ron-
cati, "L'Arsenico contro le Malattie Nervose," * Gaz. Med. Lomb.,' 1872, 9. Bailly,
"Des Paralysies consecutives a quelques Maladies Aigues," 'Gaz. des Hop.,' 1872, 93.
c. Diseases of the Respiratory System.
(Edema Glottidis, Laryngismus, Sfc.
Boelt (' Rec. de Mem de Med. Mil.,' xxvi, 43) gives the following
case: — ^A soldier, set. 29, had two years before had an attack of
dyspnoea, which lasted two hours, and was followed by oedema of
the neck and face. On May 11, 1870, he had another suffocative
attack. He had been revaccinated on the 4th ; on the i oth his
conjunctivae were slightly injected, next day the dyspnoea com-
menced, with a feeling of difficulty in swallowing. There was con-
siderable oedema of the velum, epiglottis, and aryteno-epiglottidean
folds. The parts were scarified and sponged with a solution of nitrate
of silver, with great relief. Later, oedema of the right hand and upper
lip was succeeded by oedema of the right foot and lower lip. The
symptoms disappeared, and the patient recovered. In the absence of
any cause to be discovered in an affection of the heart or kidneys,
Eoelt ascribes the sudden occurrence of the oedema, which was unac-
companied by any symptoms of inflammation, to hyperaemia due to
paralysis of the vascular branches of the sympathetic nerves.
Eussell (' Glasg. Med. Journ.,' 1871, iii, 209) reproduces an already
published case of laryngeal obstruction, preceded by erysipelas, in a
woman set. 21. Tracheotomy was performed, but the obstruction still
exists and the patient still wears the canula. He gives a second case of the
same kind, occurring in a female, set. 18, attacked with typhus. Nothing
abnormal was revealed by the laryngoscope about the epiglottis or vocal
cords. The laryngeal obstruction became so severe that tracheotomy was
performed, and the patient was relieved. Later, the obstruction still re-
102 REPORT ON PRACTICAL MEDICINE.
maining, a laryngeal mirror was introduced through the opening in the
trachea, and showed that the latter was closed below the rima glottidis
by swelling of the mucous membrane. Introduced in the usual manner,
the mirror showed the epiglottis erect, the cords widely separated, and a
circular fleshy tumour with a dark central spot like that seen from
below. He looks upon both as cases of laryngitis resulting in per-
manent stricture of the submucous tissue below the rima glottidis. In
the second case there was undoubted constitutional syphilis.
Johnson (' Brit. Med. Journ.,' 187 1, i. 469) arranges cases of spasm
of the larynx in the following groups: — (i) Hysterical laryngismus ;
(2) laryngismus stridulus in children ; (3) laryngeal spasm, due to
pressure on the pneumogastric or recurrent nerves, by aneurism or
other thoracic tumour ; and (4) that produced by the presence of a
foreign body, or the inhalation of irritating gases or dust, or by inflam-*
mation of the laryngeal mucous membrane. He gives the case of a
girl, aet. 22, who suffered from the first cause. Chloral was prescribed in
doses of ten grains every six hours, and the laryngeal stridor ceased.
The aphonia which accompanied it yielded to galvanism.
Navratil (' Berl. Klin. Woch.,' 1871, 394) gives the result of his
experiments on five dogs and a cat, as to the function of the laryngeal
nerves. He finds that the superior laryngeal has no influence on the
motor function of the larynx, and the spinal-accessory nerve none on
the muscles of the vocal cords.
Tait, " Laryngismus Stridulus," * Dublin Journ.,' li, i r 7. Mackenzie, " On
the Differential Diagnosis of Chronic Inflammations of the Larynx " (simple
chronic inflammation, laryngeal phthisis, syphilis, cancer of the larynx), ' Lancet,'
1872, i, 7. Veale, "On the Movement of Mucus in the Trachea and Larynx," ib.,
1 87 1, ii, 121. Rogers, "Acute Laryngitis, Tracheotomy, Recovery" (in woman,
set. 23), ib., ib., 159. Mackenzie, "Constriction of the Trachea, Syphilitic Deposits
in the Liver and Kidney" (man, aet. 39), 'Path. Soc. Trans.,' xxii, 33. Norton, "Epithe-
lioma of the Larynx" (man, set. 62), ib., xxiii, 43. Simpson, " Clinical Lectures on
the Use of the Laryngoscope," ' Brit. Med. Journ.,' 187 1, i, 415. Bergeret, " Trache-
otomie non-croupale : Contribution a I'histoire des affections du larynx," ' Lyon Med.,*
vii, 59. Fieber, "Vortrage iiber Laryngoscopie," ' Wien. Med. Ztung.,' 1871, 359.
Rehn, " Chloralhydrat gegen Spasmus Glottidis," ' Jahrb. f. Kinderheilk.,* iv, 130.
Diphtheria and Group.
Letzerich ('Berl. Klin. Woch.,' 1871, 187) continues to insist upon
his favourite fungi as the origin of diphtheria. After the entrance of
the spores into the blood and lymph a secondary constitutional disorder,
according to him, diphtheritis generalis, is set up. The patients may
die rapidly of collapse, or a febrile state may suddenly occur, with head-
ache, abdominal pains, nausea, apathy, constipation, with some tympa-
nitis. The urine is diminished in quantity, and often contains albumen
and casts made up of masses of the fungus (!) ; the lumbar region is
tender on pressure. Convulsions often occur in children up to the age
of five years. His treatment consists in the use of a warm bath for a
quarter of an hour, followed by continued applications of linseed-meal
poultices to the lumbar region; a teaspoon or dessert-spoon of lime-
water every half hour, and in protracted cases quinine.
In another paper ('Yirch. Arch.,' Hi, 231) he gives the results of 118
DIPHTHERIA AND CROUP. 108
further experiments, in continuation of his former papers on the pro-
d action of diphtheria by specific spores. He fed rabbits of diiferent
ages on the cultivated fungi, so as to eliminate all diphtheritic exuda-
tion. The symptoms produced were loss of appetite, malaise, increasing
inability to swallow fluids, elevation of temperature, diarrhoea, or, in
the older animals, obstinate constipation and almost complete sup-
])ression of urine. The animals were killed, and the post-mortem
appearances were, on the whole, as follows: — Hypersomia of the
stomach, ulcers in it and in the duodenum, which was covered with
whitish masses ; hypersemic kidneys, and in some cases albuminous
urine. Microscopic examination showed the presence of the peculiar
spores and filaments in white masses, and in other parts, even among
the glands of Lieberkiihn, in the tubules and pelvis of the kidney, in
the ureters, and in the urine. No symptoms followed the swallowing
of peaicillium glaucum, nor were its spores found in any of the organs
examined. He concludes that, through the destruction of the mucous
membrane openings are made into the blood-vessels, lymphatics, &c.,
by which portions of the fungus make their way into the circulation,
setting up a general disorder, which has its special seat iii the kidneys,
where the spores and filaments are developed to an enormous extent.
The same origin and course of symptoms and microscopical appearances
he finds in the diphtheria of children. The latter name he would apply
to the local affection of the fauces, and that of diphtheritis to the secondary
symptoms. In reference to Grohe's experiments with other fungi, he
believes that the peculiarity of the diphtheritic fungus is that, while other
spores must be artificially injected to produce like symptoms, the former
makes its own way through the tissues which it first destroys.
In a third paper (* Yirch. Arch.,' Iii, 493) he discusses the physiology
of ciliated epithelium and the development of the exudation in croup
and diphtheria. On mucous membranes with smooth epithelium the
exudation is thick and closely adherent ; on others with ciliated or
cylindrical epithelium it is creamy and easily stripped off". He holds
that croup and diphtheria are not identical, though they may be de-
veloped side by side, and may pass from one into the other.
Oertel (' Deut. Arch.,' viii, 242) writes an extremely full and very
long paper on experiments made in reference to diphtheria. With
the same view he makes use of several very instructive autopsies
made on human bodies. According to him diphtheria causes con-
stant capillary haemorrhages, most numerous in the subepithelial
and submucous tissues, next in the pleura, pericardium, diaphragm,
dura mater, and in the capsules of the lymphatic glands, and again
in the brain and spinal cord, in the sheaths of the nerves, and in
the large organs. Micrococcus is developed and proliferates in the
diseased mucous membrane and extends into the blood, into the
neighbouring lymphatic glands, and over the whole body. i. Am-
monia and other chemical irritants set up a pseudo-membranous
inflammation in the larynx and trachea. The writer made this experi-
ment on fifteen rabbits, and caused an inflammation agreeing in all its
symptoms with croup as it occurs in the human body, and becoming
fatal through suff'ocation. There was no affection of the other organs.
104* REPORT ON PRACTICAL MEDICINE.
The fungus was found on the surface of the membranes, but nowhere
else, and inoculation with it gave negative results. 2. Inoculation in
the trachea of twelve rabbits with diphtheritic membrane taken from
men caused death in five by suffocation, in three by the constitutional
infection. The post-mortem examination showed, not only diphtheritic
inflammation in the larynx and trachea, but also numberless haemor-
rhages in the most various organs, especially haemorrhagic inflammation
of the cervical and axillary glands, capillary ecchymosis, and dege-
neration of the muscles. The kidneys were swollen and livid, both
cortical and medullary substances exceedingly hyperaemic, with
ecchymosis here and there. 3. Inoculation with diphtheritic membrane
under the skin and in the muscles, in five rabbits, gave the following
results: — The wound was covered with grey slimy deposit, the muscles
and connective tissue around and about it boggy and ecchymosed. The
kidneys were highly hyperaemic and swollen. 4. Inoculations with
decomposing animal substances gave altogether different results to
those of diphtheritic membranes. 5. The diphtheritic poison introduced
from men into animals, reproduced in them and increased, may be
inoculated into other animals, even those of diff'erent zoological classes,
and into different tissues and organs, with the same diphtheritis of the
wound, and severe constitutional affection. Oertel concludes that the
local disease begins in one spot of infection, and from it extends over
the body. He insists upon a sharply marked separation between croup
and diphtheria ; the latter can provoke a croupous inflammation ; the
former never passes beyond the limits of a local inflammation.
Hartmann (' Yirch. Arch.,' lii, 240) refers briefly to three views — (i)
that croup and diphtheria are identical ; (2) that the latter is only an ad-
vanced stage of the former; (3) that the two are distinct affections, the
diphtheria being a blood disease, exhibiting its local effects in the fauces
and larynx, just as the typhoid process is localised in the intestine. He
holds that croup always precedes diphtheria (p. 246) ; that in the former
the raucous membrane is intact, while in the latter it is destroyed.
Classen ('Virch. Arch.,' lii, 260) gives an analysis of 155 cases
of diphtheria treated by him at Eostock, from October, 1862, to
the end of March, 1870. Thirty-seven were fatal : 27 from suf-
focation, from extension of the affection to the respiratory organs,
2 from capillary bronchitis after tracheotomy (a third case of tra-
cheotomy, in a child, recovered), and 8 from exhaustion or blood-
poisoning. Thirty-eight were under the age of 10 years, 26 between
10 and 20, and 31 over 20 years. He considers the so-called false
membranes to be only dead mucous tissue, and he has been unable to
find any of Letzerich's spores, &c. He discusses at some length dif-
ferent modes of treatment, and publishes what he thinks a unique case
of affected vision in a boy, set. 15, after diphtheria, due probably to
haemorrhage into the sheath of the optic nerve.
Hutchinson ('Lancet,' 1871,1, 13) gives three cases of paralysis of
the ciliary muscle from diphtheria. The cases are peculiar and easy of
diagnosis, the patients generally children. The defect of sight, usually
inability to read, comes on suddenly, always after convalescence has
seemed to be established, and disappears in a month or six weeks.
DIPHTHERIA AND CROUP. 105
Kraft-Ebing (' Deut. Arch.,' ix, 123) gives the following contribution
to paralysis occurring after diphtheria. A man, set. 30, suffering from the
affection, was attacked in the course of a few days with a progressive
paralysis gradually extending to all the extremities, leaving the bladder
and rectum intact. The paralysis was accompanied by cutaneous and
muscular anaesthesia. In the course of four, or five months the symptoms
disappeared. At the end of about twenty weeks the contractility of the
muscles was lost to faradisation, but normal to galvanism. He looks
upon the case as another proof of the peripheral origin of the paralysis in
diphtheria. (C£. Buhl, "Einiges iiber Diphtherie," ' Centralbl.,' 1871,
Griiterbock (' Virch. Arch.,' Hi, 523) records five cases of subcutaneous
emphysema occurring in diphtheria without tracheotomy. He agrees
completely with the views of Yirchow as to the mode of its occurrence,
and with Traube considers it a symptom of interlobular emphysema of
the lung. It is rare, much rarer than that which takes place during or
after tracheotomy. The five cases, like those given by Sachse, Bartels,
and Hueter, terminated fatally ; while in eight cases of emphysema of
the skin after tracheotomy three recovered.
Kersey ('Brit. Med. Journ.,' 1871, i, ^66) describes an outbreak of
diphtheria (forty cases) in West Kent, without any apparent cause.
Some cases occurred near the lesser Stour, others on ground nearly a
hundred feet above, and a mile from the river. Four terminated fatally.
One case is given at length, in which the membrane was extensive,
albumen present in great amount, and there was paralysis of the pha-
rynx and of accommodation, followed, during convalescence, by
paralysis of the extremities and of the muscles of the neck and back.
Grreenhow described to the Clinical Society (ib., i, 488) a case of
diphtherial paralysis in a female, set. 26, treated successfully with
faradisation.
Underbill (ib., 323) exhibited five tracheae on which tracheotomy had
been performed for membranous croup in children, a thick layer being
present in all. Tracheotomy does not seem to have been successful
tit the Children's Hospital, Birmingham, having been performed eight
times between Sept. 1870 and Eeb. 1871 — twice for croup following
scarlet fever, and once for diphtheria, once for oedema of the glottis fol-
lowing gangrene of the tonsils in enteric fever, and four times for mem-
branous croup, in each case with fatal result.
Gr. Buchanan (ib., 217) holds that tracheotomy is admissible only
in the sthenic form of these diseases, when other treatment has failed,
and the tendency to death is from apnoea rather than exhaustion, and
before the vital powers are lessened by the struggle for breath. A clear
indication for the operation is a well-marked and increasing drawing-in
of the costal cartilages and intercostal spaces, with a moderately good
pulse. He gives, in full, a case in which the tube was removed on the
eighth day, in a boy of six years and he adds a table (cf. ib., 310) of
thirty-nine cases in which he performed tracheotomy — fourteen in croup,
twenty-four in diphtheria, and one in which a chicken-bone had lodged
in the glottis ; twenty-six were fatal ; nineteen of the operations were
in children under four years, two of which were successful ; and twenty
106 UEPOUT ON PRACTICAL MEDICINE.
in children four years and over, eleven of which were successful ; two
thirds of the whole, therefore, were fatal.
Cooper Eorster (ib., 309) records a case of successful tracheotomy in
a child of eleven months for croup. [He adds a case in which he per-
formed tracheotomy in a man, set. 80, with malignant growth in the
larynx.]
Bell gives (ib., 369) a successful case of tracheotomy in a child of
seven months for croup.
Cordier (' Lyon Med.,' ix, 92 ; and see discussion on this paper, ib.,
106) gives three cases of diphtheria, two fatal, in boys set. 7, and one in
a girl, set. 5, on whom tracheotomy was successfully performed, and the
canula removed on the tenth day.
Olivier (' Graz. des Hop.,' 1871, 85) publishes two cases of croup;
one was in a girl, set. 7, in whom tracheotomy was performed in
extremis, and the canula removed after seven days. The daily tem-
peratures, &c., are given. The other was in a boy, set. 4, who also
recovered after tracheotomy, the canula being removed on the thirteenth
day. In this case there was laryngeal paralysis.
As to other means of treatment in diphtheria, Schiitz (' Wien. Med.
Woch.,' 1871, No. 31) uses a solution of bromide of potassium with
bromine (gr. vj to 5iv) for pencilling the larynx and for inhalation.
Brasch ('Ber. Klin. Wochr,' 1871, 551) gives glycerine of iron in-
ternally and carbolic acid locally. Under this treatment the mortality
was 20 per cent., while under the employment of nitrate of silver and
mercurials it was 157 per cent.
Heifer ('Deut. Klin.,' 1871, 229) obtains good results from the use
of carbolic acid.
Bouchut (' G-az. des Hop.,' 1871, 326) uses injections of a mixture
of coal tar and tincture of saponine (coaltar saponine), and induces
the children to allow it by giving sugar water in the same syringe. He
gives a case (ib., 582) where an emetic had good effect.
Laserre (' Bull, de I'Acad. de Med.,' xxxv) found, when he was
called in early enough, that keeping the patient in a warm bed and in
a heated chamber, and the administration of diaphoretics, brought about
successful results.
Bouchut (' Bull.' de Therap.,' Ixxxiii, 373, and cf. Ixxxii) records
notes of five more cases treated by emetics (tartar emetic). In three
of the cases tracheotomy was proposed, but either rejected or deferred ;
four cases recovered and one died from lobar pneumonia. The tartar
emetic caused vomiting of the false membranes. The children were five
years old or younger, and the medicine was given in doses of one to
two grains, according to age, in two ounces of sugar-water. On days
when it was not given as an emetic it was employed as a " counter-
stimulant." A grain was dissolved in two ounces of water, and two
teaspoonfuls given every two hours. Thick soup or bread soaked in
water or sugared wine was the nourishment given, and but little drink,
so as to prevent the purging effects of the tartar emetic.
Vaneschi, " Zur Frage iiber die Traclieotomie bei Laryngitis Diphtheritica,'* * Berl.
Klin. Woch./ 1872, 163. Mxihsam, " Ueber Diphtheritische Lahraungen," ib., 21.
Roth, " Lymphatische Wucherungen nach Diphtheritis " (female, set. 53, with
THE RESPIRATORY MURMUR, ETC. 107
autopsy), * Virch. Arch./ liv, 254. Moos, " Ein Fall von selbstandiger Diphtheritis
(Ics ansseren Gehorgangs" (boy, set. 10), 'Arch. f. Aug.-u.-Ohrenheilk.,' 1871, 86.
Schiiller, " Primarer Croup der Nasenschleirahaut," ' Jahrb. f. Kinderheilk.,' iv, 331.
Eouchut, "Traitement du Croup par rEmetique," * Gaz. des Hop./ 1872, i. Cowan,
" On the Medical Treatment of Diphtheria," ' Glasgow Med. Journ.,' iii, 219. Balfour,
"Chlorine-water in the Treatment of Diphtheria," ' Edin. Med. Journ.,' xvii, 513.
Menzies, "On an Epidemic of Diphtheria observed at Naples in 187 1, with an
attempt to determine the common origin of Cerebro-spinal Meningitis, Typhoid
Fever, and Diphtheria," ib., xviii, 217. " Quinia in Croup," 'Amer. Journ. Med.
Sci.,' Ixi, 598. Murchison, " Case of Diphtheria, with extension of the Membrane to
tlie Bronchial Tubes " (man, .set. 24), ' Path. Soc. Trans.,* xxii, 35. Savage, *' Success-
ful Case of Tracheotomy in Croup " (boy, 7, removal of the tube on eighth day),
'Brit. Med. Journ.,' 1871, i, 531. Greenhow, " Paralysis after Diphtheria" (man,
at. 32), ib,, 1872, i, 538. Giacchi, Natura e Therapia dell' Angina Difterica, Poppi,
1872; pp. 23.
The Hespiratory Murmur^ ^c.
Stone, in a valuable paper •' On^gophony" (' St. Thos. Hosp. Rep.,'
1871, 187), observes "that a pure musical vibration within the limits
of the ordinary speaking voice is not transmitted at all, either through
consolidated lung or through a layer of pleuritic fluid ; but that the
same note, when vocalised and modified by the addition of vowel sounds,
immediately passes through the media at a changed pitch." He found
that the e and i sounds, whicli Helmholtz obtained with great difficulty
in his experiments, and only by reinforcing the extreme high harmonics
at the expense of the fundamental notes, were exactly the sounds on
which aegophony was most distinct, whether in a living lung or an
india-rubber bag containing water. He concludes that aegophony has
for its cause the fact " that the layer of fluid, while it stops the larger
and coarser vibrations of the ground-tone, lets pass the finer and closer
undulations of the high harmonics."
In reference to the peculiar mode of respiration first described by
Cheyne, and later by Stokes, C. Bruckner (* Virch. Arch.,' Iii, 155)
writes on what his father had taught twenty -two years ago as pendulum-
like respiration. He notices it especially in children aff'ected with tuber-
cular meningitis. After the pause the patient breathes at first almost
inaudibly, but with gradually increasing force, till the highest point ia
reached, the respiration gradually falling till the pause again recurs.
The latter generally lasts as long as the sum of all the respirations be-
tween two pauses. The number of respirations varies in diflerent
patients, sometimes only 6 — 8, in others 20 — 30. According to the
elder Bruckner, the symptom is caused only by the presence of watery
fluid within the skull, and the son has also noticed it in cases of the
same kind only.
Merkel (' Dent. Arch.,' viii, 424) records a case in which the same
phenomenon was present. The patient, a man, set. 44, was first seen
in the autumn of 1 866, extremely anaemic, and suffering from haemor-
rhoids. His arteries were rigid. At the end of [869 he had an apo-
plectic fit, followed by left-sided paralysis. His respiration at that time
was at first superficial, and increased in depth, but not in frequency, till
it developed into a well-marked dyspnoea. This condition lasted fop
108 REPORT ON PRACTICAL MEDICINE.
30 — 4^ seconds, and was succeeded by a complete pause of 20 — 30
seconds, during which the pupil was contracted and immovable, and
again the same round of symptoms was repeated. He never lost con-
sciousness. He was again seen in November, 1870; the peculiar
respiration was still present, and a month later the patient died. The
autopsy is given, but neither it nor the writer throw any further light
on the cause of the phenomenon. The case is noticeable on account of
the long period during which the peculiar form of respiration had lasted.
Waldenburg (" Die Manometrie der Lungen, oder Pneumatometrie
als diagnostiche Methode," *Berl. Klin. Woch.,' 1871, 541) describes a
manometer to measure the pressure of inspiration and expiration in
diseases of the lungs. The instrument proves what is already known,
that in the normal state the pressure of expiration is stronger than that
of inspiration, the former averaging between 70 and 180, or even 200
millimetres, the latter between 60 and 120. The average of the expira-
tory pressure in men is 80 — 120, of the inspiratory 70 — 100 ; in women
the expiratory is 30 — 80, the inspiratory 40 — 90. In emphysema the
inspiratory pressure is normal, the expiratory greatly diminished, this
insufficiency of expiration depending on the lessened elasticity of the
air-vesicles. On the other hand, in the early stages of tuberculosis the
pressure of expiration is normal, while that of inspiration is abnormally
low ; in the later stages, however, the expiratory pressure is also dimi-
nished. These facts may be used in the differential diagnosis of
disease. In cases of stricture of the trachea both pressures are
diminished.
Korner (" Beitrag zur Lehre von der Tuberculose," * Wien. Med.
Ztung.,' 187 1, 189) refers to the detrimental influence exerted by
small development of the respiratory muscles of the neck upon the
course of affections of the apices of the lungs. The defective inspira-
tion leads to defective supply of arterial blood, and this, again, aids the
cheesy degeneration of bronchitic or pneumonic products. He thinks
that the fever which occurs during the process of cheesy change and
softening is produced by the reabsorption of dead matter, and that it
usually persists in proportion to the extent and density of the indura-
tion which surrounds the cheesy deposits and the vomicsB.
Brown-Sequard ('Lancet,' 187 1, i, 6) gives the following results of
his experiments on guinea-pigs, &c. Crushing or wound of the pons
Variolii caused numerous ecchymoses, and even real apoplexy in the
lungs, generally most marked on the side opposite to that of greatest
lesion. The influence is exerted mainly through the spinal roots of the
sympathetic nerve. Anaemia of the lungs, from spasm of the blood-
vessels, also results from injury to the pons. QEdema of the lung
appears principally after injury to the medulla oblongata. According
to Kanvier, the parts of lung thus changed contain a good deal of
serum, and the minute blood-vessels are filled with white, and free from
red, corpuscles. He states as a new fact that emphysema of the lungs
" can appear when not a single respiratory movement takes place, after
an irritation of the base of the brain, either by crushing or cutting."
He draws attention to the frequency of pulmonary changes dependent
on brain- influence. Of 188 cases of organic disease of the brain, re-
MEDIASTINAL GROWTHS. 109
corded by Calmeil, there was a morbid condition of the lungs, especially
inflammation, in more than 60, i. e. in i oat of 3.
Whitehead ('Trans. Path. Soc.,' xxii, 82) showed some peculiar
sputa " hawked up" after eating by a woman, set. 24. The sputum
consisted, of tenacious, gelatinous-looking masses, more or less elon-
gated, of ragged outline, and non-tubular, and of delicate, transparent,
membranous laminae, varying in size from that of a minute flake to a
square inch, and streaked with irregular reticulations. The microscope
showed that both were almost entirely made up of stratified squamous
epithelium, with a few mucous corpuscles. These characters favour the
opinion that the specimen consisted of mucus yielded by a catarrhal
condition of the pharynx or upper part of the oesophagus.
Baas, " Experimenteller Beitrag zu Auf klarung derFrage iiber den Entstehungsort
und die Entstehungsart des sog. Vesicular- Athuiens und der Rasselgerausche,'' 'Deut.
Arch./ ix, 316. Lippe, "Grenzen des normalen Bronchialathmens," ib., 525. Rehn,
"Zwei Beobachtungen von Cheyne-Stokes'schen Respirations-phanomen bei Lungen-
affectionen im kindlichen Alter," ' Jahrb. f. Kinderheilk.,' iv, 432. Leven, "Dea
diverses formes d'Asphyxie au point de vue physiologique et pathologique," * Gaz. des
H6p.,' 1872, 68. Bourgeois, 'De la Congestion Pulmonaire simple/ Paris. Rohden,
**Der Zweckmassigste Geradhalter/' 'Berl. Klin. Wocb./ 1871, 236. Watts, 'Inha-
lation for Diseases of the Lungs,' London.
Mediastinal Growths.
Virchow (' Archiv,' liii, 444) describes a peculiar mediastinal tumour
(Teratoma myomatodes). The patient, a man, set. 22, had been under
observation for about two months. He had been indisposed for some
weeks, and complained of shortness of breath and pain in the right
thorax. On percussion there was dulness from the third right rib
downwards, extending in an oblique line backwards to the angle of the
scapula. No respiratory murmur was audible over this region of dul-
ness. The general condition of the patient became gradually worse,
with febrile symptoms from time to time. After four or five weeks a
painful prominence began to be developed at the junction of the carti-
lage and bone of the left rib. In about five weeks, when death occurred,
this tumour had reached the size of a small fist. At the same time the
dulness on the right side became greater in front as well as behind ; the
liver was pushed down. Eor some time there was oedema of the right
side and part of the abdomen, which gradually disappeared. Death
occurred from increasing difficulty of breathing. The diagnosis made
was an encysted exudation in the anterior portion of the pleura. The
tumour on the third rib was considered to be a " cold abscess" or an
enchondroma. The autopsy showed an elastic tumour, which had de-
stroyed the anterior part of the third rib. Instead of any pleuritic
exudation was found an enormous tumour, which occupied the greater
part of the right thorax, and extended some way over the middle line
to the left. The right lung was pushed backwards and upwards, the
heart to the left, and the liver downwards. The latter was greatly en-
larged, and contained various hard nodes, some imbedded in its sub-
stance, some prominent on its surface. The spleen was enlarged, and
presented on its upper surface several vesicles, about the size of a wal-
110 REPORT ON PRACTICAL MEDICINE.
nut, and containing bloody fluid. The kidneys were also enlarged, and
contained the same kind of nodes as the liver. On account of the ad-
vanced decomposition it was impossible to make any further examina-
tion of these three organs. The mediastinal tumour was 20 cm. long,
21 broad, and i^ thick, adherent to the right lung, the pericardium, and
the large vessels. The left and larger portion of it was almost com-
pletely solid, richly vascular in parts, but distinctly fibrous. In the
fibrillar intervening substance were numerous spindle-shaped cells,
like those of spindle-celled sarcoma ; but the chief mass consisted of
obliquely striated spindle-cells, containing one or more large nuclei.
The older elements were striated throughout their whole thickness, the
younger only on the surface (Virchow's Myoma striocellulare) . Their
derivation from normal muscle was impossible, as the cells had double
prolongations, like the branched muscle-cells of the heart. The right
and smaller half of the tumour consisted of small cysts, about 25 cm. in
diameter, containing on their inner surface small outgrowths and vesi-
cles, like those found in proliferating ovarian cysts. In many places
the cysts were confluent. In the middle of the tumour was a cavity,
25 by 15 cm., which was surrounded by a leathery wall and enclosed
hair, small plates of epidermis, cholestearin, and fat. Other cavities
were lined with ciliated epithelium. In the neighbourhood were small
scattered portions of hyaline cartilage, with a thick perichondrium, ex-
tremely like the cartilages of the bronchi, though no connection between
the two could be made out. In one place the tissue was finely spongy,
and in the meshes were roundish, granular, nucleated cells, like gland-
cells, the stroma being made up of sarcomatous round and spindle-
cells. In the tumour on the rib were cysts, striated muscle-cells, and
patches of carcinoma. One patch, the size of a hemp-seed, consisted of
round alveoli made up of elastic fibres, like foetal lung. This tumour
was entirely surrounded by perichondrium, and was not connected with
that in the mediastinum.
The variety of elements entering into the formation of this growth
points to a foetal origin. The ciliated epithelium and cartilages in the
large tumour and the elastic fibrous network in the small "recall
so vividly the organs of respiration that the mind is compelled to
think of an aberration of particles, which originally belonged to bronchi
and lungs." Still, there is a difficulty in holding this view in the face of
the fact that the greater part of the large growth, and the whole of the
small one, was developed during the latter part of the patient's life.
We must therefore, especially with regard to the tumours in the ab-
dominal glands, consider it as a " heterochronous, metastatic growth."
The paper concludes with remarks on dermoid cysts of the mediastinum
and their possible starting-points, and on lympho-sarcomata (thymus,
bronchial glands, skin).
Gueneau de Mussy (' Graz. Hebd.,' viii, 462, &c.), writes a long paper
on " Bronchial Adenopathy in the Adult." He looks upon this affection
of the bronchial glands as secondary, and following lesion in organs
traversed by the lymphatic vessels which feed them ; under the influence
of constitutional predisposition they acquire such development as to
become the predominant element in the disease ; in some cases they
'mediastinal growths. .Ill
seem to be attacked primarily, for instance, as in children, ** tubercles"
may be present in them while absent in the lungs. And in children
this " bronchial adenopathy" is more frequent than in the adult, in
whom it has been but little studied. In the first stage of the affection
the functional disorder is slight ; the patient complains of dry cough,
resembling hooping-cou^h, and dyspnoea; abnormal sensibility about
the seat of the affected glands, in the interscapular or subclavicular space,
with spontaneous pain there, due probably to the intercostal nerves,
and consequently to be looked upon as reflex. The expectoration is
little in comparison with the cough ; sometimes bronchitis is a compli-
cation, or even in some cases the starting-point of the adenitis. He
sketches at some length the plan he follows in percussing out the limits
of the gland enlargement, whether in the neighbourhood of the trachea
or the bronchi, and the alteration caused in the voice and the respira-
tion. In addition to these signs, the character of the cough, the
dyspnoea, the depression above the sternum during deep inspiration, the
respiratory sibilus often audible at a distance, and the attacks during
which the cough and dyspnoea become more violent, all draw attention
to the bronchial glands. These latter attacks, according to Fonssagrives
and Eilliet and Barthez, are to be attributed to a rapid congestion or
some temporary movement of the glands. As the disease advances
symptoms of compression and strangulation show themselves, and death
occurs either from this cause or from breaking down of the glands and
their rupture into the trachea, bronchi, lung or pleura, where they
sometimes set up pneumothorax, and in other cases into the oesophagus
or mediastinum. He speaks shortly of the differential diagnosis from
consolidation of the lung, from aneurism and other mediastinal tumours ;
and as to prognosis, though he allows that the affection is almost always
fatal, yet he thinks he has seen cases in which it has retrograded. He
has noticed it as a complication in bronchitis, pneumonia, pleurisy,
whooping-cough, measles, and typhoid fever. The paper concludes with
the histories of six cases.
Murchison (' Path. Soc. Trans.,' xxii, 68) showed specimens of lymph-
adenoma from the mediastinum and kidneys from a woman SBt. 21.
Bennett (ib., 70) also showed a growth of a same kind from a girl set.
17 ; and Payne and Clapton (ib., xxiii, 270) record a case of mediastinal
and intra-cardiac tumour, also like lymphadenoma, but having a greater
preponderance of cells (lympho-sarcoma).
Clarke ('Lancet,' 1872, ii, 10) records the following: — A mason, set.
30, had been perfectly well up to six weeks before his admission into
hospital ; at that time, after lifting a heavy stone, he noticed a swelling
in his neck and complained of dull aching pain down the right arm,
dyspnoea, dysphagia, and partial aphonia. The chest and arms, espe-
cially the right, were very oedematous, and the superficial veins were
much enlarged ; there was some flattening below the left clavicle ; defi-
cient movement and dulness of whole of left side, back and front ; and
on right side, below clavicle to fifth rib. The patient died of exhaustion
a fortnight later. At the autopsy '* a large solid mass of a carcinomatous
nature" extended over the whole of the upper part of the thorax, closely
connected with the left lung and adherent to the right pleura ; the left
112 REPORT ON PRACTICAL MEDICINE.
lung was contracted and adherent to the growth. The mediastinal
glands were much enlarged ; several masses of cancer were present in
the liver and pancreas.
Risdon Bennett, 'Cancerous and other Intrathoracic Growths, their Natural
History and Diagnosis, pp. 190, London, 1872. Horstmann, *Drei Falle von
Mediastinaltumor,' Inaug. Diss., Berlin. Pohn, * Beschreibung eines Falles von
Dermoidcyste des Mediastinum anticum,' Inaug. Diss., Berlin.
JPleurisy^ Sfc.
Huss (" Ueber den anderseitigen pleuritischen Schmerz," * Deut.
Arch.,' ix, 242) attempts to find an anatomical explanation for those
cases in which pain occurs on the side opposite to that affected with
pleurisy. Laennec first described cases in which the pain was felt else-
where than on the affected side. Andral challenged the correctness of
these observations ; Wintrich has also been unable to confirm them.
Various writers have, however, noticed the same occurrence, without
being able to give any explanation of it. Gerhardt, in a case observed
by him, in which the patient complained of pain on the left side near
the sternum, while the pleuritic rub was to be heard on the opposite
side, assumed the existence of anastomoses between the intercostal
nerves in the anterior mediastinum. Huss attempted to support this
view by investigating the anatomy of eight sterna, and in one of them
did find some such connection between the nerves of the two sides.
Handfield Jones (' Brit. Med. Journ./ 187 1, i, 139) gives a clinical
lecture on a case of effusion into the left pleura, in an engineer, sBt. 19,
on whom paracentesis was performed on the twentieth day after his ad-
mission into hospital, about eighty-six ounces of fluid being removed.
The patient had ascites at the same time, which had also nearly dis-
appeared on his discharge. In some remarks on the case the lecturer
allows that the presence of weak and distant breathing on the affected
side should not cause a postponement of the operation, such as was
occasioned here, "for lung-sounds can penetrate through a notable
thickness of fluid."
Eedenbacher ('Deut. Arch.,' ix, 240) records the following: — A boy,
set. 6, pTeviously healthy, had been for four weeks suff'ering from abun-
dant and increasing effusion in the right pleura. He had been treated
with quinine and iron, but had rapidly lost flesh. Paracentesis was
then performed. More than two pints of pus were removed, with im-
mediate relief to the patient. The cavity was washed out twice daily
with lukewarm water. The canula was taken out on the fourteenth
day. A month later the patient was greatly improved in health, and
there was no difference, either in measurement or respiratory murmur
on the two sides.
Paul (" De la Thoracentese, comme methode de traitement de la Pleu-
resie Aigue," ' Bull. Gen. deTherap.,' Ixxxi, 83) publishes eight cases of
acute pleurisy in patients between the ages of 21 and 56, in which he
practised paracentesis with success. They were dismissed well in from
two to three weeks later. After remarking on certain precautions to be
taken, he asserts the perfect harmlessness of the operation, and, as an aid
in prognosis, insists upon the fact that when the fluid readily coagulates
PLEURISY, ETC. 113
after its exit, it may be pretty certainly assumed that the effasion will
not reoccur, or if it does reoccur will do so in so small a quantity as to
be soon reabsorbed.
Behier gives a lecture (* G-az. des Hop.,' 1871, 349) on a case of
pleuritic effusion on the left side, in a man, set. 26. His views are
nearly the same as Paul's. The dangers caused by the effusion he
considers to be displacement of the heart, and the hindrance thus placed
in the way of its functions, the slow asphyxia resulting from com-
pression of the lung, the long-continued fever and suppuration, with
its tendency to tuberculosis, and the deformity caused in the thoracic
walls. He also discusses the objections brought against the operation,
and gives the following as indications for it. It is necessary in cases
where the effusion does not yield to ordinary remedies, and wliere it
increases ; when the patient is too feeble to wait for any length of
time the absorption of the fluid ; when the opposite lung is attacked
with bronchitis or any other affection preventing its full and normal
working, and when there is any reason to suppose a tendency to tuber-
culosis. As regards the period at which the operation should be per-
formed, it is ordinarily the ninth or eleventh day of the affection ; in.
general it may be delayed until symptoms of inflammation have sub-
sided. An exception is to be made in cases of necessity, when it should
be performed on the fourth day of the effusion.
Bouchut (ib.,505) describes the different modes of operating incases
of pleuritic effusion, from the earliest times. He himself prefers
Dieulafoy's aspirator.
Evans (* St. Thom. Hosp. Eep.,' ii, 69) reviews the literature of
paracentesis thoracis, and gives tables of cases observed by different
liors and by himself. He insists upon an early evacuation of the
ised fluid, and inclines to the view that the sudden death, by no
means uncommon in cases of pleuritic effusion, is due to coagulation of
blood in the pulmonary artery.
Various papers discussing the propriet^^ of tapping in pleurisy and
empyema, by Fuller, Priestley, l)ouglas Powell, and others, may be
found in the first volume of the 'Brit. Med. Journ.' for 1872. The
j^^apers placed in the bibliography of this subject are sufficient proof of
the interest taken by Prench writers in paracentesis.
Carter (' Brit. Med. Journ.,' 1872, i, 583) records a case of pleuritic
effusion on the left side, in a sailor, a^t. 24, on whom paracentesis was
performed. The patient died rather suddenly the sixth day after the opera-
tion, and the autopsy revealed a large " abscess" in the left lung, which
had recently emptied itself by a rupture in its outer and upper surface.
Yallin ("De I'Apoplexie dans les Epanchements de la Plevre," 'Eec. de
iMem. de Med. Milit.,' xxvii, 388) gives, at length, the report of a case
[of pleuritic effusion on the left side in a man, set. 21. On the thirteenth
iday of his admission into hospital he became temporarily unconscious.
jThis fit was followed by paralysis of the right side of the face and of
[the right extremities. Thoracentesis was performed the same day, and
jiSoo grammes of serous liquid removed. The heart, which had been
.slightly displaced, returned to its normal position; resonance and
puerile breathing reappeared in the upper and front part of the thorax.
8
I
114 ilEPOIlT ON PRACTICAL MEDICINE.
Some days later, after a rigor and persistently high temperature, tlie
effusion returned, and another operation removed 2100 grammes of
opalescent fluid containing a few flocculi. A drainage tube was kept
in the wound after a third withdrawal of pus ; the opening was
enlarged and the cavity washed out with iodine and alcohol, the para-
lysis of the right side gradually disappeared, but the patient died at
length of exhaustion. At the autopsy the left pleural cavity formed an
enormous purulent sac ; the heart contained only recent clots ; the left
corpus striatum was softened, and two branches of the middle cerebral
artery were obliterated by a compact mass of the consistence and
colour of wax, the blood-vessels being completely healthy. He looks
upon this as an embolus detached from one of the cavities of the heart,
and supports his theory by the fact that about the time at which the
apoplectic fit occurred a gangrenous patch appeared on the right foot,
due, probably, to the same cause. He remarks on the rarity of this
case, and is able to find only two other similar ones. The first is
recorded by Potain (' Bull, de la Soc. Anat.,' i86i, 39). In this case,
that of an elderly woman, who was attacked suddenly with hemiplegia
during an acute attack of pleurisy, and died in twenty-four hours, the
anterior cerebral artery was found obliterated, and the heart contained
old clots. The second case was published by Robinson (' Army Med.
Bep.' for 1869). Here, in a soldier, set. 22, also suflering from pleuritic
effusion, paralysis of the left side, occurring about two months before
death, was connected with softening of the right corpus striatum.
Eenault (' Union Med.,' xii, 291) records the case of a man, set. 27,
under the care of Besnier. The patient had effusion on the right side,
and died suddenly in his bed. The autopsy showed a large fibrinous
clot, completely filling the right auricle, extending into the ventricle
and pulmonary artery. The cerebral arteries were perfectly healthy.
Besnier, who had purposely deferred an operation, concludes that in all
cases in which there is considerable effusion, on the right side as well
as the left, thoracentesis ought to be performed as promptly as
possible. Death was due in this case, he thinks, to general arrest of
the circulation caused by the large clots in the right heart.
Hayden publishes (' Dubl. Quart. Journ.,' Hi, 49) a record of four
cases of diaphragmatic pleurisy, together with the particulars of six
cases already published by Andral in his ' Clinique Medicale.' He
concludes that the affection is characterised by —
1. Sudden and severe pain in either hypochondrium, extending in
the line of the costal cartilages, generally likewise down the corre-
sponding side of the abdomen, occasionally upwards to the tip of the
shoulder, and aggravated by movement of body, full breathing, cough,
aad vomiting.
2. Shallow and thoracic breathing, dorsal decubitus, and compa-
rative freedom from pain in that state of rest.
3. Absence of febrile action in mild cases uncomplicated by general
pleuritis, pneumonia, perihepatitis, or other form of acute inflamma-
tion ; and in severe cases, whether complicated or not, symptoms of
collapse.
4. Partial or complete suspension of respiratory sound in the base of
PLEURISYj ETC. 115
tho lung on the aifected side, and faint frofctement, or rustling sound,
Ttudible with respiration.
5. Inability to swallow ; nausea and vomiting of occasional but rare
occurrence, and confined to the most aggravated cases.
6. Displacement of tlie diaphragm upwards in recent cases attended
with suppurative inflammation, but downwards when the antecedent in-
flammation has proceeded to the formation of pus.
7. Resistance of the symptoms to active treatment, and yielding to
dry cupping, the use of belladonna and opium internally ( ! Bep.).
All his four cases recovered.
Wolff, "Empyema Traumaticum,'* *Deut. Klin.,' 187 1, 219. Mxiller, "Ueber Em-
pyema necessitatis pulsans " (with case of a man, set. 24 ; pleurisy of left side, tapped
and washed out daily; recovery), 'Berl. Klin. Woch.,' 1872, 37. Quincke, "Zur
Behandlung der Pleuritis," ib., 65. Parona, "Due Casi di Empiema vantaggio-
Bamante curati con ampia apertura," 'Gaz. Med. Lomb./ 1872, 41. Laboulbene,
" Pleuresie purulente suivie de Pyopneumothorax, guerie au moyen de la Thoracentese
et du lavage de la Plevre " (girl, sot. 7 ; seen three years afterwards ; the only abnor-
mality to be found at that time was slight depression of the left thorax and slight
prominence of the scapula ; the case is given at fearful length — fourteen pages),
'Bull. Gen. de Therap.,* Ixxxii, 97. Id., "Note sur I'Elevation de la Temperature
centrale chez les Malades atteiuts de Pleuresie aigue, et auxquels on vient de
pratiquer la Thoracentese," 'Gaz. des Hdp.,' 1872, 11 78. Bouchut, "De la Thora-
centese par I'Aspirations pneumatiques dans la Pleuresie purulente," ib., 529.
Id,, "La Jeune et la Vieille Thoracentese,** ib., 681. "Thoracentese," ib., 337, and
cf. ib., 445. " Observations pour servir a la question du Traitenent de la Pleuresie
purulente," ib., 522. Chaillou, "Quelques Observations de Pleuresie traitees par le
Thoracentese" — (i) girl, set. 18, leftside, recovery; (2) girl, a}t. 22, left side, sudden
death; (3) girl, a3t. 16, right side, recovery; (4) man, eet. 68, left side, death;
(5) man, a^t. 30, left side, death; (6) boy, ajt. i^, right side, recovery; (7) man,
at. 45, right side, recovery; (8) woman, set. 36, double, death; (9) man, set. 40,
recovery; no autopsies in any of the fatal cases; ib., 444. Jalabert, "Deux faits
pour servir a I'Histoire de la Pleuresie purulente et de TOperation de I'Empyeme par
rincision," ib., 473. Pernet, " Epanchement Pleuretique, Thoracentese, Mort"
(woman, set. 42, death twenty-four days later from syncope), ib,, 540. Spirt,
"Empyeme, Thoracentese, Drainage, Amelioration" (man, a^t. 27), ib., 571.
Dujardin-Beaumetz, " Eeflexions sur nn cas d'Empyeme," ib., 810. Roger, "Docu-
iments pour servir a I'Etude de TEmpyeme," ib., 627. Salomon, " Pleuresie purulente
jtraitee par la Thoracentese et les Injections au Nitrate d' Argent," ib., 667. Rinaldi,
j"Deux cas de Pleuresie purulente, Punction et Injection lodee, Guerison," ib., 844.
jEichet, "Des Abces Pleuraux," ib., 721. Behier, " Pleuresies a Epanchements
jmoderes, Thoracentese avec Trocarts capillaires et Aspirations ; Appareils divers,"
jib., 1017, &c. Raynaud, "Operation de TErapyeme par une Methode mixte," ib,,
497. Thorowgood, "Cases of Pleuritic Effusion marked by very Foetid Expectora-
tion," 'Brit. Med. Journ.,' 1871, ii, 7. Axford, "Thoracentesis with Admission of
Air " (boy, set. 4, full expansion of lung later), ib., 1872, i, 498. Liveing, " Empyema,
•Paracentesis, drainage-tube worn for three and a half years" (man, set. 20), ib., 582.
iMaclagan, " A New Mode of performing the Operation of Paracentesis Thoracis,"
-ib., ii, 63. Playfair, "Case of Empyema, treated by Paracentesis and subsequent
Drainage," 'Lancet,' 187 1, ii, 219. Chaplin, "A Case of Paracentesis Thoracis in
which a large opening was successfully employed " (in a boy, set. 1 2, pleurisy left
side, empyema, recovery), ib,, ib., 428. Thompson, "A Case of Pyothorax " (man, set.
43, paracentesis, recovery), ib., 1872, i, 114. Williams (C. T.), "Case of Empyema
liapped, great improvement from Drainage-tube " (man, set. 28), ib,, 1872, i, 251.
IWade, " Treatment of Pleuritic Effusion by Diuresis" (boy, set. 13, left side), ib., ii,
411. Ramskill, "Two Cases of Pneumothorax treated by Aspiration," ib., 187 1, ii,
259. Thompson, "Clinical Lecture on a Case of Pneumothorax" (empyema in con-
nection with cavity, fibrous degeneration of lung in a man, set. 52), ib., ib., 389.
IIG REPORT ON PRACTICAL MEDICINE.
Laffan, " Observations illustrative of the Use of Dieulafoy's Pneumatic Aspirator,"
* Dubl. Quart. Journ./ liii, 202. Fitzmaurice, "Cases of Effusion into the Chest,"
ib., lii, 388.
Bronchitis and Emphysema.
Julian ('New York Med. Eec.,' vi, 357) thinks that the indication
in suffocative capillary bronchitis is ohviously to get rid of the mucous
material as speedily as possible, and restrain the hypersecretion of the
membrane. Eor this he has very successfully employed the sulphate
of zinc and tincture of sanguinaria. Of the former, he gives to a cliild,
sBt. 6 to 18 months, doses of one half to a grain, and from five to ten
drops of the tincture every two or four hours ; but when called at a
later period and the malady threatens suffocation, he gives as much as
from three to thirty drops of the latter, at intervals of one half to two
hours, regardless of vomiting. He quotes the case of a man whom he found
in a state of collapse, and to whom he applied his treatment with success.
Isaakson ('Virch. Arch.,' lii, 466) has studied the changes in the
vessels in emphysema. He finds them much smaller than normal,
stretched instead of winding ; several in places granular and cloudy,
filled with thrombi and not allowing the coloured injection to pass.
After the injection of silver solution, the normal appearance of endo-
thelium was absent in the earliest stages ; here the vessel-wall was
finely granular, lined with white blood-corpuscles, which were the
starting-points of coagulation and complete thrombosis of the canal.
These portions underwent fatty changes and entirely disappeared.
He considers this destruction of the vessels to be the primary stage of
emphysema.
Berkart ('Lancet,' 1871, ii, 745) describes an instrument which he
has used with the best results in emphysema, and which, by the simple
action of a pump, withdrawing air at the end of each expiration,
increases the abnormally lessened expiratory power in this affection.
Hertel (* "Berl. Klin. Woch.,' 1871, 301) records a case occurring in
the practice of Traube in which there was most extensive increase in
the resonance of the lung, sonorous rales over nearly the entire thorax,
nummular sputa, cyanosis of the face and body, contracted pupils,
somnolence, and the phenomena of double diastolic sound. Traube's
diagnosis was as follows : — Diffuse catarrhal inflammation of the bronchi,
probably with bronchiectasis ; increased volume of lung, probably with
true vesicular emphysema; dilatation and hypertrophy of the right
ventricle ; fatty degeneration of the right ventricle, which, according
to Traube's experience, is always present when a chronic inflamma-
tion of the lungs is accompanied by persistent and increasing cyanosis.
The diagnosis was completely confirmed by the autopsy. Traube dis-
cusses questions as to the increase of secretion in the bronchi and the
diagnosis of catarrhal inflammation of the bronchi and bronchiectasis.
The double diastolic sound he explains by the hypertrophy of the right
auricle, and the consequent stretching of the tricuspid valve, which he
considers to be far from uncommon.
De Savignac, " Scries des Formulcs pour le Traitement de la Bronchitc," 'Bull.
Gen. de Tlierap.,' xxxi, 252. Decayeux, "Les Fievres Catarrhales" (an advertise-
BRONCHITIS — ASTHMA — WHOOPING-COUGH. 117
ment of the Syrup of Peter Lamouroux), * Gaz. des Hop./ 187 1, 510. Laffau, " Local
Bleeding in the Dilated Right Ventricle of Chronic Bronchitis," ' Brit. Med. Joiirn.,*
1872, i, 128. Greenhow, "Lungs from a Case of Cured Phthisis, Death from
Capillary Bronchitis, Cavities lined with False Membrane in both Lungs, Prolifera-
tion of Interlobular Connective Tissue, and great thickening of the Pleura" (man,
8Bt. 30), * Path. Soc. Trans,,' xxiii, 47. Wilks, " Bleeding in Emphysema and Bron-
chitis" (woman, set. 60, relief), ' Lancet,' 1872, i, 88. Leyden, " Tyrosin in Sputum "
(girl, with putrid bronchitis), ' Virch. Arch.,' Iv, 239. Neureutter, " Bronchiektasio
und hochgradiges Emphysem als Compensation bei einem sieben Jahr alten Knabon,'*
*Oesterr. Jahrb. f. Paediatrik,' 1872, 18.
Bronchial Asthma.
Leyden ('Zur Kenntniss des Asthma Broncliiale,' Eostock, 1871)
describes a peculiar expectoration occurring in bronchial asthma. It is
scanty, very tenacious, and transparent. It contains a mass of fila-
ments and flakes, some very marked from their thickness and yellow
colour. They are brought up from the finest bronchi, and contain in
their meshes granular mucus-corpuscles, and generally a large quantity
of very beautiful and peculiar crystals, of an elongated octahedral form.
The largest are visible under a power of 300 diameters, the smallest
under one of 600. Crystals of the same kind have been described by
Friedreich in croupous bronchitis, and they are probably identical with
those found by E. Neumann in the medulla of the bones. In the
blood of leuchsemic patients Leyden thinks that these crystals may
act as mechanical or chemical irritants on the peripheral ends of the
pneumogastric in the mucous membrane, and provoke reflex contraction
of the muscles of the small bronchi.
Weber, "Das Aubree'sche Geheimmittel gegen Asthma Nervosum," 'Dent. Arch.,*
viii, 217. Lessdorf, "Asthma Nocturnum Periodicum. Morphium Injection Palli-
ativmittel; Comprimirte Luft Radicalmittel," 'Deut. Klin.,' 1871, 15. Anstie,
" On the Pathological and Therapeutical Relations of Asthma, Angina Pectoris, and
Gastralgia," 'Brit. Med. Journ.,' 187 1, ii, 550. Gaskoin, "On the Treatment of
Asthma," ib., 1872, i, 339. Thorowgood, "A few Remarks on the Treatment of
Asthma," 'Med. Press and Circ.,' 1872, i, 27.
Whoop ing- cough .
Steff"en ('Jahrb. f. Kinderkr.,' iv, 427) confirms the good results
obtained by the employment of quinine in whooping-cough, as first
pointed out by Binz, and verified by Breidenbach. In the majority of
cases he found it work speedily and readily, failing only in a few. He
employed pretty strong doses, half to one gramme in the twenty -four
hours, in children from two to five years. He gives two cases in full.
In a case of a child of three years, who could not be got to take the
drug, he used injections for the purpose. In three days nine injections,
i containing altogether two grammes of quinine, were given, with allevia-
I tioD of the symptoms.
i MacCall (' Glasgow Med. Journ.,' 187 1, iii, 162) during the winter of
I 1869-70 found ulceration of the frsenum linguae in iii out of 252
children attacked with whooping-cough, or in about 44 per cent. The
aftection varied in degree from a mere abrasion to a deep fissure with a
2frey or yellowish surface, and often bleeding during or after a
118 REPORT ON PRACTICAL MEDICINE.
paroxysm. In 105 out of the iii it was situated in front of the
fraenum ; in four out of the other six its varying position was accom-
panied by some abnormal disposition of certain teeth. He considers it
to be due to the rubbing of the tongue against the latter in the act of
coughing. He looks upon it as a valuable diagnostic sign in cases in
which the cough is not heard at the time when the patient is seen.
Prestwich, "Cod-liver Oil in Whoopiupr-cough," 'Lancet/ 1871, ii, 812. Murmy,
"Extract of Nettles in Whooping-cough," ib., 1872, i, 539. Grantham, "Effects of
the Vapour of Ammonia in the Treatment of Whooping-cough," 'Brit. Med. Journ.,'
JS/i, ii, 323.
Pneumonia.
Kevillout (* Gaz. des Hop./ 187 1, 273) discusses the question
whether pneumonia is a disease having a defined course and type, and
whether it be true, as Jaccoud affirms (' Traite de Pathologie Interne,'
Paris, 1 87 1, ii) that it cannot be abridged a single hour. He looks
at the affection from the point of view of other diseases, e. y. albu^
minuria, syphilis, &c., and concludes that the holding of any such view
transforms the physician into a fatalist (" transforme en un Musulman
dans le sens Arabe et precis de cette expression ").
Earquharson (' Edin. Journ.,' xvi, 988) brings forward ten cases in
support of his view as opposed to those of Trousseau, Hughes Bennett,
and Sturges, which convince him of a special lowering of vitality which
almost invariably attends extension of inflammation to the apex of
either lung. In some remarks on the treatment of pneumonia he
gives a single case in which he thinks aconite cured an extremely
doubtful {Bep.) case of the affection.
Pitzmaurice ('Dublin Quart. Journ.,' Iii, 386) concludes from his
own observation that pneumonia in children and infants, and in some
cases in which chest symptoms are absent, is often mistaken for other
ailments, as dentition, worms, &c. He considers the law as laid down
by West, that if the posterior part of the chest is free from a consider- '
able amount of crepitation the infant is not suffering from any serious i
lung disease, to be inaccurate. His own experience leads him to believe
that simple hepatized lung is oftener found in other part's of the chest.
" By keeping the ear perseveringly to the chest, when exhaustion takes
place (after crying, &c.), the hurried breathing facilitates the discovery
of tubular breathing, the first sign of pneumonia generally observed in
the child." Blistering is, in his opinion, the sheet-anchor in this
disease ; and dressing with mercurial ointment, he finds, excludes the ;
air more effectually than simple dressing. He gives four cases to
illustrate his position. The fourth case, which he seems to have looked
upon as croup, he "cured" by giving large doses of decoction of
senega.*
Sturges (" The Etiology of Pneumonia," * St. George's Hosp. Bep.,*
V, 13 j) writes on the general influence of the weather upon the so-called
inflammatory diseases of the chest. Taking the average of ten years
* Croupy cough and laryngeal stridor are more frequently than is generally ad-
mitted the forerunners of simple hronchitis in children. — A. B. S.
PNEUMONIA. 119
(i8f;7 — 66) the highest number of deaths in England from bronchitis
occurs in the middle of January, while for pneumonia it is nearly two
months earlier, i. e. at the end of November. As regards the influence
of temperature, it would seem that cold does not necessarily affect the
pneumonia rate, but always and markedly the bronchitis rate. Por
instance, a low temperature towards the end of October, and again in
the middle of November, 1 869, is followed by a bronchitis rate greatly
in excess of the average, while pneumonia, though not unaffected by the
change, is only slightly so, and remains to the end of the month much
under its average. Then, with excessive cold and a north wind, it
rises considerably. Again, extreme cold in the middle of January,
j 1867, is followed by a large increase in the rate of bronchitis, while
pneumonia actually decreases in the same time, and to the end of the
month remains below its ten years' average, the direction of the wind
j being north-west and south-west. His data show that rain increases
the rate of bronchitis out of all proportion with that of pneumonia.
During the rains of the monsoon in India the latter disease shows a
; remarkable decrease. Wind is favourable to pneumonia, chiefly, if not
I altogether, when its direction is northerly or easterly. The writer
shows that these facts are generally confirmed by a comparison of years
of high and low mortality.
Popoff (" Experimente iiber Lungenentziindung," ' "Wien. Med.
Jahrb.,' 187 1, ^^^) injected ammonia into the lungs of dogs narcotised
I by morphia, in order to set up inflammation. No symptoms of pyrexia
I occurred under these conditions, the morphia diminishing the tempera-
iture (Strieker and Albert). The blood pressure was increased in all
leases immediately after the injection. In dogs which had not been
[narcotised there was an increase of temperature, lasting for twenty-
ifour hours.
Lebert (''Ueber die Veranderungen der Korperwarme in der
primitiven acuten Pneumonic," 'Deut. Archiv,* ix, i) after a full and
exhaustive paper on the temperature of pneumonia, gives the following
among other conclusions : — The affection may occur with slight and
even no pyrexia ; there are no so-called critical days ; double pneu-
monia, as well as being more dangerous to the patient, has a longer
course ; lobar pneumonia, if accompanied with diffuse bronchitis (by
no means to be confounded with broncho-pneumonia), has slow conva-
lescence ; a pneumonia may, much more frequently than is generally
supposed, have a protracted, subacute, or even chronic course, without
any necessary result in true tuberculosis, though it may frequently tend
to shrinking of the lung and bronchiectasis. In a sixth of the cases
observed by the writer no crisis occurred.
Hayem (' Gaz. Med.,' 187 1, 399) records the following case in which
death occurred suddenly during convalescence from pneumonia. The
patient was a woman, set. 49, who had passed safely through a simple
i inflammation of the right lung, and at her own request had been
allowed to leave her bed. During the day she went to the closet, but
there cried for help, and was found on the floor in a state of syncope.
Keplaced on the bed, she was very pale, her extremities cold, her re-
spiration anxious, but she was still conscious. She had had no oedema
120 REPORT ON PRACTICAL MEDICINE.
of tlie legs, but after deatli varicose veins, which had been overlooked
during life, were discovered on them. In addition to the signs of the
lobar pneumonia in course of resolution, and some signs of old lung-
mischief, there were found seated upon and extending from the bifurca-
tion of the pulmonary artery into its different branches a number of
clots, non-adherent to the walls of the vessels, and showing impressions
of venous valves. Clots of the same kind were found in the varicose
veins, especially on the right side ; the walls of these vessels were per-
fectly healthy, excepting the usual changes found in such veins.
Except when they were entangled among the valves, &c., the clots lay
quite free. The emboli in the pulmonary artery were evidently por-
tions of these clots, formed without any phlebitis during the pneumonia,
and detached by the muscular exertion when the patient got up from
bed. Hayem refers to a case of the same kind which had occurred in
the practice of Tardieu in 1868. But in the latter the varicose veins
were inflamed, and were felt as hard cords, and easily explained the
coagulation which led to the same fatal result.
Moxon ('Path. Soc. Trans.,' xxii, 38) describes a peculiar form of
pneumonia in a syphilitic subject who was killed by fracture of the
cervical spine. The lower half of the left pleura was much thickened
and coated with recent firm lymph ; the lung corresponding to this
portion showed a state of grey fibroid change, with diminution of bulk
and hardening and darkening of the tissue. This state aff'ected nearly
all the lower lobe, and spread with an irregular border into the upper.
The right lung showed large patches of thickening on its lower half.
The vocal cords were thick. The liver was enlarged, lardaceous, and
contained cicatricial patches like those on the lung. The spleen,
kidneys, and supra-renal capsules were also lardaceous. No symptoms
of chest disease seem to have occurred during life, nor is any micro-
scopical examination of the new tissues mentioned as being made after
death, but Moxon concludes, from the presence of marked general
syphilis, that the pleurisy and pneumonia were syphilitic.
Green (" Interstitial Pneumonia," ib., xxiii, 39) records the appear-
ance found in the lungs of a man SBt. 60, who sufiered from chronic
bronchitis and died of an acute attack of that affection. The right lung
was adherent, its pleura thickened and soft. There was no consolida-
tion or caseation, but the lower lobe looked like a piece of sponge, and
was made up almost entirely of dilated bronchi and fibrous tissue, per-
fectly lax and soft. The left lung was, like the upper lobe of the right,
pigmented and tougher than natural. The kidneys were slightly
indurated. The microscope showed a growth of fibro-nucleated tissue
round the bronchi and blood-vessels, affecting also the alveoli.
Brouardel (see 'Lancet,' 1872, ii, 493) draws attention to the very
rapid formation of interstitial pneumonia and of false membranes, which
reduce the size of the lung and form an obstacle to its expansibility,
and consequently the harmlessness of early, and the danger of late,
paracentesis.
Strohl ('Union Med.,' xi, 134) has been using for some years the
neutral acetate of lead in cases of pneumonia. He was casually led
to do so in 1841 in treating a woma^ who, in spite of bloodletting.
PNEUMONIA — HYPERTROPHY. 121
antimouy, and blisters, had a return of the affection on going back to
work too soon, and in whom a recurrence to the same treatment was
impossible. Eapid recovery followed the exhibition of the lead in doses
of five, increased to fifteen centigrammes, in the day. He next applied
it to cases of the disease in old and feeble people, in whom the
heroic treatment above mentioned had had no effect or could not
be resorted to ; and lastly, he employed the drug in cases of pneumonia
occurring in all ages. He publishes in full 14 out of S3 cases. The
mortality was over 10 per cent. The average period of the pneumonia,
dating from the commencement to the cessation of the physical signs,
as revealed by the stethoscope, was 10' 2^ days.
Papillaud, "Du Traitement do la Pneumonie," *Gaz. Med.,' 1871,312. Hosier,
" Ueber biliose Pneumoiiie und dadurch complicirteu Typhus recurrens," ' Deut. Arcli.,'
X, 266. Alt, " Ueber die Behandlung des crouposen Pneumonie mit Veratrin " (witii
curves of pulse and temperature of three cases, besides one in the text ; twenty-one
cases given altogether), ib., ix, 129. Weigand, "Zur Pneumoniefrage,^' *Berl. Klin.
Woch.,' 1872, 6. Liebig, " Behandlung der chronischen catarrhalischen Pneumonie
mit erhohtem Luftdruck," ' Wien. Med. Woch.,' 1871, No. 20. Moxon, "Acute
Interstitial Pneumonia/' 'Lancet,' 1872, ii, 779. Williams, "Pneumonia," *Med.
Times and Gaz.,' 1872, i, 121. Eead, *' Oxygen in Diseases of the Lungs" (sixteen cases
of phthisis, acute and chronic pneumonia, and chronic bronchitis, in which the gas
was used regularly, and for a sufficient time to warrant the drawing of a conclusion
as to its effects), * New York Med. Journ.,' xiv, 382.
Brown Induration and Hypertrophy,
Delafield (* Amer. Journ. Med. Sci.,' Ixi, 95) records his observations
on " pigment induration" of the lungs, based on twenty autopsies, in
which he found this change in connection with disease of the heart.
The lungs are small, their lobes adherent to one another and in
part to the costal wall ; the pulmonary pleura thick and opaque. On
section the lung-tissue is resistent, very dry, containing scarcely any
air, blood, or serum. The microscope revealed (i) new pigment, (2)
hypertrophy of the walls of the air-cells, (3) dilatation of the capil-
jlaries, and (4) a marked increase of cellular elements within the
alveoli. An analysis of the cases shows that mitral stenosis is almost
always accompanied by pigment induration of the lungs ; that simple
mitral insufficiency causes it in nearly half the cases ; and that aortic
disease causes it in one fourth. A full analysis, with tables, is given of
the post-mortem appearances in the other viscera, &c.
Eindfleisch (' Centralblatt,' 1872, 65) writes on the muscular tissue
of the smaller bronchi, which becomes much hypertrophied in the so-
called brown induration of the lungs. He describes a peculiar and
I distinct layer of circular muscular fibres as surrounding the smallest
I bronchi, forming a kind of sphincter where they open out into the
j infundibula ; these circular fibres send loops into the openings of the
I latter, which are also surrounded by smooth muscular fibres. These
! fibres may be easily made out in the normal lung by those who have
I observed them in the hypertrophied condition.
( Thierfelder, "Ein eigenthumlicher Fall von Hypertrophic und epithelialer Hepatisa-
I tion der Lungen," ' Dent. Arch.,' x, 209.
12^ BEPORT ON PRACTICAL MEDICINE.
Gangrene and Abscess.
Senator ('* Ein Fall von Lungenabcess mifc allgemeinem Haut-
emphysem," ' Virch. Arcb,,' liv, 278) publishes a case of abscess of tb
lung supervening on pneumonia, breaking through into the subcuta-
neous tissue and causing general subcutaneous emphysema. The latter
came on suddenly and with great rapidity, and was due, according to
the patient, to violent crying out. The autopsy revealed a cavity in
the posterior part of the left lower lobe, about the size of a fist, and
filled with purulent fluid. The pleura and layer of muscles which
limited it were ecchymosed, rotten, and boggy. A sound could easily
be passed from it in several directions into the pleural cavity.
Salkowski ('Berl. Klin. Woch.,' 187 1, 169) writes on this rare and
little known afiection, and gives a case, occurring in Ley den's
clinique, in which abscess followed an attack of croupous pneumonia
of the right lower lobe. The patient was an ill-conditioned man of
49, who had been a drinker. The dulness cleared up with all symp-
toms of a crisis on the eighth day ; next evening a fresh attack of
pyrexia occurred, with tearing cough and abundant, thick, puriform,
sputa. On the fifteenth day shreds of lung-tissue were found in it
under the microscope, which gradually increased in amount and in size,
reaching the length of an inch. A month after the first commence-
ment of the aff'ection these shreds were found for the last time ; the
sputa altered in character, became muco-purulent, and lastly dis-
appeared. About the same time the thorax sank in, the general
condition of the patient improved, and on the fiftieth day he left able to
work. The diagnosis of lung abscess is based especially on the sputa ;
the temporary presence of shreds of lung-tissue, the absence of signs
of decomposition or fungus spores, prevent its being confounded with
gangrene ; the accompanying symptoms leave out of question the
possibility of phthisis, in which aff'ection, also, the elastic fibres may be
found. The treatment consisted of inhalation and exhibition of car-
bolic acid, quinine, cod-liver oil, and wine.
Waring- Curr an ('Lancet,' 1872, ii, 669) gives a somewhat doubtful
case of abscess of the right lung bursting through the diaphragm and
umbilicus. The boy is still alive; in February, 187 1, he had typhoid
fever, followed by pneumonia; in September, 1872, a swelling ap-
peared under the edge of the ensiform cartilage, which, four days later,
" had moved, and was lower down, to the right, in the sheath of the
rectus muscle." Next day this swelling burst and gave exit to an
enormous quantity of offensive pus.
Leared (ib., 187 1, ii, 47) records the occurrence of gangrene of the
right lung in an intemperate man, sBt. 49, who had fallen from a height
of eight feet into the water, and had been submerged twice. He
quotes two cases as occurring after immersion in water out of four
cases of gangrene of the lung recorded by Stokes, and a case mentioned
by Lankester in which gangrene followed the repeated dashing of cold
water oyer a woman poisoned by opium. Death occurred in Leared's
case thirty-five days after immersion. The temperatures taken were
remarkable for sudden oscillations.
GANOEENE — CANCEU — PARASITES, ETC. 123
Browne (^ Brit. Med. Journ.,' 1871,!, 141) publishes a case of
gangrene of the left lung in a religious and melancholic lunatic. The
first symptom seems to have been haemoptysis after a severe attack of
pleuro-pneumonia. The writer has noticed this lesion in 3 out of
n about 600 lunatics whose bodies he examined post mortem. In all
[the previous mental derangement was melancholia. His experience
I does not agree with that of Cruveilhier, who directed attention to the
! frequency of gangrene in epileptic patients, nor with that of Trous-
'seau, who intimates that amongst the insane it is sometimes due to
I inanition.
Burman (ib., ipj) was moved by Browne's paper to examine the
records of such cases in the Devon County Lunatic Asylum from 184^
lo 1869. He finds that gangrene of the lung was the cause of death
in 14 out of 132 j deaths during that period; 1 1 were males and 3
j females; in 4 cases both lungs were affected. The form of mental
[disease was in 4 cases mania, in 3 dementia, in 3 imbecility, in 2
I general paralysis, and in 2 melancholia. In 3 cases only is it recorded
^ ^^nt there was refusal of food, and only i of the patients was an epileptic.
Anthracosis; Cancer ; Parasites, Sfc.
Mayet ('Rev. Med.,' 1872, i, 69) records the following : — A miner,
cTt. 48, had had a morning cough for two years, and had been unable to
I work the last six months ; the signs on auscultation, &c., revealed the
I presence of emphysema, chronic pneumonia, and probable coal-infiltra-
jtion. The autopsy showed the lungs immensely enlarged, the left
having seven lobes and the right five. They were strongly adherent
posteriorly, largely emphysematous, intensely black, and very hard and
resisting. There were no cavities in them anywhere. On section
the tissue was tough (sclerosed) and infiltrated with particles of coal.
\ The bronchial glands were enlarged and in parts infiltrated with the
'same. Besides slight increase in the volume of the heart there was no
I abnormal signs in the other organs. In a discussion which followed
'the reading of his paper (see 'Lyon. Med.,' viii, 796) he promulgates
jthe opinion that the coal-particles were introduced, not through the
I respiratory, but the digestive organs (!)
Eoss (' Dubl. Quart. Journ.,' li, 93) writes on the diseases of the
lungs affecting those who work in dusty atmospheres. He gives five
cases, with four autopsies.
Merkel (" Zur Casuistik des Staubinhalations-krankheiten," ' Deut.
Arch.,' viii, 207, and ib., ix, 66) gives a series of observations of lung
aft'ection caused by the inhalation of various kinds of dust. The
first case is that of a man whose occupation consisted in rubbing
pieces of iron 'with sandstone. His symptoms were those of
phthisis. The autopsy showed a cavity in the anterior lower third
of the right upper lobe, communicating with a bronchus ; the lung-
tissue of a greyish-black colour, indurated and shrunken. The
colour was due to the presence of pretty large particles of oxidized
iron, especially round the bronchi. The diagnosis during life rested
on the occurrence in the sputa of the same particles, sometimes
124 UEPORT ON PRACTICAL MEDICINE.
I
free, sometimes enclosed in cells. In tlie second case the patient
was working in an ultramarine manufactory, and had presented a few
weeks before death the symptoms of typhoid. After death the lungs
were found filled with foreign particles, but there were no signs of
enteric fever. The third case was one of siderosis. The patient,
a man of 29, had worked for six years in a gold-leaf manufactory,
and had inhaled the fine particles of oxide of iron. Tor the last seven
years he had ceased to work at his trade. The post-mortem examina-
tion showed, in addition to a cavity about the size of a fist on the left side,
shrinking, induration, and colouration of the lung-tissue by the particles
of iron. The fourth case was one of anthracosis ; here were found, besides
the pigmented condition of the lungs, cheesy pneumonia and general
tuberculosis (lungs, kidneys, and intestines). The case comes under
Traube's phthisis melanotica. In the fifth case, in which no symptoms
had been observed during life, the subject, a workman in an ultra-
marine manufactory, presented cavities of various sizes, filled with a
bluish-black fluid mass, made up of coal-particles, cholestearine, fat-
crystals, &c.
Risdon Bennett (' Path. Soc. Trans.,' xxii, 76) records the occurrence
of secondary scirrhous or fib ro- cancerous infiltration of the connec-
tive tissue of the lung in a woman, a3t. 42, six months after the removal
of the left mamma for the same afiection. She sufi'ered with symptoms
of acute bronchitis. A microscopic examination of the sputa revealed
nothing special ; and she died as if from syncope.
Arnott (ib., 231) gives a case of epithelioma of the heart and lungs
in a woman, set. 50, secondary to epithelioma of the clitoris.
Sparks (' Lancet,' 187 1, ii, 13) publishes a short note of the post-
mortem appearances found in a case of primary cancer of the lungs.
The patient, a woman, set. 22, was supposed to have died of pleuro-
pneumonia. There were nodules of encephaloid cancer in some false
membrane on the right pleura and in the lower lobe of the right lung.
The lower two thirds of the left lung consisted of a mass of ence-
phaloid nodules, one of which was as large as a man's fist. The growth
extended towards the middle of the body, pushing the heart far over to
the right. It projected also into the left pleura, and had infiltrated the
diaphragm, so that nodules projected on its under surface. No cancer
was found elsewhere.
"Waters (ib., 26) found the right lung the seat of scirrhous cancer
in a man. He was said to have been quite well up to about twelve
weeks before death. He was then seized with pain in the right side
of the chest and dyspnoea, attended with cough and expectoration of
white frothy sputa. Two weeks later his head, neck, and upper extre-
mities became oedematous. The mediastinal glands were greatly en-
larged and scirrhous throughout.
Lebert (' Berl. Klin. Woch.,' 187 1, 25), gives three cases of hydatid
cysts occurring in the lungs. The first case is that of a man, a>t. 40,
whose earliest symptoms, in the autumn of 1 869, were those of tuber-
culosis. Half a year later, during' an attack of varioloid, there was
found some consolidation of the upper lobe of the left lung. In May,
1870, he spat up hydatid cysts, and again in October, since which time
Cancer — phthisis. l25
jie got better and was still alive when Lebert wrote. In tbe second
case, a girlof 23 presented a fluctuating tumour in the left hypochou-
(Irium, which was supposed to be hydatid of the spleen. In the third
ca^ise pneumothorax occurred from perforation of the echinococcus cysts
through the pleura. During life this case had also been looked on as
tuberculosis. Lebert makes some remarks on the diagnosis and etiology
of the rare occurrence of primary echinococcus of the lung. The seat
is generally in the lung-tissue.
in the case recorded by Zuber (*Gaz. des Hop.,' 1872, 730), of a
man, set. 22, one of two hydatid cysts burst into the pleura and so
caused death. In this case also the symptoms during life were those of
tuberculosis.
Bird (quoted from the 'Australian MedicalJournal,' 'Lancet,' 1871,
ii, 23) has published a paper on the disease, whicb seems to be more
frequent in Australia. The most common site of hydatids of the lung
is the base of the organ. There may be no symptoms, and when they do
occur they are those of mechanical pressure or irritation. According
to the author, the rarity of visible venous engorgement distinguishes
the case from one of intrathoracic cancer. One tapping, followed by
bromide or iodide of potassium and kamela, are generally successful.
(No light is thrown by any of these writers upon the origin of the
hydatids in primary echinococcus-cysts in the lung ; they seem to con-
tent themselves with the fact that it is most common in places where
the drinking water is polluted by the excreta of dogs containing the ova
of taenia. — Eep.)
Phthisis.
j Condie (" On Spurious Consumption," * Amer. Journ. Med. Sci.,' Ixii,
J389) distinguishes a tubercular and a non-tubercular phthisis, which
I may be very easily confounded. In both there is the same progressive
jand extreme emaciation, cough, expectoration, debility, hectic fever
jand night sweats. Their physical signs are also alike. But as regards
1 prognosis it is essential to recognise the difference, and to do so atten-
ition must be paid to the constitution, predisposition, hereditary tenden-
|cies, and sputa of the patient. In tubercular disease of the lungs the
I sputa, in the early stages at least, consist most commonly of a white
j frothy mucus ; later they become consistent and glairy, and of a darker
I hue. They are intermixed with small whitish particles of a cheese-like
I appearance — broken-down tubercular matter — and not unfrequently
with distinct masses of a well-defined puriform character. The non-
1 tubercular affection occurs somewhat suddenly, in most instances after
I exposure, with acute bronchitis or pneumonia.
Moxon (' Path. Soc. Trans.,' xxii, 66) finding in the same lung
patches with iron grey centre, but surrounded by zones which differed
jin character, believes that the case proves the identity of "grey and
I yellow tubercles." He assumes that these patches grow from within
[outwards ; that the central is the older portion, the peripheral the most
'recent. The outer zone of one patch presented grey (miliary) tubercles ;
[that of the other "larger, opaque, yellowish-white tubercles of the most
scrofulo-pneumonic type." Both kinds "were seated in the proper
i
126 REPORT ON PRACTICAL MEDICINE.
pulmonary tissue, and not especially about the ends of the bronchial
tubes."
Fox (E. L.) ('Brit. Med. Journ.,' 187 1, ii, 463) reviews Niemeyer's
assertions, and opposes them generally. He holds that chronic pneu-
monia, when it is found associated with miliary tubercle, is not connected
with it as cause and effect, and that the tubercle is only developed
in cases in which the patient has previously had the tuberculous taint
of constitution. Further, he insists that it is not unusual to find
general (miliary?) tuberculosis without pre-existing cheesy degene-
ration.
Sommerbrodt (' Virch. Arch.,' Iv, 165) has made experiments on dogs
to test Niemeyer's theory as to the effect of haemoptysis in causing
phthisis. The blood drawn from the carotid artery of the animals was
injected through a wound in their trachea, and they were killed at
periods varying from one hour to twelve days after the operation.
iSome of the experiments and the post-mortem results, as well as the
microscopical appearances found in the lungs, are given in full. Both
catarrhal and croupous pneumonia followed the injection. At the end
of a very long paper the writer comes to the conclusion that his experi-
ments show that the presence of blood in the lungs — hsDmoptysis — can
provoke a catarrhal pneumonia in subjects predisposed to phthisis. In
a note (p. 195) he quotes a case of Waldeyer's, who found in the lungs of
a suicide who had divided his trachea, and died three or four days later,
the characteristic cells of catarrhal pneumonia in certain portions of the
tissue to which the blood had found its way.
Korner (" Beitrag zur Lehre von der Tuberculose," ' Wien. Med.
Zeitg.,' 1 87 1, 189) disagrees with Niemeyer's views on cheesy pneumonia
and tuberculosis. He thinks the distinction between the two is simply
artificial, and cannot be supported by anatomical facts, inasmuch as the
two results are almost always found together. In addition to this
Niemeyer is unable to say why cheesy pneumonia leads to the develop-
ment of tubercle in one case and not in another. Korner adopts
Eokitansky's views as to the anatomical relations of tubercle, and puts
forward the following theory as to its origin : — The normal elasticity of
the lung can be preserved only by full respiration, and this needs well-
developed inspiratory muscles. The latter are ill-developed in patients
of the so-called phthisical habit, and here the deformity is secondary.
But, on the other hand, it may be acquired, from anaemia, &c. In
either case the apex of the lung obtains less than normal respira-
tory power, and becomes relaxed. Korner concludes that this
collapse leads to abnormal pulsation in the vessels, to changes in
the circulation in the vasa vasorum, and thus to altered nutrition of
the lung-tissue.
Kennedy ('Dubl. Quart. Journ.,' li, 106) opposes Niemeyer's views
on phthisis, supporting the old theory of the pathology and course of
the disease. (It is, perhaps, well that the author admits at the very
commencement of his paper that his " remarks have been put together
somewhat hurriedly."— JK^p.)
According to the ' Med.-Chir. Eev.' (xlvii, 545) Skoda also criticises
the doctrines of Niemeyer. He seems to think that observations, both
i»HTHlsis. 127
on the living and the dead, compel the admission that, whether before
or during tuberculosis, haemorrhage is bronchial and not intra-alveolar.
All he can admit is thathajmorrhage may produce serious consequences
in a tissue already diseased; for instance, on the internal surface of a
cavity, where a little blood may remain and contribute to irritation. He
argues that blood itself is not an irritant to the tissues, as is proved by
tlie ease with which blood is absorbed in bruises. Chronic pneumonic
exudation is not to be confounded with tuberculosis.* Haemoptysis is
a symptom of the latter, or of the morbid state which predisposes to it.
Huhrssen (" Ueber intermittirende Tieber bei chronischer Lungen-
schwindsucht und chronischer Lungentuberculose," 'Berl. Klin. Woch.,'
187 1, 613) holds that a regular intermittent pyrexia occurring in the
course of a chronic phthisis, and in the absence of any other cause,
denotes absorption of cheesy products. The occurrence of such pyrexia
in a doubtful affection of the lungs probably points to a tuberculous
origin, and means directed against the fever have but little eifect.
Paul (" Conferences cliniques sur la Phthisic," *Gaz. des Hop,,' 1871,
517 ; 1872, 282) does not add much to the literature of phthisis. He
refers to a peculiar discolouration of the skin, similar to that found in
Addison's disease, which commences on the forehead, and spreads from
the eyebrows down to the mouth, and might be confounded with the
affection mentioned, or with the chloasma occurring in connection with
uterine disturbance.
C. T. Williams ('Med.-Chir. Trans.,' liv, 95) gives some account of a
thousand cases of phthisis seen in private practice, with the object of
deducing the amount of influence which the conditions of age, sex,
family, predisposition, and origin, exercised on the duration of the
malady. The patients belonged chiefly to the upper and middle classes,
and each case was at least one year under observation ; 625 were males,
and 375 females; 41 per cent, of all the cases were attacked between
twenty and thirty, 25 per cent, between thirty and forty, 19! per cent,
under twenty, and 13! above forty. The average was greater among
females than males. Family predisposition was traced in 48 per cent,
of the patients ; nearly half of the cases had only brothers and sisters
affected. The commonest origin in 31^ cases were pleuro-pneumonia
(143) and bronchitis (118). Haemoptysis was present in 57 per cent,
of the patients ; 198 died after an average duration of life of seven
years, eight months, and three quarters ; of the 802 living, 72 per
cent, have regained their health sufiiciently to follow their occupations,
28 were still invalids. The author then discusses the views of different'
writers, and his own statistics on the conditions which influence the
duration of the disease.
The same writer (ib., Iv, 233) enlarges on three grounds for form-
ing an opinion as to the selection of proper climates for consumptive
patients : — i. The alleged immunity of some localities from the disease.
2. The existence in certain localities of atmospheric conditions the
reverse of those under which the disease was contracted. 3. The ascer-
* It is simply tiresome to read papers by many writers — of what nation it matters
not — no two of whom either agree about or define their meaning of " tuberculosis,'*
—A. B. S.
l^g REPORT ON PRACTICAL MEDICINE.
tained results of certain climates on similar cases. He then gives a
statistical account of 251 of the above 1000 cases who at one time or
another were submitted to the influence of warm climates for periods
varying from one to eleven years. He gives a short description of the
climates of different places, and concludes that, compariug the deaths of
those who wintered abroad and those who did not do so, there was an
extension of four months and a half in favour of the climate cases.
Condie (' Amer. Journ. of Med. Sci.,' Ixii, 119) discusses the question
of the contagiousness of phthisis, and gives three cases which seem to
give more or less probability to this theory. The third case is that of a
previously healthy man who died of consumption nineteen months after
his wife had succumbed to the same disease.
To the question whether it be proper for consumptives to marry,
C. J. B. Williams ('Brit. Med. Journ.,' 1871, i, 164), E. Barnes (ib.,
191), and H. Bennet (ib., 295), agree with Virchow in giving a nega-
tive answer.
Tait ('Dubl. Journ.,' lii, 317) wishes to substitute the term 7)ij/oidema
for the muscular irritability often seen in patients suffering from chest
affections, and first noticed by Graves and Stokes. These writers
described the appearance, after percussion, of a number of little tumours
exactly corresponding to the number and situation of the points of the
fingers where they had struck the integuments of the chest. They
continued visible for a few moments and then subsided, but could be
again made to appear by repeating the percussion. Their appearance
seemed to be due to the contraction of muscular fibres, in consequence
of the irritation of the blow (factitious urticaria of Gull, &c. — JRcp.).
Tait gives short notes of 117 cases in which he noticed the phenomenou,
and a table of 90 other observations in which it was present. Only 26
of his 117 cases died, and he finds one comfort in the fact "that the
majority of practitioners have no very accurate notion of how many
cases of consumption there are which recover — get well as absolutely as
do cases of measles." (The writer gives no physical signs in the
majority of the cases, and hints only slightly at the post-mortem appear-
ances in two cases {^0^ and 55). The whole paper is most careless and
dogmatic. — Bep .)
Ludwig, "Im Oberengadin entstandene todtlich verlaufene Phthisis,'* 'Arch. d.
Heilk./ xii, 494. Hirsch, " Beitrag zur Casuistik der galoppirenden Lungenscluvind-
sucht (kasige Pneuraonie)," • Beii. Klin. Woch.,' 1871, 198. Pilz, "Ein Fall vou
chronischer Pneumonie mit Gehirntuberculose und Ektasie der Speiserohre," * Jahrb.
f. Kinderheilk.,' iv, 433. Van der Corput, " Nouveau mode de Traiteuient de la
Pbthisie au moyen de rbuile do Foie de Morue saponifiee par la Cbaux," • Bull. Gen.
deTberap./ 80, 205. Perroud, "De quelques Pbenomenes uerveux survenaut dans le
cours de la Phtbisie Pulmonaire ," ' Lyon Med.,' ix, 6. Mayet, " Inflammation dcs
Follicules clos de I'lntestin dans la Phtbisie,' ib., t,^^. Boudant, "De la Phthisic aux
eaux de Mont-Dore," ib., vii, 439. Tyson, " Cirrb'osis and complete Atrophy of the
Left Lung, Cheesy Deposit with Miliary Tubercle throughout the Rigbt Lung "
(man, at. 26), ' Amer. Journ. Med. Sci.,' Ixi, 163. Id., (i) " Phthisis, Cavity at Apex
of each Lung, disseminated Miliary Tubercle and Cheesy Deposit" (boy, a}t. 19) ; (2)
"Phthisis, Cavities, Cheesy Deposit only" (girl, at. 25), ib., 429. Hutchinson,
" Phthisis diagnosticated by aid of the Microscopic Examination of the Sputa " (bov,
Sit. 19, with autopsy), ib., 153. Condie, "Tubercular Pneumonia," ib., 365. Id.,
" Hemoptysis in Consumptive Patients," ib., Ixiii, 97. Id., " On Hectic Fever," ib.,
PHTHISIS CARDIAC MTUlMUllSj ETC. ' 129
ib., 365. Simons, "Climate and its relations to the Production, Progress, Ameliora-
lion, and Cure of Consumption," ib., ib., 82. Bennet (J. H.), " On the Treatment of
Pulmonary Consumption by Hygiene, Climate, and Medicine, in its connection with
Modern Doctrines," Lond(m, 1871. Moxon, "On the Varieties of Tubercle, and the
relation of Tubercle to Inflammation," ' Med. Times and Gaz.,' 187 1, i, 64, Hartsen,
" Two well-known Symptoms of Phthisis ; Remarks on their Explanation," ib., ii, 586.
Allbutt, "Phthisis as a Neurosis," ib., ib., 613. Russell, "Acute Pulmonai'y Con-
sumption," ib., ib,, 526. Williams (T.), " Case of Contractile Phthisis causing
remarkable Displacement of Organs," ib., ib., 732. Ogle, "The Action of Sulphate
of Quinine upon the Temperature in Pulmonary Phthisis " (no proportionate modifi-
cations of respiration, pulse or heart beat, accompanied the fluctuations), ' Lancet,'
1872, ii, 9. Philipson, "Report of a Case of Phthisis Pulmonalis, accompanied by
Ulceration of the Larynx and Plastic Exudation into the Trachea and Bronchi "
(man, aet. 30), ib., i, 855. Bradbury, "Notes of a Case of Phth'sis ab Hsemoptoe (?),
with Remarks," ib., 1871, ii, 602. Broster, " On the Treatment of Phthisis' Pulmo-
nalis by Glycerine and Indian Hemp," ib., i, 47. Peacock, " Clinical Lecture on
Haimoptysis," ib., ii, 875. Bradbury, "Case of a rare form of Pulmonary Hsemor-
rliage, with brief Remarks," 'Brit. Med. Journ.,' 1871, i, 35. Id., "On the
Prognostic Value of Haemoptysis," ib., ii, 259. Waters, " Clinical Remarks on the
Treatment of Haemoptysis," ib., i, 247. Jamieson, " Subcutaneous Injection of Ergo-
tiue in Haemoptysis, ib., 587." Eames, " Haemoptysis in advanced Phthisis," ib., i, 433.
Cotton, " Notes on Consumption," ib., i, 192. Law, "Lungs and Larynx of a man,
tet. 44, who died with Phthisis Laryugea," ib., 342. Green, " Aneurism of a Branch
of the Pulmonary Artery in a Phthisical Lung," * Path. Soc. Trans.,' xxii, 37. Powell,
" Some Cases illustrating the Pathology of Fatal Haemoptysis in advanced Phthisis,"
ib., 41. Squire, " Part of the Upper Lobe of Left Lung, where two years ago signs
of Tuberculosis had been arrested by Quinine; also Enlarged Kidneys and Ulcerated
Ileum, with large Mesenteric Glands from the same child," ib., xxiii, 35. Greenhow,
" Lungs from a Case of Cured Phthisis ; Death from Capillary Bronchitis ; Cavities
lined with False Membrane in both Lungs, Proliferation of Interlobular Connective
'J'issue and great Thickening of the Pleura," ib., ib., 49. Gueneau de Mussy,
" Observations de Phthisic latente," ' Gaz. Hebd.,* viii, 296. Perroud, " Influence de
la Variole sur la Phthisic latente," ' Lyon Med.,' viii, 371. (And see under "Climate.")
D. — Diseases , of the Circulatory System.
Origin of Cardiac Murmurs, S[c.
Jacobson (" Ueber Herzgerausche," 'Berl. Klin. Woch.,' 1871, 588)
remarks that even experienced auscultators find a difficulty in ascer-
taining the precise coincidence of a murmur with a certain period of
the heart's action. The usual attention to the pulsation of the
carotid, or to the heart's impulse, is hardly precise enough in the
absence of a simultaneous proof obtained by hearing and feeling. To
remedy this defect he has invented an instrument, through which the
movements of the artery are transmitted by a lever to an electro-mag-
netic clockwork. The motion of the latter gives an audible signal,
which may thus be compared with the normal or abnormal sounds of
the heart. The use of this instrument is said to be as easy as that of
the ordinary sphygmograph.
Giese ("Versuche iiber die Entstehung der Herztone," 'Deut.
Klin.,' 1 87 1, 393) has repeated and confirms the experiments of Bayer
on the mode of origin of the first sound of the heart. He made use of
fresh calves' hearts, in which he removed the left auricle so as to
expose the mitral valve, and also cut away the aortic valves. Into the
9
130 REPORT ON PRACTICAL MEDICINE.
aorta he introduced a tube ten feet long, with a stopcock. On openiDg
the latter water poured into the ventricle and closed the mitral valves.
The stopcock was so constructed (see the original paper) that after
the valve had closed it opened again of itself. Auscultation was made
with a stethoscope dipped in the water, but not resting immediately on
the heart. In this way a weak and dull sound was heard on the closure
of the valve, beginning, but not ending, sharply, and in no way whatever
like the first sound heard in the living body. In insufficiency of the
valve the sound was not heard. In another series of experiments on
the semilunar valves a clear clapping sound was obtained, exactly like
that of the second sound of the living heart. The conclusion he draws
is, that the closure of the mitral valves (during life) does appear to
produce a sound, but that this sound is not that of the full first sound
of the heart, and that the coming together of the valve plays only a
secondary part in the production of the real first sound.
Poore ('Lancet,' 1872, ii, 118) intensifies the cardiac sounds by
placing the patient on his back on a wooden bench, applying the end of
a stick between the third costal cartilages, and balancing the sounding-
box of a guitar, with its aperture towards the thorax of the patient on
the other end of the stick.
Hyde Salter ('Lancet,' 187 1, ii, 151) calls attention to the existence
of auricular pericardial friction, and gives four cases, in three of which,
a man, set. 21, and two women of middle age, a friction sound was
audible at the inner extremity of the third right intercostal space ; in a
fourth case, in a woman set. 29, the same murmur, resembling a pre-
systolic one, was limited to a point on the third left rib, about an inch
to the left of the margin of the sternum. The autopsies of two, whose
death was due to ursemic pericarditis, are given, in proof of the correct
diagnosis. In one the left auricle was covered and roughened with
lymph, which was confined to the surface of the auricle ; in the other,
the sound extended down over the ventricles and became general, as
did the pericarditis. Attention is strongly drawn to the presystolic cha-
racter of the sound. In the first case (ib., 251) Salter noticed a
curious phenomenon : — One morning the pulse beats and respirations
were exactly equal, 58 ; next day there were two beats to one respira-
tion, and the day following the pulse beats, without any connexion
with the respiration, came regularly in " couples." The former pecu-
liarity he had noticed in a few other cases, one of which he gives;
and he thinks that the explanation of what he terms "sphygmo-
pneumal synchronism" is to be found in an accommodation of the
respiratory movements, perhaps without any consciousness on the part
of the patient, to the movements of the heart. In both cases recorded
there was probably adherent pericardium, or adherence between it and
the lung. He gives two further cases, to illustrate the occurrence of
" couple-rhythm."
Oueneau de Mussy (' Oaz. des Hop.,' 1871, 133) gives a clinical
lecture on a case of aortic insufficiency. Here the diastolic murmur
became gradually feebler, while a loud systolic murmur was developed.
He concluded that the abnormal aperture of the valve was gradually
being lessened and closed by vegetations, and a gradual stenosis taking
ORIGIN OF CARDIAC MURMURS^ ETC. 131
place. His diagnosis was confirmed by the post-mortem appearances
found.
Barclay, in some " Eemarks on Pre-systolic Cardiac Murmur '*
('Lancet,' 1872, i, 283, &c.) inclines to the view that it is one of regurgi-
tation, not of obstruction. He gives the case of a boy, set. 1 8, still alive,
iu whom, without any history of rheumatic, and only of scarlet, fever, a
very distinct harsh grating murmur was heard at the apex of the heart,
distinctly terminating in the first sound, while the interval between the
second and first sounds was preternaturally long. Under the influence
of digitalis, this interval became more striking, and it was found that
a short soft murmur began almost immediately after the second sound,
{terminating immediately before the harsh murmur commenced. At the
base only the harsher murmur could be heard. He reviews at some
[length the mode in which the sounds of the heart are produced, and
the opinions of different writers on this particular murmur. His own
iexplanation (p. 394) is as follows: — The mitral valve is transformed
into a ring, prolonged into a funnel-shape, with a thick inflexible
margin, the two flaps being more or less adherent to each other. The
thickened ring stands almost permanently open, and the first effect of
:ventricular tension is to drive blood through the valve, not to close it.
iBut as contraction goes on, the blood presses on the sides of the funnel
and impels them against each other, and thus the click of the valves
ia delayed, because not the edges but the sides have met, not the
earlier tension but the later contraction of the ventricle has closed them.
As soon as they meet they must more or less arrest the backward
current, and we have thus the explanation of the circumstance that the
inurmur runs up to, and terminates in, the first sound. This, too,
explains why the interval before the first sound is longer than usual,
because the closure of the valve has been delayed, and the first sound
has been thus far postponed. He holds (p. 354) that the thickening of
the walls of the auricle, never reaching that of the walls of a thin ven*
trifle, is rather due to a large quantity of blood being driven back into
it than to any obstacle to its onward flow ; that with no means of closing
!the entrance of the pulmonary veins, the auricle, in contracting, must
icmpty itself backwards if any obstacle to its onward flow exist ; ajod
that (p. 39^) the pulmonary congestion and hsomoptysis, as constant
with this as with the ordinary mitral systolic murmur, is due to this
backward flow of blood upon the lungs.
Balfour (ib., ib., 714) opposes at some length Barclay's views, uphold-
ing the generally accepted rhythm of the presystolic murmur.
Davies, in a former paper read before the Royal Society (see last
f Report,' p. 148), had assumed — (i) that the four openings of the
heart during the time the blood traverses them are circular in form ;
and (2) that the area of each orifice is unchanged — constant — during
systole and diastole. In another paper ('Lancet,' 1872, ii, 109) he
puts forward arguments in support of his assumptions, based on the
dissections of Pettigrew, and others, and meets certain objections made
to his theory.
! De Griovanni (" JSTuovo metodo per limitare la regione cardiaca,"
' Graz. Med. Lomb.,' 187 1, 261) has marked out with needles the posi-
132 REPORT ON PRACTICAL MEDICINE.
tion of the heart in a number of bodies. He holds that the assertion thai
in enlargement of the left ventricle the heart is increased vertical!}
and in that of the right ventricle is increased in breadth, is not strict];,
true.
The 'Lancet' (1872, i, 149) contains an abstract of a lecture by
Duchek, in which he discusses the origin of the hruit du diahle. Th
murmur is modified by the strength of^the pulse in the carotids
(moments of reinforcement) and by acceleration of the respiration. He
holds that it is due to the vibration of the half-opened valves in the
bulbus of the jugular vein behind the insertion of the sterno-mastoid,
and requires for its production a rapid circulation of blood and a
normal pressure of the blood in the thorax. If the latter is increased
by valvular failures, emphysema, &c., the murmur is not heard, and
hence the general view that this murmur excludes insufficiency of the
mitral.
Allbutt ('St. George's Hosp. Eep.,' v, 22) writes on the effects of
overwork and strain on the heart and great blood-vessels. He gives the
following as the order in which the chronic morbid changes seem to
present themselves for consideration : — (i) Dilatation of the right heart,
(2) dilatation of the left heart, (3) inreason,if not in time, hypertrophy
of the left ventricle, or both ventricles, (4) chronic inflammation of tl
aorta and aortic valves, (5) dilatation of the aorta, (6) incompeten(
of the aortic valves, with (7) further compensatory hypertrophy of tli
left ventricle, (8) loss of compensatory hypertrophy, with consequen
rapid failure, and often with consequent mitral regurgitation. Thi
order of succession may be complete, or may present these variation ^
among others, that after the fourth stage the inner coats of the aorta
may and often do give way, or aortic incompetence takes place. He
meets with simple dilatation and hypertrophy so constantly in patients
who have been subjected to over-exertion that he places them together,
unhesitatingly, as the beginnings of mischief. He further examines
into the facts which bear upon the above assertions, giving sphygmo-
graphic tracings of difierent cases. In several cases he has been
tempted to attribute phthisis to hsBmorrhage into the lung ; it is at
least remarkable that many of those suflfering from pulmonary
phthisis seem to have enjoyed good health up to the time when from
some cause or other hsBmoptysis occurred (cf ' Med. Times and Gaz.,'
1871,1,565).
Stone ('J^ew York Med. Eec.,' vi, ^6) feels quite certain that a large
proportion of diseases of the heart may be warded offer very much miti-
gated. A large proportion of heart diseases arise from inflammation,
which occurs mostly in the young, and a much larger number than is
supposed begin purely as functional derangements, which, if not
relieved, lead on to dilatation, insufficiency of the valves, and all the
consequences of obstructed circulation through the organ. He lays
stress upon not waiting for a friction sound or murmur, for instance in
the rheumatism of children, but exhibiting drugs at once. His remarks
on functional derangement contain nothing new.
Snelling (ib., 6) gives short notes of twenty cases in which the sub-
clavian bellows-murmur was heard. He gives a table in which the cases
ORIGIN OF CAEDIAC MURMURS, ETC. 133
are analysed, and concludes that in certain cases, "when the deposition
of tubercle is too slight to give rise to physical signs the murmur,
taken in connection with emaciation and cough, may be looked upon
almost as pathognomonic" of phthisis.
Gray ('Brit. Med. Journ.,' 187 1, ii, 94) refers shortly to three cases
occurring in his own practice, of phthisis, strumous diarrhoea, and bron-
chitis after measles, in which death from coma was preceded by a fall in
the frequency of the pulse.
Brunton (' St. Barth. Hosp. Rep.,* vii, 216) has made several experi-
ments on the effect of temperature on the rabbit's heart while it still
remained in the body, sometimes leaving all its nervous connections
untouched, and sometimes dividing the vagi. These experiments were
made by narcotising the animal with opium or chloral, and laying it in a
tin vessel well padded with cotton wool. The vessel was double, and by
pouring hot water into it, the temperature of the rabbit was gradually
raised. The belly of the animal was also covered with cotton wool,
sometimes with an india-rubber bag containing hot water. To make
respiration easier, a canuia was introduced into the trachea, and the
inspired air passed over warm water. The pulsations of the heart were
counted by pushing a fine needle through the thoracic walls into the
heart, so that it vibrated with each pulsation, and connecting its outer
end by means of a fine thread with the lever of one of Marey's cardio-
graphs. By this means it is possible to count the pulsations, even when
the heart is beating at the rate of 470 in a minute, as it did in one case.
The temperature was taken with a thermometer in the rectum. He
gives a table, from which it is seen that the heart beats more quickly
as the temperature rises till it reaches its maximum, and then becomes
slower, and finally stops. The increase in the number of beats is not
tlie same for each degree of rise in the temperature, and the number
of beats at the same temperature, and also the same amount of quick-
ening for each degree of rise of temperature, differs in dift'erent
animals. The upper limit at which the heat stands still varies in
different animals, but in the stronger ones it is between 113° and 114°
P., or even above it. In some of the experiments the power of the
vagus was tested from time to time by irritation with an induced cur-
rent, and from its persistent power the writer concludes that in the
rabbit, and probably other mammals' hearts, a temperature suffi-
ciently high to produce stoppage of the heart does not paralyse the
vagus or the inhibitory apparatus through which it acts. He is
inclined to reject Weikart's hypothesis, that death from heat is due to
coagulation of blood in the vessels, and to agree with Bernard in
finding its cause in impairment of the muscular power of the heart by
the heat.
Habershon ('Lancet,' 1871, i, ^^s) writes on the relief of nocturnal
dyspnoea arising from disease of the heart, and groups it into three
classes. In the first class are cases of failing power of the heart's
action from loss of blood and from sudden shocks to the nervous sys-
tem. In these cases the action is feeble and often irregular, and the
best treatment consists in the administration of nourishment, the proper
use of stimulants, and afterwards the employment of steel, with nar-
134 REPORT ON PRACTICAL MEDICINE.
cotics if sleeplessness or pain be present. In a second class the cardiac
disease consists in imperfection of the mitral valve, and its necessary
results ; here the treatment is to be directed to the lungs, liver and
kidneys ; narcotics have only a transient benefit, often followed by
increased distress. In a third class the dyspnoBa is produced by failing
muscular power of the heart, due to degeneration of its muscular fibre,
atheroma of the vessels, idiopathic ansBmia, disease of the aortic valves
and dilatation. Here stimulating narcotics should be used — spirit of
chloroform, camphor, senega, ammonia and Indian hemp. The paper
contains suggestions as to the general dietary regulations to be fol-
lowed, and concludes with the writer's experience of various drug^-
employed by himself.
Hering, "Ueber den Einfluss der Athmung auf deu Kreislauf," 'Wien. Med. Jahrb.,
1872, 37. Kolisko, "Beitrage zur Kenntniss der Mechanik des Herzens," ib., 87.
Beneke, " Ueber die Lumina der Arterien, deren grosse Verschiedenheit und dercn
Bedeutung fur die Entwicklung von Krankheiten," 'Jahrb. f. Kinderkr.,' iv, 380.
Jacobson, "Ueber Herzgerausche," *Berl. Klin. Wocb.,' 1872, i. Lender, "Znr
Behandlung Chronisclier Herzkrankh.," ib., 187 1, 260. Garrod, ''On the Mutu;il
Relations of the Apex Cardiograph and the Radial Sphygmograph Trace," * Proc. Roy
Soc,,' xix, 318. Jaccoud, " Indications de la digitale dans les Affections Cardiaqu(
et du Traitement de TAsystolie," * Gaz. des Hop.,' 1871, 5. Morgan, " Cardiac Lesioi;
consequent on Syphilitic Cachexia" (guramata in heart), 'Dublin Quart. Jonm.,' li
42. Fothergill, "The Treatment of Heart Disease," ' Edin. Journ.,* xvii, 776. Wilk>,
"Note on the History of Valvular Diseases of the Heart," 'Guy's Hosp. Rep.,' xvi,
209. Shapter, "Notes and Observations on Diseases of the Heart and Lungs," ' Brit.
Med. Journ.,' 1871, ii, 522, 1872, i, 7. Williams, "On Triple Sounds of the Heart."
ib., 1871, ii, 788. Gairdner, " Clinical Observations in the Glasgow Royallnfinnary"
(Vanishing murmur), ib., 1872, i, 334. Johnson, "Heart Disease," 'Med. Times and
Gaz.,' 1871, ii, 790. Silver, "On Functional Regurgitant Bruit," ib., i, 361. Gray.
" Unilateral Ansethesia without impairment of Motor Power, occurring suddenly in
the subject of Heart Disease," ib.. 246. Laccassagne, " Des Complications Car-
diaques dans la Blennorrhagie," 'Arch. Gen.,' 1872, i, 15. B. W. Foster, " Digitali.s
and Heart Disease," 'Med.-Chir. Rev.,* xlviii, 214.
JEmboUsm^ Thromhosis, Sfc.
Wrany ('Oesterr. Jahrb. f. Paediatrik,' 1872, 12) gives the case of a
boy, set. 9, in whom endocarditis was followed by hemiplegia, aphasia,
and hemichorea. The autopsy showed fatty degeneration of the
heart, disease of the mitral valve, adherent pleura on both sides, pneu-
monia of the right upper lobe, oedema of the lung, embolism of the left
middle cerebral artery, with consequent softening of the corpus stria-
tum and lenticular nucleus ; infarcta of the kidneys and spleen ;
haemorrhagic erosions in the stomach, and catarrh of the large in-
testines.
Murchison (* Trans. Path. Soc.,' xxii, 1 19) records the case of a girl,
set. 14, who had for years suffered from chorea, with mitral deficiency.
While lying in bed she became suddenly unconscious, and had occa-
sional muscular twitchings of the right limbs. The right pupil was
contracted, the left dilated, both immovable. In addition to vegetations
on the mitral valve were found embolic masses in the spleen and
kidneys, and the left vertebral.and left carotid artery were mucli dis-
tended, hard, and completely blocked by a pale, firm, easily detached
EMBOLISM, THROMBOSIS, ETC. 135
clot. No embolisms of the minute vessels such as have been described
after death from chorea were found.
Bernhardt (' Yirch. Arch.,' Iv, 241) publishes the following very
interesting case: — A boy, eet. 19, had suifered for some years with
severe headache and vomiting, which occurred regularly every three or
four weeks. Later he had rheumatic pains and palpitation. One
morning, in spite of the headache, he went to work, but an hour later
was compelled to take to his bed, and almost immediately afterwards
became completely paralysed on the left side, without any loss of con-
sciousness, pain, or other antecedent symptoms. Auscultation gave the
signs of insufficiency of the aortic valves and stenosis of the mitral
(absence of the aortic diastolic sound, and marked presystolic murmur).
After death the right middle cerebral artery was found completely
blocked by a firmly adherent body which extended into the artery of the
corpus callosum. The left middle cerebral artery was blocked, but not
completely, in the same way. The whole of the brain substance was
anaemic, the greater part of the lenticular nucleus and posterior half
of the corpus striatum on the right side was in the condition of yellow
softening. The mitral valve was slightly thickened, and had an open-
ing of the size of a cherry-stone in its anterior curtain. The aoitic
valves were adherent, atrophied, and dragged downwards, and on their
surface corresponding to the defect in the mitral valve was a chalky,
irregular, warty body, 2^ — 3 cm. long, covered with fresh coagula,
which almost blocked the opening from the aorta. (A plate is given.)
Both kidneys, especially the right, contained infarcta; the branches
of the renal artery were completely obstructed by bodies similar to those
in the vessels of the brain. Bernhardt remarks shortly on the case as
it bears upon the diagnosis made, and refers to a case recorded by
Moxon (see last 'Report,' p. 160).
Luneau (' Gaz. Med.,' 1871, ^4) gives two cases in which the left
vertebral artery was obliterated. Both cases occurred in the clinique
of Proust, within a few days of each other. The first patient was a
woman, set. 68, who five months before had had an apoplectiform attack,
followed by hemiplegia, from which she completely recovered. On the
day of her admission into hospital she suddenly felt a weakness of the
left side, and lost all power of speech, though she preserved her con-
sciousness. On admission there was incomplete paralysis of the left
side of the face and body, with hyperaesthesia of the arm and leg ; com-
plete aphonia and dysphagia ; the intellectual power was perfect ; the
tongue was pushed to the left side, and its movements embarrassed ;
the velum was completely insensible, and the muscles of the pharynx
also paralysed. She passed her urine involuntarily ; on the seventh day
she died. At the post-mortem examination the basilar and right
vertebral arteries were atheromatous, but their canals free. The upper
end of the left vertebral was obstructed by a slightly decolourised clot,
distant about half a cm. from the basilar. The posterior and inferior
cerebral arteries were also obliterated. Charcot examined the portions
of the medulla oblongata nourished by these arteries, and the left lobe
of the cerebellum, and found them in a condition of ischsemic softening.
The left kidney alone showed any trace of infarctus, and in spite of any
136 REPORT ON PRACTICAL MEDICINE.
evidence gained elsewhere, the author concludes that the original cause
must have been embolism. The second case was that of a man, aet. 63,
who had been much addicted to drink. On the evening before his
admission into hospital he was suddenly attacked with vomiting and
inability to swallow. On his admission there was general muscular
weakness, but complete intelligence and liveliness. There was complete
loss of power to swallow, though the velum contracted well. There was
tremor, but no paralysis of the upper extremities, slight hyperaBsthesia
of the lower ; he tottered if he attempted to stand, and showed a
tendency to fall towards the left side. Next day he died. The valves
of the heart were found thickened and atheromatous, as also the arte-
ries at the base of the brain. One centimetre from its opening into the
basilar the left vertebral artery was completely obstructed by deco-
lourised, yellowish clot. No traces of infarctus were found in any of
the abdominal organs. Charcot remarks on the cases, that the
symptoms observed were extremely similar to those seen in labio-glosso-
pharyngeal paralysis.
King, "A Case of Aortic and Mitral Valvular Disease, with Extensive Infarction of
the Spleen and Cerebral Softening" (man, at. 32), 'Path. Soc. Trans.,' xxiii, 63. Id.,
" Aneurism of the Aorta associated with Fracture of the First Rib, and Embolism
of Left Middle Cerebral Artery " (man, sec. 42), ib., 70. Molliere, " De TEmboUe
des Arteres Mesenteriques, etudes critiques et bibliographiques," ' Lyon. Med.,' viii,
691. Ramskill, "Thrombosis of Right Iliac Vein, Embolism of Pulmonary Artery,
Sudden Death " (man, aet. 35), * Med. Times and Gaz,,' 187 1, i, 660. Merkel, " Cheyne-
Stokes'schen Respirationstypus mit Pendel-bewegungen der AugapfeL Rheumatische
Endocarditis; Encephalitis in Folge von Embolic der Arteria fossae Sylvii dextra'*
(girl, set. 22), * Deut. Arch.,' x, 201. Schmid, " Zur Differentialdiagnose von Apoplexie
und Embolie des Gehirns," ib., 305. Cohnheim, " Untersuchungen iiber die Em-
bolischen Processe," Berlin, 1872, pp. 112 (reviewed, ib., 316).
Pericarditis.
Wilks (' Guy's Hosp. Eep.,' xvi, 196) writes on adherent peri-
cardium as a cause of cardiac disease, and discusses the different views
held by Hope, Corvisart, Barlow, Chevers, &c. He holds it probable
that loose cellular adhesions have no appreciable influence on the
action of the heart, but that the thickened pericardium of a carti-
laginous consistency, investing the heart closely, arising from an inflam-
mation at an early period of childhood, does lead to obstruction of the
circulation, and then to dropsy, after the manner of heart disease. The
condition of adherent pericardium cannot be regarded as a rare one.
He gives six cases in which death was apparently due to this affection,
and is almost inclined to offer the proposition, that in a well-marked
case of disease with cardiac symptoms in young persons without any
valvular bruit pericardial adhesions may be fairly expected. In older
persons, of course, we should look rather to degeneration of muscular
tissue. Of the cases recorded in this paper, five were males, aged re-
spectively 21, 9, 12, 26, and 24 ; the other is that of a girl, aged 16. The
symptoms common to all were dyspnosa, cyanosis, dropsy ; in none was
any bruit heard ; in all the pericardium w^as universally and closely
adherent. (The first case has been recorded already by Barlow, 'Guy's
Hosp. Eep.,' ser. 3, xi, ^^y.—Rep.)
PERICARDITIS MYOCARDITIS, ETC. 137
Glover ('Lancet,' i, 893) records the case of a girl, 88t. 12, who had
complained of pain in her left side for two or three weeks. Her tem-
perature seven days before death was 101°. No physical signs seem
to have been made out. The autopsy showed the pericardium
distended with pus, and purulent lymph adhering to its inner
surface.
Fremy, " Pericardite. Epanchement de Serosite purulente. Ponction avec TAppareil
du Dr. Dieulafoy, Guerison" (man, set. 21), 'Bull. Gen. de Therap.,' t. 81, p. 125.
Thiriar, "Pericardite, avec Epanchement considerable et brides adhesives, suite
d' Affections Rhumatismales " (boy, set. 16, autopsy), 'Presse Med. Beige,' 1871, 32.
Heaton, "Rheumatic Pericarditis with Effusion, Recovery" (man, set. 21), 'Brit.
Med. Journ.,' 1871, ii, 96. Thorowgood, "Pericarditis with Effusion, Death" (boy,
aet. 10, autopsy), 'Lancet,' 1872, i, 682.
Diseases of Myocardium ; Heart Aneurism, ^c.
Quain ('Lancet,' 1872, i, 391) thinks that affections of the walls of
the heart have been somewhat neglected in the attention paid to
valvular affections. He holds that clinical study of the former teaches
that — (i) the really serious effects of heart disease result from hyper-
trophy, or from dilatation, or from a combination of the two ; (2)
valvular diseases may exist up to the close of a long life without ren-
dering the subject of them conscious of their presence ; (3) it is possible
to refer to cases in which, valve disease having existed without causiDg
any inconvenience, something occurs which damages the condition of
the muscular walls, and serious disturbance is the result ; (4) there are
cases in which some additional mischief occurs to valve disease already
existing, and this mischief is remedied by the supervention of further
compensatory hypertrophy ; (5) the converse of the last class is seen in
cases of valve disease in which the heart walls fail and the disease pro-
gresses ; (6) cases occur in which valvular disease — i. e. incompetency —
is caused by dilatation of the heart. Enlargement of this organ may
depend — {a) on an increase in the muscular fibres, the exact change
being still unknown ; {h) on an increase in the connective tissue, due to
chronic interstitial inflammation or hyperplasia ; {c) on an increase of
fat, not to be confounded with fatty degeneration. The causes of
enlargement of the heart may be classified as— agencies acting through
the nervous system, as overstrained excitement ; agencies acting mecha-
nically, as severe and repeated muscular exertion, obstructed circu-
lation, pregnancy ; agencies originating in disordered conditions of the
nutritive functions of the heart, as chlorosis, ansemia, good living with
insufiicient exercise, Bright's disease, adherent pericardium. The
author proceeds to discuss (ib., 426) the systemic effects of enlarge-
ment, and the relation of heart disease to phthisis and renal disease, and
the second lecture concludes with the diagnosis and treatment of it.
In simple muscular hypertrophy, repose, and the administration of
aconite ; in connective-tissue hypertrophy, if diagnosed in its early
stage, remedies likely to subdue the inflammation in which it origi-
nates ; and in fatty hypertrophy, treatment calculated to prevent the
formation of fat, are recommended ; and to obtain compensatory hyper-
trophy, iron and digitalis. In a third lecture (ib., 459) he enlarges on
138 REPORT ON PRACTICAL MEDICINE.
fatty degeneration and rupture (see under that head). He then
describes aneurism of the heart, the walls of which are formed of the
thin and altered cardiac walls, all the layers of which may be detected
near the base, but in many cases over the rest of the wall the muscular
layer has disappeared. Occasionally bony plates are found in the sac.
This affection' seems to occur with nearly the same frequency at
different ages, but always with a marked preponderance of males in the
cases collected. It may originate in inflammation, fatty degene-
ration, or the bursting of an abscess. The lesion is most frequently
seated at the apex, and is not accompanied by any special symptoms.
Fothergill also discusses (' Brit. Med. Journ.,' 1872, i, 236) the
subject of hypertrophy and dilatation. As to its mode of origin, "as
some name must be used to cover what we do not know, hypertrophy
may be called a trophic action of the cardiac ganglia," by which the
heart resists dilatation. He thinks that in time it may be possible to
demonstrate that it is the consequence of an increased blood supply to
the muscular structure, dilatation of the coronary vessels, and secondary
elongation of the heart-fibres.
Thompson (" Distrain of the Heart," * St. George's Hosp. Eep.,' v,
119) records three cases, to show that dilatation of the heart is not
always a chronic disease, but may arise suddenly and from an accidental
cause. Two of these occurred in men, set. 23 and 28, and the other
in a girl, set. 19. The post-mortem appearances are given in the first
two cases, the last one recovered. He has seen seven of these cases
altogether, and of the whole number three made a good recovery,
the constitutional disturbances passing away, though the heart remained
permanently injured.
Smith ('Brit. Med. Journ.,' 1872, i, 597) showed to the Pathological
Society of Dublin the heart of a young man, set. 22. He had caught
cold some time before his admission into hospital ; oedema of the feet,
general anasarca, and cyanosis followed. The area of prsecordial
dulness was increased ; there was no murmur, but the first sound of
the heart was doubled, and ultimately the action of that organ became
strikingly vermicular. The left half of the tongue became swollen, and
the patient died rather suddenly. The pericardium contained half a
pint of serum ; there was no recent pericarditis ; the heart was much
dilated, but its valves were normal. The right auricle was much en-
larged, but not hypertrophied.
Wagstaffe ('Path. Soc. Trans.,' xxii, 12) records a case of fibrous
tumour of the heart. The specimen had been lying in pickle for
fifteen years before it came into his hands. The patient from whom it
was taken was a female child, set. 3 months, which seems to have died
from convulsive fits. At the post-mortem it was found that the peri-
cardium was distended with a quantity of pinkish serum. The heart
was greatly enlarged, its shape elliptical, the apex nearly as large as the
base, and on one side of this, towards the right ventricle, the muscular
structure appeared to be thinned, and presented an almost tendinous
appearance. The cavities of both auricle and ventricle were dimi-
nished by the projection into them of the septum, in which could be
felt a tough inelastic mass. On cutting down upon this it was found
DISEASES OF MYOCARDIUM^ ETC. 139
to be a pinkisli- white tumour, fully the size of a hen's egg, lying
between the muscular layers of the septum, which it had dissected
from one another from base to apex. This distension had given rise to
the thin and tendinous appearance of the heart- walls when seen from
the outside. Wagstaffe discusses shortly the structure of this tumour,
and remarks on the rarity of simple tumours of the heart.
Payne (ib., 125) gives the autopsy of a woman, set. 41, who presented
during life the signs of malignant disease of the liver. Within the
right auricle, in tlie corner of the appendage, was a small nodule of new
growth the size of a pea, projecting into the cavity among the trabecules ;
a similar nodule was found in the apex of the left ventricle. These
masses were of a whitish colour, and on microscopical examination
presented very definite cancerous structures. Inside the iliac veins,
just at their junction, but more in the left than in the right, was a
mass resembling a blood-clot, but of a peculiar pinkish colour and
spongy texture. Sections of pieces hardened in chromic acid showed a
network of organized tissues enclosing areas of red blood-corpuscles.
There were further considerable masses of undoubtedly cancerous
growth in various organs, especially the liver, in the lymphatic glands,
and the lumbar vertebra. The author remarks on the rarity of cancer
of the heart, and holds that in this case it cannot be clearly decided
that there was any mechanical transference of the disease from the veins
to the heart.
Goodfellow (ib., xxiii, ^3) publishes the case of a man, set. 48, who for
some months before death had suffered from palpitation, dyspnoea, and
pain in the cardiac region, which gradually increased in severity.
There were symptoms of valvular affection produced, as was found after
death, by vegetations on the aortic valves, and ulceration of the one
corresponding to the anterior flap of the mitral. Between them was an
aneurismal sac, of a conical form, passing upwards between the posterior
wall of the aorta and the left auricle, which it compressed ; it then
curved forwards, and terminated in a rounded end projecting into the
pericardium. Its walls at this part were as thin as tissue-paper, quite
transparent, and evidently on the points of giving way.
Murchison (ib., ^4) gives a case of aneurism of the left ventricle in a
woman, set. 6^, the subject of contracted kidneys. At the inner edge of
the mitral valve, and slightly behind the posterior flap, was a pouch in
the muscular wall, which would have admitted a cherry ; at the bottom
of this was a rounded opening, the size of a pea, which led into a sac as
large as a small orange situated in the posterior wall of the left ven-
tricle, and in the intraventricular septum. It protruded slightly into
the right ventricle. At its upper and back part the walls were formed
by thickened pericardium.
Townsend (ib., 96) describes an aneurism of the left ventricle in a
healthy man, set. 42, who died from the effects of an accident. Here
there was at the apex of the ventricle a bony tumour very much
resembling, both in appearance and size, the half of a hen's egg. In
sawing through it a cavity was found opening by a small circular orifice
into the left ventricle, and containing blood.
Crisp (ib., 87) records the occurrence of three abscesses in the left
140 UEPORT ON PRACTICAL . MEDICINE.
cardiac wall, in a child set. 4 years, who died from pysBrnia. He also
adds a table of forty-two cases of the latter disease, to be found in the
* Path. Soc. Trans.'
Coats ('Glasgow Med. Journ.,' iv, 433) records two cases of cal-
careous infiltration of the muscular fibre of the heart. In the first case
the salts of lime, probably composed entirely of the phosphates, had
been deposited in the fibre in the form of minute round granules,
giving the appearance both to the naked eye and under the microscope
of fatty degeneration. The patient, a man who died of fever, presented
signs of chronic bronchitis and emphysema, with probably some syphi-
litic taint. In the second case, one of relapsing fever and pyaemia, the
muscular fibres were converted into cylinders having a considerably
crystalline texture. The lime salt was deposited in a minutely granular
form, and consisted in great part of carbonate of lime, which effervesced
on the addition of hydrochloric acid.
Endocarditis.
Peacock (" On the Prognosis in cases of Valvular Disease of the
Heart," 'St. Thom. Hosp. Eep.,' 1871, 233) regards incompetency of
the valves as a more serious defect than obstruction, and incompetency
of the aortic more dangerous than that of the mitral valves. On the
other hand, obstruction of the mitral is apparently a more important
defect than constriction of the aortic valves. He reviews the general
questions of diagnosis and treatment at some length.
Pagge ("On the Murmurs attendant upon Mitral Contraction,'*
* Guy's Hosp. Eep.,' xvi, 247) writes with special reference to the pre-
systolic murmur. The paper contains histories, more or less full, of
sixty-six patients, arranged in three groups ; seven in which the mur-
mur was heard during life and mitral contraction found after death,
forty cases in which the latter condition was found without any pre-
systolic murmur being heard, and nineteen in which the murmur was
heard but no autopsy made. He gives also two cases in which a
peculiar murmur was audible, and in which he diagnosed mitral
contraction.
Heiberg (* Virch. Arch.,' Ivi, 407) refers to a case of ulcerative endo-
carditis published by "Winge, and described by him as " mycosis
endocardii." The patient, a man aet. 44, had had an ulcer on one of
his toes, pains in his joints and rigors. The autopsy, which Heiberg
gives, showed vegetations on the valves of the heart, and the microscope
revealed the presence of numerous fungi in the vegetations, and also in
the emboli found in the renal and other arteries. Winge referred
their probable origin to the ulcer on the toe. Heiberg records a case
of the same kind occurring in his own practice, in a pregnant woman,
set. 22. During life she had rigors and pains resembling rheumatic
pains. She had also sores on the sacrum. After death, in addition to
these gangrenous ulcers, the autopsy showed ulcerative endocarditis of
the mitral valve, with thrombi containing fungi ; infarcta of the spleen
and kidneys, with metastatic abscesses in the latter. He looks upon
the fungus as Leptothrix ; but Yirchow, in a note to the paper, though
ENDOCARDITIS. 141
accepting the main facts, does not agree with this view. Inoculation
experiments were made from both cases, but without any results.
Miiller ('Deut. Arch.,' 1872, i) describes the case of a woman
dying from mitral insufficiency, in whom after complete cessation even
of the slightest respiratory movement the heart-sounds and the pulse
in the carotids could be distinguished after the lapse of seven minutes.
Pulsation was perceptible in the jugular veins fourteen minutes after
the last sign of breathing. In addition to the mitral mischief, the
autopsy revealed tubercular meningitis of the base of the brain.
Simon ('Berl. Klin. Woch.,' 1871, 437) gives the case of a boy, £et.
16, who suffered five weeks before death with dyspnoea, palpitation,
rigors, convulsions, and loss of consciousness. The area of heart's dul-
ness was increased, the heart-sounds muffled, but unaccompanied by a
murmur. Shortly before death there was an eruption of petechi^e. At
the autopsy were found the following : — Numerous extravasations on
the pia mater ; numerous points of red softening in the brain, most
marked in the left temporal lobe ; several arteries corresponding to
these places were found blocked with emboli. There was sero-fibrinous
inflammation of the pericardium, which exhibited numerous ecchymoses
and miliary tubercles. On opening the left ventricle was found an
" aneurism of the mitral valve," which is described in full in the text.
There were numerous ecchymoses on the pleura, and several embolic
infarcta in the myocardium, both kidneys, mesentery, &c.
Whipham ('Trans. Path. Soc.,' xxii, 117) gives an interesting case of
diseased tricuspid valve in a man, set. 5j. Its free edge, as well as the
chordae tendinese, were ragged and eroded from ulcerative processes.
The valve was thick, opaque, of a dull red colour, contrasting strongly
with the transparent and glistening appearance of the mitral. The
other post-mortem appearances were pleurisy and hsemothorax ; disin-
tegration of the right lung; cirrhosis of the liver; coarse and con-
gested kidneys. In the absence of any origin for blood-poisoning, the
writer thinks that pyaemia was the cause of ulceration of the valve and
of the pneumonia.
Peter (' L'Union Med.,' xii, 662) gives a very full lecture on aortic
insufficiency. After giving the physical signs of the affection, he insists
that it is generally a disease of the aorta, and not of the heart. The
pain behind the sternum, the angina pectoris, and the sudden death,
which often accompany it, point to the disease of the vessel, not to the
incompetent valves. He divides cases of aortic insufficiency into two
classes, those with and those without diseased aorta, the latter being
by far the most common. The disease consists in the 'atheromatous
degeneration and the inflammation of the coats of the vessel, with their
consequences. Old age, abuse of drink, and gout, are the chief origi-
nating causes. The other form of aortic insufficiency is caused by
affections such as rheumatism, &c. The role which the aorta plays can
be easily recognised by the pain and angina caused by the participation
in the mischief of the cardiac plexus, by the hard radial pulse, and the
arcus senilis, and especially if there have been antecedent gout or chronic
alcoholism. After remarking on the sudden death which frequently
occurs in the affection, and the shares taken in the mechanism of it by
142 REPORT ON PRACTICAL MEDICINE.
the disease of the aorta and the cardiac plexus, he speaks of the morbid
series formed by angina, aortitis, and aortic insufficiency, and in con-
clusion he holds that the hypertrophy which generally follows in-
sufficiency is not to be looked on as a compensatory and helpful process,
but as a complication of the worst kind, aggravating the patient's
condition.
E/iegel (' Deut. Arch.,' viii, 129) in a case described by him, recog-
nised the symptom to which Duroziez first drew attention as found in
aortic insufficiency — a double sound in the femoral artery. In this case
a double sound, not a blowing murmur, was audible in both femoral
arteries. With Traube he thinks it is characteristic of a very advanced
stage of insufficiency ; at' the same time an elastic state of the arterial
walls, and great hypertrophy of the left ventricle, are necessary re-
quisites for the production of the symptom in question. Consequently,
it is better heard in young people with healthy vessels and true
hypertrophy of the left ventricle, while it disappears, or is diminished,
in extensive atheroma of the artery and fatty degeneration of the
heart.
Paul ('Union Med.,' xii, 716) writes a very long paper on stenosis
of the pulmonary artery after birth, its symptoms and complications,
and the pulmonary phthisis which frequently succeeds it. The paper
is based on twenty-seven observations. He discusses the modes in
which it may occur, the almost constant secondary hypertrophy of the
right ventricle, the insufficiency as well as stenosis of the pulmonary
valves, and the affections of other valves of the heart which may
accompany it. Its characteristic symptom is a systolic, more or
less rasping murmur, heard over the origin of the pulmonary artery, and
in its direction. Cyanosis is not a consequence of this stenosis.
Pepper, "Ulcerative Endocarditis, Embolism of Kidneys*' (man, rot. 30, no
autopsy), *Amer. Journ. Med. Sci.,' Ixi, 431. Padova, " Endocardite Ateromatosa,
insufficienza e stenosi della mitrale ; essudato pleurico recidivaute ; accessi d'asma
accompagnati da furor uterino in donna di 68 anni," * Gaz. Med. Lomb,,' 1872, 197.
Balfour, " Clinical Lectures on Diseases of the Heart, (i) On the Murmurs and other
physical signs distinctive of Mitral Stenosis," ' Edin. Journ.,' xvii, 431. Beveridge,
**Case of Direct Mitral or Presystolic Murmur" (girl, vat. 17, autopsy), * Brit. Med.
Journ.,' 187 1, ii, 353. Habershon, " Heart Disease " (two cases— i, man, aet. 30. with
aortic insufficiency, &c. ; 2, boy, set. 11, with mitral obstruction and insufficiency,
embolism), ib., 710. Hayden, "Cardiac Hypertrophy, Pericarditis, Mitral and Tri-
cuspid Constriction and Inadequacy, Aortic Obstruction and Reflux " (man, set. 23),
ib., i, 91. Sieveking, "Case of Hypertrophy of the Heart, with Double Tricuspid (?)
Murmur," ib., 62. Allbutt, " Tricuspid Regurgitation " (man, ajt. 55, autopsy), ib.,
63. Fitzgerald, "Visible Pulsation of the Arteria Centralis Retina? in a Case of
Incompetency of the Aortic Valves," ib., ii, 723. Johnson, " A Lecture on Disease
of the Valves of the Heart," ib., 1872, i, 34. Duckworth, "Case of Heart Disease
with Loud Musical Murmur, which passed away," ib., 187 1, ii, 667. Gray, " Endo-
and Peri-carditis without Affection of the Joints, following Subacute Rheumatism,
after a five weeks' interval of obscure febrile symptoms," 'Med. Times 'and Gaz.,'
187 1, i, 41. Powell, " Case of Mitral Obstructive Disease (funnel mitral) terminating
fatally, with cerebral complication; with remarks on this form of heart disease,"
i^-» 395- Salter, " Double Aortic Murmur, Bulging of Aiilla from Hypertrophous
Elongation of Heart, Absence of Regurgitant Pulse," &c., ib., 539. Looinis,
" Interesting Cases of Cardiac Diseases," 'New York Med. Rev.,' vi, ^28. Sparks,
" Disease of Tricuspid and Pulmonary Artery Valves, without Afeection of the Left
EUPTURE OF HEART. 143
Heart" (man, set. 27, probable congenital stenosis of pulmonary artery), 'Lancet,'
i87i,ii, 13. Traube, " Ueber den Doppelton in der Cruralis bei insufficienz der
Aortenklappen," 'Berl. Klin. VVoch.,' 1872, 573. Paul, " Retrecissement de I'Artere
pulraonaire " (man, aet. 36, rheumatic fever ten years before), ■ Gaz. Hebd.,' viii, 431.
reucock, " Extensive Disease of Heart of long duration, Obstructive and Regurgitant
Disease of the Mitral Valves, and Obstructive Disease of the Aortic Valves" (boy.
Hit. 17), ' Trans. Path. Soc.,' xxiii, 59. Id., '* Obstructive and Regurgitant Disease of
the Aortic Valves and Regurgitant Disease of the Mitral, Albuminuria, Bloody
Tumour of Thigh" (man, set. 20), ib., 6i. King, " A Case of Aortic and Mitral
Valvular Disease, with extensive Infarction of the Spleen and Cerebral Softening "
(man, set. 32), ib., 63. Kelly, "Acute Chorea associated with Valvular Disease of
the Heart " (girl, set. 9, vegetations on tricuspid and mitral), ib., 95. Black, " The
Relative Frequency of Disease between the llight and Left Sides of the Heart," &c.,
*Lancet,' 1872, ii, 253.
Sujoture of Heart.
Quain, in his third Lumleian lecture (' Laacet,' 1872, i, 459)
discusses fatty degeneration of the heart and rupture. Out of 88
cases of the latter, 6;^ occurred in persons over 60 years of age, ^^
between 60 and 70, and 24 between 70 and 80. The two sexes are
aifected with equal frequency.* Out of 190 cases death was sudden —
i.e. within one or two minutes — in 71. One patient, however, lived
eight days, one six days, one three days, and five lived over 48 hours.
The seat of rupture in 100 cases was 76 times in the left ventricle (45
in its anterior wall) ; 13 in the right ventricle (9 in its anterior wall) ;
80veD times in the right, and twice in the left auricle ; four times in the
ecptum. The heart had undergone fatty degeneration in 77 ; in 6 it
was " softened ;" in one case the rupture was due to the bursting of an
aneurism, in one to an abscess. In 12 the heart was said to be healthy
or not examined, but m most mention is made of endocarditis or
changes in the coronary artery.
Barth ('Arch. Gen. de Med.,' xvii, 5)-hasesapaper on "spontaneous
rupture of the heart" upon 24 cases recorded in the ' Bulletins de la
Societe Anatomique' during the forty years between 1826 and 1865.
Of these 7 were men and 17 women. * Only two were under 60 years
of age, the rest were between the ages of 60 and 84. The following
were some of the apparently determining causes of the rupture : —
Vexation or anger, an over-large meal, brandy taken in the coffee, the
effort of getting into bed, and in five cases the elfort of defecation. la
the majority of cases death was sudden. In all the cases, without
exception, the rupture was in the left ventricle ; in nine cases it was
situated about the middle of the heart, in four near the base, and in
eight near the apex ; its average length was about 2 centimetres, with
generally irregular ecchymosed borders. In one case only is the heart
stated to have been healthy, but in this case the coronary arteries were
ossified and diminished in calibre. In all the other cases the heart pre-
sented circumscribed infiltrations of blood, ecchymoses, and soft and
* This seems more like the truth than the statement made by some other writers,
according to whom rupture of the heart is more common in males than females.
The abstracts in the text show twenty-one cases in the latter against twelve in the
former.— A. B. S.
144 REPORT ON PRACTICAL MEDICINE.
flabby muscular tissue; in most of the cases it was covered by an
abnormal amount of fat, and the fibres of the muscle had themselves
undergone fatty change. The arteries, in the cases in which they were
examined, were ossified, or contained calcareous plates in their walls.
In one case the mitral was affected ; in a great number of cases the
aorta was diseased. Barth looks upon the interstitial haemorrhages into
the walls of the heart and the fatty change in its muscle as the two
principal pathological facts of the aflfection. He mentions, as rare
occurrences, ruptures of the heart from the presence of a coronary aneu-
rism and of hydatids. He thinks it probable that the rupture occurs
at the commencement of the systole, when the heart has to exert its
greatest amount of energy. The most characteristic phenomena of
its occurrence are syncope, a feeling of suffocation and anxiety, and of
very violent pain at the lower left portion of the sternum and mammary
region. Death occurs, not from the loss of blood, but from compression
of the heart by the effused blood. Treatment of rupture of the heart
is, of course, useless ; but, in the way of prevention, something may be
done by carefully watching old people, in whom the hard radial artery
suggests disease in the cardiac capillaries, by recommending moderation
in the use of alcoholic drinks, regular diet, abstinence from fat-forming
materials; moderate exercise, without muscular effort or fatigue.
Should any symptoms arise which threaten partial rupture of the heart
the patient must be kept in bed, and drugs administered which
diminish the action and so favour the gradual cicatrization of the
muscular tissue ( ! ? Rep.) Notes of the cases are contained in the
body of the paper.
Yedie (' Gaz. des Hop.,' 1871, 145) gives a case of rupture of the
heart in a woman affected with dementia, whose age is not given, pro-
bably due to degeneration of the muscular fibres. Here there was a
rent in the anterior wall of the right auricle. No murmur had been
heard during life, though there -were vegetations and insufficiency of the
aortic valves. She died suddenly, after being in a prostrate condition
for twenty-four hours.
Thompson ('Lancet,' 1871, ii, 63c;) records the followinjT:— A
gentleman, eet. 56, had been in good health and actively employed up to
twenty-four hours before he complained of pain. He had retired to bed
well, but towards morning he died. In this case there was a rupture
an inch long in the anterior wall of the left ventricle, close to the apex.
The muscle had undergone fatty change.*
Beck (ib., 803) gives a case of rupture of the left ventricle in a man,
set. 71, in whom the muscle was also fatty. He fell down speechless
and apparently senseless, about twenty minutes before he died.
Matthews (ib., ib.) publishes the case of a man whose age is not
given, who had suffered for some time with symptoms of valvular
disease. He died suddenly, and at the post-mortem examination a
hole was found at the base of the left ventricle, about the size and shape
* It would be well if others in the same position as this writer would place on
record as he has done here " cases in general practice." In England, at least, the
publication of cases, not always well and briefly reported, as these are, is too much
confined to the consultants of large, especially metropolitan, hospitals.— A. B. S.
of a fartiiing, completely plugged with a black clot. " This hole was
apparently the result of ulceration ( ! Rep.), and must have existed for
I some time, as the edges were completely rounded off, and the plug of
! clot adherent."
In the case recorded by Wiltshire (ib., 1872, i, 290), a woman,
?ct. ^7, who had during life presented symptoms of ulcer of the stomach,
suddenly died. In addition to the ulcers in the posterior wall of that
organ, a rupture, three quarters of an inch long, was found in the right
ventricle. The muscle was markedly fatty.
Hughes (ib., ii, 41) gives a case very like that of Thompson. The
patient, a man of about 2>^, had been in his usual health, and had worked
I hard all day. At midnight after retiring to bed, he complained of
i nausea, and of pain " as if his liver was being torn to pieces." Soon
! after he died. The autopsy showed a rent, half an inch in length, in
i the wall of the right ventricle, about midway between the apex and
! base, close to and parallel with the longitudinal sulcus. The walls of
the heart, though not examined microscopically, were soft and thin —
probably fatty.
Lowe (ib., 524) also gives a similar case occurring in a woman, set,
66, who after going to bed in her usual health, woke with sickness and
vomiting, and died about seven hours later. Here the rupture was
j found in the left ventricular wall, immediately to the left of and
I parallel to the sulcus, and measured about three quarters of an inch
in length. The substance of the heart was soft and flabby, and pale
in colour.
Watson (ib.,' 659) publishes a case of rupture, to the extent of an
inch, in the wall of the left ventricle, parallel with the sulcus. The
patient was a woman, set. 71, and the muscular tissue of the heart was
pale and flabby.
Westcott (' Brit. Med. Journ.,' 1872, i, 554) records a case in which
i the symptoms of nausea and vomiting, though as in some other cases
' they might have been premonitory (?) of the mischief in the heart, are
doubtful from the fact that the patient, a man, set. 6^, was more or less
a drinker, and the rupture might have been the result of the vomiting
1 (Bep.). In this cfise the heart showed the following appearances: — ■
I on the wall of the left ventricle were three longitudinal fissures, the
j lowest extending through the entire thickness of the wall, and mea-
suring rather over a quarter of an inch in length : internally the
rupture extended to three quarters of an inch. Some of the musculi
papillares were ruptured, and the microscope proved the fatty degene-
ncration of the muscle.
Sherman (' New York Med. Eec.,' vi, 345) publishes the case of a man
in whom, after being crushed between two railway cars, the heart was
found ruptured in three places.
JVeurosis of the Heart.
Nunneley (' Lancet,' 1871, i, 228) groups cases of palpitation of the
heart for convenience, and in the absence of any scientific classification,
10
146 &EPOET ON FllACtlCAL MEDICINE.
aa follows — {a) cases occurring in persons free from structural disease
of the heart, or of any organ having a nervous connection with it
whether (i) in the young, in whom degenerative changes have not com-
menced, or (2) those in middle or advanced life in whom they made
considerable progress; {h) cases oi distinctly reflex origin; (c) pal
pitation associated with structural disease ; {d) due to mechanical dis-
placements of the heart ; (e) palpitation as a prominent symptom iu
certain conditions of blood — anaemia, gout, exophthalmic goitre, ex-
cessive smoking or tea-drinking ; (/) cases, of which he gives threi
examples, two with autopsies, characterised by the occurrence of pal.
pitation in definite attacks of sudden access, and by the proportioi
which is observed between the perversion of the heart's action, and thef
patient's sensations, and by the evidence of disturbed innervation of
organs connected with the heart. They form the transition, as it were,
from palpitation to angina pectoris. He discusses (ib., 266) the
treatment of palpitation, which consists in the removal of the imme-
diate cause, regular hygiene and diet ; tonics — iron, arsenic ; difl"usible
stimulants and anodynes ; local applications, such as belladonna.
Althaus has advocated the application of the galvanic current to the
pneumogastric and sympathetic nerves in their course, and "Waller
their compression in the neck by the thumbs ; Nunneley thinks these
two methods deserve study.
Moinet ('Edin. Med. Journ.,' xvi, 608) discusses the pathology of
angina pectoris, and concludes that it is a paralysis occurring in and
depending upon a weakened heart, as no other theory can account for
the symptoms and history of the disease. As to treatment he recom-
mends, during the paroxysm, diflTusible stimulants and opium, hot
brandy and water, sinapisms to the feet, and placing the hands and feet
in hot water ; and generally tonics, galvanism and bleeding.
Under the term of " irritable heart," Da Costa (' Amer. Journ. Med.
Sci., Ixi, 17) describes a form of functional disorder which he observed
in upwards of three hundred soldiers during the American war. The
men had been for a longer or shorter time in active service, and com-
plained of inability to march, on account of dyspnoea, dizziness, palpi-
tation, pain, and a feeling of oppression and tightness in the chest. In
numerous cases there was a history of some disturbance of digestion.
Though the men seemed to be in good condition, this derangement of
the heart's action was very chronic, and the heart itself became in time
hypertrophied. In addition to the palpitation, an almost constant
symptom was the sharp paroxysmal pain at the heart ; there was in-
creased frequency of the pulse, much affected by position, &c., a hard
and jerky pulse, disturbance of the nervous and digestive functions.
Both sounds of the heart were equal and short, sharp and metallic, but
generally unaccompanied by a murmur ; when the latter was present it
was usually systolic. The causes of the affection are analysed, the
writer enumerates certain preceding conditions of ill health, such as
malarial fevers, diarrhoea, hard field service, long marches. The pre-
disposing causes may be misuse of tobacco and spirits, venereal excesses,
syphilis, exposure to sun, &c. Da Costa looks upon the affection as
the result of a disordered innervation on a heart rendered irritable by
CAEDIAC NEUROSIS — MALFORMATION^ ETC. 14t
over-action and excitement. As regards treatment, rest is the first
requisite; digitalis, aconite, veratrum viride, gelsemium, belladonna, are
all used with success, the latter especially in irregular action of the
heart. Generally the course of treatment requires a long time.
Mazza ("Del Cardiopalmo Nervoso e del suo piii congruo tratta-
mento," 'Ann. Univ. di Med.,' ccxv, 3) writes on nervous palpitation.
He describes it as preceded by various nervous disorders — hemicrania,
singing in the ears, and such like. Its chief symptom is the altered
action of the heart. The access of palpitation is accompanied by
pulsation in the carotid, swelling of the jugulars, &c. The length of
the paroxysm varies greatly, sometimes extending over several days,
generally occurring in the night, The differential diagnosis is based on
the absence of any signs of organic disease in the heart and large
vessels, the simultaneous presence of other symptoms of nervine dis-
turbance, and the alternation of normal action of the heart with palpi-
tation. The cause is to be found in anything that produces abnormal
irritation of the organ ; the misuse of stimulants ; cachectic diseases,
especially those of the uterus, &c. The prognosis is more or less
favourable. The treatment is mainly hygienic and dietetic. The writer
prefers the sulphate or citrate of quinine in combination with carbonate
of iron and bismuth.
G-reen ('Brit. Med. Journ.,' 1871, ii, 613) records a case of disturbed
cardiac innervation in a man, set. 47.
Congenital Malformation of fhe Keart, Sfc.
Hertel ('Berl. Klin. Woch.,' 1871, 337) publishes a case, occurring
in Traube's clinique, of congenital stenosis of the aorta, complicated
with aortic insufficiency, and adds some remarks by the latter on
sclerosis of the aorta. The patient was a man, set. 38, and the post-
mortem examination gave the following results : — enormous enlargement
of both sides of the heart ; the valves, with the exception of the aortic,
I healthy. The latter were insufficient, two of them adherent, thickened
on their free edge ; the ascending aorta was dilated, but its walls were
' not thickened ; the arch was of normal dimensions'. At the point of
.entrance of the ductus Botalli, there was complete stricture of the
i aorta, with very great thickening and calcification of the walls,
; and an opening which admitted only a very fine probe. Above and
1 below this narrowed portion there was well-marked sclerosis, especially
i at the points where the large vessels were given off. The corresponding
I collateral arteries (thoracic, mammary, epigastric, &c.) were enormously
dilated ; the thoracic aorta was about its normal size, the abdominal
narrow in proportion. Traube offers a new theory as to the origin of
arterial sclerosis ; he thinks it is not to be referred, as most writers do
refer it, to endarteritis, but to a slow movement of the blood stream.
He illustrates his theory from the condition of the pulmonary vessels,
in which sclerosis occurs only when there is great obstruction to the
passage of the blood from them ; and from the cases of drinkers, in
whom the increased tension of the aortic system is due to the con-
14^ ilEPORt ON PRACTICAL MEDlClNl!.
traction of the smaller arteries. He sketches the role which the whit'
blood corpuscles play in this retarded blood movement, and supports hi
theory by quoting Eanvier and Cornil (* Arch, de Physiol.,' 1868, t. i)
according to whom the white blood corpuscles are found withii
the protrusions as well as on the free surface of the internal coat, ii
endarteritis.
Kelly (' Path. Soc. Trans.,' xxii, 93) records the case of a child
fet. three months, which had been cyanotic from birth. A loud systolii
bruit could be heard all over the thorax, but most distinctly at t;
apex. The child generally had a convulsive attack every morning. A
the autopsy the aorta was found arising from the right ventricle, an'
the pulmonary artery from the left. The right ventricle was hyper
trophied, the ductus arteriosus closed, the foramen ovale open. The
valves of the heart were healthy, the bronchial and coronary arteries
given off normally.
Pye Smith (ib., xxiii, 80) gives a case somewhat similar. The patient
was a male child, 14 weeks old when it died, in whom there had beei:
persistent cyanosis since birth. The heart was large for the age.
Externally it scarcely appeared ill-formed, the apex being formed by
the left ventricle. The right ventricle was hypertrophied, and half at
thick again as the left. The septum was perfect. Arising from a shoi :
conus venosus on the right side was the aorta, with three perfect sen
lunar valves, and two coronary branches ; it next gave off an innominate ,
carotid, and subclavian branch, shewed an open ductus arteriosus at
the usual point, and then turned down to the left side of the chest.
The orifice and the whole of the aorta were small, but nowhere con-
stricted. The pulmonary artery arose from the left ventricle, with
valves larger than those of the aorta; it was enormously dilated, as was
also the right auricle, which was hypertrophied as well. There was a
cribriform opening in the foramen ovale. The writer makes some
valuable remarks on the origin of this not very rare abnormality.
Dyce Brown ('Lancet,' 1871, i, 677) relates a case of stenosis of the
pulmonary artery, followed by tubercular phthisis, occurring in a
female, £et. 25. Both her parents had died of phthisis. From the age
of two years it had been noticed that she was cyanotic. About the
age of 23, she began to have a cough, and died at last of profuse
haemoptysis. There was a very loud systolic bruit during life. The
autopsy showed slight enlargement of the heart, hypertrophy of the
right ventricle, atrophy of the left ; slight thickening of mitral and
tricuspid valves ; closed foramen ovale ; stenosis of the right conus
arteriosus, with a hard and distinctly cretified rim all round. The
pulmonary valves were normal. About half an inch from this contracted
orifice, to its right, was a triangular opening in the septum ven-
triculorum. Both lungs contained miliary tubercles and cavities. He
refers to Lebert's remarks on stenosis of the pulmonary artery (see
*Med. Times and Grazette,' 1870, Jan. i.).
Peacock, " Cases of Malformation of the Heart"— (i) entire obliteration or atresia of
the orifice and trunk of the pulmonary artery; cyanosis; death from cancrum oris
(boy, at. 2i) ; (2) great contraction, or stenosis, of the pulmonary artery ; defect in
the septum of the ventricles and aorta, arising equally from the two cavities ; no
MALFORMATION OP HEAUT — ANEURISM. 145
ductus arteriosus, but that vessel replaced by two small branches connected with the
aorta; cyanosis (boy, set. 17, with plate), 'Trans. Path. Soc.,' xxii, 85. Kelly, 'Mal-
formed Heart, defective Septum Ventriculorum " (girl, gst. 6), ib., 95, King, "Mal-
formation of the Heart associated with Caries of the Right Mastoid Bone, and
Abscess in the Right Cerebral Hemisphere " (boy, set. 4, open septum, stenosis of
aorta, dilatation of pulmonary artery, no ductus arteriosus), ib., xxiii, 83. Smart,
"Stenosis of the Pulmonary Artery from Endocarditis in Fatal Stage, increased by
Endocarditis after Puberty, death by Phthisis" (boy, set. 18, incomplete septum),
'Lancet,' 187 1, ii, 288. Broadbent, "A Study of a Case of Heart Disease, probably
Malformation" (woman, set. 31), ib., 1872, ii, 850. Jullien, "Maladie Bleue,' ' Lyon
Med.,' viii, 391. Sutherland, " Case of Morbus Caeruleus" (girl, set. 13), ' Med. Times
and Gaz.,' 1871, ii, 526. Mackey, "Cyanosis, Murmur with the First Sound of the
Heart, Patent Foramen Ovale " (female child, set. 5 months), 'Brit. Med. Jouru./ 187 1,
ii. 666.
Aneurism, Sfo.
Balfour (' Edin. Journ.,' xvi, 704) records four cases in illustration of
some diiScultiea in the diagnosis of aneurism close to the heart. In all
the cases a pulsating tumour was present, with a systolic or double
murmur at the base of the heart ; but on post-mortem examination no
aneurism was found, and only some slight valvular mischief in some
cases, in others retraction of the lungs. He calls attention to the
importance of these cases in relation to the diagnosis of aneurism in
this situation, especially to the points in which they differed from
aneurism, viz. : — (i) the entire absence of all the subsidiary phenomena
dependent upon pressure on the neighbouring organs ; and (2) the
fact of the isochronous pulsations being less forcible than those of the
heart.
(jT. Johnson records the case of a man, set. 2>3i i^i whom aneurism of
the aorta was diagnosed by the aid of the laryngoscope (' Brit. Med,
Journ.,' 1871, ii, 720). The diagnosis was borne out by the appear-
ances found post-mortem. At the back of the transverse aorta there
was a shallow pouch an inch and a half in diameter, communicating with
an aneurism about the size of a walnut, which pressed backwards on the
trachea just above its bifurcation, and nearly filling its canal ; the
cartilages were eroded. The posterior wall of the aneurism was mainly-
composed of mucous membrane, in which was an ulcerated openmg
a quarter of an inch in diameter, and plugged only by a clot of fibrine.
The symptoms during life were dyspnoea, dysphagia, and tracheal
stridor ; the latter was heard also over the upper dorsal spinous pro-
cesses, when the voice had a loud bronchophonic character.
Crisp (' Path. Soc. Trans.,' xxii, 106) records a rare case of aneurism
of the right coronary artery in a man, set. 6^,. He had been formerly a
great drinker ; twenty years before his death he had fallen into the
Thames, and was with difficulty resuscitated. Since then he had had
palpitation of the heart. In December, 1870, he had hsemorrhage
from the stomach; three months later he died suddenly. At the
autopsy the pericardium was found distended with blood, which came
from a small orifice opening into an aneurism on the commencement of
the first branch of the right coronary artery. It was the size of a small
walnut, and passed back between the root of the aorta and the
auricular appendix ; its walls were very thin. The coronary arteries
150 REPORT ON PRA.CTICAL MEDICINE.
were atberomatous. The writer gives a table of 12 cases in which this
description of aneurism was found ; its most frequent termination is by
rupture into the pericardium.
Earth (' Arch. d. Heilk.,' xii, 253) gives a case of dissecting aneurism
in a man, ^t. 57. After a motion of his bowels he was suddenly seized
with paralysis and loss of sensation in the right leg, accompanied by
severe pain in the chest. During the succeediug days the pains
appeared in the right leg, and also in the left. The right leg was cold.
Four days after another motion, death occurred somewhat suddenly.
The autopsy showed about three pints of blood in the left pleura, into
which projeeted a large tumour, the size of a child's head. The left
ventricle was hypertrophied, but there was nothing else abnormal
about the heart. The sheath of the aorta and pulmonary artery within
the pericardium were infiltrated with blood. The commencement of the
aorta was atheromatous. In the lower and middle part of the arch was
a rent through the internal and muscular coats, about 4 cm. broad.
Close by and for 10 cm. along the thoracic aorta, the sheath and mus-
cular coats were hollowed out by a large effusion of blood. The latter
communicated through a rent in the sheath in the highest part of the
arch with a collection of coagulated blood under tbe pleura, bulging
into the left pleural sac, and slightly into the posterior mediastinum.
The writer explains the pain in the right leg by supposing that the dis-
sected portion of the aortic wall was pressed against the opposite wall,
somewhat in the fashion of an alternating valve, and so temporarily hin-
dered the outflow of blood to the body.
Other papers on aneurism and disease of the aorta are :
Tirifaliy, "Anevrysme de la Crosse de I'Aorta,*' 'Presse Med. Beige,* 187 1, 109,
Vallin, " Observation d' Anevrysme de I'Aorta, ouvert dans la bronclie gauche,"
'Rec. de Mem. de Med. milit./ xxvii, 310. Ducbamp, "Anevrysme de I'Aorta,"
' Lyon Med.,' viii, 326. Heath, " Saccuhited Aneurism of the Arch of the Aorta
simulating Aneurism of the Innominate Artery," 'Path. Soc. Trans.,' xxii, 95.
Croft, "Aneurism of the Thoracic Aorta; cured Popliteal Aneurism," ib., 100.
Williams, " Aneurism of the Arch of the Aorta bursting into the (Esophagus," ib.,
102. Morris, 'Aneurism of Abdominal Aorta which had burst behind the perito-
neum, and subsequently into the peritoneal cavity," ib., 104. Whipham, "Dissecting
Aneurism of the first portion of the Arch of the Aorta," ib., 1 13. Ilawkes, "Rupture
of Aorta; Tumour of Brain," ib., 115. Baumler, " Case of Aneurysm of the In-
nominate Artery, pressing on the right Pneumogastric and Recurrent Nerves," ib.,
xxiii, 66. King, " Aneurysm of the Aorta associated with Fracture of the first Rib,
and Embolism of left middle Cerebral Artery," ib., 70. Ledliard, *' Case of sudilen
death from an Aneurism of the Arch bursting into the Pericardium." * Edin. Journ.,'
xvii, 418. Chartres, " Case of Aneurism of the Thoracic Aorta ; death from Rupture
of the Sac " (in soldier with history of syphilis), * Dublin Journ.,' lii, 36. Foot,
" Case of Aneurism of the Abdominal Aorta in a Female," ib., li, 85. Russell, " Very
large Intrathoracic false Aneurism closing the Superior Vena Cava by adhesion, and
giving rise to a compensating Venous Anastomosis in the wall of the Chest and
Abdomen," ' Med. Times and Gaz..' 187 1, ii, 130. Moxon, "Sudden death from Sub-
acute Inflammation of the Aorta," ib., 182. Bradbury, " Case of Aneurism of tbe
Aorta; adhesions of the Heart and Pericardium ; temporary improvement under the
use of Iodide of Potassium " (man, set. 58, death, autopsy), * Brit. Med. Journ.,' 1S71,
i, 223. Stokes, " Case of Aneurism of the Aorta simulating perinanent patency of
the Aortic valves;" with autopsy (man, set. 31), ib., 224. Neal,*" True and False
Aneurism of the Abdominal Aorta ; rupture of the false aneurism and effusion into
the subperitoneal space; death on the twelfth day" (man, rot. 36, autopsy), ib., 417.
ANEURISM — AFFECTIONS OF THE MOUTH, ETC. 151
Woodman, "Aneurism of the Abdominal Aorta presenting unusual Features (soldier,
ait. 52, gangrene of right leg two years before), ib., ii, 380. Egan, "Aortic
Aneurism," ib., 1872, i, too. Browning, "Kupture of Aorta within the Pericardium'*
(man, set. 34), ib., 661. Lincoln, "A case of Aneurism of the Arch of the Aorta
treated by Electrolysis," 'New York Med. Rec.,' vi, 127. Moxon and Durham, " On
a case of Abdominal Aneurism cured by Compression of the Aorta" (man, set. 27),
'Med.-Chir. Trans.,' Iv, 213. Bryant, "A case of Abdominal Aneurism treated by
Distal Pressure" (man, set. 30), ib., 225. Habershon, "On some Obscure Forms of
Abdominal Disease, i. Aneurism of the Abdominal Aorta simulating spinal disease.
2. Aneurism of the Aorta both in Chest and Abdomen ; rupture ; symptoms resem-
bling those of renal calculus. 3. Aneui'ism of the Abdominal Aorta at the Coeliac
Axis ; gastric symptoms ; pain in the testicle ; rupture behind the peritoneum,"
'Guy's Hosp. Reports,' xvi, 389. Domville "Case of Aortic Aneurism" (man, set.
40), 'Lancet,' 1871, ii, 287. Sparks, " Intrapericardial Rupture of the Aorta in a
Boy of 16," ib., 13. Schrotter, "Case of probable partial Obliteration of Aorta"
(man, set. 28, still alive), ib., ib. Waters, " Clinical Lecture on Thoracic Aneurism"
(three cases, and another already published), ib., 1872, i, 247.
E. Diseases of the Oegans of Digestion.
Affections of the Mouth, 'Pliarynx, and Salivary Glands.
Isambert (' Gaz. Hebd.,' 1871, 757) gives a sketch of scrofulous
(pliaryngo-scrofulous) angina. It is, according to him, characterised
by a slight degree of ulceration, or only erosion, of the follicles situated
especially at the back of the pharynx ; syphilitic ulcerations, on the
contrary, commence on the velum, pillars and epiglottis before attack-
ing the posterior wall of the pharynx. The scrofulous ulceration may,
however, spread to these parts, and to the orifice of the Eustachian
tube and the arytenoid cartilages. They are indolent and unaccom-
panied by any swelling of the cervical glands. They are yellow, rough,
and covered with muco-purulent matter. In the worst cases the
whole mucous surface is obscured by a greyish deposit, the breath is
foetid, and yellow pointed pustules like small boils are visible. It is not
always easy to distinguish the scrofulous and syphilitic lesions of the
pharynx, though the diagnosis is generally easy in extreme cases ; but
the treatment which cures those due to the syphilitic poison only aggra-
vates the scrofulous ulcers, which are healed by tonic and anti-scrofulous
remedies. Adhesions of the velum may follow their cicatrisation,
and must be remedied by surgical means ; the deafness which often
succeeds, and is due to obliteration of the Eustachian tube cannot
apparently be cured. He recommends iodide of iron, general tonics,
cod-liver oil, and local applications of tincture of iodine, either alone or
with opium ; sethereal tincture of iodoform; solutions of chloride of zinc,
or concentrated chromic acid; inhalations of a powder composed of
iodoform and lycopodium ; and in cases in which the ulceration is
accompanied with haemorrhage, the local use of perchloride of iron. In
the discussion which followed the reading of this paper in the Societe
Medicale des Hopitaux, Labbe strongly opposed the term " scrofulous''
as applied to the affection, on the ground that scrofula is not a disease,
but a diathesis.
Lubanski (' Lyon Med.,' viii, 426) writes upon " Ulcerative angina,"
which complicates ulcerative stomatitis in soldiers, and is more pro-
152 EEPORT ON PEACTICAL MEDICINE.
perly called " pseudo-membranous stomatitis." He had occasion to
observe the affection as it occurred in an epidemic of " ulcerative
stomatitis" in a portion of the garrison at Lyon during the late war.
Of twenty cases five presented well-marked ulcerative angina, in two of
which the stomatitis was absent. The patients' condition was generally
good, but they complained of pain in swallowing ; examination of the
throat showed one or two more or less extensive yellowish patches on
the pillars of the fauces and the tonsils. He lays great stress upon
their yellow colour ; they were seldom grey or blackish like the deposit
in diphtheria. The underlying ulcerations were only slight, not sur-
rounded by any swelling or induration of the mucous membrane, and
with no tendency to spread. The affection never extended beyond the
isthmus of the fauces ; generally it was unilateral. The pain was only
slight. The submaxillary glands generally took no part in the dis-
turbance, though sometimes they were only slightly swollen. The
breath was always foetid. The patients continued their occupations
throughout the affection ; there was no pyrexia ; in one case only were
there slight febrile symptoms at the commencement. The length of
the angina depended on the treatment ; generally all symptoms disap-
peared at the end of a fortnight. Change of air and diet, gargles, and
the application of nitrate of silver, were the means employed.
Crisp, " Cancer of the Tongue and Simple Stricture of the (Esophagus " (female,
fflt. 64), * Path. Sec. Trans.,' xxii, 128. Bristowe, " Cancer including Pharynx, Larynx,
neighbouring Lymphatic Glands and Lungs" (woman, ajt. 48), ib., 132. Bradley,
"Adhesion of the Velum Pendulum Palati to the Posterior Wall of the Pharynx;
loss of the epiglottis, syphilis," ib., xxiii, 10 1. Thorowgood, "Salivary Calculus
removed from the Orifice of the Parotid Duct," ib., 103. Arnott, " Macro-glossia or
Congenital Enlargement of the Tongue," ib. 109. Fairlie Clarke, " Hypertrophy
of the Tongue," ib., iii. Id., " On a Case of Unilateral Atrophy of the Tongue,"
' Med.-Chir. Trans.,' Iv, 91. Stroppa, "Faringite ed esofagite flemmonose con sup-
purazione delle tonsille ed edema acuto della glottide " (the last the cause of death,
man, set. 47), * Gaz. Med. Lomb.,' J871, 277. Decaisne, " Paralysie du voile du palais,
application de sangues, guerison" (woman, aet. 98, with simple angina), *Gaz. des
Hop.,' 1871, 278. Heidenhain, " Ueber die Wirkung einiger Gifte auf die Nerven
der Glandula Submaxillnris," 'Pfluger's Arch.,' v, 40. Handfield Jones, '• Treatment
of Acute Tonsillitis with Belladonna," * Lancet,' 1871, i, 12. Id., "Case of Pseudo-
tonsillitis," ib., 504. Laseque, " Stomatite erythemateuse," 'Gaz. des Hop.,' 1872,
81. Packard, "Report of a Case of Tonsillitis associated with Parotitis; Laryngo-
Tracheotomy, death" (boy, s&t. 4I years), 'Amer. Jouni. Med. Sci.,' Ixiii, 404.
Priestley, " On Cancrum Oris," 'Brit. Med. Journ.,* ii, 577. Dujardin-Beaumetz,
"Des Troubles de la Secretion Salivaire," *Gaz. des Hop.,* 1872, 211.
Affections of the CEsopTiagus.
Porro ('Annal. Univ. di Med.,' ccxvii. 421) records a case, with
plates, of congenital atresia of the CDSophagus, the lower part of which
communicated with the trachea. A newborn female child, after
beginning eagerly to suck, was suddenly seized with cough, choking,
and regurgitation of the milk. The introduction of a sound proved
the condition of the tube. The child lived two days. The upper
portion of the oesophagus was found to terminate in a blind end 2}^ cm.
below the glottis : from the blind end a bundle of muscular fibres was
AFFECTIONS OF THE (ESOPHAGUS, ETC. 153
continued along the posterior wall of the trachea to the bifurcation :
here there was an opening between the lower portion of the oesophagus
and the trachea. Some traces of milk were in the stomach, which
must have found their way thither through the trachea and the open-
ing. There was but slight expansion of the right lung.
Fagge, "A Case of Simple Stenosis of the (Esophagus followed by Epitlielioma '*
(male, set. 84, oesophagus in upper part rather less than an inch in diameter, dilated
to li inch at a point 4I inches from cardia, thence gradually narrowed till it admitted
only an ordinary lead pencil, epithelioma of dilated portion), ' Guy's Hosp. Rep.,'
xvii, 413. Clapton, " Cases of Stricture of the J^sophagus" (two, one autopsy, both
males, set. 51 and 55), 'St. Thomas's Hosp, Rep.,' ii, 177, and see Bristowe's report
of the first case, 'Trans. Path. Soc.,' xxii, 134. Demarquay, " Retrecissement de
I'cesophage' (in a boy set. 15, who had drank a glass of potash-solution; the catheter
by wliich he was fed seems to have passed through the softened oesophagus, a com-
munication being found post-mortem between the latter and a large empyema), ' Gaz.
des H6p.,' 1872, 36. Greenhow, " Cancer of the (Esophagus, with a Fistulous Opening
into the Trachea" (man, set. 59, epithelioma), 'Path. Soc. Trans.,' xxii, 129. Thorow-
good, " Cancerous Stricture of the (Esophagus " (man, ast. 64, epithelioma), ib.,
xxiii, 115. West, "On Syphilitic Constriction of the (Esophagus and Pharynx,"
'Lancet,' 1872, ii, 291. Lowe, "On Gastrotom}^" with case (of a woman, set. 51, in
whom the autopsy showed schirrhus of the oesophagus), ib., 1871, ii, 121.
Affections of the Stomach.
Flint ('New York Med.Eec.,' vi, 40) publishes a paper on the patholo-
gical relations of the gastric and intestinal tubules, based mainly on the
researches of Handfield Jones, "Wilson Fox and Fenwick.
Hilgendorf and Paulicki ('Virch. Arch.' lii. 153) found extensive
ulceration of the mucous membrane of the stomach, with purulent
embolic deposits in the liver, in an ape (' Cebua Apella ?'). The
animal had had diarrhoea for some time.
Ward ('Brit. Med. Journ.' 1872. i. i8j) records the occurrence of
medullary sarcoma of the stomach in a man, aged 53. He had no
actual pain, but a little uneasiness after taking food, and vomited at
intervals a small quantity of dark foetid, not foecal, fluid. There was
no pain anywhere on pressure, nor was any tumour perceptible. A
large fungated growth was found in the interior and posterior wall,
occupying part of the lesser curve of the stomach, as well as the
pyloric half. The pyloric orifice and greater curve were free, so that
food could readily pass. The cardiac section of the stomach was not
dilated, and its walls were not perceptibly thickened. Microscopic
examinations of the growth showed small round nucleated and granular
cells imbedded in connective tissue.
Affleck (' Edin. Journ.' xvii, 1104) gives two cases of dilatation of
the stomach, in which the method of Kussmaul (see last Eeport, p.
168) was employed. In both cases there was evidence of stricture of
the pylorus. Both patients were men, aged 0,6 and 42. The second case
was less promising than the first, in that the disease had existed longer,
the dilatation of the stomach was greater, and there was (doubtful ?)
evidence of ulceration. Both cases, however, obtained great relief from
the use of the stomach-pump. The author attaches great importance to
the restoration of the urine to its normal quantity and character, aa
154 REPORT ON PRACTICAL MEDICINE.
indicating that tlie mucous membrane of the stomach is in a healthier
condition. In these cases (ib. xviii. 378) the stomach was emptied
between breakfast and dinner, at first once a day, then after the lapsf
of two or three days, and at last dispensed with altogether.
Schliep ('Lancet,' 1872, ii, 851) communicated a paper on the same
subject to the Clinical Society. The results of the application of the
stomach pump had been eminently satisfactory, and appeared in
general in the following order : — Vomiting ceased, the pains disappeared,
the appetite and action of the bowels soon became better, the general
health was improved, and the patient's weight was increased. He had
tried soda, creasote, bromic acid, and permanganate of potash for wash-
ing out the stomach with good effect. The patients soon became
accustomed to the tube, and there was but little fear of sucking some
mucous membrane into its opening. This had occurred only once in
about six hundred applications of the pump by the writer, and was
followed by no bad consequences.
Crisp showed to the Pathological Society ('Trans.,' xxiii, 137) a
dilated stomach from a woman aged 60, who had suffered for some
years from indigestion, flatulence, acidity and pyrosis. Her skin was
of a yellowish, coppery tint. She had also commencing cirrhosis of the
liver.
Habershon {' Gruy's Hosp. Eep.,' xvi, 399) records the three following
cases : — The first was that of a woman, set. 47, who had had pain and
vomiting after food for a year, and had become gradually weaker. Her
feet and ankles swelled, and soon after her abdomen became enlarged.
On admission, there was anasarca of the whole of the lower extremi-
ties, oedema of the abdominal walls, and ascites. The heart sounds
were very feeble ; the urine free from albumen. About a month later
she was seized with violent pain in the epigastrium, soon became col-
lapsed, and died. At the autopsy the abdomen was greatly distended,
and contained a considerable quantity of fluid, of a milky appearance,
in the peritoneum. The stomach also was greatly distended with dark-
coloured fluid, consisting of semi-digested food and blood. The pylorus
was very much thickened ; the submucous cellular tissue was an inch
in thickness, white, fleshy, and oedematous, without cancerous juice,
the thickening becoming gradually less, but reaching nearly five inches
from the pylorus. The muscular coat was very much hypertrophied,
a quarter of an inch in thickness at the pylorus. There was slight
ulceration at one point as large as a threepenny-piece. The microscope
showed that " the greater part of the white tough substance was com-
posed of organised fibrous tissue, but in parts the substance was a more
delicate tissue, with numerous small, spindle-shaped cells, with very
long tails blending in the intercellular fibroid or fibrillated texture."
The mucous membrane itself was not affected. The other organs, ex-
cepting the heart, which was small and atrophied, were normal. The
case is considered to be one of sarcomatous disease of the pylorus. In
the second case, a man, set. 45, in whom there had been scarcely any
vomiting, a large cancerous ulcer existed in the stomach ; it reached
the pylorus, but the ulceration had removed the obstruction. The
growth and ulceration extended for three inches at least into the
AFFECTIONS OF THE STOMACH. 16S
stomach, and occupied both the anterior and posterior aspect. There
I were no nodules in the liver itself, but some enlarged glands had ex-
: erted pressure upon the bile-ducts, and had caused the jaundice noticed
during life. In the third case, a man, set. 44, there was the most ex-
tensive ulceration of the stomach, by which the pyloric valve was
destroyed. For some weeks before death the vomiting, which had
existed at first, ceased almost altogether.
Mayer ('Deut. Arch.,' ix, 10^) gives a case in which softening of the
stomach occurred during life. The patient was a man, sdt. 37, who had
been at a former period under treatment for stricture of the cardia.
j He was suddenly seized with symptoms of perforation after having
taken a large quantity of new beer in a state of fermentation, and black
I bread. A few hours after the symptoms first set in, the liver dulness
had disappeared, and in six hours and a half the patient was dead. The
post-mortem examination showed a rent, 9 centimetres long, in the
fundus of the stomach, with extensive brown softening, the cavity of
the peritoneum distended with gas, and the contents of the stomach ;
the latter covered the coils of intestine in more or less thick layers.
Mayer agrees with Hoff"mann as to the pathological process which takes
place, and which the latter writer believes to consist in hsemorrhagic
infiltration of the walls of the stomach, and their solution from the
eff'ect of the acid contents of the organ.
Moxon, " Case of Gout in the Stomach (?) and Phlegmonous Colitis " (man, set. 39,
albuminuria, diarrhoea, contracted kidneys, gouty deposit in joints), * Trans. Path. Soc.,*
xxii, 139. Skoda, "Ueber das perforirende Magengeschwur. Klinischer Vortrag,"
• Wieu. Med. Zeitung,' 187 1, 97. Heubner, "Ueber einen seltenen Fall von indirecter
Magenlungenfistel, in Folge eines Perforirenden Magengeschwiirs " (woman, a3t. 27,
autopsy, with engraving), 'Arch. d. Heilk.,* xii, 193. Janeway, " The Cause of Per-
forating Ulcer of the Stomach " (woman, set. 34, large old ulcer, with perforation,
and hffimorrhagic infiltrations in its neighbourhood, embolism of gastro-epiploic
artery), 'New York Med. Rec.,' vi, 427. Crisp, "Fatal Hjeraorrhage from simple
Ulcer of the Stomach" (woman, set. 62), 'Path. Soc. Trans.,' xxii, 141. Ross, "A
Case of Perforating Ulcer of the Stomach, Recovery," 'Lancet,* 1871, i, 81. Tinley,
" Case of Peforating Ulcer of the Stomach, Recovery," ib., 503. Farrar, " Case of
Ulcer of the Stomach" (?!), ib., ii, 574. Wiltshire, "Ulcer of the Stomach, Rup-
ture of the Heart" (see under latter), ib., 1872, i, 290. Heslop, "Ulcer of the
Stomach" (woman, set. 36, autopsy), 'Brit. Med. Journ.,* 1872, i, 223. Stewart,
" Case of Ha^matemesis Treated by the Hypodermic Injection of Ergotine," * Edin.
Journ.,' xvii, 511. Johnson, "Cancer of the Stomach" (woman, aet. 52), 'Brit.
Med. Journ.,' 1871, ii, 527. Bristowe, "Cancer of Stomach, Liver, Lungs, Lym-
phatics of the Thorax, with involvment of Left Recurrent Laryngeal, and Paralysis
of the Left Side of the Larynx" (man, aet. 49), 'Path. Soc. Trans.,' xxii, 137.
Wilson, " Cancer of Stomach, with Cheesy Deposits in Lungs of later Formation "
(female, a)t. 46), ' Amer. Journ. Med. Sci.,Mxi, 425. Ziemssen, "Zur Technik der
Localbehandlung des Magens, zugleich eine Mahnung zur Vorsicht bei der Anwen-
dung der Magenpumpe," ' Deut. Arch.,' x, 65. Gee, "Thrombosis of Varicose Veins
of Stomach " (man, set. 63), * St. Barth. Hosp. Rep.,' vii, 148.
Affections of the Intestines.
Under the term "membranous enteritis," Da Costa ('Amer. Journ.
Med. Sci.,' Ixii, 321) describes the affection of the intestines " in which
membranes or skins are voided." He thinks it is the discharge of the
inner coat of the bowel spoken of by Paulus Egineta ; one of the in-
156 REPORT ON PRACTICAL MEDICINE.
farctus of Kaempf ; the diarrhoea tubularis, pellicular enteritis, pseudo-
membranous enteritis of later writers. The disease is characterised by
attacks of abdominal pain, followed by the discharge of moulds or long
tubes. There may be but one attack ; more generally the paroxysm is
followed by others at varying intervals. The shortest time for an
attack to last is, according to his experience, a week. The discharge is
preceded by distension, sense of burning, colicky pains, and, at times,
a sluggish state of the bowels, and succeeded by a condition of com-
parative health. Palpitation of the abdominal aorta is common ; be-
tween the attacks the bowels are irregular, the patient suffers from
disturbance of his general health and nervous system, and irritable
bladder, with discharge of large quantities of mucus. He gives the
notes of seven cases. The membranous discharge may come away with
every movement of the bowels, almost continuously for months, perhaps
years. The microscopic examination of the tubes passed shows a
transparent, amorphous, basement-substance, here and there indistinctly
fibrillated, and having imbedded in it granules, free nuclei, and small,
shrivelled, irregular, and rather granular cells. There are not many
well-marked epithelial cells, nor white or elastic fibrous tissue cells.
The chemical reactions of the membranes do not throw much more light
upon them. He discusses the differential diagnosis of the affection,
looks upon the prognosis as unfavourable, and suggests rest in bed, ap-
plication of hot water to the abdomen, slight purgatives, and an easily
digested diet, as most suitable during the attack. The treatment in
protracted cases consists in a strict regime, the disuse of purgatives,
the steady use of iron, acids, bismuth, injection of nitrate of silver, and
the application of the continuous current.
Whitehead C" Mucous Disease," 'Brit. Med. Journ.,* 1871,1,143)
gives an historical account of the same affection. Out of 120 writers on
the disease, he cannot refer to any half dozen who have described it by
the same name. He considers himself justified in stating that the cha-
racteristic discharge from the bowel may be divided into three stages :
— (1) Masses of more or less inspissated mucus, having the appearance
of jelly. They are perfectly membranous, and contain only the
merest trace of albumen. (2) Tubular casts of the gut, which occur
as cylindrical sheaths, and also membranous shreds or flakes of
various forms, which can be shown to be nothing more than fragments
of the tubes in various stages of development. These contain an abun-
dance of albumen, but no fibrin. (3) Membranous shreds of lymph,
mixed with blood and pus. This form contains both albumen and fibrin
in abundance, the latter in a fibrillated form. Middle-aged persons,
children, and old people, may be held as liable to the disease in the order
in which they are enumerated. It occurs far more frequently in females
than in men. Constipation, and the retention of excreta within the
system, while it is a consequence, is also an exciting cause of the dis-
ease. It is generally observed in persons of a cold temperament and
relaxed habit of body, with feeble circulation, cold extremities, and a
peculiar whitish-yellow paleness of skin ; in those who are apathetic,
and wanting in decision and energy in their moral and intellectual cha-
racter, though at the same time they possess a highly excitable condi-
A5*PfiCTlONS OF THE INTESTINES. l5?
tion of the nervous centres. "Women who suffer during menstrual
periods, and those who are victims to membranous dysmenorrhoea, are
peculiarly prone to it. It is often met with in women who are either
childless, or have ceased early in their married life to bear children.
The most common existing cause of the malady is the irritation of the
intestinal canal, produced by crude and indigestible articles of diet.
The writer discusses at further length the symptoms and the treatment
of " raucous disease."
McSwiney (' Dub. Journ.,' li, 396) writes on diarrhoea, with green
stools, in infants. As to their nature and constitution he leaves them
still unexplained. He thinks there may be a "congenital functional
digestive weakness," by which a true gastro-intestinal catarrh would be
caused, followed by acid fermentation, and the action of the acids so
produced perhaps on the bili-verdin.
Eosse (' New York Med. Eec,,' vi, 332) has found the best results
from the treatment of cholera infantum with bromide of potassium.
The medicine was usually prepared by mixing from twenty to forty
grains of the bromide with two ounces of mucilage of acacia ; the dose
was from ten drops to a teaspoonful according to circumstances. Occa-
sionally a drachm of krameria was added to the mixture. The food
given was the expressed juice of fresh beef, seasoned with cayenne
pepper.
The ' Bulletin de I'Acad. de Med.' (xxxvi, J22), contains a discus-
sion on gastro-intestinal puncture in tympanites, opened by Bouley who
affirmed the harmlessness of the operation as practised by veterinary
surgeons on animals. Depaul, Piorry, Barth, and others, give their
experience of the operation as performed on the human subject, and
generally speak well of its results.
Beach (' New York Med. Journ.,' xiv, 397) records a case of fatal
peritonitis in a woman, set. 32. The autopsy showed general perito-
nitis, the appendix vermiformis was greenish-black, and contained a
hard ovoid mass made up of oat-hulks ; between the external surfaces of
the head of the ascending colon, the ileum and the appendix was an
abcess tying together these parts of the intestine.
Murchison (' Path. Soc. Trans.,' xxii, 146) gives a case of the same
kind in a girl, set. 18, in whose appendix vermiformis were found three
small concretions, the largest about the size of a pea. She died of acute
peritonitis due to ulceration and perforation of the appendix.
Fonssagrives, " De la Ponction dans la Pneumatose Gastro-intestinale et Perito-
neale," 'Lyon Med.,' viii, 155. Piorry, " Memoire relatif; soit aux Collections de
Gaz contenus dans les Cavites Abdominales ; Oazo-gastrasie, Oazo-enierasie, Oazo-
peritonasie {asie, abreviation d'ectasie), varietes de la Ttfmpanite des auteurs, soit a la
Ponction de ventre, pratiquee dans Tintention d'evacuer des Fluids Elastiques," * Bull,
de TAcad. de Med.,' xxvi, 943. Watben, " On Punctures of the Colon for the relief of
Tympanites," 'Brit. Med. Journ.,' 187 1, ii, 464. Braxton Hicks, "Abdominal Puncture
in Tympanites," ib., 526. Brown, on same, ib., ib. Saunders, " Puncture of the Intes-
tine for the relief of Tympanites," ib., 583 (and see Rooke and Wilks on the same
subject, ib., 584). Chauffard, "Ulcere simple du Duodenum; perforation; peritonite
generalisee; mort," * Gaz. des Hop.,' 1871,373. Barclay, "A Case of Perforating
Ulcer of the Duodenum " (man, at. 56), 'Lancet,' 1871, i, 377. Wadham, "A Case
of Perforating Ulcer of the Duodenum" (man, set, 51), ib., 230. Rogers, " Perforating
Ulcer of the Duodenum" (man, set. 56), ib., ii, 159. Tyson, "Ulcerative Disease of
J[58 EEPOUT ON PRACTICAL MEDICINE.
he Large Intestine" (man, a3t. 28), 'Amer. Journ. Med. Sci.,' Ixi, 154- .Weber.
"Abscess of the Appendix Vermiformis," 'New York Med. Journ. xiv, 142.
Chambers, "On Obscure Disease of the Caecum,'; 'Brit. Med. Journ., 187 1, 1, 7.
Elliott, "Obscure Disease of Caecum,'' ib., 35- Jackson, " Case of Perityphilitis
ib ii 6:5 Waldeyer, "Mycosis Intestinalis," 'Virch. Archiv,* hi, 541. Munch,
"Mycosis' Intestinalis und Milzbrand," « CentralbL,' 1871, 802 Weiser " Ueber die
Behandlunff des Durchfalls bei Sauglingen," ' Wien. Med. Woch., 187 1, ^o. 35-
"Diarrea nei Bambini," 'Med. Gaz. Lomb.,' 1872, 30. Gueneau de Mussy,
*'Lecons Chniques sur la Diarrhee Chronique," *Gaz. des Hop.,' 1872, 27. Simon,
"Diarrhee palustre; sulfate de quinine," 'Arch. Gen.,' xix, 108. Heslop, "Case of
Abdominal Intumescence, with Displacement of the Heart, from Fsecal Accumula-
tion" (girl, »t. 14), 'Lancet/ i87i,i, 647.
Intestinal Obstruction.
Kiittner (' Yirch. Arch.,' liii, 274) discusses tlie pathological processes
which a portion of invaginated intestine undergoes, before the intus-
suscepted part dies and separates, and before recovery is complete. He
gives three cases with autopsies, two in boys of 18, and one in a man
34 years old. In all the cases the first symptoms of obstruction were
succeeded by diarrhoea : and the post-mortem appearances in all three
showed that after inflammation and necrosis the intestine became again
permeable, but death occurred, as it frequently does, from perforation
of the intestinal walls and general peritonitis.
The following cases must speak for themselves ; they have been
arranged according to the classification given by Fagge (' (3-uy's Hosp.
Kep.,' xiv, 272 ; and see last 'Bienn. Kep.,' p. 172. — Rep).
1. Cases in which the gut is plugged by its contents :
Simon, " Histoire d'une Occlusion Intestinale complete par un Calcul Biliaire,
quelques remarques sur le Traitement de ce grave accident," • Bull. Gen. de Therap.,'
Ixxxi, 178. Meynott, "Impaction of a large Gallstone in the Ileum," 'Lancet,'
1872, i, 576. Clarke, "Large Biliary Concretion in the Ueum/' ' Med.-Chir-. Rev.,
Iv, 1. Prunac, "Occlusion Intestinale Produite par TAccumulation de Matiercs
Stercorales. Emploi dela glace intus et extra," 'Gaz. des Hop.,' 1871, 486. Black,
" Clinical Lecture on Obstinate Constipation and Obstruction of the Bowels," ' Brit.
Med. Journ.,' 1871, i, 83.
2. Intussusceptions or invaginations :
Greene, " Invagination of the Large Intestine " (child, ajt. 4^- months, autopsy),
* Brit. Med. Journ.,' 187 1 , ii, 279. Gray, " Report of a case of Intussusception " (child,
a3t. 5 years, autopsy), 'Lancet,' 1871, i, 338. Hunter, "Interesting ease of Intus-
susception" (child, set. 9 months), 'Lancet,* 1872, i, 349. Crisp, "Intussusception
in an Infant" (girl, a3t. 8 weeks, autopsy), 'Path. Soc. Trans.,' xxiii, 125. Durham,
" Intussusception of the Rectum, with Adenomatous Growth " (man, at. 44, colotoray,
death four days later, autopsy), ib., 116. Kjelberg and Blix, "Fall af tarminvagina-
tion hos et spadt barn " (female child, a3t. 1 1 months, invagination of upper part of
large intestine and portion of the small intestine in descending colon, and sigmoid
flexure), * Hygiea,' 187 1, 97. Moretti, " Invagimento intestinale, Nota ed osserva-
zione," ' Annal. Univ. di Med.,' ccxvi, 542. Herz, " Zwei Falle von Darminvagination
bei Kindern" (i, female, set. 6 months, intussusception of transverse and ascending
colon, csecum, and end of ileum, operation, death six hours afterwards; 2, female, a3t.
7 months, death), ' Oesterr. Jahrb. f. Paediat.,' 1872, i, i. Dubois, "Occlusion intes-
tinale, elimination d'une portion d'intestin grele longue de 40 centimetres." Guerison,
(boy, set. 15), "Bull, de I'Acad. de Med.,' xxxv, 849. Halleguen, "Guerison depuis
dix ans d'une invagination intestinale avec expulsion de 75 centimetres d'intestin
INTESTINAL OBSTRtJCTION. 16 ^
grele" (woman, set. 50), ib., 851. Rogers, "Intussusception" (boy, SDt. 7, recovery),
'New York Med. Kec.,' vi, J 15.
3 and 4. Strictures and contractions :
Thompson, " Congenital Narrowing of the Canal of the Rectum " (male, a3t. 46,
autopsy), 'Lancet,' 1871, ii, 635. Bristowe, " Complete Stricture of the Upper Part
of the Descending Colon caused by a growth of Colloid Cancer. Ulceration of the
Colon and Ileum, and Perforation of the latter," * Path. Soc. Trans.,' xxiii, 119.
5. Yolvuli :
Crisp, "Fatal Strangulation from the Twisting of a portion of the Colon" (male
set. 62, autopsy), ' Path. Soc. Trans.,' xxiii, 112. Bell and Croom, "A case of Obstruc-
tion of the Bowels, attended by Unusual Symptoms, with Remarks" (man, ajt. 50,
twist of intestine above colon, rupture of intestine, general peritonitis), * Edin. Journ.,'
xvii, 971. Panas, "Cas d'Occlusion Intestinale produite par le Reuversement d'une
Anse de I'lleon sur ellememe. JEtablissement d'un Anus Artificiel, Mort, Autopsie"
(male, set. 75), ' Gaz. des Hop.,' 1871, 359. Meade, " Case of Chronic Ileus " (woman,
set. 40), 'Brit. Med. Journ.,' 1871, ii, 261. Thompson, "Clinical Lecture on a Case
of Intestinal Obstruction" (woman, set. 51, omental), 'Med. Times and Gaz.,' 1871 ,
ii, 97. Handfield Jones gives the following cases: — Volvulus in man, set. 55, Twist-
ing of Mesentery in girl, set 10; ib., 1872, i, 3.
6. Strangulation :
Habershon, "Adhesion and Contraction of the Omentum, the cause of fixed
Abdominal Pain, afterwards of Colic and of Obstruction," ' Guy's Hosp. Rep.,' xvi,
i 415. Heiberg, "Ueber innere Incarcerationen," * Virch. Arch.,' liv, 30, Id., "Nach-
trag zu dem Aufsatz iiber innere Incarcerationen," ib., 282* Taylor, " Intestinal
Obstruction from a Knot on the lower part of the Ileum " (woman, set. 40 ; with
autopsy and drawing), 'Brit. Med. Journ.,' 1871, ii, 119. Salter, " Strangulation of
a Loop of Intestine by Fibrous Bands, Death " (man, set. 69, with autopsy), ' Lancet,'
187 1, i, 153. Gay, " Strangulation of Intestine by a Solitary Baud" (! no autopsy),
ib., 233. Southey, " On Two Cases of Persistent Omphalomesenteric Duct, leading
to Fatal Intestinal Obstruction" (boy, set. 16, girl, set. 13!), 'Med. Times and Gaz.,*
1872, i, 412. Handfield Jones, "Cancerous Stricture of Intestine" (woman, sot. 64),
ib., 64. Dubay, "Incarceratio Hernise Mesogastricae dextr. in Folge der abnormen
Bildung des Mesenteriums " (man, rot. 35), ' Virch. Arch.,' Ivi, 271.
Dysentery.
Bierbaum, "Dysenteria. Erlebnisse aus der Kinderpraxis," ' Deut. Klin.,' 1871, 29.
Valentiner, " Storungen der Hautcirculation und Hauternahrung in einem Falle von
Dysenteric," 'Berl. Klin. Woch.,' 1871, 9. Luton, "Note sur I'emploi de I'ergot de
seigle contrc la Dysenteric," 'Gaz. Hebd.,' viii, 610. Temoin, "Considerations
Generales sur le Traitement de la Dysenteric," 'Bull. Gen. de Therap.,' Ixxxi, 412.
Habershon, " Dysentery in China, Chronic Irritation of the Colon, deep-seated pain
behind the Spleen, Abscess, Effusion into the Chest, and Death " (man, set. 50), ' Guy's
Hosp. Rep.,' xvi, 422. Ward, "Notes on Fifteen Cases of Chronic Dysentery,"
•Lancet,' 1871, ii, 160. Murray, "Recent Specimens of Acute Dysentery from
Sedan," * Path. Soc. Trans.,' xxii, 142.
Affections of tlie Liver.
{a) Suppurative Hepatitis — Abscess.
Jameson ('Lancet,' 187 1, i, 569) tapped an abscess in the liver of a
Mahommedan, set. 40, at Hurdui, Oudh, and removed seventy-two
ounces of purulent fluid. Eour days later the patient died. The
autopsy showed that a single abscess occupied the whole substance of
the liver except a small portion of the posterior part of the right lobe*
160 llEI»dRT ON pkActical UEhictM.
Its cavity was found capable of contaiuing only eighteen ounces of
water, so rapidly had it contracted.
ChunderRoy (ib., lo) records a case in a Mahommedan, SBt. 30, in
whom the introduction of a canula was followed by an even stream of
dark venous blood ; the orifice of the canula, which was left in situ, was
plugged, but the patient died three days later of exhaustion. The post-
mortem examination revealed a large abscess occupying the right lobe
of the liver, which was transformed into a uniform cyst, bounded by a
wall of hepatic substance not thicker than half an inch. A few lines
of hepatic tissue intervened between the point of the canula and the
cavity of the abscess.
Black, "Abscess of the Liver, Operation, Recovery" (man, set. 31), ' Lancet,' 1872,
i, 647. Ward, " Supposed Hepatic Abcess discharging through the Lung " (man, at.
56), ib., 681. Moxon, "Abscess of the Liver," ib., ii, 778. Bennett, "Hepatic
Abscess," *Brit. Med. Journ.,' 1872, i, 625. Arnould, " Abces et infarctus duFoie et
de la rate," * Gaz. Med.,' 1872, 4. Gallard, "Lecons sur I'Hepatite et sur les Abces
du Foie," * Union Med.,' xii, 680.
(h) FarencTiymatous Hepatitis — Acute Atrophy.
Duckworth and Legg (* St. Earth. Hosp. Eep.,' vii, 208) give notes
of three cases of acute yellow atrophy of the liver. A girl, ajt. 10, had
been jaundiced for some days before admission, and after attacks of the
most furious delirium, and almost incessant vomiting, died eighteen days
later. The hepatic dulness was somewhat diminished. On opening the
abdominal cavity, numerous ecchymoses were seen studding the omentum
and colon. The liver was adherent by a few old adhesions to the
diaphragm ; it did not seem to be shrunken in size. The coecura and
colon were filled with scybalous masses of a pale clay-colour ; about an
inch below the pylorus there was a small ulcer about the size of a three-
penny piece covered by a coagulum of blood. The stomach contained
about four ounces of chocolate-like fluid. The bile-ducts contained a
few drops of a viscid greenish fluid. The liver was flaccid, and felt
doughy ; it was considerably mottled and presented islets of a bright
yellow colour, which were continued into the substance of the organ ;
the acini were quite distinct. The knife was rendered distinctly greasy.
In the left lobe there was a light yellow staining of the whole liver
substance, and no acini could be made out. Sections of the left lobe
showed under the microscope no trace of liver-cells, only an extremely
dark and granular appearance, with large and small globules of fat and
balls of pigment about the size of a granulation- corpuscle. In the
sections from the right lobe a few hepatic cells remained undissolved,
but in other respects their appearance was the same. The spleen was
soft, the kidneys somewhat degenerated. The other organs were
natural. In the other two cases occurring in men, aged 23 and 19,
no post-mortem examination could be made. The second of these two
was a brother of the girl first mentioned. A noteworthy point in con-
nection with other symptoms in the diagnosis of the disease would
seem to be the occurrence of severe hepatic pains associated with a
temperature either natural or even below the normal.
Chamberlain C New York Med. Kec./ vi, 265) gives a case of atrophy
I LIVER — ATROPHY — CIRRHOSIS. 161
i of the liver in a woman aged 22. The symptoms were icterus, black
, vomit, coma, suppression of urine ; death occurred after six days. The
liver weighed 2 lbs. 8 ounces.
' Porter (' Amer. Journ. Med. Sci.,' Ixi, 409) gives notes of a case of
the same kind in a merchant aged 23, with an account of the post-
mortem appearances found.
Clements (' Brit. Med. Journ.,' 1871, i, 367) records the following : —
A girl, aged 17, previously in good health, became jaundiced, and com-
plained of drowsiness. She then had persistent vomiting and became
. delirious, and died comatose. The autopsy showed all the organs healthy
. except the liver, which weighed only 13 ounces. Not a trace of hepatic
i cells could be found under the microscope.
I Goodridge (ib., 609) gives the case of a man, aged 20, in whom acute
! atrophy of the liver complicated early secondary syphilis. Here the
liver weighed only 301- ounces, and hardly a trace of hepatic cells could
' be found.
Murcbison, " Jaundice from Gall-stones, followed by Acute Atrophy of the Liver,
with Puriform Deposits " (man, £et. 66), ' Path. Soc. Trans.,' xxii, 159. Moxon, " Sub-
acute Red and Yellow Atrophy of the Liver" (woman, set. 34, with plate), ib., xxiii,
138. Wadham, *' Case of Yellow Atrophy of the Liver " (man, set. 28, autopsy),
I 'Lancet,' 1872, i, 288. Sieveking, "Acute Yellow Atrophy of the Liver, Death"
I (man, set. 24, autopsy), ib., ii, 224. Jones, "A Case presenting the Symptoms of
I Acute Yellow Atrophy of the Liver, Recovery " (woman, set. 26), 'Brit. Med. Journ.,'
i 1872, i, 468. Zenker, "Zur Pathologischen Anatomic der acuten gelben Leber-
! atrophic" (with plate), * Deut. Arch.,' x, 166. Steiner, "Ein Beitrag zur acuten
j Atrophic der Leber aus Fettdegeneration " (boy, set. 10), *Jahrb. f. Kinderheilk.,'
I iv, 428.
i
(c) Interstitial Hepatitis — OirrJiosis.
Olivier ("Memoire pour servir a I'histoire de la Cirrhose hyper-
trophique," ' Union Med.,' xii, 361) gives a case of cirrhosis of the liver
in a man, SDt. 22, a wine-seller. He had been a hard drinker since the
age of 13 ; at the age of 18 he noticed that his belly was swollen; he
had great digestive derangement, vomiting, epistaxis, and jaundice.
, His liver was enormously increased in size, extending to the umbilicus
and to the spleen, which was also enlarged. After death the liver was
found to weigh 2-850 grammes, and was markedly cirr hosed, the inter-
lobular tissue having undergone considerable hypertrophy. The spleen
: and kidneys were also increased in size. The writer discusses the ques-
; tion of cirrhosis, collecting several cases of the affection in which the
I liver was enlarged, from other authors. He concludes that hypertrophic
' cirrhosis is a definite affection, not the first stage of an incomplete
cirrhosis. It is more rare than the form in which the liver is atrophied.
Like it, it is characterised anatomically by chronic proliferation of the
■ cellular tissue and atrophy of the glandular substance from -com-
; pression ; but while in the atrophic form this proliferation ceases,
I in the hypertrophic form it is continuous, and to this incessant
growth the enlargement of the liver is due. In addition to the ordinary
symptoms of cirrhosis, the hypertrophic form presents an enlargement
of the organ, either general, or only partial. According to his
11
162 REPORT ON PRACTICAL MEDICINE.
observation it is accompanied by an early and profound change in
the blood, under the influence of which occur various haemorrhages,
and jaundice more frequently than in the ordinary form. Its only
cause is excessive alcoholic drink.
Cheadle ('Brit. Med. Journ.,' 187 1, ii, 545) gives a clinical lecture 01
a case of extreme cirrhosis of the liver in a boy set. 18. He had com-
plained five months before of debility and wasting, which gradually
increased. There was slight enlargement of the liver and spleen ; ascites ;
oedema of the legs ; wild delirium ; paralysis of the right with spas-
modic jerking of the left arm and leg, and death by coma. The cirrhosis
of the liver was most extreme, the spleen was enormously enlarged and*
hard, the kidneys were congested, and their capsules adherent. There
was an unusual quantity of dark pigment over the surface of the parietal
peritoneum about the pelvic region. The boy had been in the habit of
taking a considerable quantity of drink, especially gin, when at work.
There was complete absence of jaundice throughout. Nothing was
found in the brain to account for the cerebral symptoms.
Green also ('Trans. Path. Soc.,' xxiii, 133) records a case of in-
terstitial hepatitis and obstruction of the common bile-duct in a
boy, aged 10. Twelve days before death he vomited, became jaun-
diced, drowsy, and screamed at intervals ; his pupils were dilated. Ho
died comatose. The brain and thoracic organs were perfectly healthy.
The stomach and small intestines contained a very large quantity of
dark blood.
Moxon (ib., 153) describes a case in which suppuration took place in
syphilitic deposits in the liver of a man aged 29. One of these had
opened a large bile-duct, so that its substance was deeply stained with
bile-pigment. The liver was extensively diseased, having in its upper
and middle regions many masses which at first sight had the appearance
of sarcomatous tumours decaying in the centre. They were enclosed
in what appeared to be a fibrous cyst. From these soft masses there
were gummata in all gradations down to common depressed syphilitic
scars with caseous centres. The microscopic character of the soft
formations was not very definite — crowds of cells larger than pus-cells
in a granular filamentous matrix. One testis showed very cha-
racteristic gummatous syphylitic orchitis.
Rommelaere, " Cirrhose et Degeneresccnce amyloide du Foie " (woman, tct. 39,
enlarged liver ; lardaceous liver, spleen, and kidneys), * Presse Med. Beige,' 187 1, 133.
Eames, " Cirrhosis of the Liver" (drunkard, age not given), * Dubl. Journ.,' liii, 495.
Id., "Carnified Liver" (man, intemperate, age not given; liver, hard and dense,
weighed 45 ounces), ib., 496. Morgan, •* Syphilitic Deposit in the Liver, Ulceration
of the Larynx" (man, age not given, gummatous deposits in liver and glands), ib.,
231. Handfield Jones, "Case of Cirrhosis of the Liver, Haemorrhage and Ascites,
Paracentesis Twice, temporary amendment from Digitalis, Clinical Remarks " (man,
set. 34, formerly gin-drinker), 'Brit. Med. Journ.,' 1871, i, 319. Thompson, "Cirrhosis
of the Liver" (man, set. 59), ib., 1872, i, 113. Black, "Cirrhosis of Liver, Ery-
sipelas" (man, set. 26, autopsy), 'Lancet,' 1872, ii, 117. Crisp, "Incipient Cirrhosis
of the Liver and Baggy Stomach" (woman, set. 60), 'Path. Soc. Trans.,* xxiii, 137.
Liveing, " Syphilitic Cirrhosis of the Liver and Caries of the Skull, associated with
Amyloid Disease of the Abdominal Viscera, Chronic Phthisis, and Ulceration of the
Colon" (man, set. 21), ib., 144.
LIVER — ECHINOQOCCI, ETC. 168
(d) Carcinoma.
Cases of cancer of tlie liver are recorded by the following writers : —
Headland ('Lancet, 1871,1, 268) gives a case of primary medullary
cancer existing only in the liver, and nowhere else, in a man aged 40 ;
Smyth ('Brit. Med. Journal,' 1871,!, 421), scirrhous, in liver only,
in a man aged ji ; Simms, (' Path. Soc. Trans.,' xxiii, 135), soft cancer,
in liver only, in a man aged 64. Gowers (ib., 145) gives notes of the
case of a woman, aged 30, in whom growths of medullary sarcoma were
found in the liver, lungs, and mamma. Church, who made a micro-
scopical examination of the new tissues, thinks it probable that the
disease originally began in the lumbar glands. Whipham (ib., xxii,
164) publishes the case of a woman, aged 64, in whom the liver,
weighing 77 ounces, contained numerous growths, on an average
about the size of a common marble. The microscope revealed an ap-
pearance as of gland-tubes lined in some portions, with columnar
epitheliuig, and the writer refers the growth to the columnar-cell
epithelioma described by Eorster, Cornil and Eanvier, &c.
Perls, "Zur Histologie des Lebercarclnoms," 'Virch. Arch.,' Ivi, 448. Gee,
** Cancer of the Liver in an Infant," *St. Barth. Hosp. Rep.,* vii, 143.
(e) EcJiinococci,
Murchison ('Path. Soc. Trans.,' xxiii, 129) gives the case of a man
aged 4^, whose abdomen during life presented a distinctly nodulated
or botryoidal appearance, from the presence of numerous tumours.
These tumours continued to increase in size, though no signs of any
booklet could be found in their contents on puncture. Ascites, en-
largement of the abdominal veins and oedema of the feet, preceded
death, which occurred rather suddenly. At the autopsy were found
two enormous cysts in the liver, one in front, growing down from the
under surface of the left lobe, and containing an enormous quantity
of hydatid cysts, with a small quantity of thin pus, the entire contents
measuring six pints. This cyst had been tapped during life. The
other cyst was in the back part of the right lobe, and contained be-
tween four and five pints of thin opaque fluid, in which there was bile-
; pigment and a few hydatid cysts. Numerous smaller cysts were
found in the liver and growing from the omentum and other parts of
the peritoneum. Altogether there must have been many hundreds of
them. There was one as large as a man's fist in the spleen, and
another still larger in the left iliac region ; another of the size of a
large orange, and quite globular, was attached by a narrow pedicle
below the umbilicus ; and two as large as oranges, and with thick
opaque white coats, lay quite loose in the peritoneal cavity in the right
flank. Nothing was found to account for the patient's sudden death.
The history of the case seems to leave little doubt that the disease
commenced in the liver, and that it was not till after many vears that
the peritoneum was secondarily invaded.
Bouchut (* Gaz. des Hop.,' 1872, 137) records the case of a girl aged
1 1, in whom he punctured a cyst in the liver with a capillary trocart
164 REPOUT ON PRACTICAL MEDICINE.
He gives his reasons for looking upon the cyst as a serous and not an
hydatid one. The girl got well. \
Cleghorn ('Indian Med. Q-az.,' March, 1871, quoted in ' Lancet,' '
187 1, i, 624) believes that a considerable number of the hepatic
abcesses that occur in India are due to suppurative changes taking
place in old hydatid cysts.
Fagge and Durham, " On the Electrolytic Treatment of Hydatid Tumours of the
Liver, with an Addendum on simple Acupuncture," * Med.-Chir. Trans.,' liv, i.
Bahrdt, " Spontan geheilter Echinococcus der Leber mit Abgang der Blasen durch
die Gallengange und den Darm" (girl, set. 26), *Arch. d. Heilk.,' xiii, 467. Ricbet,
"Observations sur les Kystes hydatiques du Foie traitees par le Methode des
Caustiques, des larges Ouvertures, et des Injections astringentes et alcooliques," * Gaz.
des Hop.,' 1872, 369. Widal, " Kyste hydatiques du Foie, Pleuresie concomitante
du Cote droit, Ouverture et Extraction totale du Kyste, Guerison," ib., 457. Dieu-
lafoy, " Du Diagnostic et du Traitement des Kystes hydatiques et des Abces du Foie
par I'Aspiration," ib., 385. Fox, "Hydatids of the Liver" (in girl, a)t. 14, treated
for six months with iodide of potassium, recovery), * Brit. Med. Journ.,' 187 1, i, 499.
Duckworth, "Case of Hydatid Tumour of the Liver, with Icterus" (woman, at. 25),
ib., ii, 179. Hett, "Treatment of Hydatid Cysts by simple Tapping" (with very
fine trocar, girl, set. 7), 'Lancet,' 1871, i, 357. Duffin, "Hydatid of "the Liver,"
ib., 1872, ii, 780. Murchison, "Multiple Hydatid Tumours of the Liver (?) and
Peritoneum, in part successfully removed by operation " (woman, at. 29), • Path.
Soc. Trans.,' xxiii, 126.
{f) Affections of the Bile-ducts, Sfc.
Decaisne (**Sur un Epidemie d'Ictere essentiel observe a Paris;"
* Gaz. des Hop.,' 1872, 4; ' G-az. Med.,' 1872, 45) describes a kind of
epidemic of jaundice which occurred in Paris and its immediate neigh-
bourhood in the autumn of 1870. He himself had occasion to observe
28 cases, thus attacked, 17 males, and 11 females. The symptoms do
not seem to have differed much from ordinary cases of jaundice. The
ordinary period of the affection was about ten or eleven days.
McPherson (' Am. Journ. Med. Sci.,' Ixi, 409) records the case, with
autopsy, of a female, set. jp, who suffered from biliary calculus, and in
whom a fistulous passage extended from the cystic duct to the umbilicus,
through which bile was discharged from time to time.
Murchison (' Path. Soc. Trans.,' xxii, 152) gives the particulars of a
very interestiDg case of biliary fistula in the abdominal wall of a female,
set. 40, from which bile was discharged. The patient was alive at the
time the notes were made.
Pugliese, " De I'Hydrate du Chloral dans les Coliques h^patiques," • Lyon Med.,' viii,
438. Noblet, " Observation d'un cas particulier d'Ictere," * Gaz. des Hop.,' 187 1, 594.
"D'Ictere simple et du Catarrhe des Voies biliaires" (re\Tie), ib., 1872, 153. Fereol,
"Ictere, chronique, Mort, Calculs du Canal choledoque, Hemorrhagies internes"
(woman, aet. 32, autopsy), ib., 259. Villard, *;Stude sur le Cancer des Voies biliaires,'
Paris, 1871, pp. 104. Crucknell, "Malformation of the Gall-bladder and Hepatic
Duct" (man, aet. 40), ' Path. Soc. Trans.,' xxii, 163. Nunneley, " Congenital Oblitera-
tion of the Hepatic Ducts" (boy, set. 6 months), ib., xxiii, 152. Moxon, " Syphilitic
Disease of the Liver suppurating and opening a Bile-duct" (man, rot. 29), ib., 153.
Thorowgood, "Gall-stone" (woman, aet. 67), ib., 151. Murchison, "Sequel of a
Case in which Gall-stones were discharged by a Fistulous Opening through the
Abdominal Parietes" (cf. ib., xix, 260), ib,, xxii, 154. Id., "Fistulous Communica-
tion between the Gall-bladder and Colon" (woman, aet. 60), ib., 158. Duckworth,
"Case in which a Biliai'y Calculus was passed fi*om the Umbilicus," ib., 157.
Ai*J*ECTlONS OF THE LIVER AND SPLEEN. l66
(ff) Various.
Steffen Q Jahrb. £. Kinderheilk.,' v, 47) gives several tables of the size
of the liver and spleen in children, from birth up to 14 years of age.
Eobin presented to the Paris Academy of Science, March 18, 1872,
some observations by Eitter on colourless bile. The author states that
in all cases in which colourless bile vras found, the hepatic cells had under-
gone more or less fatty degeneration.
Eoy ('Lancet,' 187 1, i, 10) gives a case of rupture of the liver and
left kidney in a man, set. 25, the effects of a fall. The liver had three
or four rents, extending only a few lines into its substance, on its convex
surface.
Steiner (' Jahrb. f. Kinderheilk.,' iv, 333) writes on the presence of
blood in the peritoneal cavity of new-born children from superficial
rupture of the liver and spleen. He remarks on the rarity of the affec-
tion, giving a case of each, and considers that congestive hypersemia, and
not disease of the liver, is the primary cause.
Other papers referring to the liver are —
Dalton, "Sugar Formation in the Liver," 'New York Med. Journ.,' xiv, 15.
Bennett, " Report on further Experiments demonstrating that Mercury has no special
action on the Liver," 'Brit. Med. Journ.,' 1871, i, i. Habershon, "Lettsomian
Lectures on the Pathology and Treatment of Diseases of the Liver," ib., 1872, ii, 31.
Quincke, "Ein Fall von Aneurism der Leberarterie," 'Berl. Klin. Woch.,' 1871, 349.
Ward, 'On some Affections of the Liver and Intestinal Canal, with Remarks on
Ague and its Sequela3, Scurvy, Purpura, &c,,' London, 1872. Fox, "On some
Abnormal Conditions of the Liver accompanied by Jaundice," 'Brit. Med. Journ.,'
1872, ii, 8. Habershon, "Inflammation of Glisson's Capsule, Occlusion of Vena
Portse, Blood Cyst, Dropsy, Peritonitis" (woman, sot. 34), 'Guy's Hosp. Rep.,'
xvi, 405. Solowieff, " Veranderungen in der Leber unter dem Einflusse der kiinst-
lichen Verstopf ung der Pfortader," ' Centralbl.,' 1872, 337. Gee, " Complete Oblitera-
tion of the Mouths of the Hepatic Veins," ' St. Barth. Hosp. Rep.,' vii, 144. Bock
and Hoffmann, "Ueber das mikrochemische Verhalten der Leberzellen," 'Virch.
Arch.,' Ivi, 201. Riegel, " Zur Casuistik der Missbildungen der Leber,'* 'Deut.
Arch,,' xi, 113.
Affections of the Spleen.
Payne (* Path. Soc. Trans.,' xxii, 278) gives the following case of
Hodgkin's disease complicated with acute tuberculosis. A boy, set. 10,
had presented during life great enlargement of the spleen, which reached
from the seventh rib to the crest of the ilium vertically, behind into the
lumbar region, and in front almost to the middle line. There was no
increase in the number of the white blood-corpuscles. He became
gradually weaker and died of exhaustion. The spleen was found to
contain numerous tumours of the kind called lymphadenoma and
infarctus. Small tumours of the same kind were found in the liver and
right kidney. The lymphatic glands throughout the body were affbcted
in the same way, and some of them contained masses of a soft caseous
consistency, which would, had they occupied the whole of the gland, have
caused it to be called scrofulous. There was, in fact, a distinct transi-
tion to the type of disease called by that name. In addition there were
numerous miliary tubercles in the pia mater and lungs.
166 UEPOUT ON l>RACTiCAL MEDICINE.
Moxon, "Case of Acute Splenitis (?) in a Syphilitic," 'Path. Soc. Trans.,' xxii, 274.
Squire, "Specimen of Enlarged Spleen,'' ib., 276. Bisch-Hirschfeld, "Der Acute
Milztumor," 'Arch. d. Heilk.,' xiii, 389. Mosler, " Ueber die Wirkung von Eucalyptus
globulus auf die Milz," « Deut. Arch.,' x, 159. Olga Stoff und Sophie Hasse,
" Einige Notizen tiber die Circulations-Verhaltnisse der Milz.," * Centralbl.,' 1872, 753.
Affections of the "Pancreas.
Pepper (' Amer. Journ. Med. Sci.,' Ixi, 159) gives the following case.
A man, set. 45, of very intemperate habits, first noticed haemorrhage from
the bowels in the early part of 1870. This recurred from time to time,
the last time in August of that year, when there w^as such rapid haemor-
rhage into the stomach and bowels as to prove fatal in one hour. There
was no vomiting at any time. At the autopsy marked but not extreme
cirrhosis of the liver was found; the stomach and intestines contained a
large amount of blood, which had entered them through an opening in
the ductus communis choledochus. A probe passed through this open-
ing directly entered a cavity in the head of the pancreas, which waa
filled with fluid blood and clots. From a microscopical examination of
the head of the gland, which was enlarged and hardened, it was con-
cluded that the specimen was a well-marked case of cirrhosis of the
pancreas.
Affectimis of the Peritoneum.
Habershon ('Guy's Hosp. Eep.,' xvi, 418) gives two cases which
show that abdominal pain may be due to old adhesions between the
stomach and transverse colon. Both become limited in their movements,
and whenever the one or the other becomes distended, pain is the result.
In the first case, that of a man, aged nearly 60, there had been fixed
pain in the region of the gall-bladder, without jaundice ; death occurred
from haemorrhage. Old and firm adhesions were found between the
liver, stomach, colon, and duodenum. The gall-bladder contained five
irregular small calculi. In the second case, also a man of 60, the same
pain without jaundice was present ; the patient passed a considerable
number of biliary calculi, and digital examination gave the idea that the
duodenum and colon were adherent to the transverse colon and to the
stomach. The patient recovered.
Giles ('Brit. Med. Journ.,' 1871, i, 447) traces the connection
between gonorrhoea and peritonitis in women. He thinks that the
gonorrhoeal matter may readily come into direct contact with the peri-
toneal membrane through the Fallopian tubes. After childbirth or mis-
carriage this occurs with greater freedom, and in prostitutes neglected
gonorrhoea, though with less facility, may in the same manner lead to
peritonitis. The disease differs from puerperal peritonitis in its shorter
duration and its usually successful termination. He gives a few cases
in support of his views.
Dobson (ib., 475) draws attention to the fact that West in 1858 had
put forward a similar view in speaking of acute uterine inflammation.
Dickinson (' Path. Soc. Trans.,' xii, 287, 296) publishes two very
interesting cases. In one, a boy 3^ years of age, a tumour of tlie
Ai^FECTlONS 0^ THE PEUITONEUM, KIDNEY, ETC. 16?
lumbar glands occupied almost the entire right half of the abdominal
cavity. In the other, a girl, aged 2 years, the left half of that cavity was
nearly filled by a mesenteric tumour. A full report of the microscopical
appearance of both tumours is given.
' Vigla, "Peritonite granuleuse" (man, set. 21, autopsy), *Gaz. des H6p./ 1871, 253.
Herard, " Peritonite chronique" (man, rot. 39), ib., 264. Lange, " Eigenthumlicher
Verlauf einer Peritonitis," • Berl. Klin. Woch.,' 1871, 74. Id., "Peritonitis mit
Periorchitis bei einem 3 Wochen alten Knaben/' ib., ib. Egan, " Peritonitis
Meretricium," 'Brit. Med. Journ.,' 1871, i, 475. Murchison, "Multiple Hydatid
Tumours of the Liver (?) and Peritoneum, in part successfully Removed by Opera-
tion" (woman, at. 29), 'Path. Soc. Trans.,' xxiii, 126. Id., "Multiple Hydatid
Tumours of the Liver and Peritoneum" (man, set. 45), ib., 129. Greenhow, "Loose
Tumours from the Peritoneal Cavity," ib., 241. Southey, " Old Peritoneal Adhesions
interfering with the Rise of the Uterus into the Abdomen at the Fourth Month of
Pregnancy ; Cystitis ; Retention of Urine ; Distension of the Bladder ; Death from
General Peritonitis" (with autopsy), ' Lancet,' 187 1, i, 610.
Afhctions of the Kidney.
(a) Nepliritis. — "Wood, writing on acute dropsy, scarlatinal and idio-
pathic ('Am. .Journ. Med. Sci.,' Ixii, 75), attempts to show that a large
proportion, if not all, cases of this kind, are due not to a mechanical im-
pediment to the circulation, but to a peculiar condition of the cellular
tissue, whereby its natural secretion or exhalation is enhanced, so that the
water may be said to be actively thrown or drawn out from the vessels.
From a review of difi'erent cases and writers he concludes — i. That in
acute Bright' s disease, whether originating from scarlet fever, arsenical
poisoning, or cold, the dropsy is not a result of the kidney disease, but
with the latter is dependent upon a common cause. 2. That an irritant
poison, organic or otherwise, may give rise to dropsy without any
appreciable organic disease. 3. That exposure to cold and wet may
produce dropsy, without other disease, and that there is, therefore, such
an afi'ection as idiopathic dropsy. 4. That acute dropsy is mostly, if not
always, the result of irritation o£ the cellular tissue.
(jr. Johnson ('Brit. Med. Journ.,' 187 1, i, 3), in a "Lecture on the
Diagnosis and Prognosis in cases of Bright' s Disease," insists upon the
necessity of a careful examination of the urine in all cases of deranged
health. The urine in cases of the acute affection is usually scanty, of
normal specific gravity, more or less blood-tinged, highly albuminous,
and contains numerous epithelial and blood-casts, with scattered renal
epithelium and blood-discs. The hsematuria of acute Bright's disease is
distinguished from that of renal calculus by the presence of these casts.
Small and large hyaline casts also occur, the latter moulded in tubes
from which the gland-cells have been removed, the former from those
whose walls were still covered by them. Another form of tube-cast is
that which contains small round cells with compound nuclei (exudation-
cells). The appearance of these in great numbers is a less favourable
sign than when epithelial casts alone are present. In some undoubted
cases of acute Bright's disease the urine, though highly albuminous,
contains no blood and retains its normal colour. When symptoms of
the disease have continued beyond a month or six weeks, more or less
I
168 HEPORT ON PRACTICAL MEDICINE.
oil begins to appear in the casts and in the desquamated epithelium.
Johnson has, however, seen cases of recovery even after the presence
of oily casts and cells. The disease is essentially a curable one ; its
prognosis more favorable in the young and middle-aged than in the
old, and in those who are able to avoid exposure to cold and other bad
influences. Among the earliest signs of amendment are a copious secre-
tion of urine, paler and of lower specific gravity, and decrease of dropsy.
The albumen is usually the last symptom to disappear.- If the urine
continues albuminous for more than six months the prognosis is more
doubtful, but such cases do get well. Scanty secretion of highly albu-
minous urine, frequent and distressing vomiting, dropsical efi'usion into
the serous cavities, are all symptoms of grave though not fatal import.
Kecovery sometimes occurs, in the acute disease, after the most formid-
able symptoms of ursDmic poisoning have been present.
Q-ull and Sutton publish (*Med.-Chir. Trans.,' Iv, 273) a paper
on Bright's disease with contracted kidney (arterio-capillary fibrosis) in
which they arrive at the following conclusions : — (i) There is a diseased
state characterised by hyalin-fibroid formation in the arterioles and
capillaries. (2) This morbid change is attended with atrophy of the
subjacent tissues. (3) It is probable that this morbid change commonly
begins in the kidney, but there is evidence of its beginning primarily in
other organs. (4) The contraction and atrophy of the kidney are but
part and parcel of the general morbid change. (5) The kidneys may
be but little if at all affected, whilst the morbid change is far advanced
in other organs. (6) This morbid change in the arterioles and capil-
laries is the primary and essential condition of the morbid state called
chronic Bright's disease with contracted kidney. (7) The clinical his-
tory varies according to the organs primarily and chiefly afi'ected. (8)
In the present state of our knowledge we cannot refer the vascular
changes to an antecedent change in the blood due to defective renal
excretion. (9) The kidneys may undergo extreme degenerative changes
without being attended by the cardio-vascular and other lesions charac-
teristic of the condition known as chronic Bright's disease. (10) The
morbid state under discussion is allied with the conditions of old age,
and its area may be said hypothetically to correspond to the *' area
vasculosa." (11) The changes, though allied with senile alterations,
are probably due to distinct causes not yet ascertained.
Johnson, in a paper read before the same society (' Med. Times and
Gaz.,' 1872, ii, 688; 'Lancet,' 1872, ii, 882), strongly opposes the
views of these writers, and maintains that the appearances noticed by
them are due to distension of the coats of the vessels by the reagents
employed.
Koberts ('Brit. Med. Journ.,' 1871, ii, ^21) opposes Dickinson's view
that the abuse of alcohol is not one of the most important causes of
Bright's disease, and gives a table of the proportional number of deaths
from intemperance, from diseases of the kidney, and diseases of the liver
in difl'erent districts.
Bradley (ib., i, 116) relates the case of a child, four months old,
covered with syphilitic psoriasis, whose urine was highly albuminous,
and whose face, arms, and legs were oedematous. The microscope
AFPECtiONS OF THE KIDNEY — NEPHRITIS. 169
revealed the presence of numerous epithelial and granular casts. All
the symptoms disappeared under the employment of mercury. He
looks upon the case as one of syphilitic renal dropsy.
Johnson (ib., 1872, i, 2^6) publishes a clinical lecture on a case of
chronic Bright's disease in an intemperate woman, xt. 46, who died of
rapidly fatal apoplexy. He gives some engravings of the thickened
arteries from the kidney and the subcutaneous tissue. A large portion
of the right hemisphere on a level with the lateral ventricle was exca-
vated by effused blood ; the outer margins of the corpus striatum and
optic thalamus were partly broken down by the clot, and the blood had
passed through the torn septum into the left ventricle.
Broadbent ('Lancet,' 1872, i, J03) gives a clinical lecture on a case
of renal disease ending in apoplexy in a woman who two years pre-
viously had had a left- sided hemiplegia during pregnancy. She was
again pregnant at the time of her death. The autopsy showed con-
tracted granular kidneys ; an enormous heart, weighing 19 ounces with
healthy valves, and muscular hypertrophy of the minute arterioles. A
clot lay to the outer side of the right corpus striatum and thalamus,
and had torn through the fibres passing from them into the hemisphere.
It extended along nearly the whole length of the ganglia, but did not
turn round the anterior end of the corpus striatum. Its upper part
was on a level with the intra-ventricular surface of these bodies. Infe-
riorly it was separated by a very thin stratum of nervous matter from
the fissure of Sylvius, the source of the bleeding being probably the
small branches of the middle cerebral artery here penetrating the brain
substance.
Moxon ('Brit. Med. Journ.,* 1872, i, 637) records a case of extreme
granular degeneration of the kidneys, without hypertrophy of the heart.
The subject of it was a man, set. 72, whose death was due to an accident.
He thinks it very probable that some atrophic kidneys commence in a
congenitally imperfect structure, and supports his view by an opinion
of Virchow's (' Krankh. Greschw.,' Bd. i) as to the continuation into
later life of a partial foetal degeneration.
Murchison (' Path. Soc. Trans.,' xxii, 17 7) records a remarkable case
of fatal uraemia from atrophied kidney in a footman, set. 1 8, of temperate
habits. Ten days before admission into hospital, having been previously
healthy, with the exception of pain and swelling in the throat with
dysphagia five years before, he was seized rather suddenly with pain at
the pit of the stomach, palpitations and dyspnoea on exertion. Five days
later he complained of shivering and pain in the loins, and after that
became very drowsy. On admission he presented no sign of chronic
disease, no notable anaemia, no oedema. There was nothing abnormal to
be discovered in the lungs ; no eruption. His temperature was 95*4° F.
The urine drawn off by a catheter was colourless, limpid, sp. gr. 1007,
and contained a small trace of albumen. The drowsiness and the amount
of urine increased ; the temperature remained below normal. On the
fifth day of his stay in hospital he died comatose, after one or two fits
of general convulsions. All the organs were found healthy except the
kidneys, of which the right weighed ii oz. and the left | oz. The
capsules were adherent, and the microscope revealed the ordinary
170 REPORT ON PRACTICAL MEDICINE.
characters of granular contracted kidney. The blood from the cerebral
sinuses and veins contained urea.
Stohr (' Deut. Klin./ viii, 467) employed transfusion in three cases
of uraemia. In the first case death was imminent, but the patient lived
thirteen days after the operation. The second died in sixty-four hours,
and the third in six hours after the transfusion. In the first two the
urine passed after the operation contained blood-colouriDg matter, but
no blood-cells.
Einney ('Dub. Journ.,' lii, 245) showed cirrhosed kidneys from a
man, sot. 20, who had passed urine in such large quantities as to sug-
gest at first the possible existence of diabetes.
Stewart, "Notes of a Case of Inflammatory Bright's Disease; Fatal in third
stage" (man, set. 31), 'Brit. Med. Journ./ 1872, ii, 94 (and cf. * Edin. Journ.,' xvi,
1093). Ackermann, " Ein Fall von Parenchymatose Nephritis mit Retention der
Cylinder in den Nierenkelchen und in Nierenbecken " (man, set. 20, with plate),
' Deut. Arch.,' x, 298. Dujardin-Beaumetz, and Hardy, " Note sur un cas d'Uremie,"
'Union Med.,' xiv, 130. Moxon, "Case of Gouty Granular Kidneys and Irruptive
Pneumonia; Fatal by Acute (Edema of the Larynx and Lungs," 'Lancet,' 187 1, ii,
217. De Giovanni, " Pnemnonite e Nephrite" (three cases), ' Gaz. Med. Lomb.,'-
1872,261. Lambert, "Ophthalmoscopic Diagnosis of Bright's Disease," 'Lancet,*
1872, i, 321. Gueneau de Mussy, "fitude sur le Traitemeut de quelques Albumin-
uries," *Gaz. des Hop.,' 1871, 473. Handfield Jones, " Clinical Lecture on instances
of Successful Treatment of Degenerative Disease of the Kidneys," ' Med. Times and
Gaz.,' 1871, ii, 151. Morris, "On the Use of the Turkish Bath in Albuminuria,"
'Brit. Med. Journ.,' 1871, i, 193. Bradbury, "Remarks on a Case of Bright's
Disease," ib., 1872, ii, 37.
(h) Hcematuna,Sfc. — Pavy ('Brit. Med. Journ.,' 1871, i,66) read to the
Clinical Society notes of a case of paroxysmal hsBmaturia, and exhibited
specimens of the urine. The patient, previously in good health, was
seized, after exposure to cold, with nausea. His urine was the colour of
porter, but after rest in bed gradually became normal. Exposure to cold
eleven days later brought on another relapse. During the paroxysms the
urine contained coloured granules and crystals of oxalate of lime, but no
casts or blood-cells. He insists on the case being distinct from one of
ordinary hsematuria.
Stevens (ib., ii, 323) gives a case of "intermittent hsematuria" of
more than twenty years' duration in a woman set. 75.
Drysdalc, "Haematuria ending fatally" (male, a3t. 73, autopsy), 'Med. Press and
Circ.,' 1872, i, 36. Harley, "Endemic Haematuria of the South-Eastern Coast of
Africa," 'Med.-Chir. Trans.,' liv, 45. Ogle, "Haematuria" (man, aet. 61), 'Lancet,*
1871, ii, 540. Cobbold, "On the Development of Bilharzia Haematobia, together
with Remarks on the Ova of another Urinary Parasite (the so-called Trichina cystica
of Dr. Salisbury), occurring in a Case of Hajmaturia from Natal," ' Brit. Med. Journ.,'
1872, ii, 89. Couto, * Haematuria endemica dos paizes quentes,' Bahia, 1872.
(c) HypertropJiied Kidneys — Sydatids^ Sfc. — Kosenstein ('Virch.
Arch.,' liii, 141) has made experiments on dogs and rabbits, with a
view of proving whether compensatory hypertrophy really takes place
in one kidney when, from some cause or other, the other kidney
ceases to perform its functions. At the same time his experiments
throw some light upon the share which the kidneys take in the
formation of urea. He starts with the fact that the size of the
BiEMATUitlA — HYDATIDS, ETC. 171
right kidney to the left is, speaking generally, as i'i2 to i. The
animals bore the extirpation of one kidney well on the whole; on
removal of the other they died with ursBmic symptoms. The second
kidney, though removed a long time after the first, was not always
liypertrophied, and when it was so the enlargement bore no propor-
tion to the period between the two operations. The increase was chiefly
in weight, not in an alteration in the glomeruli and cortical substance.
"When the animals ate well, as they frequently did, after the operation,
the amount of urea excreted on the second day was almost the same,
and from this fact Eosenstein concludes that the kidneys take no share
in the production of urea, inasmuch as it is impossible to conceive that
the remaining kidney could in so short a time take on an increased pro-
cess in the work of excretion.
Perl (ib., Ivi, 305) sums up his j)aper on the same subject as follows :-—
(i) The physiological growth of the kidney is essentially a hyperplasia ;
the vessels alone undergo a true increase in size. (2) The compensatory
enlargement is a true hypertrophy. (3) The various elements of the
organ take a different share in this hypertrophy, the convoluted tubes
and their epithelium are most concerned in it ; the straight tubes, as well
as the Malpighian corpuscles, apparently not at all.
Shepherd (' Lancet,' 1872, i, 646) records the occurrence of hydatids
in the kidney in a man, set. ^i, in whom the disappearance of a tumour
in the left flank was accompanied by the passage of the cysts per
urethram.
Sawyer, ' Floating Kidney, its Causes, Diagnosis and Treatment' (all in women),
Birmingham, 1872. Ferber, " Zur Pathologie der bewegliclien Niere/' * Virch. Arch.,*
lii, 95. Jago, "Movable Kidneys," * Med. Times and Gaz.,' 1872, ii, 328. Longuet,
" Case of Hydatid Cyst of the Right Kidney simulating Ovarian Cyst," * Lancet/
1872, ii, 713 (quoted from *Mouvement Medical,' of Nov. 9). Eberth, "Myoma
Sarcomatodes Renum" (female child, set. 17 months), 'Virch. Arch.,' Iv, 518. Morris,
" Cyst connected with the Left Kidney, associated with Medullary Cancer of the
Liver, Lungs and Left Kidney" (man, aet. 69), ' Path. Soc. Trans.,' xxii, 171. Trotter,
"Encephaloid Disease of the Kidneys" (man, set. 30), ib., 173. Heywood Smith,
"Unnatural Extension of Kidney" (left, weighing 9 pounds, from a woman, set. 27,
suffering from pyonephrosis and calculus), ib., 1 74. Pye-Smith, " Stricture of the
Ureter and Dilatation of the Kidney, apparently of Traumatic Origin " (man, set. 24),
ib., xxiii, 159. Whipham, " Lymphadenoma of the Kidney" (woman, set. 43), ib.,
166. Leared, "Renal Calculi of Cystic Oxide" (from woman, set. 30), ib., 165.
M'Cai-thy, " An Account of some Renal Calculi of Unusual Shape found in the Left
Kidney of a Woman who died of Cancer of the Uterus," • Med.-Chir. Trans.,' Iv, 263.
Other papers referring to the kidney are —
Unruh, "Ueber Blutungen in Nierenbecken und Ureteren bei Pocken," 'Arch. d.
Heilk.,' xiv, 289. Eberth, "Ueber die Muskeln der Niere," * Centralbl.,' 1872, 225.
Lipsky, " Ueber die Entziindlichen Veranderungen des Epithels der Harncanalchen,"
' Wien.Med. Jahrb.,'1872,155. Prescott Hewett, "Ruptured or Lacerated Kidney from
a Railway Accident," &c., 'Brit. Med. Journ.,' 1871, ii, 722. Chunder Roy, "Rupture of
Liver and Left Kidney" (from fall), ' Lancet," 187 1, i, 11. Rovida, " Intorno all'origine
dei cilindri deU'urina," 'Gaz. Med. Lomb.,' 1872, 285. Letzerich, " Ueber Nephritis
Diphtheritica," 'Virch. Arch,,' Iv, 324. Browning, "Diphtheritic Albuminuria,"
'Brit. Med. Journ.,' 1872, ii, 95. G. Johnson, "Clinical Lecture on Dropsy," ib.,
187 1, ii, 723. Taylor, "A Case of Acute Dropsy without Albuminuria," 'Med. Times
and Gaz.,' 187 1, ii. StefEen, " Zur Wirkung der heissen Bader bei Hydrops," ' Jahrb.
f. Kinderheilk.,' iv, 317.
17^ UEPORT ON PEACTICAL MEDICINE.
Analysis of Urine, Sfc.
"Wernich (" Ueber postmortale Harnansammlung," * Centralbl.,' 187 1,
6^8) gives the results of certain experinients. He removed the urine by
means of a catheter in a number of women a quarter or half an hour
before death ; at the autopsy he found from 30 to 50 grammes of cloudy
urine in the bladder. In one case in which death took place almost
while the operation was being performed, and in which the bladder
apparently contained not a single drop, over a table-spoonful was with-
drawn with a catheter eight hours after death.
Falck (' Virch. Arch.,' liii, 282) finds from experiments that urea
injected into the blood of dogs is passed unchanged with the urine in
the course of the following hours. In a third section (s. 315) he gives
a full historical review of researches into the physiology of urea.
Seegen (' Pfliiger's Arch.,' v, 359) opposes the views of Briicke, Kiihne
and others, as to the presence of sugar in normal urine, and decides
from his own experiments that none is present in the healthy state,
and that continued excretion of even very small quantities is accom-
panied by all the symptoms of diabetes.
The same writer ('Brit. Med. Journ.,' 1872, 1,469, and of. 'Cen-
tralbl.,' 1872, 68), while considering that Trommer's is the most delicate
test for sugar, asserts that its delicacy only holds good with a watery
solution of sugar. For this reason he filters the urine through animal
charcoal, which retains most of the constituents of the urine, more
especially the colouring matters and uric acid, these substances pre-
venting the precipitation of the suboxide when it is formed. Having
filtered the urine several times till it is completely colourless, he washes
the charcoal on the filter with a little distilled water, and to this water,
when filtered off, he applies Trommer's test. In this way he can detect
o'l per cent, of sugar. Eor quantitative analysis this filtration cannot
be performed, as the charcoal always retains a certain quantity of sugar
which cannot be removed again by washing.
Barclay ('Lancet,' 1871, ii, 117) writes on the chemical relations of
urates and phosphates. Years before, he had been puzzled by the presence
of phosphatic deposit in decidedly acid urine. In a case which he now
records of severe diarrhoea the neutral urine contained a turbid floccu-
lent deposit insoluble by heat, but dissolved by acid in combination
with heat, insoluble also by acid without heat. The microscope showed
the presence of globular, highly refracting urates, with some crystals of
oxalate of lime.
"Wanklyn ('Brit. Med. Journ.,' 1872, i, 133) shows that, though the
strength of the urine in health is subject to great variation, a certain
relation is maintained between the mineral matter (salts) and the organic
matter existing in the urine. In five specimens of healthy urine there
was never a larger proportion of organic matter than 17 times as much
as the mineral matter. In disease, on the other hand, the proportion of
organic matter is increased.
Traube (' Berl. Klin. Woch.,' 1871, 0,^^) gives the following as dif-
ferential tests in deciding whether blood contained in urine has come
ANALYSIS OP THE URINE, ETC. 173
from the kidneys or the ureters. In the former case (i) the microscope
shows in the urine rings with colourless contents, and a double or
single outline smaller than normal blood-cells. The altered blood-
corpuscles do not occur in haemorrhages from the ureters. (2) The
colouring matter of the blood-cells is soluble in urine, and the latter
exhibits dichroismus, on account of the solution in it of haemoglobin free
from oxygen. The first appearances are explained by the fact that the
blood-cells have lingered some time in the so-called tubes of Bellini.
G-enerally cylinders also occur, composed of blood-cells in rolls, the
diameter of which proves them to be true casts of the same tubes.
Laborde, "Augmentation de TUree dans certalnes Maladies," *Gaz. Med./ 1871,
522. Fowler, "Quantitative Analysis of Urea," 'New York. Med. Journ.,' xvi, 277.
Maly, "Zur Bestimmung der Harnsaure," ' Pfluger's Arch.,^ vi, 201. Salkowski, "Die
Bestimmung der Harnsaure," ib., v, 210. Gaetbgens, " Zur Frage der Ausscheidung
freier Saurendurch den Harn," ' Centralbl.,' 1872, 833. Seegen, "Ueber eiue Methode,
minimale Mengen Zucker in Harn mit grosseren Sicberbeit nacbzuweisen," ib., 68.
Manassein, "Ueber Quantitative Bestimmung des Zuckers in diabetiscben Harne nach
dem Unterscbiede im specifiscben Gewicbte des Harns vor und nacb der Gabrung,"
*Deut. Arcb.,* x, 73. Liborius, " Beitrage zur Quantitativen Eiweissbestimmung," ib.,
319. Treskin, "Die Veranderungen des Harnes bei langerem Verweilen in der Blase,"
' Centralbl./ 1872, 147. Jaffe, "Ueber den Urspruug des Indicans in Harns," ib., 2.
Soborow, " Ueber die Kalkausscbeidung im Harn," ib., 609. Mebu, "Etude sur una
Urine a Sediment violet," ' Bull. Gen. de Tberap.,' Ixxxiii, 260. Lebon, " Sur la
Xantbine et sa recbercbe dans les Calcus vesicaux," ' Compt. Rend.,' Ixxiii, 47.
Tbompson, " Diagnosis by Examination of Urine in obscure forms of Urinary
Disease," 'Brit. Med. Journ.,' 1871, i, 6. Tidy and Woodman, "On Ammonia in tbe
Urine in Healtb and Disease," 'Lancet,' 1872, i, 809. Treskin, "Ueber die Anwend-
barkeit der Metbode zur Harnstoffbestimmung von Bunsen fur das Blut.," ' Vircb.
Arcb.,' Iv, 488. Rosentein, " Das Koblensaure Ammoniak und die Uramie," ib., Ivi,
383. Leared, "Renal Calculi of Cystic Oxide" (from woman, set. 30), 'Patb. Soc.
Trans.,' xxiii, 165.
G. AFFECTIONS OF THE SKIF.*
General. — Neumann ('"Wien. Med. Zeitg.,' 1871, 295) writes on the
changes found in the involuntary muscles of the skin in cutaneous afiec-
tions. In variola he finds always great increase in size, perfectly distinct
from the true hypertrophy of the muscles which Derby, Rossbach,
Korner and others, have shown to be present in lichen ruber, icthyosis,
elephantiasis arabum, prurigo, and sclerema adultorum. It is impossible
to decide whether in these cases we have to deal with an hypertrophy or
an hyperplasia ; the individual fibres, as well as the rod-like nuclei, are
very much enlarged, and with them the whole muscle. Derby refers
this increase in size to increased muscular exertion in pressing out the
secretion from follicles with narrowed openings. In addition to this
hypertrophy there is atrophy of both muscle-cells and nuclei.
Smith (*Dub. Journ.,' lii, s^^) gives an analysis of iioo cases of
skin disease treated at the Adelaide Hospital, Dublin, since September,
* Simplicity is not to be laid to tbe charge of writers on diseases of the skin. No
one but tbe entomologist can rival them in the smallness of their distinctions : their
varieties, like tbose of insects, are already distinguished by the names of the authors
who bad the good (!) fortune to describe tbem first. — A. B. S.
174 UEPORT ON PRACTICAL MEDICINE.
1869. The table includes examples o£ all the common, almost all the
less common, and one or two of the rare diseases, such as "alopecia
areata, ichthyosis, keloid, leucoderma, moUuscum sebaceum, pemphigus,
purpura, favus, urticaria, and one or two others." (Some of these may-
be uncommon in Ireland — Bep.) The writer touches upon what he
considers to be points of special interest in some of the affections, and
gives his treatment.
Anderson ('Lancet,' 1871, ii, 672, &c.) gives an analysis of 11,000
consecutive cases of skin diseases. A few of the more interesting
cases are abstracted in the text below. Eeference must be made to
the paper itself for his classification of his cases, which are divided
into functional and organic diseases, the latter again frequently sub-
divided. The most frequent affection of the skin by far was eczema, of
which their were 2875 cases ; erythema was met with in 569 ; ecthyma
in 97 ; psoriasis in 831 ; acne in 342 ; pemphigus in 16. A few cases
of somewhat rare occurrence are described.
Grueneau de Mussy (' G-az. des Hop.,' 1871, 413) writes on the
symmetrical distribution of afiections of the skin, with special reference
to a case of symmetrical erysipelas of the face occurring in a male
patient. He thinks the case confirms the law laid down by Grraves
('Clin. Lect.,' 2nd ed., ii, 327) that when this afiection commences in
the median line it is developed symmetrically on each side of it. He
commences his paper by asserting that this tendency to symmetry is a
law of normal organic evolution which reveals itself often under patho-
logical conditions. For instance, decay of a tooth on one side is often
followed by decay of the corresponding tooth on the other side ; the
same result occurs in affections of the eye, in gout and rheumatism, in
the eruptive fevers, and in several cutaneous diseases. In his case the
erysipelas commenced on the back of the nose, and spread to the two
sides symmetrically. On the third day it extended over the forehead,
leaving two triangular spaces perfectly free. On the left side the
triangle corresponded with an old cicatrix, the remains of a wound
which had divided the integuments down to the bone. No lesion was
present on the opposite side, and yet the erysipelas aff'ected the same
portion and dimensions of skin, &c., in the same form as on that
side. In seven days the erysipelas had disappeared, and the patient was
well.
Erythema. — Lipp (*' Beitrag zur Kenntniss des Erythema exsudativum
multiforme, Hebra," 'Arch. f. Derm, und Syph.,' iii, 221) treated this
affection in 17 women and 2 men. It was preceded by pyrexia, rigors,
malaise, and restlessness. It put on various appearances, small or large
nodes, patches resembling erythema annulare and gyratum, or punc-
tated spots arranged in circles or half circles. In two cases there were
buUsB, and in one pustules. The affection attacked any part of the body,
and several times the mucous membrane, proceeding to ulceration and
loss of tissue. The feverish symptoms were present in almost all cases,
lasting for 18 days, and sometimes recurring. In one case there was
endocarditis and pleurisy, in nine rheumatic symptoms, and in several
cases constitutional syphilis.
Wilson ('Brit. Med. Journ,,' 187 1, ii, 34) gives a case of erythema
ERYTHEMA— HERPES. 176
fiolare, affecting tlie face and hands on exposure to the sun, in a woman
ffit. 38. During the seven years she noticed this symptom she found
that her skin was remarkably free from sweat. Wilson thinks the case
necessarily recalls pellagra.
Serpes. — "Wyss ('Arch. d. Heilk.,' xii, 261) reviews the literature of
herpes zoster, and gives the case of a man, set. 68, who, previously well,
was attacked with headache and symptoms of general febrile disturbance.
Three days later vesicles of herpes labialis appeared. Xext day redness
showed itself about the right eye and forehead, the nose, the right ear
and cheek, as far as the border of the lower jaw, and extended to the
other side of the face. There was no pyrexia, nor was there increased
heat of the affected parts. Two or three days later vesicles of herpes
appeared on the right side of the face, the right cornea and conjunctiva.
Eleven days after the first symptom the patient became unconscious
and died. At the autopsy the vesicles and scabs of herpes were found
to be entirely limited to the right side and to the parts supplied by the
first branch of the fifth nerve. The latter was broader and thicker than
the corresponding nerves on the left side, of a deep grey colour, soft,
and with its fibres separated by a greyish-red soft tissue, abundantly sup-
plied by vessels. This change was found throughout its course from its
entrance into the orbit to its finest ramifications. Traced backwards as
far as the Gasserian gangloin, it was found surrounded by extravasated
blood, but on the other side of the ganglion it appeared to be normal.
The ganglion itself was larger and softer than the left, and its substance
was bright red, with a mass of ecchymosis on its inner side. Great
increase of cell-growth was found in the cornea and in the layers of the
skin. Wyss concludes that herpes zoster is a typical affection of the
skin, set up by inflammation of the Gasserian or a spinal ganglion, and
of the nerve passing through it. Both ganglion and nerve may be only
partially effected ; this would explain those cases in which only a branch,
and not an entire nerve, is found to be the seat of herpes.
Sichel ('L'Union Med.,' xii, 580) reviews the literature of herpes
zoster frontalis, to which, according to him, but little attention has
been as yet paid among French writers. It has been confounded with
erysipelas and certain syphilitic affections (corona veneris). It never
passes the median line, and is always limited to one half of the fore-
head or face, and always follows the distribution of certain nerves,
curiously presenting the form of a fan when it appears over the
branches of the infra-orbital nerve. In other particulars his descrip-
tion does not differ from that of Hutchinson and other writers in
England. The affection is characterised by symptoms of gastric dis-
turbance and of hypersesthesia followed by anaesthesia ; it is generally
accompanied by insomnia and loss of appetite, often by falling off of
the hair ; generally it attacks persons of a gouty or rheumatic tempera-
ment, in whom constipation is the rule. The usual termination is
favourable. He concludes his paper by giving the notes of three cases.
Parrot (' Gaz. Hebd.,' viii, 374) attempts to prove that there is a
morbid condition to which he gives the name " herpetic fever," under
which should be included the majority of cases described as synochial,
ephemeral, gastric and other fevers {fievr^ angioteniq^iie and angina
\
176 REPORT ON PRACTICAL MEDICINE.
herjpetique) ; that this morbid condition is characterised by the presence
of various herpetic eruptions and by an acute lobular pneumonia, to
which the name herpetic pneumonia should be given ; that the whole of
the affections named have a common bond in the disturbance of the
nervous system, and that in febrile affections the appearance of herpes
is almost always a favourable prognostic sign.
An account is given ('Lancet,' 1872, i, 399) of a case of herpes
impetiginiformis under the care of Hebra. The patient was a woman
aged 25, in the ninth month of her second pregnancy. This was only
the fifth case Hebra had seen. They all occurred in women at full
time, except one, which took place during the course of pregnancy ; the
first four all terminated fatally. They all resembled one another in
beginning in the region of the genitals, in the general diffusion over the
body in a later stage, and in the herpetic character (groups of vesicles
on the same inflamed base) which they presented. They were all
accompanied by fever and rigors. There was no restriction to the
course of certain nerves.
Broadbent ('Brit. Med. Jour.,' 187 1, i, 444) relates the case of a
man, aged 39, who presented on the right side of the neck an eruption
exactly resembling that of herpes zoster of the region of the cervical
plexus, and was at the same time the subject of factitious urticaria.
On drawing the back of the finger-nail sharply across the skin there
was produced immediately a broad line of elevated hair-follicles ; this
subsided, and in two minutes was succeeded by a similar line of
elevated hair-roots, but this time of a bright red colour, which in four
minutes and a half or five minutes had developed itself into a long,
smooth, elevated wheal of urticaria, pale, with red margins. In ten or
twelve minutes the mark had almost faded again.
Pemphigus. — Bumstead ('Am. Jour. Med. Sci.,' Ixii, 99) records the
following case of pemphigus produced by the administration of iodide
of potassium. A man, aged 28, with an imperfect history of syphilis,
and with ecthymatous ulcerations on his legs, complained, after taking
three doses, each containing 20 grains of the drug, of heat and a
burning sensation in his face and hands, which were observed to be
reddened. Next day large bullae appeared on the exposed parts of his
body, and the patient affirmed that on three previous occasions he had
taken the iodide with the same result.
Psoriasis. — Buck ('Berl. Klin. Woch.,' 1872, 161) treats psoriasis as
follows. The patient is placed in warm soap-baths to soften and loosen
the epidermis ; the scales are then removed with a soft brush, and the
parts attacked by the eruption dabbed with acetic acid, at first once a
day, and afterwards as often and as strenuously as the patient is willing
and able to support the pain caused by the application. The dark colour
of the skin caused at first soon disappears, and no scar remains.
Pollock ('Lancet,' 187 1, i, 683) records a case of psoriasis guttata in
a woman, set. 43. The disease had existed, according to her own
account, for the last twenty years. She strongly denied the possibility
of any syphilitic taint. Ten grains of iodide of potassium were given
her three times a day, and a lotion of equal parts of glycerine and water
PEMPHIGUS — PSORIASIS — PITVrIasIS. 177
Was kept constantly applied. On the fiftieth day there was no rash
whatever, nor did it return.
Pityriasis. — T. Fox ('Path. Soc. Trans.,' xxii, 313) showed a man, set.
49, who presented the condition originally described by Devergie under
the term "pityriasis pilaris," in a perfect form. Six months previously
he had been attacked with pityriasis rubra, which within a week from its
commencement involved the whole body. After a general tonic treat-
ment of six months' duration, the appearance of pityriasis pilaris was
produced by the interfollicular portions of the skin gradually assuming
a healthy appearance, whilst every follicle remained plugged and dis-
tended by little whitish, hard knots, the size of pins' heads, and
slightly larger, which gave the surface, in certain parts, the feel and
aspect of a rasp or nutmeg grater. This condition was observed at the
back of the neck, all over the back, over the chest, on the outer parts
of the arms. In tracing the disease from the lower limbs upwards
transitional stages between pityriasis rubra and pilaris were observed.
The disease began to break up into patches by the appearance of
healthy islets of skin here and there ; at other places were red papules
more or less isolated. These latter were seen to be produced by the
distension of hair-follicles by plugs of epidermis, which had been shed
from the lining membrane of the follicle. The condition found com-
pletely confirmed the truth of Devergie's description.
The same writer ('Brit. Med. Journ.,' 1871, i, 392) publishes a
clinical lecture on lichen ruber with reference to a case occurriug in his
own practice. A woman, set. 46, had been well up to the age of 38,
when she became subject to boils and severe onychia. Two years and
a half later an attack of lichen ruber commenced, with intense itching
and redness of both eyes. At the end of eighteen months the face
began to redden considerably; she complained of excessive debility.
Nine months subsequently the redness had spread to the head, neck,
and back, and the reddened parts were somewhat scaly. Soon the
whole body was affected. The redness was removable by pressure, and
was accompanied by burning and itching, especially towards evening
and morning. The patient had suff'ered for the last year or two from
"neuralgia" in the shoulders and arms, indigestion, and menorrhagia.
She was admitted into hospital in November, 1869. She was then
thin. At various times during the day the skin was the seat of con-
siderable itching whenever the eruption was present ; this irritation
was paroxysmal, lasting half an hour or more. The colour of the face
was deep red; the skin dry, wrinkled, and indurated, resembling xero-
derma. The whole of the scalp was reddened, and covered by minute
scales; the hairs were normal. From the back of the head to the
scapula the skin appeared to be discoloured by a minute sub-
cutaneous mottling, due to the presence of small reddish-brown
flattish papules, of the size of pins' heads, seated at the follicles, and
covered by exceedingly minute white scales. The front of the whole of
the chest and the abdomen was marked by the same appearance, except
roand the umbilicus and the lower part of the abdomen. On the back
of the thighs the papulation was still more marked ; the leg was very
rough below the knee ; the scales were confluent over the ankle. The
12
178 Hei^out on i>ractical medicine.
arms were affected in the same way. The nails were thin and their
roots red. The soles of the feet and the palms of the hands were free
from disease ; the extensor surfaces of the fingers were red, indurated,
scaly, and showed a disposition to crack. During her stay in hospital
the patient improved greatly in every way, but had a relapse in May,
1870, from which she again recovered. Pox considers the case to be
one of well-marked pityriasis rubra, due to " a general congestive con-
dition, dependent upon perversion of the regulative influence of the
nervous system." There was " active dilatation of the minute blood-
vessels, followed by effusion of plastic matter into and about the
follicles, hypertrophic growth of the root-sheath, and in some cases of
the papillary layer of the skin." The treatment consisted of alkaline and
bran baths every night, with an oxide of zinc and chalk lotion applied
many times a day. The internal treatment was directed to the procuring
of sleep, and the regulation of the general functions.
Prurigo. — Gay (' Archiv f. Derm. u. Syph.,' iii, i) gives with a plate
the results of his microscopic researches into the changes taking place in
the skin in prurigo. He thinks that the different parts of the skin are
more or less affected : the rete Malpighii, the hair-bulbs, sweat-glands,
corium, and papillae. The changes in the rete consist of increase in
the cells of the deep and some of the middle layers, due probably to
proliferation. Their thickness extends also to the horny layer. The
vessels of the hair-sac are found dilated and enlarged. The erector
muscles, the outer sheath of the root, and the papillae, are greatly de-
veloped. The sebaceous glands are generally diminished in size, and
the cells of the openings horny in character. On the other hand, the
sweat-glands are dilated, their cells loosened from the membrana pro-
pria, and their blood-vessels also dilated. The same dilatation is found
in the vessels of the papillae ; the cells of the corium are very marked,
and are mixed with branched and wandering cells ; the papiUae are en-
larged. In conclusion, he agrees with Neumann, that the eruption of
prurigo is due to increase in young cells and the presence of a fluid
exudation in the tissue of the papillse.
E. Wilson (' Brit. Med. Journ.,' 1871, ii, 34) records the occurrence
of a pruriginous eruption in a man, aet. ^"j. The papules were of a kind
to be felt rather than seen, and apparently due to congestion and infil-
tration of the vascular coat of the follicles. The number of spots
never exceeded ten or twelve. On scratching them an angular or
square-shaped excoriation remained, which dried up into a thin reddish
scab. The patient had formerly suffered from gout.
The same writer (ibid., i, 608) publishes a case of prurigo mitis
" from simple debility," in a woman, set. 21. The papules were found
chiefly in the face, a few on the fingers ; the whole eruption did not
exceed ten or twelve spots.
Scleroderma. — Pagge (' Path. Soc. Trans.,' xxii, 309) records the post-
mortem appearances found in a woman, aet. 64, the subject of " difiused
scleriasis." She had become latterly incapable of taking nourishment, be-
cause the skin of her face became so tight that she was scarcely able to
move the mouth. The skin was of a yellowish colour, hard and tightly
stretched over the tissues beneath. At those parts where the cuticle was
PHUEIGO— -SCLERODERMA. 179
H^Pged in the form o£ dense conical papillsD, which retained their cha-
■^''racter in thin sections. In many regions, however, the epidermis was
scarcely, if at all, thicker than natural. All the elements entering into
the composition of the corium were increased in amount, and supplied
by numerous perfectly constructed arterioles. This increased produc-
tion of areolar tissue aiFected also the underlying superficial fascia in
very unequal degrees ; the fat-cells in it were more or less atrophied.
The liver was congested, distinctly hardened and crisp, with a granular
fracture.
Curran (' Edin. Journ.,' xvii, 112) publishes notes of a case of
bcleriasis in a soldier, set. 29. When first seen he was sufiering from a
hardness and rigidity of the skiu over the whole surface. The integu-
ment of the face was tightened, brawny, and shining. The skin
covering the neck, chest, shoulders, arms, and legs was similarly
affected ; the only parts that escaped were the genitals, and, to a lesser
extent, the upper eyelids. His face was utterly without exjDression.
The disease appears to have commenced while he was in Cape Town in
1869, in a small patch on the back of his neck, and gradually extended
over the arms, trunk, and abdomen. It produced throughout a feeling
of tingling or numbness in the parts on which he lay in bed ; there was
no evidence of diminished temperature ; friction and baths failed to pro-
duce perspiration. All forms of treatment were adopted without success.
Dufour (' Gaz. Med.,' 187 1, 475) reports at length the occurrence of
scleroderma, with atrophy of the hands, in a married woman of 39,
which was said to have commenced after an attack of ague. In this
again all remedies, whether internal or external, were all but useless,
though the patient was reported to be slightly better. He quotes
another case somewhat similar, and concludes that there must bo cases
of scleroderma which are the result of atrophy of the fingers.
The two following papers are included here rather as curious records
than as of practical importance :
TJllersperger ("Ein Beitrag zur ethnischen, Dermatologie," 'Deut.
Klin.,' 1 87 1, 188) writes on a case exhibited at Paris by Paul, and
gives the opinions of various persons upon it. It was that of a boy of
I fifteen, who presented a symmetrical aftection of the palms of his hands
i and the soles of his feet. In these places the epidermis was thickened,
I horny, and of a yellowish colour, and was broken by fissures with a
I whitish-red base. There was nothing in the patient's occupation to
i account for this affection. It first made its appearance when the boy
; was ten years old, and this duration of five years and its symmetrical
i distribution must depend upon some internal cause. Bazin referred it
' to simple induration. Hardy looked upon it as ichthyosis. Diego
I Parada, of Madrid, calls it hipertrodermosis palmo-plantaris, or paculosis
, epidermica of the hands and feet ; he has observed it several times, and
' almost always simultaneously on both sets of members. Stulli de-
' scribes the affection as epidemic in Malta. Parada found it in Castile
and Asturia. TJllersperger concludes that it occurs almost exclusively
I in the Eomanic (i. e. French and Spanish) and Arabo-Komanic races
I (^« €. in Malta).
180 UEPORT ON PRACTICAL MteDIClNIi.
In reference to this paper Liicke (" Zur ethnischen Dermatologie,"
ib., 217) gives a case of the same kind ("paculosis" of Gintrac) occur-
ring in the Grermanic race. A boy of nineteen had for eight years ha '
symmetrical thickening of the epidermis on the soles of his feet and tl.
palms of his hands. He looks upon the affection as a local one, ana
obtained temporary relief by removing the thickened epidermis, by ap-
plications of liquor potassoe, by tincture of iodine, and by alkaline
baths.
Keloid.— Kohn (' Wien. Med. Woch.,' 1871, No. 24) writes on keloid.
He shows that Alibert was the first to describe this cicatrix-like tumour
of the skin ; and that the name cancroid, afterwards changed to cheloid,
bore no reference whatever to any resemblance to cancer, but to the
likeness which the peculiar processes in keloid present to the feet of a
crab. Keloid may be described generally as a flat prominence,
implanted in the skin, sharply defined, raised half a line to several lines
above the surrounding level, tough and elastic, and in appearance ver;
like an hypertrophied scar ; of a white glistening colour, in parts of
rosy red. It is generally painful on pressure ; in many cases severu
pain exists of a burning or stabbing character ; and by means of this
innate pain Alibert and other writers make a distinction between true
and false keloid. Its most frequent seat is the skin of the upper part
of the trunk, the sternum, the mamma, the lateral regions of the
thorax, the back, and the neck. From his own and Hebra's cases
Kohn finds that it occurs in the proportion of one to two thousand of
the other diseases of the skin. The general health is not affected by i
the disease. Little is known as to its development and course, as the ^
opportunity seldom occurs of following it from its earliest to its latest \
stages. At first small brownish-red streaks are noticed in the skin,
flat, or slightly raised, resistent on pressure, and sensitive. They may
grow very slowly until they reach a certain extent, and then remain
stationary. After a time the keloid may become superficially destroyed,
or undergo the so-called retrograde metamorphosis. Alibert and
Hebra have seen spontaneous disappearance in a very few cases. As
to its etiology, very small local injuries or irritations have been traced
as the cause — leech-bites, blistering-plasters, and, in negroes especially,
lashing with a whip. Scars in some cases may also be the origin of
keloid. It is not always possible to make a certain diagnosis between
the keloid and hypertrophied scars. On making vertical sections of
the aff'ected skin, thick masses of fibrous tissue are seen running
parallel with the surface in the cerium, normal layers of which seem to
enclose it above and below. Under the microscope are seen a few
nuclei and nucleated spindle-shaped cells, the latter most numerous
about the processes of the keloid, where the fibres appear to make
more of an open network. No vessels or glands are found in the
middle of the tumour.
T. Pox (' Path. Soc. Trans.,' xxii, 313) showed four tumours ranging
in size from a small fist to a walnut, which w^ere removed from the ears
of negroes in Jamaica. They are very common among them, and
spring up in the site of the perforations made in the ears for earrings.
On section they presented a dense, white, glistening, fibrous appear-
CHELOID — PAPILLOMA — ELEPHANTIASIS. 181
mce, and under the microscope the structure was that of condensed
brous tissue.
ll FapiUoma. — Gerhardt (' Jahrb. f. Kinderheilk.,'iv, 270) gives two cases
3f papilloma of the skin, somewhat resembling the case of papilloma
irea-elevatum published by Beigel (' Path. Soc. Trans.,' xx, 414). The
jases were unmistakably connected with some central nervous disorder.
The first case is that of a girl, aged 6 years, in whom papillomata were
present over the whole of the right side of the breast, and the whole
right arm. The left half of the nose, the left upper lip, a portion of
bhe left cheek, and the skin behind the left ear presented papillomatous
swellings. From the age of 3 the child had had incomplete epileptic
attacks, which became fully developed later. In the second case, a
man of 61, the growths occupied almost wholly the right half of the
body, especially the axilla. He gives a minute microscopical account
of the tumours, which he refers to increase in the papillae, accompanied
by melanotic pigmentation of the skin. Both cases also must be ex-
plained by the implication of certain nerves; the affection in the
second case following the distribution of spinal nerves, while in the
first it pointed to some such morbid condition as generally obtains in
Idiseases of the base of the brain.
Elephantiasis. — Yanlair ('Bull, de I'Acad. de Med. Beige,' v, 941 ; and
Virch. Arch.,' lii, 292) has made researches into the histology of elephan-
Itiasis arabum. According to him the erysipelatous zone, which separates
the healthy from the diseased portions, and is characteristic of the first
stage of the malady, diff'ers from ordinary erysipelas. It is limited to the
papillary zone of the derma ; the morbid change commences below, in the
dermatic alveolar zone. There is progressive and proportionate hyj)er-
plasia of the three layers (papillary, connective-tissue, and elastic) of
normal derma, with progressive atrophy of the panniculus adiposus.
The epidermic hypertrophy is consecutive to that of the subjacent vas-
cular tissue. The sweat-glands remained, while the hair-follicles and
sebaceous glands had disappeared ; there was interstitial hyperplasia of
the nerve-fibres ; in the superficial portions of the muscles the longi-
tudinal striae were exaggerated, while the transverse were eff'aced. The
lymphatics and glands were unaltered. The subcutaneous veins
(saphena, &c.) were varicose, with their walls hypertrophied in places.
He throws no further light on the cause of the hyperplasia.
Gay ('Arch. f. Derm. u. Syph.,' iii, 489) has examined into the
pathology of the sweat-glands in elephantiasis. He finds that the
morbid change commences in swelling and proliferation of the epi-
thelium, by which the openings of the ducts are obstructed and the sac
swelled up. The cells which have undergone proliferation degenerate
into an indistinct, homogeneous, glassy mass, in the middle of which
homogeneous circular structures sometimes appear, the smallest re-
sembling cells, the larger structureless. The glands themselves are
next seen filled with the same material. The ducts are aff'ected earlier
and more severely than the glands. He gives a plate in illustration of
his paper.
Hattute ('Eec. de Mem. de Med. Milit.,' xxvi, 112) records the
occurrence of elephantiasis in an Arab, set. about 22, strong but of a
18 -2 REPOUT ON PRACTICAL MEDICIXE.
scrofulous habit. For three years his right foot had iucreased consi-
derably in size (measures of his two feet are given for comparison). It
"was hard, of the consistence of bacon, and took no impression from the
fingers. Its sensation was diminished, there was almost complete
analgesia, but not anaesthesia. The patient demanded amputation on
account of the inconvenience to which he was put by the affected limb, and
the operation was performed. In addition to the histological changes
generally found, the amputated foot presented a considerable number
of small soft cheesy masses of different sizes, enclosed in a fine mem-
brane and situated in the subcutaneous intermuscular tissue. Some of
the cysts contained also pus and blood. He considers this "tuberculo-
caseous" form of elephantiasis to be not uncommon in Algeria.
Anderson ('Lancet,' 187 1, ii, 844) records eight cases of ele-
phantiasis arabum, and three of elephantiasis grascorum. One of the
patients suffering from the latter was a -young Highlander who had
never been out of the country; another was a boy aet. 12, who had
returned from India four years before ; and the third was a girl set. 15,
who had come home from Jamaica at the age of seven, about which time
the disease commenced on the face. The eruption consisted for the most
part of yellowish-red tubercular patches of different sizes, the sensation
of which was deadened.
Mollusciim. — Balmanno Squire ('Brit. Med. Journ.,' 1872, i, 45)
claims to have discovered in molluscum contagiosum spores with
rounded angles, which he believes to be the special vegetable parasite
of the sebaceous glands, just as that found in chloasma is of the epi-
dermis, and that of favus and tinea of the hairs.
Duckw^orth (ib., 98) reminds him that Hardy had already described
such parasitic structures.
Eerrier (ib., ii, 682) considers the existence of a vegetable parasite to
be entirely negatived by the result of his investigations. When the
secretion expressed from the follicles was treated with caustic potash
and examined under the microscope, it gradually became clear, from
saponification of the fat, and the outlines of the epithelial cellular con-
tents became sharp and distinct. In the secretion so treated, especially
the soft central part from the large tumours, he has seen one or two
unmistakeable torula-cells in the act of germination, not differing in size
or form from those of penicillium. But, in addition, a great many other
spore-like bodies were to be observed in the angles of the cells, appa-
rently multiplying by germination, and even lengthening out into
mycelium. They were of various sizes and forms, and liad a peculiar
vacuolate aspect. They might readily be mistaken for true spores ; but
he has come to the conclusion that they are artificial products of the
action of the caustic potash on the fatty matters. In the contents of
the follicles, after several days' maceration in ether, he has failed to
detect any spore-like bodies, nor has he been able to produce any such
appearance by treating them subsequently with caustic potash. Nor
could he find any spores in the small and still firm tumours. He has
attempted, with the same result, to cultivate the secretion in Pasteur's
solution. He gives the case of a child, aged nine months, in whom
twenty-two molluscous tumours were situated on the lips, cheek, and
MOLLUSCUM — HiEMATIDROSIS — XANTHELASMA. 183
neck, some pedunculated, others sessile, varying in size from a pea to a
millet-seed, the largest being on the lips. Two others were situated on
the buttocks ; they began to appear at the aged of four months. Some
had fallen oiF of their own accord, and had been succeeded by others.
The mother had two well-marked tumours on the left breast, which as far
as could be learnt, came after the appearance of those on the child's
lips. She attributed the affection to contagion from a girl, who had
" warts" on the face and body. The tumours speedily disappeared on
being evacuated and touched with perchloride of iron.
Liveing (ib., i, ii) relates the occurrence of the affection in five chil-
dren of the same family between the ages of ^ and 13. In all of them
the molluscum was confined almost entirely to the face.
Duckworth ('Lancet,' 1872, i, 61 j) showed to the Clinical Society
three patients suffering from molluscum contagiosum. The tumours
began three years before in the first child of a healthy woman ; she was
next affected about the face and breast ; and the second child presented
numerous tumours shortly after birth. Lastly, the grandmother, who
had slept with the eldest child, and had often nursed the baby, became
affected.
Alterations in the secretion of the shin. — Wilks (' Gruy's Hosp. Eep.,'
1872, xvii, 215) records the presence of hsematidrosis in a woman, sst.
2)^, affected at the time with tetanus, which proved fatal later on.
The supposed blood-stains yielded, on chemical examination, a little
iron, but unlike the true colouring matter of blood, were quite insoluble
in water and alkaline solutions ; nor could any coloured solution or
blood- corpuscles be procured from the stains.
Anderson (' Lancet,' 1871, ii, 707) gives a case of the same kind in a
girl set. 14 (See ' Journ. of Cutan. Med.,' i, 328). The parts implicated
were the arms, the front of the chest, and legs. The haemorrhage
occurred from round erythematous patches, one on the brow ; one on
the chin ; one on each cheek ; four in a row on the front of each arm ;
two on each upper arm ; and two on each forearm. A similar arrange-
ment was found on the sternum and legs. One of the most marked
peculiarities in the haemorrhage was the suddenness of its invasion,
generally at 11 a.m. each day. The writer considers it to have been a
case of vicarious menstruation.
Berger (' Wien. Med. "Woch.,' 187 1, No. 7) and "Wiedemeister
(' Yirch. Arch.,' lii, 437) give cases of ephidrosis unilateralis in men aged
respectively 28 and 30. In both the sweating occurred on the left
side.
Xanthelasma. — Hutchinson ('Med.-Chir. Trans.,' liv, 171) writes on
xanthelasma palpebrarum with special reference to Addison's belief that
it was usually associated with disease of the liver. He sums up his con-
clusions as follows : — It never occurs in children, but is fairly common in
the middle and senile periods of life; jaundice and enlargement of the liver
occurs in severe cases; the former precedes the appearance of the patches,
and is of a black tint rather than yellow ; however great the enlargement
of the liver, it may subside, and the patient recover perfectly; attacks of
liver disturbance also occur, without any jaundice, in some of the cases ;
the affection occurs more frequently in females than in males, in the
184 REPORT ON PRACTICAL MEDICINE.
proportion of two to one ; in all cases the xantlielasmic patches appear
in the eyelids first, extending in not more than 8 per cent, to other
parts ; they invariably begin near the inner canthus, and almost invari-
ably on the left side. It is probable that of the causes mentioned under
which the pigmentation of the eyelids may be disturbed, disorder of
the liver is the most powerful.
Diseases of the hair. — Crisp (' Path. Soc. Trans,,' xxii, 305) pub-
lishes a case of general alopecia in a healthy man. About the
time at which he first noticed a small bare spot on his head, he had
numbness of the sliin of his left side from the armpit to the hip. Other
bald patches appeared on the head, chin and cheeks, and other places,
till the whole of the hair had fallen off his body by about the end of a
year. He had never had syphilis. His finger-nails split into layers,
and were rough, with numerous indentations and furrows, and of a
brownish colour. His toe-nails were normal. No trace of fungus
could be found either about the hairs or nails, on careful microscopical
examination. From his own statistics Crisp concludes that nearly all
subjects of this complaint are strong, young, healthy men, w^hilst in
porrigo decalvans the majority of the patients are females. Of the
seven cases of total alopecia he has collected, all were males ; of the
eight examples of the disease, confined chiefly to the head and face,
six were males, and two were females.
Berger (' Yirch. Arch.,' liii, ^^3) relates two cases of premature grey
hair. The first patient had typhoid fever in 1866, followed six weeks
later by paralysis of the right side of the body and of the right facial
nerve, which disappeared in about ten weeks, when partial greyness
of the right side of the head and face was noticed. The second patient,
who had a number of white hairs under an abundance of blond hair,
spoke of the white forelock as an heirloom of his family.
Pincus ('Deut. Klin,,' 1871, 3) makes a sharp distinction between
alopecia on one side, and baldness and premature grey hair on the
other. The first is a true disease of the hair independent of any
aff'ection of the skin. Alopecia simplex attacks healthy persons between
the ages of 18 and 35, and. in the course of five to fifteen years results
in more or less extensive baldness of the scalp. On the other hand pre-
mature baldness aftects only a portion of the latter. He holds that
according to his investigations (' Berl. Klin. "Woch.,' 187 1, ^3^) the
view that alopecia is the result, in middle and advanced age, of
atrophy of the skin, is erroneous. He shows instead, from micro-
scopical examination, there is really present an induration of the
cellular tissue.
Parasitic qfections. — Tilbury Fox ('Lancet,' 1872, i, 5) has detected
the tricophyton in the air of the wards of an institution in which an out-
break of ringworm (300 cases, 1 20 at one time) occurred. As to treatment,
besides cutting the hair, and blistering, he recommends isolation, good
feeding, careful inspection, and, for the removal of the floating germs,
disinfection of the wards by burning sulphur.
The same writer (ib., 187 1, i, ^36) describes the presence of tricho-
phyton in a patient whose affection began as erythema marginatum,
and was complicated with urticaria and ecthyma.
PARASITIC SKIN DISEASES. 185
Yanlair ("Sur I'herpes tonsurans," 'Bull, de I'Acad. Med. Beige,'
V, 699) describes a fungus agreeing iu some characters with that
described by Robin as trichophyton tonsurans, in others with a fungus
described by Malmsten.
Anderson ('Lancet,' 1871, ii, 742) asserts that tinea favosa is much
more frequent in Scotland than in England; he treated 160 cases of
it. *' The frequency of favus in mice, coupled with the mousy odour
which is one of the characteristics of the complaint, renders it not
improbable that favus was originally communicated to human beings
from them " (!). He met with 178 cases of ringworm, 121 of tinea
versicolor, due to the presence of microsporon furfur, and 197 of tinea
decalvans.
Neumann ('Wien. Med. Ztng.,' 187 1, 89) describes the differences
between parasitic and non-parasitic sycosis. In the former the hairs
and their sheaths are affected first, while in the non-parasitic form they
suffer no change till later ; for instance, when the exudation into the
hair-sac becomes purulent, the pus-corpuscles make their way between
the sheath, and so loosen the hair. In the parasitic affection the deep
subcutaneous tissue is affected, in the other only the hair-bulbs and
the corium. The ordinary sycosis may remain at a standstill for
months and years. The parasitic one spreads very rapidly. In two
cases Neumann found, in the neighbourhood of the pustules and
papules, spots and rings of herpes tonsurans, and in another case
mycelia and conidia. As in all these cases he found traces of herpes
tonsurans iu some form or other, and as this affection preceded sycosis
parasitica in 9^ cases out of 100, he considers the latter as a form of
the herpes affecting the hairy parts of the skin of the face. As to
treatment, depilation is not necessary. He employs soft soap, succeeded
by the application of Ung. Diachyli (Hebra), weak solutions of corro-
sive sublimate, and sulphate of copper, or an ointment containing
creasote and sulphate of copper.
The same writer ('Arch. f. Derm. u. Syph.,' iii, 212) gives the
results of his experiments on the culture and development of
achorion.
Kohn (ib., 381) concludes that clinical symptoms prove the identity
of erythema multiforme and herpes iris and circinatus. He describes
the fungi which he finds, and recognises another form of the affec-
tion, which he designates as herpes tonsurans maculosus.
Monti ('Wien. Med. Woch.,' 1871, No. 37) treats itch in children
with balsam of copaiba and carbolic acid. The former produces severe
burning and redness of the skin, which lasts for about half an hour.
The superiority of the drug consists in the rapid cessation of the
itching after the first inunction ; the disappearance of the eruption
after three or four rubbings in ; and its cheapness as compared with
Peruvian balsam. The carbolic acid (4 parts to 36 of water, or to 120
of lard) is said to be better still. It is to be applied thrice a day, and
the scabies ought to be got rid of in from two to four days. If
eczema is present, the treatment must be persisted in for some time
longer.
AVeinberg ("Ueber die Ambulatorischa Behandlung Scabieskranker,"
186 REPORT ON PRACTICAL MEDICINE.
* Wien. Med. "Woch.,' 1872, s. 102), in cases where tbe aiFection is
slight, and the patients' skin tender, employs the nsual formula :
p, Styracis Liq., ^j ;
Olei Olivar., 5ij.
To be rubbed in twice after a bath. He finds its effect certain. In
patients with a thicker skin, he combines the styrax with soft soap and
chalk :
P) Styracis Liq.,
Floruin Sulpli.,
Cretae Albaj, ana ^iss ;
Sapon. Virid.,
Axungia) Porci, ana 5j.
To be rubbed in for two or three evenings. This ointment has a
greenish -yellow colour, a doughy consistence, and agreeable smell ; one
to two ounces are sufiicient for one person, according to the severity of
the affection. A bath is necessary only in persons of a generally dirty
habit. Patients treated with the ointment state that the itching is
quickly mitigated by it, so that they got a comfortable night's rest ;
and after the second or third inunction it disappears altogether.
Other papers on diseases of the skin are arranged as far as pos-
sible in the order of the preceding :
General. — R. M., "One Source of Skin Diseases" (soap), 'Nature,* v, 464.
Mapotherj " Lectures on the Treatment of Chronic Skin Diseases," ' Med. Press and
Circ.,' 1872, i, 29, &c. T. Fox, "Notes on the General Principles of Cutaneous
Therapeutics," 'Lancet,' 1871, i, 641. Wilson, "Lectures on Dermatology," 'Brit.
Med. Journ.,' 1871, i, 163. Curran, "Notes on Cutaneous Therapeutics," * Journ.
Cutan. Med.,' iv, 35.
JErythema. — Buck, " Erythema Nodosum," *Berl. Klin. Woch.,' 1872, 163. Siredey,
" Les Rapports Pathogeniques de I'l^rytheme noueux avec le Rhuraatisme," * Ann.
de Derm, et Syphl.,' iii, 241.
'Eczema. — Tait, " Note on the Cure of Inveterate Eczema in Children by Vaccina-
tion," 'Brit. Med. Journ.,' 1872, i, 92. Wilson, "Eczema," ib., 1871, i, 163.
Herpes. — Deshayes, "Fievre herpetiqne" (woman, set. 53), * Gaz. Hebd.,' viii, 643. j
Broadbent, '," Herpes Frontalis giving rise to Contagious Erysipelas," * Brit. Med.
Journ.,' 1871, ii, 34. Frazer, "On Herpetic Eruptions and Allied Affections observed
in Dublin during the year 1869," 'Journ. Cutan. Med.,' iv, 29. Coutagne, "De!
I'Herpes Generalise Febrile," 'Ann. de Derm, et Syph.,' iii, 162.
Pemphigus. — Picot, " Pemphigus buUeux traite par la Ouate et le Liniment
Oleocalcaire " (two cases), 'Gaz. des Hop.,' 1872, 17. Wilson, " Phlyctenous Erup-
tion affecting the Hands, Ankles, and Buccal Mucous Membrane, recurrent thrice
yearly, repeated for several years" (man, ait. 21), 'Brit. Med. Journ.,' 187 1, i, 608.
Impetigo, — Devergie, "Du Cancroide, du Noli me tangere, de I'lmpetigo, Rodensj
ulcereux et non-ulcereux," &c., 'Bull. Gen. de Therap.,' Ixxxi, 433.
Psoriasis. — Laycock, "Defective Cutaneous Sensibility in Cases of Psoriasis,'
'Med. Times and Gaz.,' 1871, i, 275. Purdon, "On the Treatment of Psoriasis by]
Balsam of Copaiva," ' Dubl. Journ.,' li, 393.
Lichen. — Charpy, " De la nature du Lichen hypertrophique," 'Ann. de Derm.,
iv, 26.
Ichthyosis.— Clarke, "Ichthyosis linguae," 'Lancet,' 1872, i, 648. Tait, "On thej
Pathology of Ichthyosis," 'Journ. Cut. Med.,' iv, 263.
Rhinoscleroma. — Scleroderma. — Geber, " Ueber das Wesen des Rhinosclerom, eine j
SKIN DISEASES — TUMOURS. 187
Kliniscli-lustologlsche Studie," *Arcli. £. Derm. u. Syph./ Iv, 493. Guillemin,
"Sclereme des aduUes," 'Ann. de Derm, et Sypb./ iii, 521. Heller, " Ein Fall von
Sklerodermie als Bcitrag zur Patliologie des Lymphgefasssystems," * Deut. Arch./
X, 141.
Lupus. — Gxiterboclr, " Ueber Lupose Verkrummungen der Finger," * Virch. Arch.,'
Iii, 344. B. Squire, "Living Specimen, showing the earliest stage of Lupus" (girl,
rot. 24), 'Path. See. Trans.,' xxiii, 291.
Elephantiasis. — Bakewell, " Elephantiasis Arabum " (with engraving), ' Path. Soc.
Trans.,' xxiii, 288. E. Wilson, " Elephantiasis Grascorum " (man, ait. 43), ' Brit.
Med. Journ.,' 1871, ii, 34. Milton, "On the Ancient Leprosy, or Elephantiasis
Gra3Corum,'' 'Journ. Cut. Med.,* iv, 81. Gordon, "The Leprosy in olden times in
Glasgow," ib., 207.
Pigmentation.— Ko\m, "Ueber Xanthelasma oder Xanthoma," ' Wien. Med. Woch.,*
1872, No. 8. Virchow, "Ueber Xanthelasma Multiplex (Molluscum lipomatodes),"
'Vircli. Arch.,' Iii, 504. Waldeyer, "Xanthelasma palpebrarum," ib., 318. Hilgen-
dorf and Paulicki, "Abnorme Pigmentflecken in der Haut bei einem weiblichen
Schimpanse (Simla troglodytes),'' ib., 297. Geber and Simon, "Zur Anatomic des
Xanthema palpebrarum," ' Arch. f. Derm. u. Syph.,' iv, 305. Kaposi, " Idiopathisches
multiples Pigmentsarkom der Haut.,' ib., 265. E. Wilson, "Melasma Frontis, with
General Melasma in Patches, originating in Cachexia," 'Brit. Med. Journ.,' 1871,
ii, 34. Frank- Smith, " On Morbid Pigmentation of the Skin," ' Journ. Cutan. Med.,'
iv, 72. Purdon, "Pigmentation of the Skin," ib., 228.
Hair. — Pincus, " Der Einfluss des Haarpigments und des Markcanals au£ die
Farbung des Haares," 'Arch. f. Derm. u. Syph.,' iv, i. Drysdale, "Tinea Decalvans,"
'Journ. Cut. Med.,' iv, 78. Paxton, "Note on Diseased Hair," ib., 197. Purdon,
"Note on Fragilitas Crinium," ib., 252. Devergie, "Note sur la Tricoptilose, Affec-
tion de Cheveux non-decrite," 'Ann. de Derm, et Syph.,' iii, 5.
Parasites.— T. Fox, "Remarks on the Treatment of Itch," 'Lancet,' 1871, ii, 672.
Weigert, "Ueber Bacterien in der Pockenhant," ' Wicn. Med.. Woch.,' 1871, No. 37.
E. Wilson, "Phytosis Versicolor (Pityriasis Versicolor of Willan), Orbiculate, Guttate,
and Pruriginous Variety, occurring in a ' Tea-liquorer '" (man, set. 52), 'Brit. Med.
Journ.,' 1871, i, 609. Bertulus, " L'ecole moderne et le Phthiriasis ou Maladie
Pediculaire spontanee," 'Gaz. Med.,' 1871, 352. Spillmann, "Observation de Favus
simulant un Pityriasis du Cuir Chevelu," 'Ann. de Derm, et Syph,,' iii, 347.
H. — TUMOURS.
Numerous cases of tumours will be found under the various organs;
tlie following papers deal with their more general occurrence in the
body.
Neumann (" Kenntniss der zelligen Elemente der Sarcome," 'Arch,
d. Heilk.,' xii, 66) iinds that tlie same method takes place in sarcoma-
tous new growths as he had already convinced himself occurred in the
new connective-tissue growth in pleuritic adhesions. In both the pro-
toplasm of the cellular elements is metamorphosed into the intercellular
substance of the new tissue. He thinks that this supports the old
theory of Schwann, lately rehabilitated by Beale and Max Schulze, in
opposition to Yirchow's theory. On the analogy of osteoblast and
odontoblast, he proposes to call these elements fibroblasts. In illustra-
tion he gives the following six cases : — Medullary sarcoma of the rectum
with partial melanosis, fungoid sarcoma of the skin over the knee,
melanotic sarcomatous warts of the great toe, ulcerated sarcoma of the
cheek, sarcoma of the sheath of the tendons in the foot, and melanotic
sarcoma of the bulb. He is inclined to look upon the pigmentation in
melanotic tumours as a form of cell degeneration, like fatty or cheesy
188 REPOET ON PRACTICAL MEDICINE.
transformation, rather, than with Langbans, as some result of change
in the colouring matter of the blood.
Seitz (' Virch. Arch.,' Hi, 114) publishes the case of a man, a^t. 49, in
whom were found multiple fibro-sarcomata of the nerves. Over various
parts of his body were numerous large and small tumours, which after
death were found to be neuromata. The largest was the size of a fist,
and was situated on the left peroneal nerve ; the next largest, the size
of a walnut, was on the internal cutaneous nerve of the thigh. Alto-
gether there were twenty-two. On microscoj^ic examination the small
ones were found to be made up of fibrillar connective tissue ; in the
larger there was a transition into round- and spindle-celled sarcoma.
The nerve-fibres were not enlarged, though in some places they had un-
dergone fatty change. The brain and its nerves, the spinal cord, the
sympathetic, the cervico-brachial and lumbo-sacral plexuses, were not
aftected. The patient died suddenly after being admitted into hospital
for strumous stenosis of the trachea.
Arnold (" Ein Beitrag zu der Lehre von dem Bau und der Entwicke-
lung der Psammome," ' Yirch. Arch.,' ib., 449) describes three tumours
of the meninges allied to fibroma, which showed extensive deposit of
lime-salts in the ribbon-like fibres of the tissue, in the cell-groups lying
between them, and in the thickened sheaths of the arteries and capil-
laries. Several of the vessels contained thrombi. Erora his own ob-
servations Arnold is opposed to the view of Cornil and Kanvier, accord-
ing to whom this deposit of lime occurs in the psammoma and in the
normally or pathologically dilated vessels. The first tumour was found
on the dura mater, at the base of the brain, in a woman of sixty-five,
who had died of cancer of the stomach and oesophagus. It was 6 by
3"j centimetres in size, and had caused no symptoms during life. In
the second case, a woman of sixty-seven, there was, on the other hand,
peculiar symptoms ; here the tumour was situated on the surface of the
right cerebral hemisphere, close to the longitudinal fissure ; its size was
A'S t)J 3 centimetres. In the third case, a woman of seventy, who had
died suddenly from the bursting of a dissecting aneurism of the aorta
into the pericardium, the tumour was round, with a diameter of about
2 centimetres, and was situate on the right side of the falx.
Zillner ('Virch. Arch,' ib., liii, 140) records two cases of the occur-
rence of colloid cysts, one in the under lip of a boy, aet. 10, w4iich dis-
appeared after being punctured ; the other case is that of a woman, set.
^6, who had died of typhoid, and in whom the thyroid gland and the
connective tissue in its immediate neighbourhood were found to contain
numerous colloid cysts.
Luschka (ib,, lii, 323) also gives, with a plate, two cases in which
colloid cysts were found in the larynx.
Wagner (' Arch. d. Heilk.,' xiii, i) concludes his long account of
tuberculoid lymphadenoma of the various organs with a comparison of
tubercle with lymphadenoma.
Maier ("Zur Casuistik du Lymphoma," ib., 148) publishes two cases
of lymphomatous tumours. In the first case, a man of twenty-eight,
the diagnosis during life had been cancerous pleurisy. The right pleural
sac was found filled with tumours of the size of a fist, most of them
fUAiotiR^. 189
springing from the pleura covering the lung and the diaphragm. They
were cemented together by very vascular adhesions, and there were
numerous large and small prominences. The upper lobe of the lung
contained a tumour the size of a fist, a cavity in which, the size of a
walnut, contained serous fluid of a yellowish-green colour. On section
the tumours were greyish-white, and exuded a watery juice. In the
lower lobe of the left lung were immense tumours, one reaching the
size of a child's head. Another, the size of a nut, existed in the wall
of the right ventricle, and projected into its cavity. The mediastinal
glands were large and dark. A half-degenerated tumour, the size of a
walnut, was found in the tongue. The spleen was enlarged, and con-
tained two tumours. The mediastinal glands and the other abdominal
organs were healthy. The microscopical characteristics — those of lym-
pho-sarcoma — are given in fall. In the second case, a man of sixty-
nine, there was simple hyperplastic lymphoma of the mesenteric glands,
M^th two tumours in the pylorus. The entire freedom of the thoracic
and abdominal glands in the first case is remarkable. The writer con-
cludes with the diagnosis between the scrofulous, leuksemic, and these
new growths. In the second case there was no increase in the white
blood-cells.
Eoth (ib., liv, 2^4) records the occurrence of multiple lymphomatain
a woman of fifty-three, who six months before death had been attacked
with diphtheria of the fauces. Three months later she had catarrh of
the bladder and of the bronchi. The autopsy showed great enlarge-
ment of all the glands in the neck, the axilla, mesentery, pelvis, groin,
&e., with enlargement of the spleen. The glands were soft and mar-
row-like, and were of different sizes, from that of a walnut to a pigeon's
egg. The whole intestinal canal was studded with numerous miliary
deposits, consisting of lymph-corpuscles, situated in the submucous
tissue ; deposits of the same kind were found in the mucous membrane
of the larynx, the pelvis of the kidneys, and the neck of the bladder.
The kidneys were greatly enlarged, and contained grey miliary and
larger masses, which, under the microscope, appeared as round cells in
a vascular stroma. In the brain were numerous microscopical deposits
of round cells in the interlobular connective tissue. There was no in-
crease in the number of the white blood-cells.
Birch-Hirschfeld (" Zur Cylindromafrage," ' Arch. d. Heilk.,' xii, 167)
describes a peculiar tumour removed from the abdominal cavity of a
man, set. ^9, who had died of phthisis. It was the size of a fist, and in
connection with the base of the vermiform appendix, and sent three
cylindrical processes with knobbed terminations into the cavity of the
pelvis. The tumour and its microscopical characters are described at
length ; and from the whole he concludes that the anastomosing net-
work of which it was composed was the relic of obliterated vessels,
and all the other growths in it products of changes in their adven-
titia ; and that the hyaline degeneration which the growth had under-
gone was caused by the deposit of (probably emigrated) lymph-cor-
puscles, which had partly been transformed into spindle cells. The
starting-point of the tumour must have been the vessels of the serous
coat of the vermiform appendix and neighbouring parts. He refers
loo llEPORT ON PUACTICAL MEDICINE.
to the published cases of cylindromatoua tumours, and calls the one
described by himself angioma mucosum proliferum.
Dc Morgan, "On the Origin of Cancer," * Lancet,' 1871, ii, 6. Aruott, "Notes on
the Pathology of Malignant New-growths: Carcinoma," 'Med, Tiines and Gaz., 1871,
i, 566. Silver, "Cancer beginning in the Inguinal Glands and extending upwards
along the Lymphatics into the Chest" (man, set. 23), ib., ii, 769. Coats, "The
Structure of the Myxoma and Sarcoma, with Illustrative Specimens," * Glasgow Med.
Journ.,' iv, 35. Kaschewarowa-Rudnewa, " Myoma Striocellulare seu Rhabdomyoma
Myxomatodcs Vaginse," 'Virch. Arch.,' liv, 65. Lang, " Ein Beitrag zur Kenntniss
der sogenannteu Dermoidcysten," ib., liii, 128. Armauer-Hansen, " Beitriigc zur
nonnalen und pathologischen Anatomie der Lymph driisen," ib., Ivi, 280. Perls,
" Beitrage zur Geschwulstlehre," ib., 437. Acker, " Zur Pathogenese der Geschwulst-
metastasen," *Deut. Arch.,' xi, 173. Neumann, " Ueber Sarcome mit endothelialen
Zellen nebst Bemerkungen iiber die Stellung der Sarcome zu den Carcinomen,"
'Arch, d. Heilk.,' xiii, 305.
I. — CLIMATE AND HEALTH-EESORTS.
Holden ("Ostracism for Consumption," *Amer, Journ, Med. Sci.,'
Ixi, 107) asserts that the elEcacy of a long sea voyage is gradually
becoming more evident. The testimony even of those who have simply
crossed the Atlantic on their way to Italy, Madeira, or Syria, will be
almost universally found in its favour. "Within a week after losing
sight of land the cough frequently subsides or changes in character,
dyspnoea is relieved, the appetite returns, and with it a sense of new
vigour and hope of recovery. The voyage to Cape Horn, Sydney, and
thence to San Erancisco by sea, &c., offers all the combined benefits to be
looked for. As to American resorts, he recommends Plorida, Aiken,
South Carolina, and Minnesota. At the same time the object of his
paper is to "protest agsinst the growing recklessness in sending patients
who fail to improve out of sight."
Maclaren (' Med,-Chir. Eev.,' xlvii, 193) writes on a long sea voyage
in phthisis pulmonalis. He gives short notes of his own and nine other
cases, and relates some useful facts as to the voyage to Australia.
From the time of leaving England the temperature steadily rises until
the vessel is close on the line, generally in a month or five weeks ; it
then gradually falls, until the most southerly point in the passage is
gained, which may, perhaps, be in another month ; during the remainder
of the time it rises slightly until Australia is reached. He sketches
the good hygienic conditious in which the patient is placed — pure un-
contaminated air, pure water, absence of drains, good food, with gene-
rally a large proportion of fat. *' But a sea voyage is a rough remedy,
and it cannot be expected that it will be beneficial in every case."
Eattray (' Proc. Eoy. Soc.,' xviii, 529 ; xix, 295) describes some of
the more important physiological changes induced in the human
economy by change of climate, as from temperate to tropical, and the
reverse. Tropical climate causes loss of weight and depression of both
mental and bodily energy. With hard work and diet of salt meat the
loss is greatly increased.
Sesary (' He la temperature de la ville d'Alger au point de vue des
Maladies Chroniques de la Poitrine ;' Alger, 1872) shows that the
study of maximum temperatures is of more importance from a medical
CLIMATE AND HEALTH-RESORTS. lOl
point of view tlian that of mean temperatures. From the ist of May
to the ist of November, or thereabouts, the climate of Algiers is hot,
and utterly unsuitable for phthisical patients, who would find benefit
from the temperate season between the beginning of November and
the end of April. (This publication is probably referred to in an
I article on "Algeria as a Health Eesort" in the ' Lancet,' 1872, i, 342.
' —Bep.)
Pulling, " The Pine Forests of Georgia as a Resort for Invalids," ' New York
i Med. Journ.,' xiv, 232. Mattocks, 'Minnesota as a Home for Invalids,' Philadelphia,
1871. Reimer, "Climatische Wintercurorte," ' Deut. Klin.,' 1871, 422. Lantoin,
"Notes concernant la Topographic medicale de differentes Localites du littoral de
rOcean Pacifique, recueillies pendant la campagne dela Fregate VAstree (1868-187 1),'*
*Arch. de Med. Nav.,' xvii, 161. Bourel-Ronciere, *' Le Station Navale du Bresil et
de La Plata," ib., 23. Macpherson, " Notes of Visits to Foreign Baths," ib., 460.
Taylor, " The Climate of Pau," ib., 1871, ii, 535. Simons, "Climate in its relations
to the Production, Progress, Amelioration and Cure of Consumption," 'Amer. Journ.
Med. Sci.,' Ixiii, 82. Morehead, " Remarks on the Health-Resorts of Europe," * Edin.
Joui'u.,' xvii, 1080. Grabham, 'The Climate and Resources of Madeira,' London,
187 1. Cannes and the Isles of Lerins " (good general description), ' Sat. Rev.,' Sept.
2, 1871, 304. Brown, 'Wintering at Mentone, on the Riviera,' London, 1872, pp.
1 76 (light reading).
19^
RDi^OET ON PUAdTICAL MEDlClNti.
List of Errata in last 'Report on Practical Medicine.
Page 50, line 10 from top, /or "lanula" read "lunula."
52, „ I „ o/iter " suchung " dfe^ full stop.
59, „ 7 „ read ring."
66, Seidel's cases should probably have been included under typhoid fever.
73, line 3 from bottom, /or "considerable" read "considerable."
88, „ 8 ,, /br " sudariparous " reac^ " sudoriparous."
92, „ 3 from top, after " Gaz." read " 1869,"
102, „ 19 „ yor '*i'^ reac^ "1."
i03> 5J 7 » a/^er " Hysteric " <?e?e full stop.
119, ,,17 „ /or " Acetus " reaci " Acutus."
119, „ 4 from hottom, for " retina} " read " Retina?."
132, „ 14 from top, /or "Thus" rea/? "In the same way."
i39> j> 13 » /or " pas " reac? " par."
147, „ 24 „ /or "Arabree'sche " reat? "Aubree'sche."
185, „ 15 from bottom, /or "Eutozoares" read " Entozoaires."
187, „ 18 from top,/or "latter" reac^ "delirium."
187, „ 17 from bottom, /or "these" rea<i "there."
" lb." is in many places printed for " Id."
The following errata in the present Eeport have been overlooked :
Page 34, line 24 from bottom, /or " appearances" read " appearance."
40, „ 21 from top, /or "abaissment" reat^ "abaissement."
41, » 19 „ /or " Burke" reac? " Barker."
44, „ 2 from bottom, /or "Selteuer" read "seltener."
47, last line, after " employment" read " in."
50, line 14 from bottom, /or " Dr." read " Do."
70, „ 7 from top, after " 1872" read " pp."
73> >, 10 „ a/)fer " Beitrag" cZeZe full stop.
79, „ II from bottom, /or "Des Parasiten" read " Die Parasiten."
KEPORT ON SURGERY.
BY
WAEEN TAY, F.E.C.S.,
ASSISTANT-SUEGEON TO THE LONDON HOSPITAL, ETC.
AncBsthetics. — The number of deaths which have occurred, lately, from
chloroform, the reported immunity of ether from such accidents, the
visit of Dr. Joy Jeffries to the Ophthalmological Congress held in
London, and his practical demonstrations of the manner in which ether
is given in America, have contributed to excite, anew, the discussion aa
to the relative merits of the various anaesthetics, and to lead to a trial
of ether on a large scale in this country. All the journals have con-
tained articles on the subject, and papers have been contributed by
many administrators.
In the 'Lancet' for Nov. i6 and Dec. 7, 1872, is a report on anaes-
thetics and anaesthesia. In the former number is an account of a case,
published in the ' New York Medical Eecord,' of a death from the ad-
ministration of ether. This case is also noted in the other journals.
Ether and chloroform. — Mr. "W. Haward gives the following conclu-
sions as to the effects of chloroform in fatal cases: — (i) That in the
majority of fatal cases the mode of death is by failure of the heart's
action. (2) That this failure is generally sudden. The chief danger
from chloroform is a sudden arrest of the heart's action, and this danger
does not appertain to ether. It has been shown, by Dr. Snow, that it
is impossible to paralyse the heart by ether inhalation. Ether, pro-
bably, even stimulates the heart. It has the advantage of being antago-
nistic to the effect of the shock of an operation. Mr. Haward thinks
that there is less liability to sickness, after the administration of ether,
than after chloroform. The chief objection to ether is the greater
quantity that is required, but this, to some extent, may be overcome.
The most convenient form of apparatus is a cone of felt, covered with
oiled silk or macintosh, into the upper part of which is fitted a piece
of sponge, which can be changed occasionally for a similar piece kept in
a basin of warm water. A shallow gutter running round the inside of
the cone prevents the ether from reaching the patient's face. An aper-
ture, the size of which can be regulated by the finger, admits more or
less air as may be required. The principles to be attended to, in the
administration of ether, are — (i) To scatter the ether on to a surface
which allows its evaporation without much absorption. (2) When the
13
194 REPORT ON SURGERY.
temperature of tliis surface is so much reduced that the ether is too
slowly evaporated, to change it for a warm one. (3) To give the
vapour freely, at first, so as to bring the patient under its influence as
quickly as possible, by which the tendency to struggling is lessened.
The two chief inconveniences, which Mr. Haward has found, are, the un-
pleasantly noisy excitement sometimes manifested when the patient is
recovering from its influence, and the rapid diftusion of the vapour
about the room, which is to some disagreeable. The easy inflamma-
bility of the vapour must also be borne in mind. A table of thirteen
cases of deaths from chloroform is given, and also a table of cases iu
which ether was administered, ninety-seven in number. In only one,
was there after-sickness, and, in that case, the patient only vomited once,
an hour after the operation. (' Med.-Chir. Trans.,' Iv, 5.)
Anaesthetics, by Dr. Jones (' Brit. Med. Journ./ Nov. 23 and 30, 1872).
Chloroform and its administration. Dr. Vivian Poore (* Lancet,' Oct. 12, 26, Nov,
16, Dec. 14, 1872) contributes clinical remarks on chloroform and its adminis-
tration.
Chloroform accidents, by J. T. Clover (* Brit. Med. Journ./ July 8, 187 1).
A clinical lecture on Death from chloroform, by Mr. Erichsen, is given in Brit.
Med. Journ./ June 8, 1872.
The administration of ether ^hy John Couper ('Brit. Med. Journ./ Nov. 30, 1872).
The administration of ether, with a figure of an apparatus, by Dr. Morgan (' Brit.
Med. Journ.,' Nov. 23, 1872).
Ether as an ancesthetic, by Dr. Morgan (' Brit. Med. Journ.,' Oct. 12, 1872).
The administration of ether, by G. E. Norton (' Brit. Med. Journ.,' Dec. 7, 1872).
He figur-es an apparatus.
Ether V. Chloroform, article in *Brit. Med. Journ.,' Nov. 2, &c., 1872.
Nitrous oxide still holds its place as a safe anaesthetic, adapted, at any
rate, for short operations ; chiefly the extraction of teeth. A case is
just now reported from Exeter, in which death followed the administra-
tion of nitrous oxide, but the pulse and respiration were noticed for
some minutes after serious alarm was excited. There was no post-
mortem. The case will probably remain doubtful as to the exact way in
which death occurred. (' Brit. Med. Journal,' &c., Feb. i, 1873.)
Antiseptic surgery. — Mr. Lister's address, before the Brit. Med.
Assoc, enters, fully, into the question of antiseptic surgery. It has
been published in all the medical journals, and, therefore, must be
accessible to most readers. l^'uU abstracts referring to previous papers
are given in preceding ' Bien. Hetrosp.' We need, now, only refer to the
carbolic spray and the gauze dressing ; the chief novelties, we believe,
which have been introduced and which have been adopted in many
quarters. Numerous cases of successful antiseptic treatment have been
noted in the various journals. Antiseptic gauze. — Mr. Lister de-
scribes it as being a loose cotton fabric, the fibres of which are impreg-
nated with carbolic acid, securely lodged in insoluble resin, which holds
the carbolic acid with remarkable tenacity, while, at the same time, a
little paraffin is added to prevent the adhesiveness, which the mixture of
carbolic acid and resin would otherwise possess. The fabric is porous.
A piece of oiled silk protective is applied next the skin, then a con-
siderable quantity of the gauze is taken and folded into about eight
layers and placed over the protective. In order to compel the dis-
ANTISEPTIC AND OTHER DRESSINGS. 195
charge to pass through the whole of the gauze before it can reach the
surface, some impermeable surface must be interposed between the
gauze and the external air. A cheap and light form of macintosh,
termed " hat-lining" by the india-rubber dealers, answers well. A piece
of this is cut and placed beneath the layer that is intended to be out-
ward. The discharge, then, cannot come straight through. The whole
is retained by a bandage carefully applied. The dressings are changed
according to the same principles as formerly noted. Carbolic spray. —
This is applied by means of one (or more) of Richardson's spray pro-
ducers. The spray is kept playing over the part, operated on, or being
dressed. The solution of carbolic acid need only be of the strength of
one part in two hundred of water. Mr. Lister discusses the treatment
of abscess ; ligature of arteries ; application of catgut stitches to ten-
dinous openings in umbilical hernia, &c. ; ununited fracture of neck
of thigh bone ; removal of loose cartilages from knee-joint ; senile gan-
grene ; ulcers, &c. ('Brit. Med. Journ.,' Aug. 26, 1871, and other
journals).
Some surgeons wash the wound out with a strong solution of chloride
of zinc (Mr. De Morgan's plan, noticed in previous ' Bien. Retrosp.'),
and then dress antiseptically, instead of using the spray the whole time.
The antiseptic catgut ligature is spoken of, favorably, in many quarters.
The principles involved in its employment have been noticed in pre-
vious * Bien. Eetrosp.' Cases in which secondary hsDmorrhage has oc-
curred, in spite of it, are recorded, now and then ; some are alluded to
further on. Mr. Lister does not recommend the catgut ligature unless
the surgeon can make sure of antiseptic dressing afterwards.
A case illustrating the present aspect of the antiseptic system of treat-
ment in surgery is narrated at length by Mr. Lister. In the treatment
of an old injury about the elbow he found it necessary to divide the ulna
and snip off the head of the radius to allow of the reduction of a dis-
location which existed. He did this, with confidence, under the influ-
ence of the antiseptic dressing. (* Brit. Med. Journ.,' Jan. 14, 187 1, 30.)
Antiseptic surgery, a graduation thesis, by Dr. James Cuniming, is given in the May
number of the 'Ed. Med. Journ.,' 1872, 985. Statistical tables of cases treated by
Mr. Lister are appended.
Dressings of dry lint, Sfc. — In the * Edin. Med. Journ.,' February,
187 1, are narrated various cases of amputation of the thigh, excision of
the knee, removal of the breast, &c., under the care of Dr. Gillespie, in
which rapid recovery followed, the only dressing used being dry lint, at
first, and then water dressing. For the removal of tumours, in five in-
stances, the average length of incision was seven inches ; the average
time of complete recovery was ten days. See also Mr. Callender's
cases further on.
Treatment of wounds hy alkaline amplications. — Mr. Monson (* Brit. Med. Journ.,
Oct. 5, 1872).
The "open treatment of operation wounds.— Dr. Kronlein, in an
fessay on this subject, gives the results of observations made on 6000
cases in the surgical clinic at Ziirich during the years 1 860-1 872. He
196 REPORT ON SURGERY.
draws a comparison between the results observed from i860 to 1867,
when, under Billroth, the open treatment was but rarely followed, and
those met with in 1868-1872, when, under Rose, this plan was followed
almost without exception. There were no alterations of any importance
in the building or other arrangements of the hospital during the time.
Kronlein first gives a history of the subject. In 1856, Yezin, of
Osnaburgh, described, in the * Deutsche Klinik,' the results of thirty
amputations which he and Bartscher had performed in the course of
twenty-one years, and of which only three had proved fatal. In 1859,
Burow, of Konigsberg, stated that he had had only three deaths in 62
cases of amputation. Vezin and Bartscher applied no kind of means
for uniting the wounds ; while Burow used sutures half an hour after
the operation, tying them, however, in such a way that they could be
readily loosened in case of distension. In all other respects the wounds
were left without dressing. In 1866, Burow had increased the number
of his cases to 94, still with only three deaths. In 1867, Passavant
stated that he had followed the method in cases of resection ; it was also
adopted by Billroth and Esmarch, while Stromeyer, Pirogoff, and
Liicke, spoke with more reserve of its value. Rose's plan agrees with
that of Bartscher and Vezin ; he does not attempt to obtain healing by
the first intention, but regards careful arrest of haemorrhage, and as
perfect rest as possible, as conditions necessary for success.
In the statistical portion of his essay Kronlein gives the comparative
results obtained in the larger amputations, extirpation of the breast,
and the conservative treatment of complicated fractures. During the
years i860 — 1867 there were 140 amputations, of which 72, or ^1*4 per
cent., were fatal ; from 1867 — 1871 there were 85, with a mortality of
•17, or "20 per cent. Neither the place of the amputation nor its
cause, the age or sex of the patient, or the mode of operating, produced
any essential differences, and Kronlein thence concludes that the
improved results can only be attributed to the after-treatment. In six
cases healing took place without any fever. Of extirpation of the
breast there were, in the first period, 34 cases, with a mortality of 32-2
per cent. ; and, in the second, 22 cases, with a mortality of 13*6 per cent.
In the first period, 86 cases of complicated fracture were healed con-
servatively, of which 25*^ per cent, died; in the second, 6^ cases, with
a mortality of 21 '5 per cent. Hence Kronlein concludes that, in the
Ziirich hospital at least, the open method of treatment has proved
superior to all others.
Some interesting statistics are given regarding the occurrence of
accidental surgical disease. In the first period, the proportion of deaths,
from pyaemia and septicaemia, to the total number of deaths was as 22*6
to 40*3 ; in the second, it was as 6*9 to 197. On the other hand, the
number of cases of erysipelas increased ; in the first period, there were
39 cases among 260 patients, or 11*5 per cent. ; while, in the second,
there were 26 cases among 172 patients, or 15' i per cent. This increase
of erysipelas Kronlein attributes to the changes of temperature, which
occur in a hospital freely ventilated by natural means, as is that at
Ziirich ; and he suggests that it might be obviated by well-regulated
artificial ventilation.
ACUPRESSURE. ] 97
Acupressure. — Prof. Pirrie writes on this subject in the ' Lancet,' ii,
187 1. Having, since his former communication, nearly doubled his
experience, and feeling fully convinced as to the efficacy of acupressure,
he is anxious to see it more generally adopted. Three modes only are
required ; they are now named Circumclusion, Torsoclusion, and Retro-
elusion. In the first method, a pin and a loop of inelastic wire are
required, in the other two, only a pin. Circumclusion consists in enter-
ing a pin in the tissues, a line or two to one side of the artery, pushing
it behind and causing its point to emerge a little beyond the vessel ;
passing a loop of inelastic iron wire over the point of the pin, bringing
the wire over the track of the artery and behind the stem of the pin,
drawing it sufficiently tight to close the vessel, which is proved by the
arrest of the haemorrhage, and fixing it by a single twist around the
pin. The slight amount of direct and continuous pressure required to
produce perfect arrest of circulation through an artery is remarkable.
Of all methods of acupressure this is the best ; it is perfectly reliable,
it is most generally applicable, it may be performed in an amazingly
short time, and, like the other methods, in ordinary circumstances with-
out the aid of an assistant. When the artery is to be relieved from
pressure the head of the pin must be gently twirled, and having been
thus loosened, may be pulled out with the greatest ease without caus-
ing any pain ; after which, the loops, being liberated, can be readily
withdrawn.
Torsoclusion is the " Aberdeen" method, or the method by the twist.
It consists of two stages. A pin is thrust into the tissues close to the
mouth of a vessel, pushed along in its direction for a short distance ;
then, secondly, a quarter turn is given to the pin, so as to place its
emerged extremity, above, and at right angles to the artery ; it is pressed
well down against the small portion of tissue between the instrument
and the artery, and the point is sent, for some distance, into the tissues
beyond the artery, for the purpose of securing the pin in position and
of maintaining the twist. This is the simplest, the easiest, and the
quickest method, and is perfectly efficient. There can be but little
molecular injury or straining of tissues, and by the gentlest twirl and
traction the pin can be easily withdrawn, with extremely little, if any,
discomfort to the patient.
Retroclusion, so named in consequence of the pin passing ultimately
behind the artery, is a convenient mode of securing vessels of small, or
very moderate size. In the first step, the pin is entered in the mus-
cular tissue, a little to one side of the artery, held almost flat upon the
wound, caused to emerge and passed in front, across, and a little beyond
the track of the artery. Only a few muscular fibres are raised upon the
pin, and it is caused to emerge before being sent across the track of the
artery. In the second step, the head of the pin is made to describe the
greater part of a semicircle, so as to be placed nearly flat on the opposite
side of the wound ; its point is then sent behind the artery, in the con-
trary direction to that in which it passed in the first movement, and
pressed on until it is fixed in the tissues beyond the vessel. Figures
are given.
Experience has shown that in ordinary circumstances where acupres-
198 REPORT ON SURGERY.
sure has been skilfully performed, vessels of comparatively small size,
such as the facial, temporal, radial, ulnar, mammary, and spermatic,
may be safely freed from pressure in eight hours ; and larger arteries,
as the brachial, axillary and femoral, in twenty-four. In one case a boy
vrhose thigh had been amputated removed the pin in four hours, from
the femoral, without any haemorrhage resulting. In another case the
axillary was relieved in fifteen hours without ill result. Of two thousand
arteries, acupressed, haemorrhage only occurred twice on the removal of
pins, and the vessels were immediately secured again. Tlie result of
acupressure is adhesion of the internal surfaces, with the formation of
an internal coagulum more or less adherent to the artery. Since
March, 1864, Dr. Pirrie has practised acupressure in all kinds of opera-
tions without failing to arrest haemorrhage. Cases are mentioned in
which rapid union followed in large wounds. Dr. Pirrie has not seen
a case of septic poisoning since adopting acupressure.
Mr. Clement Lucas describes a new plan. He uses an ordinary
acupressure needle, with a ring at the end opposite the point, and a loop
of wire. The needle, at about an inch from its point, is twisted round
on itself, so as to form another ring. The loop of wire is first passed
through the ring, at the end of the needle, and then through the second
ring, so that the end of the loop will pass over the point of the needle.
The loop is then bent up out of the way, and the needle and wire may
be so kept ready for use. When employed, the pin is passed under
the artery, as far as the second ring, the loop of wire is bent down, over
the point and then withdrawn, along the needle, till the artery is com-
pressed as tightly as desirable, when the distal ends of the wire are
secured round the needle. To remove it the wire is untwisted and the
pin pulled on. If bleeding occur, the wire is again tightened, if not, the
needle is removed altogether. The plan is easy of adoption, and safe,
and is the only one which allows of being' reapplied, if bleeding occurs,
at once, without opening the stump. Pigures are given. (' Lancet,'
Sept. 2, 1871, 320.)
Cases illustrating the process of occlusion in arteries after acupressure, with
its relation to the treatment of surgical haemorrhage and as compared with ligature
and torsion, are given, by J. J. Gant (' Clin. Soc. Trans.,' iii, 95), with illustrations.
Torsion of arteries and dressing of wounds. — Mr. Callender's expe-
rience has been in favour of torsion. His first dressing has been, first,
the leaving the surfaces to nature, after carefully arresting bleeding,
and after placing them in apposition ; secondly, thorough covering up
of the wound with lint or with cotton-wool. (Clin. Lecture, * Brit.
Med. Journ.,' Jan. 20, 1872.)
Surgical treatment of aneurism. — Mr. Holmes enters, in detail, in
the surgical treatment of aneurism, in his lectures at the College
Surgeons, in June, 1872, published in full, in the * Lancet ' and in the
form of abstracts, in the other medical journals. Space will not allow
of our following him in his critical examination of the cases published.
The main propositions are stated succinctly by himself: i. That aneu-
risms, of whatever form, and however near the heart they may be, ought
not to be regarded as incurable, but should be made the objects of
It. ,
i
TREATMENT OP ANEURISM. 199
definite, methodical treatment, internal or external. 2. That there is
definite proof, from pathological anatomy and from surgical experience,
of the curative influence of Brasdor's operation in innominate aneurism,
and of its beneficial effects in some cases of aortic aneurism. 3. That
arteries may be successfully tied and obliterated without their con-
tinuity being interrupted ; and that this modification of the ligature,
whilst affording much security against secondary haemorrhage, and thus
much diminishing the danger of the operation in general, may very
probably, in future, enable surgeons to deal successfully with cases in
which it may be necessary to tie the first part of the subclavian (whether
on the distal or proximal side of an aneurism) or the innominate artery.
4. That galvano-puncture may be used with, at any rate, temporary
benefit in thoracic aneurism ; that its use is not so dangerous as to
render further trials of it inexpedient ; and that there is good hope that
the method may be so far perfected, as to make it a safe and regular plan
for the treatment of thoracic, subclavian, and other forms of aneurism.
^. That many cases, such as those in which ligature of the artery, near
to the heart, has been resorted to, for the cure of subclavian and sub-
clavio-axillary aneurism, may be made amenable to improved methods
of pressure. 6. That aneurismal tumours situated even as high as the
lower part of the abdominal aorta, those of the mesenteric and other
branches of the aorta and of the iliac arteries, may be treated with suc-
cess by rapid coagulation of blood under pressure ; but that this method
is a dangerous one, and should not be used until internal treatment has
failed. 7. That there are cases of abdominal aneurism in which Mr.
Syme's suggestion of reviving the old operation is worthy of further trial.
Mr. Bryant has published clinical lectures on the treatment of
aneurism. He narrates a case of ligature of the femoral artery for
femoro-popliteal aneurism, in which death from pyaemia resulted; a
ease of aneurism in the calf of the leg cured by pressure and flexion ;
a case of popliteal aneurism treated by digital pressure, in which a cure
resulted in forty hours ; a case of femoral aneurism treated by com-
pression, followed by ligature and pyaemia ; a case of aneurism of left
carotid, ligature, and death from sloughing of sac thirty-six days after
operation; a case of ileo-femoral aneurism, ligature of external iliac,
and recovery ; a case of aneurism of the innominate, ligature of the
subclavian, and recovery. He discusses the plans in use for flexion,
compression, ligature, and the employment of Spier's artery con-
strictor. ('Med. Times and Gazette,' June 29, July 13, and July
27, 1872.)
Electrolysis and galvano-puncture. — (See further on.)
Injection of ergotin in aneurism. — Dr. Hutoit, of Bern, describes in
the ' Archiv fiir Klin. Chir.,' xii, the case of a man, set. 40, who fell
with his arms stretched out. A swelling subsequently appeared in the
left clavicular region ; it increased, and three years later was recognised
to be a subclavian aneurism. When Dr. Dutoit saw him in October,
1 869, the aneurism was as large as an ostrich's egg ; it pulsated strongly,
and filled the supraclavicular fossa ; the clavicle was eroded and pushed
outwards, and dislocated from its sternal attachment. The integu-
200 REPORT ON SURGERY.
ments, in the neigbbourhood", were oedematous, and the veins were in a
varicose state. As ligature or compression appeared to be impossible,
it was determined to try the plan of injecting ergo tin subcutaneously,
as recommended by Langenbeck. The solution, used, consisted of a
drachm of Bonjean's ergotin, and three drachms, each, of glycerine and
alcohol. Of this, a portion, containing half a grain of ergotin gradu-
ally increased to three grains, was injected in the neighbourhood of the
swelling, at first every second day, afterwards every third day. Alto-
gether fifteen injections were made between October 25th and
December ist. A diminution of the tumour was first noticed after the
fourth injection, and after this continued steadily. The injections pro-
duced sharp pain, lasting for about two hours, but not followed by
abscess. At the points of injection, however, there was left some in-
duration of the skin and subcutaneous tissue, which compressed the
veins and, probably, had a similar eff'ect on the aneurism. In the
beginning of December, the supraclavicular fossa was free from the
tumour; digital compression was now applied during three hours, in
the morning and three, in the afternoon, for six days ; under this treat-
ment the tumour totally disappeared. As a precautionary measure,
ten injections containing, each, three grains of ergotin were administered
at long intervals, and compression, with a bandage and pad, was kept
up for some time. The aneurism, when the patient was last seen (July,
1870), was quite cured, forming a hardened mass attached to the
sternum and clavicle.
Muscular spasm relieved by compression of arteries. — M. Broca having
found, in his own person, that compression of the femoral artery relieved
cramp of the leg, conceived the idea of applying the same treatment
to constant, violent, muscular contraction in a case of fractured leg
which came under his care. The spasms were so violent and painful
that the limb could not be put up in splints. On applying pressure
to the femoral artery the contractions at once ceased ; and on their
recurring, at a later time, when the dressings were being readjusted,
compression was again applied successfully. (' Journal de Med. et
Chir. Prat.,' March, 1871.)
Aneurism of the common carotid artery; ligature. — A man, 8Bt. 39,
came under the care of Mr. James Lane on account of a large, pul-
sating tumour on the right side of the neck, of nine months' duration.
The artery was ligatured about two inches above the sterno-clavicular
joint with a silk ligature. Increase of temperature was noted, on the
same side, for the first two days. The temperature then sank to the
normal, and, finally, below that of the opposite side. The man pre-
sented himself for examination eleven weeks after the operation, and
scarcely any trace of the tumour could be discovered. (' Lancet,* Oct.
14, 1871, 541.)
Mr. Gamgee narrates a case in which he ligatured the left common
carotid artery, below the omo-hyoid, for aneurism. The patient died
six days later. It was found that he had a cancer of the rectum which
had ulcerated into the peritoneum and set up peritonitis. The condi-
tion of the wound and of the aneurism had been very satisfactory.
(* Lancet,' June 3, 1871, 741.)
ANEURISM LIGATURE OF ARTERIES. 201
Aneurism of the innominate — apparent cure. — A case in which
aneurism of the innominate was diagnosed, and in which a cure appa-
rently followed, is recorded by Mr. Morgan. Ice was applied and sul-
phate of iron and digitalis (three drops of the tincture twice daily)
given internally. The treatment was continued about a month. The
man resumed his occupation, having been quite unable to do so before.
The man remained, apparently, quite cured at the time of the last note,
at the end of eighteen months. (* Dub. Quart. Journ.,' Feb. 1871,
^44-)
A case of axillo-subclavian aneurism was treated by digital pressure
on the cardiac side. Sloughing of the skin and deep tissues occurred
around the sac. Ultimately a partial cure resulted. The patient was
a man, set. 45, under the care of Mr. Gray. ('Lancet,' Eeb. 10, 1872,
Aneurism of the ascending portion and arch of the aorta, treated hy
ligature of the left carotid artery. — A man, set. 48, a farm labourer, came
under the care of Dr. Cockle for an aneurism of the arch of the aorta.
The symptoms are given in detail. The left carotid artery was liga-
tured above the omo-hyoid by Mr. Heath. The wound healed quickly.
The symptoms, of tumour pressing forward the sterno-clavicular articu-
lation and bulging into the neck, of impulse, of inequality of the pupils,
Ac, diminished or disappeared. At the end of four months he had con-
tinued to improve, and walked fourteen miles in one day. He was
shown at the College of Surgeons, and his case was commented on b}^
Mr. Holmes. (See 'Lancet,' July, 1872; 'Clin. Soc. Trans.,' v,
Subclavian anev/rism ; temporary compression of innominate artery hy
n elastic compressor specially contrived ; ulceration of vessel ; antiseptic
ligature ; secondary haemorrhage on fifth and sixth days ; death. — Mr.
Bickersteth communicated the case to the Med.-Chir. Soc, Nov. 26,
1872. (Abstracts 'Med. Journ.')
Ligature of the subclavian artery. — Sir W. Fergusson ligatured the
subclavian artery for axillary aneurism ('Med. Times and Gaz.,' Feb. 25,
1871, and ' Brit Med. Journ.,' March 4, 1871). He found the omo-
hyoid a good guide. The patient died. A second case is also reported
('Med. Times and Gaz.,' April 22, 1871, 453). The aneurism was
traumatic. A healthy young man was wounded, five or six wrecks before,
with the prongs of a pitchfork, one of which entered at the anterior
margin of the deltoid muscle, and probably damaged the axillary artery.
The wound healed, but soon afterwards a pulsating swelling was noticed
in the armpit. When admitted, there was a tumour, the size of an
orange, high in the axilla. Sir W. Fergusson remarked that he would
have been justified, as it was a case of wounded vessel, in cutting down
and tying the artery above and below ; but there are exceptions to the
best surgical rules. The wound would be extensive ; the vein might
also be affected ; there might be great haemorrhage ; compression of
the subclavian is a doubtful safeguard. An objection to the proximal
ligature might be found in the " collateral circulation." This objection,
however, though abundantly proved as regards the brachial artery, has
never yet been established as regards the axillary.
202 BEPOIIT ON SURGERY.
Mr. Gay tied the right subclavian artery, in the second part of its
course, for an aneurism involving the subclavian and axillary arteries.
The patient died, on the nineteenth day, of bronchitis. The condition
of the parts at the seat of the operation was quite satisfactory.
('Lancet,' May 6, 1871, 611 ; also 'Path. Trans.,' xxii, iii.)
Ligature of the carotid and subclavian arteries. — In a case of aneurism
at the root of the nech, Mr. James Lane ligatured the carotid and sub-
clavian arteries. The patient, a woman, set. 40, recovered. Some tem-
porary improvement followed ; but ultimately the aneurism steadily
increased in size, the sternum and clavicle becoming eroded. (' Lancet,'
Jan. 13, 1782, 45.)
Aneurism of the arch of the aorta simulating innominate aneurism;
attempted distal operation. — Mr. Heath intended to ligature the sub-
clavian and carotid arteries, but, in attempting the former, found the
sac (of what proved to be an aortic aneurism) in the way and desisted.
Eemarks are made on the bearing of the case on distal ligature. The
patient was in a dangerous state, and might have died from bursting
of the sac at any time. Probably the operation hastened his death.
There would have been no difficulty in ligaturing the common carotid
artery, and it is an interesting speculation as to the influence this, alone,
would have on the result. The left subclavian was obstructed. (' Path.
Trans.,' xxii, 95.)
Traumatic axillary aneurism; ligature of the subclavian; recovery. — Dr.
C. C. E. Gay records the case of a man, set. 26, who had been wounded,
six years previously, by a pistol-ball, in the front of the left shoulder.
8oon afterwards a tumour was noticed in the armpit. The ball was
never removed. A tumour, as large as a child's head, projected in
front of the axilla on the chest. It seemed like a large abscess about
to burst. No bruit could be detected, nor any pulsation. The arm was
paralysed, and there was no radial pulse. A needle, thrust in, gave exit
to a few drops of blood. A trocar gave exit to a little blood. An in-
cision was made down to a blue surface, and then pressure with the
handle of the scalpel burst the sac, and blood spurted out profusely. A
free opening was then made into the sac and compression made with
the finger of an assistant, while the third part of the subclavian was
tied. On the seventh day there was secondary hiemorrhage, which
stopped with pressure. The paralysis of the arm was disappearing, but
the radial pulse had not returned when last seen. (' Am. Journ. Med.
Sciences,' Oct. 187 1, 392.)
Traumatic aneurism of the vertebral artery. — Dr. Kocher, of Bern,
relates, in Langenbeck's ' Archiv fiir Klin. Chirurg.' (xii, 867), the case
of a man named Abraham S — , set. 48, who, three weeks before his
admission into hospital, on October 27, 1868, had received three stabs
in the nape of the neck and one over the scapula. The latter wound
and two of the others soon healed ; but the fourth had remained open,
and from it there had been daily hsemorrhage, often profuse. This was
restrained by plugs soaked in styptic solutions, over which was laid a
compress of charpie moistened with solution of perchloride of iron, the
whole being covered by a bandage. On removing these dressings
there was seen, about an inch to the left of the spine, at the level of
TRAUMATIC ANEURISM OF THE VERTEBRAL ARTERY. 203
the fifth and sixth cervical vertebraB, a roundish wound about two thirds
of an inch in diameter. There was also observed through the opening
a swelling, which'was distinctly seen and felt to pulsate, though feebly.
On removing the coagulum which lay in the wound, some dark blood
escaped ; and on the removal of the finger after its introduction into
the wound, a rather violent haBmorrhage of bright red blood followed.
Digital pressure not arresting the bleeding, the wound was laid open to
the extent of about three inches, and a large quantity of coagulum was
removed by the finger. There was thus found to be a cavity of the
size of a small apple, at the bottom of which were felt the posterior
surface of the left articulating processes, and, more distinctly, the trans-
verse processes of the vertebrsB. A transverse incision was now made,
an inch and a half, in the anterior and half an inch, in the posterior,
direction ; and the blood was seen to come from a point between the
transverse processes of two vertebrae, apparently the fifth and sixth.
Arterial blood escaped from both the central and the peripheral portions
of the artery ; and the bleeding was arrested by pressure against the
transverse processes, either from above or from below. As a ligature
could not be applied, a plug of charpie of the size of a pea, soaked in
solution of perchloride of iron, was introduced between the transverse
processes, and left there, as soon as it had been ascertained that the
bleeding had ceased. The external wound, having been closed by
sutures, was covered with charpie, dipped in carbolised glycerine,
Lister's carbolic acid paste was applied, and the dressing was retained
in place by a bandage. The head was kept fixed by a stiff collar. The
plug in the deep part of the wound was removed on the fourth day after
the operation, partly by means of a stream of water, partly by forceps ;
no bleeding followed. With the exception of a slight attack of erysi-
pelas, which extended from the spine along the right side of the chest
and right arm, the patient made steady progress towards recovery,
and was discharged, cured, a little more than five weeks alter the
operation.
Kocher remarks that this is the twenty- first recorded case of
traumatic aneurism of the vertebral artery, sixteen having been collected
by Barbieri of Milan, and four having been referred to, by Pilz, in an
essay on ligature of the carotid artery, published in the ninth volume of
the * Archiv.' Of the twenty cases, eleven were the result of stabs. In
ten cases the result was fatal, before any pulsating swelling appeared.
When an aneurism was formed it was generally about three weeks
after the injury, and fourteen days after the healing of the wound. In
Kocher's case, however, and in one recorded by Mobus, violent bleeding
occurred on the seventeenth day, and a pulsating tumour was noticed on
the removal of the bandages.
The presence of a wound in the vertebral artery, or of a traumatic
aneurism, has been ascertained by post-mortem examination in seven-
teen cases. In a fatal case recorded by Praeys, in which no necropsy
was made, there was a pulsating tumour one inch below the mastoid
process, the pulsation in which was arrested by pressure, but not in
the least degree by ligature of the carotid. Kocher says, that his and
Mobus's cases, of traumatic, vertebral aneurism, are the only two that
201 REPOKT ON SURGERY.
have terminated in recovery. In Mobus's case there was a tumour
below the occipital bone on the right side. It might have arisen from
either the occipital or the vertebral artery; but pulsation was not
arrested by pressure on the occipital artery, nor was the tumour dimin-
ished by compression of the carotid. In Kocher's case it was, at first,
uncertain whether the vertebral or the deep cervical artery was injured ; |
but the haemorrhage, on the removal of the dressing, and the result of !
introducing the finger as far as the transverse processes of the vertebrsB, I
soon rendered the diagnosis clear. ]
In a number of cases, traumatic aneurism of the vertebral artery has ;
been supposed to be seated in one of the branches of the carotid.
Kocher adopts Barbieri's explanation of this. It is that, when the
carotid is compressed against the so-called carotid tubercle, on the
transverse process of the sixth cervical vertebra, the vertebral artery is
also compressed, at its point of entry into the foramen of the transverse
process. The deception is not removed by compressing the carotid at
a higher point, for the vertebral may pass up in front of the transverse
processes. If it be desired to compress the vertebral alone, the plan
recommended by Barbieri must be followed, of applying deep pressure,
from without inwards, at the inner edge of the sterno-mastoid muscle.
Kocher says that compression of the vertebral with the carotid may be
avoided by applying pressure to the latter, laterally, through the sterno-
mastoid muscle. In nine of the recorded cases the wound was at, or
above, the second cervical vertebra ; in two, it is stated, merely, to have
been at the upper part of the neck, and, in six, it was below the second
vertebra. In four of the latter cases it was in the neighbourhood of the
external carotid and its branches. Barbieri believes that the seat and
direction of the wound and the situation of the swelling will aid the
diagnosis, but Kocher dissents from this opinion.
With regard to treatment, Kocher, following Barbieri, says that in
three cases there is no record. In one case, death was the result of
haemorrhage ; in another of compression of the medulla oblongata by
the eff'used blood. Another patient died of meningitis, and another of
septicaemia following suppuration of the areolar tissue of the neck. One
patient died of haemorrhage after the removal of a bullet. In eleven
cases, the carotid artery was tied, through error in diagnosis, and this
operation probably rendered the evil greater, by increasing the pressure
of the blood in the vertebral artery ; indeed, in two of the cases thus
operated on, the patient died of violent haemorrhage from the seat of
injury, and, in three, from bursting of the aneurism. In five cases liga-
ture of the carotid was followed by paralysis and death. Liicke, in a
case in which the aneurism increased rapidly after ligature of the
carotid, injected chloride of iron into the sac, and also applied plugs
saturated with the perchloride ; the patient, however, died with symp-
toms of paralysis. Maissonneuve, in a case of gunshot wound, tied
both the vertebral and the inferior thyroid arteries, and removed the
bullet. The hsemorrhage was arrested, but death occurred from infil-
tration of pus into the spinal canal, and consequent inflammation.
In Mobus's case the treatment for the first seventeen days consisted
in the application of bandages and cold lotions. Haemorrhage then
COMPRESSION IN ABDOMINAL ANEURISM. 205
appearing, astringent solutions, and, later, iced cataplasms were used.
Two months after the receipt of the injury the patient was seized with
severe pain, during which the aneurism diminished, and at last disap-
peared, the patient recovering.
Ligature of the vertebral artery, Kocher observes, is impossible,
except in a portion, about six centimetres long, between its origin and
its entrance into the transverse foramen of the sixth cervical vertebra;
and, in most of the cases, the only remedy, in cases of wound of the
vessel, is the introduction of a plug saturated with some disinfecting
iluid and pressed deeply. If this fail, two resources are left — the appli-
cation of styptics and the Hunterian ligature of the artery. The latter
operation has been twice, only, performed on the living subject — once
by Maissonneuve, in the case already referred to, and once by Smyth,
of New Orleans, in a case of regurgitant hsemorrhage after ligature of
the innominate for subclavian aneurism. Distal ligature of the ver-
tebral artery, between the occipital bone and the atlas, as has been sug-
gested by Dietrich, would be both difficult in performance and uncer-
tain in result.
In applying styptics it is doubtful whether they should be intro-
duced deeply. In one case the nerves lying behind the artery were
iujured, and in another, attended with lesion of the bones, dangerous
inflammation of the spinal meninges took place. If simple plugging
fail, the wound must be laid well open, so that the surgeon can see the
bottom of it ; and the styptic must be applied immediately and exclu-
sively to the bleeding orifices of the vessel. The best styptic is the
solution of perchloride of iron. It is most important that the move-
ments of the head should be restrained by means of a stiff cravat.
When an aneurism has formed, digital compression of the artery on
the transverse process of the sixth cervical vertebra, or injection of
ergotin, in the neighbourhood of the tumour, may be tried. Attempts
to produce coagulation by electricity, or by injecting coagulating fluids
into the sac, are inefficient and dangerous. The Hunterian operation
is uncertain in result, on account of the collateral circulation. The
treatment in which Kocher has most confidence is the early laying open
of the sac and plugging, and, when possible, the direct application of
solution ofperchloride of iron to the bleeding ends of the vessel.
Abdominal aneurism cured hy compression of the aorta. — Dr. Moxon and
Mr. Durham record a case in which an abdominal aneurism was cured
by compression of the aorta. This is the only case recorded precisely
similar to the one narrated by Dr. Murray. The aneurism could be dis-
tinctly felt over a space extending from rather less than an inch below the
cartilages of the false ribs to the level of the umbilicus, and from the
right of the median line to about midway between the median line and
the left border of the abdomen, or rather further. The patient was
kept in bed and perfectly at rest for eleven days. Very sparing diet
only was allowed, and pills of acetate of lead and opium were adminis-
tered every six hours with the view of diminishing the desire for food.
The tourniquet was screwed down very slowly until the pulsation was
completely arrested, the patient being under the influence of chloro-
form. The lower extremities were enveloped in cotton wool and hot
206 REPORT ON SURGERY.
water bottles placed in tlie bed. The pressure was absolutely main-
tained for ten hours and a half. It then seemed desirable to discon-
tinue the treatment. The aneurism no longer pulsated. It was mani-
festly smaller and harder than before the application of the pressure,
In the course of a short time pulsation was again recognised ; it was
very much feebler than before. A little nourishment and a full dose of
opium were given. After this, the patient slept. The next day the
aneurism was smaller, much harder, and less compressible than it had
been. It still pulsated in a marked degree. The general symptoms
M ere remarkably slight considering the severity of the treatment. The
right foot was colder than the other. Tincture of iron and of digitalis
were given in ten minim doses. No bad symptom of any kind arose ;
but the pulsation of the femorals which had returned to some slight
extent soon ceased altogether. The condition of the aneurism varied.
At the end of a fortnight it was not only much smaller, harder and
feebler in pulsation, but such pulsation as remained could be arrested
with great ease, by digital pressure on the aorta. After rather more
than a month the pulsation ceased altogether to be perceptible. The
paper concludes with remarks on such cases as the above. Sphygmo-
graphic tracings of the pulse are given. (' Med.-Chir. Trans.,' Iv,
213.)
Distal compression of the aorta. — Mr. Bryant records a case in which
he employed distal compression of the aorta for abdominal aneurism
situated high up. The patient was a man set. 30. A tourniquet was
applied for twelve hours under chloroform, the tumour pulsating all the
time. Pressure was discontinued for twelve hours and was then applied
for four hours. The man then became very ill and died eleven hours,
Inter, thirty-nine hours after the first application. At the post-mortem
it was found that intestine had been damaged by pressure and had set
up peritonitis, and that the aneurism was consolidated. A drawing of
its condition is given. Mr. Bryant says, ** The interest of this case
is very great." " In a clinical point of view, it illustrates the fact that
peritonitis, as a consequence of contusion of the intestine or perito-
neum, is a danger which must be taken into account in^the use of the
abdominal tourniquet." " It demonstrates the pathological fact that
pressure upon the efferent artery of an aneurism or distal pressure, for
twelve or sixteen hours, is as capable of producing the formation of a
Holid coagulum in a sacculated aneurism, even in a large artery, as pres-
sure upon the afferent vessel, or proximal pressure. The case suggests
inquiry into the value of compression by other means than that of a
tourniquet. I would also suggest that some instrumental means should
be looked for by which the inner and middle coats of an artery may be
divided and allowed to recurve, as in torsion, without destroying the ex-
ternal coat, acting on the knowledge that an artery after a contusion
may become occluded, aud the fact Moore has given us that a blow upon
the common iliac artery may so detach its inner coats as to allow them
to recurve and thus close the vessel."
Mr. Bryant speaks favorably of Dr. Spiers' artery constrictor so
far as he has tried it on the dead subject.
*' The distal treatment of an aneurism is well worthy of renewed
i
LIGATURE OF THE COMMON II.IAC, &C. 207
attention." " Up to the present time the distal treatment of aneurism
has been, with rare exceptions, judged mainly upon the results of the
application of the permanent ligature." " I have a strong feeling that
the distal treatment of aneurism by means of pressure in one of its
forms, is likely to be followed by as much success as has already attended
the treatment by pressure when applied to the proximal side of an
aneurismal tumour." ('Med.-Chir. Trans.,' Iv, 225.)
The case of rapid cure of aneurism by pressure, under the care of Dr.
"William Murray, is published by him in a small volume with an account
of the post-mortem, and remarks on the mode of treatment generally.
Ligature of the common iliac artery for hcemorrhage from an abscess due
to sacro-iliac disease. — Mr. Morrant Baker narrates a case of unusual
character, in which he ligatured the common iliac artery. The patient,
a youth of 17, a gardener, a mouth previously, whilst digging, felt a pain
in the right hip. On examination the whole of the right gluteal region
was found occupied by a tense, elastic swelling, giving on pressure a
distinct sense of fluctuation, acutely tender, and at one point, near the
posterior inferior spine of the ilium, apparently protruding, abscess-
like. It was opened, and a small stream of apparently arterial blood
escaped, but there were no jets. The swelling did not diminish. The
haemorrhage was easily stopped. The swelling was so like an abscess
that a colleague, who was consulted, thought an artery had been wounded
over it, and that a deeper incision had better be made. Chloroform
was given, and an exploration made. The linger entered a large cavity
between the iliac bone and the glutei muscles. The iliac and psoas
regions were full and tense, and on examination through the rectum
a swelling was found in the right ilio-rectal fossa. It seemed that
blood had filled the gluteal, iliac and ischio-rectal regions. On enlarg-
ing the glutenl wound a steady stream of arterial blood welled up
through the great sciatic foramen. This was firmly plugged. It was
decided to ligature the common iliac artery. This was done by a
curved incision near the anterior spine 01 the ilium without much diffi-
culty. On removing the plug from the sciatic foramen, some bleeding
still occurred. This was easily stopped again. The gluteal wound
^became offensive, and the gluteal region and upper part of the thigh
passed into a state of gangrene. The leg and foot, however, remained
unaffected. The patient died forty hours after the operation. The
sacrc-iliac joint was found open and gaped on pressure, and the neigh-
bouring bone was diseased. The remains of a large abscess were found
involving the branches of the internal iliac artery. No trace of aneu-
rism could be found. No affection of the peritoneum or of any ab-
dominal or thoracic viscera was found to require notice. " It is, there-
fore, to be presumed that disease of the sacro-iliac joint was the
beginning of mischief, which, by extension in the pelvis, led ultimately
to ulceration through the coats of one of the main branches of the
internal iliac artery. (' !St. Barth. Hosp. Kep.,' viii, 120.)
Ligature of the external iliac artery ; femoral aneurism. — Cases under
the care of Mr. Lund, and of Dr. Lowe, are noted in the ' Lancet,'
Aug. 5, 1871 (ipi* 192): the patients recovered. Mr. Terry records
a successful case ('Lancet,' Feb. 3, 1872). Mr. H. Smith performed
208 REPORT ON SURGERY.
this operation for femoral aneurism (* Med. Times and Gaz.,' Feb. 25,
187 1, 218). A successful case under the care of Mr. Jessop is noted
in the ' Lancet,' Oct. 12, 1872. A successful case for inguinal aneurism
is noted under the care of I)r. Bernard ('Lancet,' June 22, 1872, 853).
Gangrene of the toes followed. A catgut ligature was used.
Femoro-popliteal aneurism treated by temporary deligation of the
femoral artery, 8fc. ; bullet in head of tibia. — Mr. Stokes records the
case of a man, set. ^6, admitted Aug. 17, 1870, into the E-ichmond
Hospital, suffering from a large pulsating tumour, occupying the lower
extremity of the thigh and popliteal space. He had been a soldier, and
in i860 received a gunshot wound near the knee. The ball entered a
little external to the tuberosity of the tibia, and was never extracted.
Four years later he left the service, and up to the time of his admission
was employed as an agricultural labourer. Three weeks previously,
when going home after a day's work, he felt something " jump in his
ham," and then he first observed the tumour. Pressure was applied
to the femoral, but it could not be borne. On Sept. 3, Mr. Stokes
exposed the femoral artery, placed a silver wire round the vessel, and
passed Porter's clamp down on the two free ends of the wire. These
were tightly fixed to the ring of the clamp. — (Seepreceding 'Retrospect.')
This effectually arrested all circulation through the aneurism. Fifty
hours afterwards the ligature was removed, and to Mr. Stokes' disap-
pointment there was a return of pulsation in the aneurism. The tumour
then commenced to enlarge rapidly. Digital compression was carefully
tried for twenty-four hours. The thigh was then amputated by the
circular method. PysBmia set in, and the patient gradually sank. On
examining the tumour the aneurism was found to be a diffused one.
The artery (popliteal) was ruptured on its anterior aspect. A large
mass of coagulated blood was found in the aneurism. The knee-joint
contained about an ounce of amber-coloured serum, otherwise the
articulation was quite healthy. The posterior surface of the femur at
its lower third was denuded of periosteum and slightly eroded. A
section of the head of the tibia revealed a bullet which had been
encysted for ten years. " An examination of the portion of the artery
where the temporary ligature had been applied showed that no damage
had been sustained by the artery. This is a matter of considerable
importance, as it shows conclusively that the wire compressor can be
applied to a large artery so as to completely occlude it for so long a
period as fifty hours, without doing any injury to it whatever. Mr.
Holmes, in his admirable lectures at the College of Surgeons on the
surgical treatment of aneurism, in speaking of the case where I applied
the temporary ligature to the abdominal aorta, observes that the time
(twelve hours) during which it was applied ' hardly allows a judgment
as to the action of the compressor.' In the foregoing case, however,
the instrument was applied for fifty hours without there being any
damage whatever sustained by the vessel." ('Dubl. Journ. Med. Sci.,'
Dec. 1872, 434.)
Femoral aneurism ; compression; cure, — Under the care of Mr. Jessop.
('Lancet,' Nov. 2, 1872.)
Fusiform femoral aneurism cured by compression. — Mr. Spence nar-
POPLITEAL ANEURISM. 209
rates the case of a man, set. 32, in whom compression of the femoral
cured a fusiform aneurism. He remarks on the nature of the aneurism,
and the reasons for adopting the particular mode of cure. Watson's
"pressure apparatus" was used. Fusiform aneurism in the lower
extremity is rare. Mr. Spence has only met with one other case, an
aneurism of the popliteal, which he cured by ligature of the femoral.
In the present case the oblong aneurism was in that part of the femoral
immediately above the origin of the great anastomotic artery, and, as
the contents of the dilated portion were quite fluid, such a direct,
retrograde feeder would have speedily refilled the vessel and acted as a
disturbing element in preventing the formation of a coagulum. Mr.
Spence had determined, if compression failed, to cut down on the artery
in Hunter's canal. The exact time which elapsed before pulsation
ceased is not noted, but it was the evening of the first day. Mr.
Spence lays stress on complete compression. (' Med. Times and Graz.,'
June I, 1872.)
Death from secondary hcemorrJiage after the use of a carholised catgut
ligature. — Mr. Holden records a case in which he ligatured the femoral
with a catgut ligature, and in which secondary haemorrhage occurred
on the ninth day, and proved fatal almost immediately. At the post-
mortem, a large collection of pus was found burrowing in the thigh.
At the point where the vessel was tied, there was a small, jagged perfo-
ration of the arterial coats. JNTo trace of the ligature coiild be found.
(' St. Earth. Hosp. Rep.,' viii, 189.)
Popliteal aneurism ; ligature of the femoral artery. — Two cases, under
the care of Mr. Savory, are recorded in the 'Lancet/ Aug. 5, 1871,
191. The patients recovered.
A case of popliteal aneurism, bursting into the knee-joint, and sup-
posed to be synovitis of the joint, is narrated in the ' Lancet,' June 24,
1871, 851, by Mr. Jamieson, of Shanghai.
Mr. Lister mentions (Address, ' Brit. Med. Journ.,' Aug. 26, 2871,
two cases of difiused, popliteal aneurism treated by ligature of the
femoral with catgut, antiseptically. Both patients recovered. In one
case, the ligature was applied in " a forbidden region, from the vicinity
of the profunda or other considerable branches."
Mr. Cooper Forster and Mr. Barwell relate cases of cure by com-
pression. ('Clin. Soc. Trans.,' v, 105 and no.)
Mr. Holmes records a case which was cured by voluntary fiexion of
the leg in about thirty-six hours. ('Brit. Med. Journ.,' April 6,
1872.)
Mr. Stokes figures an instrument for arterial compression (JPresse
artere), devised by Mr. O'Eeilly, and gives a narrative of a case in
which he used it. The pressure was kept up, night and day, for four
days, without causing any inconvenience or pain. ('Dub. Journ. of
Med. Sci.,' Dec. 1872, 432.)
Two cases are recorded by Mr. Holden, one of which was cured by
pressure and the other by genuflexion. After thirty hours' continuous
pressure (digital), aided by a bag of shot placed over the fingers, which
enabled each person to press for two hours, pulsation quite ceased.
Mr. Holden thinks it ought then to have been continued for a while,
14
210 REPORT ON SURGERY.
for the pulsation again returned at the end of twenty-four hours, and
they had to press for some time longer. In the second case simple
flexion was tried. On the seventh day very little pulsation remained,
and the pressure of a tourniquet was added over the femoral. At the
end of another week the pressure was gradually removed. In six weeks
from the beginning of the treatment the patient was allowed to walk
about. (* St. Earth. Hosp. Eep.,' viii, 139.)
A case of aneurism of both popliteal arteries treated successfully by
compression of the femorals is noted by Dr. Rendle. (' St. Earth. Hosp.
Eep.,' viii, 107.)
Aneurism, false. — Mr. Spence narrates some interesting cases of false
aneurism. A man came under his care for the results of a stab in the
upper and inner part of the calf of the left leg, inflicted accidentally six
weeks previously. Haemorrhage had occurred repeatedly. Pressure
on the femoral did not check venous haemorrhage. Mr. Spence felfc
convinced that the posterior tibial artery and vein were wounded. He
made an incision, about eight inches long, along the inner aspect of the
calf, dividing the gastrocnemius and soleus muscles and exposed the
vessels. It was seen that the posterior tibial artery was injured close
to the bifurcation of the popliteal, and also one of the venae comites.
A ligature was applied above and below the wound in each vessel, and
another was applied to the anterior tibial, just below the bifurcation of
the popliteal.* The ligatures were left hanging out, and wet lint ap-
plied to wound. The patient recovered, and resumed work as a post-
man in a country district. Mr. Spence remarks on the points of
interest in the case. The patient was in a very unfavorable condition,
the limb greatly swollen. The operation practically amounted to liga-
turing the lower part of the popliteal as well as a large vein, yet re-
covery followed. He also details a case o? false aneurism of the radial.
The haemorrhage at the time of the wound was controlled by a pad, &c.,
and the wound healed ; nevertheless an aneurism formed subsequently,
which had every appearance of being an acute abscess. (* Med. Times
and G-az.,' June 29, 1872.)
Ligature of artery above elbow, for aneurism lelow the bend of the
elbow. — In this case there was a high division. The aneurism had re-
sulted from a sprain, and involved only the radial, so this was tied by
Mr. Hulke above the elbow. Compression and flexion had failed.
('Med. Times and Gaz.,' April i, 1871, ^63.)
Tourniquet. — Mr. Eulley has devised a double tourniquet for com-
pressing the femoral, alternately, in one of two positions, without shift-
ing the instrument. Two pads with screws are fixed to a bar, connected
by rings at each end to a long pad, which is placed behind the limb.
The relative position of the screws in front can be altered. (' Med.
Times and Gaz.,' Jan. 27, 1872, 95.)
Congenital lymphatic varix (see previous * Eien. Ret.') — Dr. Paterson
describes a case. The child was a female. The whole right lower ex-
tremity was much enlarged, and looked much like a leg severely aff'ected
with varices in the adult. The child could move the limb. A quantity of
fluid transuded through the skin continuously. About the fifth day large
blebs appeared. Death took place on the ninth day after birth. The
• N^VUS VARIX — AMPUTATIONS. 211
varicosities proved to be enlarged lymphatic vessels filled to distension
with a milky serous fluid. (' Edin. Med. Journ.,' May, 1871, 1012.)
Memovalofncevoid growths with the ecraseur. — Mr. J. F. West has re-
peatedly employed the ecraseur for the removal of naevoid growths, with
great success. He narrates cases in the ' Lancet,' March 4, 1871, 302.
Treatment of ncevus hy subcutaneous rupture of vessels. — Dr. Mezger
describes, in the ' Arch, fiir Klin. Chir,,' xiii, the case of a child, three
months old, who had a large naevus on the left ala nasi. On prolonged
expiration the tumour increased in lividity and size. Dr. Mezger
compressed, with his finger, the vessels proceeding from the tumour, so
as to distend its capillaries with blood. He then rapidly squeezed the
naevus, thus rupturing the vessels in the interior. This operation was
repeated several times, with the result of producing extravasation of
blood and slight inflammation, followed, ultimately, by complete disap-
pearance of the nsevus.
Treatment of varix hy subcutaneous injection of ergotin. — Dr. Paul
Vogt, in the * Berliner Klin. Wochenschr.,' March 4, 1872, speaks of
subcutaneous injection of ergotin as an eflectual and safe remedy in
varix. In a case which he described be used a solution of 2 grammes
of aqueous extract of ergot in alcohol and glycerine (each 7!^ grammes),
injecting a syringeful in the immediate neighbourhood of the varix.
One of the enlargements disappeared after the first injection, and
another a few days after a second, made two days subsequently to the
first. At the points where the injections were made, there remained
some hard, circumscribed infiltration, which was not attended with
much pain, and disappeared gradually. In six weeks, during which
the patient (an old man) went about as usual, no trace of enlargement
of the veins could be detected. The treatment was afterwards adopted
with excellent results in several patients in the surgical clinic at
G-reifswald. Vogt has also used ergotin injection successfully in vari-
cocele, haemorrhoids, and certain forms of nsevus.
Death rate after amputation. — During the three years which have
elapsed since Mr. Callender published his last note on this subject, Sir
James Paget and he have performed amputations in twenty-five
cases, consecutively, without! one fatal result. There was one primary
amputation of the thigh and nine for disease ; eleven of the leg for
disease ; two others (primary) upper extremity, and two for disease.
" If amputation statistics are to be relied upon, no stronger evidence
could be given of the healthy condition of the hospital wards during
the three years to which the above figures relate." (' St. Earth. Hosp.
]Rep.,' viii, 179.)
Recurrent hcemorrhage after amputation. — A case of recurrent haemor-
rhage after amputation of the leg, treated by ligature of the femoral
with success, is narrated by Dr. McDougall. Ligature of the bleeding
artery in the leg-stump had succeeded for a time only. The vessels
were much diseased. ('Edin. Med. Journ.,' June, 1872, 1086.)
Amputation at the hip-joint. — Mr. Lister records a case of successful,
primary amputation at the hip-joint. Antiseptic treatment was
adopted. The patient was a boy five years of age. ('Edin. Med.
Journ.,' Aug. 1871, 149)
212 REPORT ON SURGERY.
A successful case, for cancerous disease, is recorded by Dr. Bramwell.
The patient died, however, live months later. Reference is made to
other cases. ('Edin. Med. Journ.,' Nov. 1872.)
A successful case, for osteo-sarcoma recurring in the femur, is recorded
by Mr. Croft. ('Path. Trans.,' xxiii, 203.)
Reamputation at the hip. — George A. Otis records in detail a success-
ful case (' Am. Journ. Med. Sciences,' Jan. 187 1, 141). He alludes to
the comparative safety of exarticulating the femur, for diseased condi-
tions succeeding a previous amputation in the continuity of the thigh.
He enumerates twenty-one cases, nine belonging to military and
twelve to civil surgery. This distinction is valueless, as the causes
for operation are strictly analogous. In twelve cases, the operation
was done for " chronic osteo-myelitis," in six, for recurrence of tumours,
&c., and, in three, it was compulsory on account of haemorrhage or gan-
grene. Fourteen, of the twenty-one {66 per cent.), were successful.
We may conclude, therefore, that in incurable disorders of thigh- stumps,
resulting either from injury or disease, disarticulation at the hip is the
proper remedy. By using a gutta-percha artificial stump, nine or ten
inches in length, firmly strapped to the pelvis by a broad chamois-lined
canvas band, an ordinary artificial limb for thigh-stumps can be used.
Supra-condyloid amputation of the thigh. — Mr. Stokes writes further
on this subject. He has found the operation a successful one, and quotes
cases, noted by others, since his communication to the Med.-Chir. Soc.
(see last 'Retrospect.') ('Dub. Journ. Med. Sci.,' Dec. 1872, 426.)
Amputation through the femoral condyles. — Mr. Eichardson gives two
cases (successful). In one he removed the patella, in the other he left
it, having removed the cartilage. He divides the rectus. In the latter
case the patella united well. Two other cases are mentioned (success-
ful), under the care of Mr. Morgan. (' Dub. Quart. Journ.,' 1871, 277.)
Amputation at the knee-joint. — In a clinical lecture on a case of
fibro-plastic tumour of the leg, in which he performed amputation at
the knee-joint, Mr. Erichsen makes some remarks on this operation.
He prefers a long anterior flap, slightly rounded at the edges, and leaves
the patella. If the latter is removed the flap is liable to be too thin t(
live, and if it is left, there is a liability to suppuration in the large
synovial pouch under the quadriceps extensor. He leaves the cartili
ginous surfaces of the femur and patella. (' Lancet,' Sept. 30, 1871, 460.
Dr. Staples records two cases in which he performed amputatioi
through the knee-joint. One patient was a man, set. 41. The opera*
tion was performed for inflammation of the leg. A semilunar incisioi
was made in front, an inch or an inch and a half below the tubercle oi
the tibia. The flap was dissected up far enough to reach the joint,j
which was then cut through, the limb being flexed, and a short post(
rior flap made. The patella filled the space between the condyles wel
The progress of the case was good. The inner condyle was exposed foi
a time, but soon became covered. In eight weeks he could bear hij
whole weight on the stump. In five months he went to work in a boot
store, and had to stand " constantly upon his feet" all day. The othei
patient was a boy, twelve years old, suffering from necrosis of tibia, &t
A similar operation was performed, and a "button of cartilage wj
RESECTION OF SHOULDER AND ELBOW OF THE SAME ARM. 213
taken from the internal condyle." In three months he could bear his
entire weight on the stump. He was a strumous lad. The patella kept
in good position. (' Amer. Journ. Med. Sciences,' Jan. 1872, 62.)
Senile gangrene. — Mr. Listen recommends amputation under anti-
septic dressings. (' Brit. Med. Journ,,' Aug, 26, 1871.)
Gangrene of the leg; amputation; recovery. — Mr. Morgan records the
case of an old man whose foot became gangrenous, and whose leg he
amputated as high up as possible. The patient recovered. The bones
of the foot were found disorganized. A figure of the condition is given,
('Dub. Quart. Journ.,' Feb. 1871, 138.)
Spontaneous gangrene of both feet, in a hoy, arising from disease of the
heart ; douhle amputation; recovery from operations ; death from cardiac
and pulmonary conditions. — Mr. Gant. ('Clin. Soc. Trans.,' v, 176.)
Amputations. — Pavorable results, in country practice, are recorded
by Dr. Benny. ('Edin. Med. Journ.,' Nov. 1872.)
Amputation of the foot. — Mr. Stokes writes on Prof. Smith's modifica-
tion of Hey's operation on the foot. The great advantage of it is that
the ball of the great toe and the base of the fifth metatarsal bone are
preserved. The operation is performed by making an oblique incision
across the four lesser metatarsal bones, commencing about three quar-
ters of an inch in front of the base of the fifth metatarsal bone, and in
a direction towards the metatarso-phalangeal articulation of the great
toe. The incision should be made down to the bones, and another in-
cision should then be made at the centre of the first one, but at right
angles to it, upwards and inwards, for about an inch or an inch and a
quarter. The flaps at each side of this incision should then be dis-
sected off the bones, and these, thus freely exposed, should then be
obliquely divided, close to their proximate articulations, with a small
saw or fine forceps. The flap should he taken altogether from the sole
of the foot. The operation appears to be best adapted for cases of
caries of the phalanges and distal extremities of the metatarsal bones,
for severe injuries of the phalanges with extensive laceration of the soft
tissues, and epithelial ulcerations not unfrequently occurring in this
situation. Mr. Stokes records the case of a woman, set. 58, sufiering
from epithelioma of the three lesser toes of the right foot. A lithograph
of the state of the stump after recovery, and a woodcut of the cast of
the stump of the patient, on whom Prof Smith first operated, are given
('Dub. Journ. Med. Sci,' Dec. 1872, 428.)
Ankle-joint amputations. — Dr. Smith concludes that ankle-joint am-
putations are only half as fatal as leg amputations, and the stumps are
better adapted both for unassisted locomotion and for the use of artifi-
cial supports. In reference to Pirogoff''s and Syme's amputations. Dr.
Smith is of opinion that the former yields the better stump for unassisted
progression, and the latter for the adaptation of mechanical aids. (" Sur-
gical Memoirs of the War of the Eebellion," published for the U. S. Sani-
tary Commission ; reviewed in 'Am. Journ. Med. Sci.,' Oct. 187 1, 4^'^i.)
Resection of the shoulder- and elhow-joints of the same arm. — Mr.
MacCormac records the case of a French soldier who was disabled at
the battle of Sedan by a shell explosion. The fragments severely lace-
rated the bones and soft parts of his right arm, in the region of the
214 REPOllT ON SURGERY.
shoulder- and elbow-joints. For twelve days he did not receive any-
special attention. When Mr. MacCormac first saw the patient, he
found a large, suppurating wound in the deltoid region, and another on
the posterior aspect of the elbow-joint. The soft parts were extensively
injured and the bones much comminuted. It almost seemed as if am-
putation at the shoulder-joint were indispensable. It was, nevertheless,
determined, if practicable, to save the limb. The man bore the first
part of the operation without an anaesthetic, but he was induced to take
chloroform for the second stage of it. The original wounds were en-
larged. The shoulder-joint was first attacked. Four inches of the
upper extremity of the humerus were removed, the bone being sawn
through at the limit of the fractured portion. The elbow-joint was then
examined. Only the external condyle of the humerus was implicated,
and only the thinnest possible slice was removed by the saw. The
ulna was extensively fractured, the olecranon process pulverised, and
the shaft split throughout its upper third. The fragments were removed
subperiosteally, and the irregular extremity of the shaft cut through at
the junction of the middle and upper third. A further portion of the
shaft, split off for an inch farther down the posterior surface, was also
removed, so that the divided extremity of the ulna only presented about
two thirds of the section of the bone. As the radius was not impli-
cated beyond its articulating head, this, only, was removed. The bones of
the forearm were, therefore, divided at very different levels ; but the
tubercle of the radius was preserved with the muscular attachments
belonging to it, and the preserved periosteum was trusted to regenerate,
in part, the portions of ulna removed. To have sawn off both bones at
the lower level would most certainly have precluded all hope of a useful
result. The after treatment consisted in supporting the injured arm
on pillows, and providing for the free outflow of matter. " Neither in
this nor in any other case of resection of the elbow- or of the shoulder-
joints did I employ splints, and from choice I always employed a single
straight incision in the soft parts." The patient did well for a week,
then symptoms threatening pyaemia set in ; an abscess, however, formed,
and was opened, and he then steadily recovered. A photograph of his
condition, eighteen months after the operation, is given : — " The elbow-
joint is thoroughly healed, and the ulna so far reproduced that there is
scarcely any appreciable deformity or loss of shape in the joint. He
can flex and extend it, and also pronate and supinate the forearm. The
power of the hand is being rapidly and completely regained. As the
shoulder-joint is not yet healed, its condition is not so satisfactory ; bat
by means of the pectoralis and iatissimus dorsi muscles he moves the
joint freely backward and forward. He cannot raise the arm very high
from the side, but this is no uncommon result after excision of this
articulation, and in this particular instance the greater portion of the
deltoid muscle was destroyed by the shell fragment causing the original
wound. I can entertain no doubt that, as soon as the necrosed piece of
humerus is removed, the sinus in the region of the shoulder will close,
and the usefulness and power of the limb become greatly increased.
Meanwhile, I submit that the man's present condition is extremely
satisfactory; and, while it affords an ample justification of the operation,
EXCISION OF THE SHOULDER- JOINT. 215
as performed, it, also, warrants me in placing this case upon record, as
one of successful resection for gunshot injury of the elbow- and shoulder-
joints of the same arm. (' Med.-Chir. Trans./ Iv, 207.)
Excision of the shoulder -joint. — Two cases are recorded by Mr.
Ewens. Both patients were females; one ait. 18, the other 32.
Both recovered well, though much out of health at the time of the
operation. The disease had existed for long. In the first case, an oval
flap was made, in the second, a vertical incision at the posterior border
of the deltoid with a superior transverse cut. (' Lancet,* Sept. 16,
1871, 390.)
Mr. Gant, after alluding to the usual conditions requiring excision of
the shoulder-joint, notes that the amount of bone to be removed is
rarely extensive, the disease being usually limited to the head of the
humerus, while the glenoid cavity is comparatively seldom affected, and,
even then, may usually be left untouched or only scraped. The
resulting state of the joint would seem to be that the limb can never be
elevated above the horizontal line ; while in many cases it hangs down
without any power whatever in the deltoid, at a greater or less distance
from the scapula. The movements of flexion, extension, and adduction
are usually free ; abduction can often be effected to the extent of raising
the arm considerably from the side, and there is, generally, sufiicient
power in the forearm to carry heavy weights, and perform many of the
ordinary domestic tasks. Mr. Grant mentions a case, under his own
care, in which excision was successfully performed, but the patient died
subsequently of internal disease. He also narrates the case of a young
lady, aat. 1"]^ at the time the note was made, whose right shoulder-
joint inflamed acutely after exposure to cold (?) six years before.
Suppuration followed, and a copious discharge occurred from several
sinuses for two months, when the joint was excised by Mr. Lane. A
vertical incision, down the inner border of the deltoid, with a short
transverse cut superiorly, was made. Two inches and a half of the
humerus were removed, and the glenoid cavity, in a deeply carious
state, was freely gouged. The patient made an uninterrupted recovery.
The arm, at the end of the six years, was four inches shorter than its
fellow, but she could move it freely backwards and forwards, without,
however, the power to raise it horizontally unless aided by the left
hand. The motions of the forearm were perfect, so that she could work
readily, write, or play the piano. (Ibid., Sept. 2, 1871, 313.)
Excision of the elbow-joint. — The conditions appropriate for excision
of the elbow-joint are summed up by Mr. Grant as — (i) Functional in-
utility of the limb, depending on disease of the joint, resulting in
destruction of the articular cartilages, without the supervention of
anchylosis, will always justify excision. (2) Osseous anchylosis, and
especially in connection with a useless position of the limb, will also
justify excision. (3) As regards the amount of bone removed there is
not the same limitation as in the case of the knee-joint. It is not so
important to keep within the limits of the epiphyses. The removal of
only a thin, superficial section of the articular ends of the bones in the
elbow-joint, leaving the section ends too nearly in contact, is apt to be
followed by osseous union, and an unsuccessful result of the operation.
216 REPORT ON SURGERY.
On the other hand, any new bone which may, not unfrequently, have
been produced, in the form of a spiculated enlargement of the articular
ends above their diseased portions, and thereby limiting the disease,
should not be included in the excision. State of the limb. — Of 104
recoveries, out of 119 cases, the majority {minus i^ amputation cases)
had useful limbs, as proved by the patient being able to resume his
ordinary avocations. Injury of the ulnar nerve — an occasional accident
during the operation — is followed by loss of sensation in the little
j&nger and adjoining side of the ring finger, with, perhaps, loss of
motion and wasting of the muscles ; but the sense of touch will pro-
bably return and the other ill consequences cease, apparently by re-
union of the wounded nerve. This accident, judging from the digital
paralysis, happened, apparently, in one of his own cases ; but the symp-
toms passed off entirely, as the functional use of the finger showed, for
the patient was a seamstress. Be-excision may be practised — as in the
knee — when necessary, rather than amputation, and even a third
attempt, it is said, has been followed by a good result. Of 197 cases of
recovery, only in three, is it noted that re-excision was practised. Of
five cases, under Mr. Gant's care, he had to re-excise in one, with a good
result. Secondary amputation. — Of one collection of 1 04 cases of recovery,
fifteen underwent amputation subsequently. Of another 197 recoveries,
three, only, were subjected to amputation, with one fatal issue. (Ibid.,
August 16, 1 87 1, 283.)
Mr. Maunder, in the course of some remarks on primary excision of
the elbow-joint (ibid.. May 20, 187 1, 679), proposes a modification in
the plan of performing the operation. Hitherto, when the H or F- in-
cision has been adopted, the transverse or the semi-transverse cut has
severed those very structures — the tendinous prolongations of the
triceps to the fascia of the forearm — by which, as Mr. Maunder has
demonstrated both on the living and the dead subject, extension by the
triceps muscle may be always secured. The integument having been
divided, the triceps muscle just above the olecranon should be cut
longitudinally. The inner portion is to be detached from the end of
the olecranon, and it, with the ulnar nerve and soft parts along the
inner side of the bone-ends, are to be separated from the bones. The
outer half of the severed muscle is to be cut transversely, but is to be
scrupulously preserved continuous with its tendinous fibres, which run
forward between the point of the olecranon and the external condyle of
the humerus. When this structure, together with muscular fibre, is
detached from the subjacent bones, a broad and thick band of tissue
will have been preserved, competent, hereafter, to extension of the fore-
arm. The subsequent steps of the operation are performed as usual.
Mr. Maunder describes his operation and gives a sketch of the import-
ant part of it, in the * Brit. Med. Journ.,' July 29, 1871.
A new method of excising the elbow-joint in cases of anchylosis. — Mr.
Annandale having had satisfactory results in several cases of compound
fracture or dislocation of the lower end of the humerus, by the "primary"
removal of the injured bone and the tip of the olecranon, without inter-
ference with the head of the radius or ulna, he was led to think that in
cases of anchylosis, the removal of only a portion of the lower extremity
EXCISION OF THE ELBOW-JOINT. 217
of the humerus, together with any new, osseous material likely to inter-
fere with the future mobility of the joint, would lead to satisfactery
results. In a case of the kind he adopted the following plan. He
made two lateral incisions, one parallel and external to the ulnar
nerve, the other internal to the projection of the external condyle. The
ulnar nerve was drawn inwards and then the bones cleared, partly from
the inner and partly from the outer incision. The attachments of the
triceps and biceps were left untouched. The tip of the olecranon was
then removed, the ligaments and the osseous union divided, and a
copper spatula having been passed between the anterior aspect of
the joint and the separated structures, the lower end of the humerus
was sawn through. The head of the radius did not move freely on the
ulna, so the knife was carried round to divide adhesions, and a thin
slice of the articular surface was sawn off. The removal of some small
portions of new, osseous material completed the operation. Should the
anchylosis be greater, after separating the soft structures, Mr.
Annandale would introduce the narrow saw under the triceps muscle
«lose to its insertion, saw completely through the anchylosed joint, aud
then remove as much of the lower end of the humerus as seemed
necessary. ('Lancet,' December 21, 1872.)
Resection of the elbow for anchylosis ; formation of a movable joint. —
Dr. Czerny relates, in the ' Archiv fUr Klin. Chirurg.' (xiii, 22^), the
case of a girl, set. 13, who, in September, 1868, came under Dr. Bill-
roth's care. Three years previously, she had had inflammation of the
elbow; the joint had become anchylosed at an angle of 145°; and, on
admission, there were six fistulous openings discharging pus abun-
dantly, and caries of the ulna was detected. In the following month
the ends of the bones were excised ; the portion removed being three
and a half centimetres long, in the aspect of flexion, and six and a half
centimetres long, in that of extension. The patient recovered with a
joint which she could bend and extend between the angles of 60° and
113°; rotation, however, was lost. Two and a half years after the
operation she died of pneumonia following an attack of suppuration
of the knee. On examination, there was found not much difference, in
length, between the two upper limbs ; and, when viewed externally,
the joint, that had been operated on, had a normal appearance. The
muscles near the joint had their normal attachments ; the triceps was
much atrophied, and ended in a portion of bone eight inches long and
three broad, which was united to the radius ; this was evidently a ru-
dimentary olecranon. There were two, distinct condyles at the end of
the humerus, having between them a concave, articular surface corre-
sponding with two facets on the upper end of the radius and ulna. The
articulating surfaces were covered, though not entirely, by cartilage ;
and there was a distinct synovial membrane.
A boy came under Dr. "Watson' s care with symptoms of dislocation
of the radius backwards of some duration. There was some anchylosis
(fibrous). Excision was performed. The dislocation was accompanied
by partial separation of the trochlear epiphysis and laceration of the
orbicular ligament. There was also partial absorption of the articular
surface of the trochlea and new, osseous deposit upon the greater sig-
218 REPORT ON SURGERY.
moid cavity of the ulna, together with fibrous bands passing between
the ulna and the humerus, constituting a partial, fibrous anchylosis of
the joint. (' Ed. Med. Journ.,' Jan. 187 1, 652).
An old case of dislocation of the elbow, treated by excision, and
according to the antiseptic method, is noted by Dr. Marshall. (' Brit.
Med. Journ.,' May 27, 1871).
Anchylosis of the elbow; excision of the extremity of the humerus. —
The anchylosis followed a comminuted fracture of the articular extre-
mities of the humerus, radius, and ulna, in a patient about twenty years
of age. Dr. Watson performed a new and original operation. A linear
incision was made over the inner side of the olecranon, in the line of
the ulnar nerve. The latter was dissected away with the soft parts and
turned over the inner condyle. The joint was then opened, freely, in
front of the internal condyle, and the latter removed with cutting pliers.
The external condyle was then cut ofi", through the same wound, but from
within outwards and from below upwards, and was twisted out of
its bed with lion forceps. The end of the humerus was then turned out
and smoothed ofi" with the saw. The insertions of the triceps and of the
hrachialis anticus are not interfered withy and, therefore, the movements
afterwards are more perfect. ('Edin. Med. Journ.,' Dec. 1871,559.)
Excision of both elbows. — Mr. Cooper Forster records a case of
excision ol both elbows. (* Lancet,' Jan. 6, 1872.)
Excision of the elbow for compound dislocation. — The case of a woman,
set. 40, of intemperate habits, who was admitted into the Sunderland
Infirmary, under the care of Mr. E. A. Malins, is recorded in the
* Lancet,' Aug. 31, 1872. The accident occurred on January 17th.
The dislocation could not be reduced even under chloroform. There
was a wound, on the inner side, and another behind. The latter was
enlarged and excision was performed. The patient did well afterwards.
On March ist the wound was quite closed. The patient could bend I
the forearm to a right angle, and rotate it without assistance. " It is^
interesting to note that, although the patient was an unhealthy syphi-
litic woman, and the parts were considerably damaged, yet the result
was good." Iodide of potassium was given her.
Excision of the wrist. — One of the patients whose case was recorded,
in the ' Lancet,' 25th March, 1865 (case No 5), was exhibited by Mr,
Lister to the Med.-Chir. Soc. of Edinburgh, at the end of about seven
years. The result was very satisfactory. ('Edin. Med. Journ.,' Aug.
187 1, 144.) In one case, Mr. Hancock made a semilunar incision^
across the dorsum, dissected up a skin flap, and pulled the extensor
tendons aside. (' Lancet,' Jan. 20, 1872.) Mr. Sydney Jones records
a case ; the patient was a male, set. 45 ; a useful hand resulted. Mr.
Lister's method was adopted. A lithographic illustration of the con-^
dition of the patient is given. ('St. Thom. Hosp. E-ep.,' ii, 283.)
Drawings of a specimen, showing the results of an excision of the
wrist, are given in the * Brit. Med. Journ.,' Jan. 7, 187 1, 12.
Excision of proximal phalanx of right thumb for enchondroma.—"
Eoyes Bell narrates a case (with illustrations) in ' Lancet,' Dec. 14,
1872.
Excision of the hip-joint. — Mr. Gant mentions the following con-
EXCISION OF THE HIP- JOINT. 219
'Ifltions as appropriate for excision : — (i). Destruction of the articular
cartilages without the supervention of anchylosis, will always justify
operative interference by excision. The state of the general health
should primarily determine the necessity for excision, in all cases,
and not any arbitrary consideration of the period of the disease
and the condition of the joint. Whenever, therefore, the general
health is manifestly failing, whatever may be the stage of the hip-
joint disease, excision should be resorted to and without further delay.
On the other hand, the most extreme state of constitutional exhaus-
tion, previous to the operation of excision, may be followed by re-
covery after removal of the diseased bone, (2). Osseous anchylosis
with malposition will not justify the peril of attempted excision.
Section of the neck of the femur is practicable. (3). In t\\Q femur,
the diseased portion, removed, may include the head, neck, great tro-
chanter and shaft, entering even into the medullary canal. In the
acetabulum, the diseased portion may include the whole floor of this
cavity, and even extend to the adjoining portions of the ilium, pubes,
and ischium. The acetabulum not unfrequently recovers itself, when
the diseased head of the femur has been removed from further contact
and attrition. (4). Dislocation is unfavorable for excision, as indicating
an advanced stage of the disease constitutionally. The significance of
this local condition, will, therefore, diminish in proportion to the absence
of marked hectic and emaciation. Operation. — Mr. Gant prefers a
T-shaped incision. Excision of the trochanter major may, occasionally,
prove suflacient. The after-treatment is very simple. The limb may
be laid straight in bed and retained in position, only, by a small side-
pillow, or roller sand-bag, without absolutely fixing the thigh. The
section-end of the femur is drawn up by muscular action and hitches
just above the acetabulum, which, having been generally more or less
superficially carious, is thus left to recover itself, undisturbed by any
attrition of the femoral end of the bone, while a new and firmly fibrous,
movable joint forms, where the end of the bone rests above the ace-
tabulum. There is very little tendency to displacement. The slight
extra shortening, which results from leaving the limb to itself, is unim-
portant, compared with the advantages in regard to the acetabulum,
and the formation of the best kind of new joint requisite for the func-
tional use of the limb, in progression, as well as for support. Mesults. —
Mr. Gant gives Dr. Hodges' and Mr. Hancock's statistics, tabulates
those of Dr. Good of America (112 cases), and has collected recent
ones from the various hospitals. He deduces the three following
general conclusions respecting the rate of mortality, (i.) In difierent
countries a very difierent mortality, being highest in Erance and lowest
in England. (2.) An average death-rate of i in 4 or 5 (about the same
as that of knee-joint excision for disease). (3.) Yery different death-
rates in the hands of individual surgeons ; no mortality; i in 2, 3, 5 ;
2 in 3 ; 4 in 5, or even total mortality, probably owing to the severity
of the cases selected. The mortality is less than half that of hip-joint
amputation, ^tate of the limb. — Of Dr. Hodges' 11 1 cases, 56 re-
covered, "with more or less useful limbs." Of Dr. Good's 112 cases,
52 recovered ; 42 of these patients could use the limb, and in the
220 REPORT OX SURGERY.
remaining to this result was not noted. Of the 42, 19 could walk with
out support, 9 with the help of a stick, i two sticks, i a splint, i a crutch.;
a two crutches. In 9 the manner of walking is not specified. In 40,*
of the 52 recoveries, it was especially noted that the limb supported the]
weight of the body. The ultimate period at which the cases were seen;
varied from three months to five years. Their cure was ascertained, in
most cases, after two or three years. In Mr. Gant's own eight cases,!
the shortest period of known, permanent cure was two years and a half 1
and the longest period of known, permanent result five years. The ave-\
rage duration of the period of recovery has not generally been noted. Ibj
his own cases, the average period of union was three months. In extreme]
eases of hip-joint excision, extreme as to the amount of bone removed,)
the resulting state of the limb may still be successful. It was so, iiil
two of the author's cases, after removal of four or four and a half inches
of the femur with one inch more of cancellated bone scooped out.
('Lancet,' July 15, 1871, 77). The particulars of the author's owe
cases are given Aug. 5, 183.
Lectures by Mr. Hancock, on this subject, are given in the ' Med,
Times and Graz.' (February 34, March 16, April 13, 27, and June i
1872). A review of the whole subject is given, and narratives of mosi
of the cases published, as well as cases of his own. He urges the im-
portance of not waiting too long ; insists on the point that it is nol
necessary for dislocation to have occurred, and that the presence ol
acetabular disease, or perforation, does not contraindicate operative
interference. He gives the number of cases recorded at various ages
and the relative proportion of success under different amounts ol
disease.
Dr. Ashhurst, in remarking on a successful case, urges that the
operation should be looked on as the last resource, not to be employee
as long as a reasonable prospect remains of saving life in any othei
way. The statistics of nearly 400 cases to which he has references,
shows, he thinks, the operation to be one of such gravity that it oughl
not to be undertaken unless when its necessity is very evident. The
mortality was about one half, and one in three at the most favorable age i
for operative interference. The removal of the diseased bone should be
as complete as possible. (*Am. Journ. Med. Sciences,' Oct. 1871.
434.)
Mr. Annandale showed a specimen, from a case in which he had
operated, four months previously. Eor two months the patient did well,
and then dropsy set in. After death, it was found that the cartilage ol
the acetabulum was destroyed, and that a kind of membrane had formed
over the exposed bone. He believed that, if the patient had lived, this
membrane would have become gradually converted into fibrous tissue,
and the whole of the exposed bone healed. He thought the case was
encouraging as regarded the performance of the operation, more espe-
cially as all the diseased section seemed to have been removed, and a
new joint was apparently being formed. (' Edin. Med. Journ.,'
Sept. 1872.)
Notes of four cases under the care of Mr. G-ay are given in the
* Lancet' (June 8, ij, and 22 1872). Two of the patients were 7
'
EXCISION OP THE KNEE-JOINT. 221
ears of age, and the others were 27 and 11. Three of them recovered
nth useful limbs. The patient, eet. 27, died. Also see cases by Mr.
3tB.j, 'Path. Trans., xxiii, 188.
A case, in which the limb was subsequently amputated, is noted by
r. Carr Jackson, ' Path. Trans.,' xxiii, 191.
Excision of the knee-joint. — Mr. Grant's experience leads him always
bo remove the patella. After the section of the bones the limb is ex-
bended, and the ends of the bones placed in even apposition — not
absolute contact — and then a piece of sponge is held on the wound
while the splints are applied. The extended limb is laid on a padded
back-splint covered with oil-silk under the knee, this splint reaching
from the folds of the nates to just above the heel. Mr. Gant noiu
prefers to have the foot-piece part of the lateral splint, as thus the heel
escapes pressure and a subsequent tendency to sloughing. Mclntyre's
splint he has long disused ; it not only causes some pressure on the
heel, and precludes access to that part for dressing, if requisite, but the
trough, in which the limb lies, induces more wasting of the muscles than
would otherwise ensue, and thence, also, a loosening of the splint at an
earlier period than when it may be safely removed for cleansing, and
reapplied. Broad strips of adhesive plaster are drawn round the limb
and splint, immediately above and below the knee, another broad strip
higher up on the thigh, and narrow strips around the ankle and instep.
A roller bandage is applied from the foot upwards, and another, high up,
from the thigh downwards, leaving tlie knee uncovered. An outside,
interrupted splint, well padded, and covered with oil-silk above and
below the interruption at the knee, and provided with a vertical foot-
piece, is now applied; this splint, reaching from above the great
trochanter downwards, and the end of the thigh-piece well supporting
the very end of the femur externally, at the seat of excision, while the
perpendicular foot-piece maintains the leg in position, and the upper
end of the tibia in steady opposition with the femoral end of the bone.
Elevation of the whole limb five or six inches will be found to further
aid the latter purpose. A short, padded, femoral splint may, also, be
placed in front of the thigh, terminating just above the femoral end of
the bone ; but if the external thigh-piece be not too wide, this anterior
splint will scarcely be necessary, and he rarely uses it. The external
splint is secured, by a roller bandage, from the foot to below the knee,
and, by another bandage, from above the knee up the thigh, and over
the end of the splint, with, perhaps, two or three turns around the
pelvis. The use of the external splint is to counteract the tendency to
displacement of the lower end of the femur, in three directions, after
excision of the knee-joint — projection outwards, by abduction, rotation
outwards, and projection forwards. Mr. Grant has had occasion to
lengthen the outside splint to the axilla, so as to counteract a tendency
to an irregular twist of the trunk, to the opposite side, in bed, whereby
the lower end of the thigh is abducted or everted, with an angular pro-
jection outwards at the knee. Rate of mortality/. — Three general con-
clusions may be established, (i.) A diminishing mortality as the
operation has continued to be practised. (2.) Since the revival of the
operation, and more recently, an average death rate of one in four or
222 REPORT ON SURGERY.
five cases. (3.) Very different death rates in the hands of individual
surgeons, varying from one, in two or three, to one in twelve, and one in
nineteen or even less. The average duration of the process of recovery
is considerable. In forty-eight cases, where the patella was removed
the average was 225 days, and in thirty-eight, where the patella was
supposed to be left, the period was 255 days. The average duration was
about eight months, therefore. In eight successful cases, all of them
children, at St. Thomas's Hospital, the average was 206 days, or about
seven months. In Mr. Grant's first case, a man, set. 2)?)^ the period of
osseous union was <5o days, or two months, the knee then supporting
the weight of the trunk. The union has stood the test of twelve
years' free use of the limb. The average period in his own cases has
been, for the production of firm, or perhaps osseous union, three months ;
and, to regain a useful limb, three months more, in a starch bandage
with gentle use of the limb, gradually, for support and progression.
Mesults of twelve cases. — Osseous or firm union, and a straight limb in
all the cases, except case 3, where it was incomplete, cases 4 and 5, which
were subjected to amputation, and case 11, the only death, and from
acute tetanus, in thirty-six hours, seventeen days after the operation.
Period of union, average three months. Average period of removal of
splints one month, when they were reapplied and removed at about the
same interval till conclusion of treatment. Re-excision was performed
in one case ; secondary amputation in three cases. Permanent result. —
Ultimate known period (i) eleven years; (2) one year and a half;
(7) one year ; (8) one year and a quarter ; (9) one year and a quarter ;
(10) six months; (12J five months. ('Lancet,' May 13, and June
3, 1871, 638, 736.)
Mr. Treves passes in review, in considerable detail, the various
sources of failure or of want of complete success which result from the
neglect of certain precautions at the time of the operation or during
the after-treatment. We must refer our readers to the paper itself.
He describes a leather splint, which he has found useful, and in the per-
fecting of which he was indebted to Mr. Clouting. It consists of leather,
stengthened, at the back, by a piece of iron about two inches wide, which
is riveted to the leather. The length of one piece reaches from the heel
to within two inches of the fold of the knee-joint, wide enough to sur-
round two thirds of the circumference of the leg. Another piece
reaches from about two inches above the joint of the tuberosity of the
ischium behind, and, on the outside and front, as high as the crest of
the ilium. These two pieces are connected by the piece of metal, which
passes the whole length of the splint, to within half an inch of either
extremity, and is firmly riveted by two rows of rivets. The leather is
softened by soaking in water, and chamois leather is pasted on its inner
surface. When the splint is applied, it is fixed by gum bandages. The
limb is laid in a Mclntyre for twenty- four hours, and then swung, when
the gum and leather are firm. (' Lancet,' Sept. 30 and Oct. 7, 187 1,
463 and 508.)
A lecture, by Mr. Holmes, is published in * Brit. Med. Journ.,' Oct.
12, 1872.
The case of a girl, aBt. 6, whose knee was excised by Mr. Canton, is
EXCISION OF A WEDGE OP BONE AT THE KNEE. 223
recorded in the 'Lancet,' Jan. 20, 1872, 79. At the end of nine weeks
the bones were found to be firmly anchylosed.
In the ' Edin. Med. Journ.,' Yeh. 1871, three cases are recorded from
the practice of Dr. Grillespie. Two were in young adults and one in a
lad of fourteen. All were cases of chronic synovial disease. The first
dressing was dry lint, afterwards weak, stimulating lotions. The soft
parts healed in sixty-five, fifty, and thirty-five days. The bone was
firmly united in ninety-five, fifty, and forty days, and the patient could
walk without assistance in 140, 100, and 160 days respectively. A
splint was kept applied for six weeks without intermission.
Mr. Sydney Jones narrates four cases. The patella was not removed.
One patient died of pyaemia ; the others did well. The patient, who
died, was a woman, set. 34. Those who recovered were two men, set. 21
and 30, and a lad, set. 13. Illustrations of the condition of the patients
are given. ('St. Thomas's Hosp. Eep.,' ii, 283.)
Mr. Terry narrates two cases of successful excision of the knee. One
patient was a man, set, 26, the other a boy, set. 12. The first left the
hospital in three months, and the limb was sound at the end of six
years. The second left in fifteen weeks ; his limb was sound after two
years. ('Lancet,' Jan. 13, 1872.)
Mr. W. W. Moxhay narrates eight cases in which he performed ex-
cision of the knee-joint. Seven of the patients did well, and when
heard of, after the lapse of some time, had thoroughly useful limbs. In
one case a patient, set. 40, amputation was necessary, and was followed
by recovery. The other patients were males, set. 29, 11, 35, and 10,
respectively, and females, set. 17, 8, and 20. The average stay in the
hospital, after the operation, was about three months. (' Med.-Chir.
Eev.,' April, 1871, 487.)
Anchylosis of the knee; excision of a wedge of hone. — Dr. Morton gives
the details of a case of complete, osseous anchylosis of the knee with
extreme flexion, in which he removed a wedge of bone with complete
success. The patient was twenty-seven years of age. The flexion was
at an acute angle, " the leg being flexed to the full extent upon the
thigh." The union was so complete and so dense that drilling was out
of the question. A horseshoe flap was dissected up, and then a wedge-
shaped portion of bone, including the condyles of the femur, a portion
of the head of the tibia, and the patella, " four and a half inches across
the base, and two and a half inches in depth," was removed with the
saw. The bony tissue, cut through, was so very dense that even the
portion covering the popliteal vessels could not be broken, as is usually
done, and it was found necessary to use the saw until the section was
completed. There was no necessity for dividing any of the hamstring
tendons. Three months after the operation the patient could raise the
limb, union having taken place to a considerable extent. Several
fistulse existed, through which necrosed bone could be felt. Five, six,
and seven months after the operation some large fragments of bone,
corresponding to the sawn surfaces, were removed and the sinuses healed
up. The patient left the city, for a distance, nine months after the
operation, able to use the limb well. There was shortening to the
extent of two inches. Fourteen months after the operation, the man
224 REPORT ON SURGERY.
was, and had been, at work as a labourer in the country, and could wall
long distances. The writer says Dr. Buck was the first to remove
wedge of bone from the situation of the joint to remedy anchylosis, anc
this is the operation which has since been generally adopted when drill-]
ing is impracticable. Dr. Hodges gives nineteen cases, of which tei
recovered, eight died, and amputation was performed in one for delayed]
union, Lyon gives eleven other cases, of which ten recovered and on(
died; eight had useful limbs, one was discharged with firm union, but|
before the limb had been used ; and in one case it is merely stated that
the patient recovered. The author has collected nine other cases. 01
these, eight were cured and one died. Of twenty cases, therefore, since
Dr. Hodges's record, only two have died. The former fatality is not
easily explained. Sir W. Fergusson has also operated, successfully, on
two cases of osseous anchylosis after excision of knee in faulty positions,
by removing wedges. Of forty-one cases in all, of operations for
osseous anchylosis, thirty patients recovered, ten died, and in one case
amputation was performed. Figures of the patient, before and after
operation, are given, and a tabulated statement of eleven cases, recent.
('Am. Journ. Med. Sciences,' April, 187 1, 321.)
Mr. James Adams records the following case, and remarks that there
are certain cases of knee anchylosis which can easily be cured by the
operation of subcutaneous osteotomy, and there are others in which
anything short of an excision of a wedge-shaped piece is wholly useless.
Diagrams are given of the state of parts in his case, and the shape, &c.,
of the piece removed by him. The patient was a lad, set. 14, fairly
nourished, but pale. The right leg was fixed at a right angle, the skin,
at the point of flexure, was marked by numerous cicatrices on all sides,
some, especially those in the popliteal space, were puckered in and ad- ^
herent to the bones. There was absolutely no pain or tenderness ; I
there was the most complete rigidity (under chloroform) ; the adjacent
portions of the bones were expanded and rounded, so as to leave no in-
terval or depression between them ; the position of the patella could
not, with certainty, be made out. The disorganization of the joint
occurred when he was one year and a half old, consequently the limb
had been wholly useless for twelve years and a half; notwithstanding
this there was not much wasting, and no appreciable shortening. A
semicircular flap was cut and raised. The original point of union of
the bones at the joint was sought for, but no indication of it could be
found. A cut was then made with the saw, nearly vertically, through
the femur above the condyles, not extending quite through the bone,
and this was joined by a second, oblique cut, sloping from before down-
wards and backwards, meeting the first about half an inch in front of
the posterior surface. The piece between them was then removed, and
the remaining portion broken, by flexing the limb. The vessels were thus
completely avoided. The ends were smoothed down with a chisel until
the limb could be easily straightened. It was then put up on a back
splint, specially made, and the wound covered with wet lint. A certain
amount of suppuration followed, and a few abscesses required opening.
At the end of eight weeks there was firm union. One noteworthy cir-
cumstance was, that for several days after the operation, the boy was
SUBCUTANEOUS OSTEOTOMY. 225
literally tortured by pain in the back, which was attributed to his being
obliged to lie in a position which, for obvious reasons, he had not been
in the habit of assuming. The limb, at the date of note, was firm and
straight, with less than two inches shortening. A few sinuses remained
open. ('Brit. Med. Journ.,' Oct. 26, 1872.)
Dr. Watson showed to the Med.-Chir. Soc. of Edinburgh a wedge of
bone, which he had removed, from the site of the knee-joint, in a case of
old-standing, rectangular anchylosis. The patient was an adult male,
and recovered well. He could walk without assistance. In straighten-
ing the limb the hamstring tendons required division. (' Edin. Med.
Journal,' Dec. 1871, 559.)
Complete, tony anchylosis of the hnee-joint ; subcutaneous osteotomy. —
Mr. Little records the case of a girl, set. 14. Both knees were con-
tracted to a right angle. The left knee was straightened under chlo-
roform, but the right knee was found to be firmly anchylosed. This
had resulted from strumous disease, and the tibia was dislocated. "A
serious operation, such as severing a wedge-shaped piece of bone,
seemed out of the question, considering the feeble state of the girl's
health, but as a subcutaneous operation, though possibly not successful,
would probably be attended with little risk, I determined to attempt
the division of the bone, somewhat after the method of Prof. Gross (see
*Bien. Eet.,' 1867-8, 256) of Philadelphia." "An incision, a third of
an inch long, was made down to the bone, through the healthy skin on
the outside of the knee, over the lower border of the outer condyle of
the femur, about midway between the anterior and posterior aspects of
the limb." Owing to the alterations in the positions of the bones it
was impossible to ascertain the relations of parts accurately. A strong
carpenter's chisel, rather less than a quarter of an inch wide, was in-
serted into the wound, and driven with a mallet through the united
bones towards the inner side of the knee, until its point was felt. The
chisel was then nearly withdrawn, and then driven through again, so
that its point emerged somewhat higher, i. e. nearer the anterior sur-
face of the limb than before. This procedure was repeated in different
directions. Finally, the limb became movable, but could not be straight-
ened, owing to contraction of the hamstrings. These were divided, but
it was considered better not to persevere in attempts at straightening.
During the next few days the girl complained a good deal of pain. On
the sixth day the limb was placed on an extension splint. In three
weeks she could put her foot to the ground and walked with crutches.
A fortnight later she walked quickly and painlessly, though with lame-
ness, without her crutches. This case is the first instance of subcuta-
neous osteotomy, for the relief of a completely anchylosed, large joint,
performed in this country. (' Med.-Chir. Trans.,' liv, 247.)
Excision of the anJcle-joint. — Mr. Gant treats of excision of the ankle
joint (* Lancet,' Aug. 5, 1871, 183). Lateral incisions are sufficient.
Mortality. — Of 32 cases, 7 died. Of these, 4 died of consumption, and
I of secondary syphilis. The average mortality, therefore, is i in 16.
Syme's amputation shows a mortality of i in 28. State of the foot. — Of
the 32 cases, 21 recovered with good useful limbs. Secondary amputa-
tion.— Of the 32, only 2 underwent secondary amputation, and both re-
15
226 REPORT ON SURGERY.
cof
covered. In 2 cases under the care of the author, both patients re
vered with useful limbs.
Dr. Watson showed a patient to the Medico- Chirurgical Society of
Edinburgh, whose ankle-joint he had excised. The parts removed,
consisting of the astragalus and the ends of the tibia and fibula,
were also exhibited. The patient did well afterwards. At the end of
ten months he could bear his whole weight on the affected limb, and
walked smartly and readily. ('Edin. Med. Journ.,' Jan. 187 1, 650.)
A successful case is noted and figured in the ' Med. Times and Graz.,'
March 2, 1872, under the care of Mr. Maunder.
A case, under the care of Mr. Canton, is noted in the 'Lancet,*
Jan. 20, 1872, 80.
JExcision of the ankle-joint and removal of tarsal hones. — Mr. Swain has
had a case under care — a boy SBt. 14 — in which, at different times, he
excised the ankle-joint and the bones of the tarsus for caries. The re-
sult was good. Illustrations of the state of the ankle are given. (* Brit.
Med. Journ.,' Jan. 7, 187 1, 10.)
JExcision of the astragalus, malleoli^ Sfc. — Dr. Watson employs a
single, external, J-shaped incision. (' Edin. Med. Journ.,' Dec. 187 1,
560.)
Excision of the astragalus. — Mr. Grant states that, of complete ex-
cision, 4 cases, only, are recorded in England. Of partial excision, in
27 cases, recorded, 8 were for caries ; 5 terminated well, i ended in an-
chylosis, and, in 2, the result is not stated. Of complete excision, 109
cases are recorded ; 14 were for disease, 13 for caries, i for necrosis.
Of the 13 cases, i died, 8 recovered with good and useful limbs, 2 un-
derwent secondary amputation, two years after the excision, and both
recovered ; in 2, the results were doubtful. The case of excision for
necrosis did well. ('Lancet,' Aug. 5, 1871, 185.)
Mr. Hancock removed the astragalus, successfully, from the right foot
of a man SBt. 47. The bone was dislocated forwards and outwards and
twisted. There was no wound. An incision was made directly over
the bone. ('Lancet,' Jan. 20, 1872, 79.)
A case in which the operation was done, for disease ^ and another, for
dislocation^ are given in the ' Path, Trans.,' xxiii, 192, by Mr. T. Carr
Jackson.
Excision of the astragalus and os calcis, — Dr. Morton removed the os
calcis and the astragalus from a lad set. 13, on account of disease. " A
very perfect recovery followed, both as regards motion in the new joint
and the usefulness of the foot, which was shortened about one inch."
('Am. Journ. Med. Sciences,' April, 187 1, 424.)
Removal of both astragali in a case of severe, double talipes. — In the
case of a boy, set. 7, suffering from severe double talipes, for whicli
much treatment had been employed without result, Mr. Lund deter-
mined to remove both astragali. A longitudinal incision was made
over the most projecting part of the head of the bone, parallel to the
antero-posterior axis of the foot, between the line of the outermost
tendon of the extensor longus and the tendon of the peroneus tertius.
After some difficulty, owing to the thick ligaments, the head of the bone
was exposed and a gouge was applied to raise the bone, the scaphoid,
EXCISION OP BOTH ASTRAGALI — OP TARSO-METATARSAL JOINTS. 227
&c., being bent backward. In doing this a thin piece of the cup of the
scaphoid was sliced off. A part of the external malleolus was also
sliced off, owing to want of room. Mr. Lund then made use of a
strong, blunt hook (figured), with a cutting concave edge. This hook
was used, as a lever, to lift up the astragalus, and passing it round
the calcaneo-astragaloid ligament, by simple traction, the latter was
severed. This proved to be the key of the operation. Seizing the bone
with lion forceps, a few touches of the hook set the bone at liberty,
and it was removed. In operating on the second foot, only the hook
was used, and the astragalus was removed alone. Everything was done
in accordance with Mr. Lister's directions for antiseptic treatment.
The result of the operation was all that could be desired. On the
sixty-first day elastic traction was employed. The boy then had
shoes ordered, and at the end of a month he could walk well. Mr.
Solly in one case removed the cuboid bone, but there does not appear
to be a case of removal of the astragalus, for talipes, on record. (' Brit.
Med. Journ.,' Oct. 19, 1872.)
Excision qftheos calcis. — Mr. Gant prefers the horizontal, horseshoe
incision over the heel, forming a sole-Jlap. A vertical incision forming a
heel-flap, like a Syme, is useful in certain cases, as adapted for Syme's
amputation, if necessary. Results of partial excision, in 42 cases,
38 were for disease — 25 caries, 12 necrosis with sequestra, and i
necrosis. Of the 25, i died, the day after the operation, of diar-
rhoea, 14 recovered at periods varying from six weeks to six months,
2 required a second operation, but recovered, and i underwent secon-
dary amputation ; while, of the remaining 7, the result is not stated.
Of the 12 cases, 3 recovered, i required a second, i secondary ampu-
tation, and, of 7, the result is not stated. Complete excision. — Of 18
cases (the particulars of which are authenticated), in 14 the disease
was scrofulous ; and in 11, of these, this condition was entirely consti-
tutional, in I it is said to have originated from a nail having been run into
the heel, and, in 2, to have followed sprains. Of the 1 1 cases, i died of
diphtheria, 7 recovered, and with perfect use of the limb, while 3
suffered secondary amputation, 2 from recurrence of the disease in
the remaining tarsal bones and owing to erysipelas. Of the 3 cases
induced by injury, 2 recovered completely; and the result of the third
was doubtful. The general results of the complete excision of the os
calcis in 34 authenticated cases — i died of diphtheria, 25 recovered com-
pletely, 4 underwent secondary amputation, and, of 4, the results are
not given. In one case of caries of the os calcis, Mr. Gant also re-
moved the cuboid bone and a small portion of the external cuneiform
bone. The patient recovered, and with a thoroughly sound and perma-
nently serviceable foot ; this result being noted after two years. The
ankle-joint had free motion. He walked without the aid of a crutch
or stick. The case is reported in the 'Lancet' of July 23rd, 1864.
M* Lancet,' Aug. 5, 1871, 185.)
I Mr. Terry narrates the case of a man, aet. 19, whose os calsis he
Kcised. The foot was thoroughly useful at the end of six years.
I (^'Lancet,' Jan. 13, 1872.)
I Removal of the second metatarsal hone and subsequent excision of all
228 REPORT ON SURGERY.
the tarso-metatarsal articulations. — The patient was a middle-aged man,
who had had a plank fall on his foot four months before admission.
There was a sinus leading down to the second metatarsal bone,
which was carious in nearly its whole extent. On Nov. 24, 1871, Mr.
Holmes dissected out the second metatarsal bone. Various abscesses
formed subsequently, and on Jan. 11, 1872, Mr. Holmes made
a semilunar incision on the dorsum of the foot, and dissected the
flap upwards. He then disarticulated at the tarso-metatarsal articu-
lation, and sawed off the ends of the four tarsal and then of each of
the four remaining metatarsal bones. The disease seemed to be con-
fined to the portions of bone removed ; on February T4th he was sent
to Wimbledon. On April 8th " the wound was entirely healed, except
a small, superficial sore at the inner part. He could just put his foot
to the ground. The toes were movable to a very slight degree, appa-
rently from the traction of the extensor tendons being transmitted
through the cicatrix. The second toe was out of the line of the others,
riding upwards between the first and third toes, which touched each
other. This, however, had been the case before the operation. The
man was well satisfied with the condition of his foot." " Many still
regard excision of the ankle with disfavour ; yet, as far as I can judge
from a limited, personal experience, there can be no question that, in
cases of traumatic origin, sound union may be confidently expected, and
the patient in such cases recover rapidly, and with a foot little inferior
to the healthy one. Three such cases have occurred to me and recovery
has been very rapid in all of them. But excisions of the bones or
joints of the foot itself are still less generally practised, although the ex-
perience of many surgeons testifies to the great success which some-
times ensues upon the complete removal of the os calcis, the astragalus,
or other single bones of the tarsus, while, if I mistake not, common
experience also testifies to the very frequent disappointment which
follows upon gouging or other partial measures. "It is worth re-
membering also that the prospects of a surgical operation are always
much better in such cases as can be clearly traced to a traumatic
cause." (*Clin. Soc. Trans.,' v, 207.)
JEoccision of the lower jaw. — In narrating a case in which he removed
part of the lower jaw in connection with epithelial cancer of the fauces,
&c., Dr. Watson especially lays stress on the advantages of the plan he
adopted. He made an incision from the angle of the mouth obliquely
downwards to the base of the jaw as far as the angle, and then upwards,
along its ascending ramus, as far as the level of the lobe of the ear.
The lower jaw was then divided in the bicuspid region, and the inser-
tion of the internal pterygoid having been divided by a sweep of the
knife along the inner side of the bone, the base and angle, upon the
affected side, was turned outwards at right angles to the cheek. The
coronoid process being affected it was necessary to disarticulate after
dissecting the tissues away from the bone upon its outer or masseteric
aspect ; this was easily accomplished by twisting the articular process
out of its bed, dividing upon the bone the parts anterior and internal
to the articulation, so as to avoid injuring the internal maxillary artery.
In attacking growths at the posterior and lateral aspect of the buccal
EXCISIONS OF THE MAXILLAE. 229
cavity, the division of the lov^er jaw affords easy access, and entire
control over the bleeding. In most cases it is not necessary to extir-
pate any of the bone. If extirpation is required two things deserve
notice in effecting it: ist, that an incision which ascends no higher
than the level of the lobe of the ear suffices and thus avoids division of
the portio dura ; 2nd, that in the removal of the jaw, at the articulation,
division of the internal maxillary artery may easily be avoided. (' Ed.
Med. Journ.,' Jan. 1871, 6^i).
In order to avoid division of the facial nerve and parotid duct in
removing the inferior maxilla, Mr. Lizars has adopted the following
plan of operating. He made one straight cut from the angle of the
mouth towards the upper part of the lobe of the ear as far as the pos-
terior margin of the ascending ramus of the maxilla ; he denuded the
jaw of its periosteum, the masseter and that part of the temporal muscle
attached to the external and lower part of the coronoid process (using
the handle of the scalpel principally), extracted the lateral incisor, and
divided the jaw with the bone-pliers (the subject being young) ; then
seizing the jaw at its cut end, drew it outwards and upwards, thus
facilitating the removal of the mucous membrane and muscles from its
inner surface, dividing the inferior dental nerve and internal lateral
ligament with the knife, and by keeping close to the bone, avoided the
internal maxillary artery. The coronoid process and neck of the jaw,
now being free, were divided with the pliers, and nearly the half of the
jaw easily removed. (Communicated to the 'Lancet,' Sept. 28, 1872,
by Sir W. Fergusson.)
Tumour of the lower jaw. — Mr. Hamiltonrecords a case of cystic tumour
of the lower jaw, on which he operated successfully. The condyle was
disarticulated at the joint, and nearly one half of the bone was removed.
(' Dub. Journ. Med. Sci.,' April, 1872, p. 283). A case under the care
of Mr. Christopher Heath, in which he removed a large fibro-cystic
tumour of the lower jaw, is noted in the 'Lancet,' March 23, 1872,
397, and 'Path. Trans.,' xxiii, 181.
Excision of half of the lower jaw. — Mr. W. Thomas, of Birmingham,
removed the left half of the lower jaw on account of a myeloid tumour.
The growth had been recognised for about seven years. The left lower
incisor tooth was extracted, an incision made along the ramus from the
condyle to the median line of the lip, the structures dissected up, and
the jaw divided at the symphysis : after a little dissection the tumour
was removed by sawing the bone below the condyle, and then after-
wards the condyle was dissected out. The divided mucous membrane
of the mouth was stitched together, and the flap of skin laid down and
united by numerous silver wire sutures. The mass removed weighed
twenty-three ounces and a half. On section it was found to consist of a
thin, bony envelope surrounding a mass of pinkish- white substance a
little firmer than brain. In its substance were two cysts. Seventeen
months after the operation the patient was in excellent health,
and presented no sign of the recurrence of the disease. (' Lancet,'
July 15, 1871.)
Tumour of the antrum ; excision of part of the superior maxilla. — Sir
W. Fergusson removed the greater part of the superior maxilla for a
230 EEPOUT ON SURGERY.
tumour of the antrum. The patient recovered . The growth proved
to be fibrous, and was undergoing calcareous change. A complete
account of the histology is given by Dr. Goodhart. (' Med. Times and
Gaz.,' May 25, 1872.)
^Excision of the superior maxilla. — A case in which Dr. Gott excised
the superior maxilla for encephaloid disease is recorded in the ' Am.
Journ. Med. Sci.,' July, 1871, 289.
Removal of hoth superior maxillcd. — Mr. Canton removed the left
superior maxilla from a woman, set. o^^y in 1864, for myeloid tumour,
and, in 187 1, the other maxilla for fibrous tumour. The deformity was
remarkably slight. (' Lancet,' Jan. 20, 1872, 79.)
Anchylosis of the lower jaw ; formation of an artificial joint on each
side. — Dr. Maas relates, in the ' Archiv fiir Klin. Chirurg.,' xiii, 429,
the case of a man, aet. 27, who was admitted into the hospital, at
Breslau, on account of inability to open the jaw. At the age of 7 he
had scarlet fever ; during which, however, he was not confined to the
house. About this time, in consequence of a cold, he was seized with
severe pain in the articulation of the jaw, on both sides, so that he could
not open his mouth. The pain ceased, but the inability to move the
jaw increased, and became complete when he was 10 years old. His
food consisted partly of fluids, partly of finely divided meat, which he
managed to thrust into his mouth between the molar teeth, which were
deficient. The shedding of the milk-teeth was attended with much
difficulty and pain ; the permanent teeth were arranged irregularly, and
most of them were displaced laterally. On admission the patient had
a pale, yellowish aspect, was in moderately good condition, and spoke dis-
tinctly though with a somewhat muffled tone. The upper part of the face
was well developed ; but the lower jaw was retreating, and the alveolar
edge was observed to be far behind the corresponding part of the upper
jaw. Attempts to move the. jaw produced pain in the articulation on the
right side, but failed, utterly, in opening the mouth, even when the man
was narcotised. Dr. Middeldorpf made an incision along the lower
edge of the jaw on the right side, and, by means of the chain saw and
Listen's forceps, removed a wedge-shaped piece of bone, having its base
below. The result of this was that the mouth could be opened, pas-
sively, to the extent of about an inch. The teeth were found to be
mostly carious, or to be so abnormally placed as to be useless ; one
molar on the left side, and two on the right, stood out horizontally from
the alveolar border. The teeth were removed, and attempts were made
for some time to produce separation of the jaws. These, however, had
very little eflfect ; and, between four and five months after the first
operation, the left side of the jaw was operated on by Dr. Fischer in a
similar manner. Four months after this the patient could voluntarily
open his mouth, to the extent of 3*2 centimetres ; and his general con-
dition and appearance were much improved.
Dr. Bottini, in 1872, communicated a somewhat similar case to the
Eoyal Academy of Medicine at Turin. The patient was a lad aet. 17,
who had fallen on his chin when seven years old. Inability to open the
mouth gradually set in, so that in a few months he was quite unable to
separate the jaws. Bottini opened the mouth forcibly during narcosis,
ARTIFICIAL MAXILLARY JOINT REMOVAL 0¥ THE SCAPULA. 231
and inserted a wedge ; this, however, was so troublesome to the patient
that it was removed. Resection was now determined on, a perpendi-
cular incision was made on one side, and the head of the jawbone, after
the periosteum had been separated, was removed by the chisel and
hammer. This had no appreciable eifect ; and it was only after the
operation had been repeated on the other side, that the jaw could be
freely moved. The wounds were healed in six weeks, and the move-
ments of the jaw were normal. Nothing abnormal could be found in
the excised portions of bone ; but the inter-articular cartilages were
absent. ('Wiener Med. Wochenschr,,' No. 27, 1872.)
Bemoval of the scapula. — Mr. Spence exhibited to the Med.-Chir. Soc.
of Edin. a tumour involving the scapula, which he had removed. The
tumour had been growing for twenty-three years. The patient, a man,
SBt. 6^, was in general good health. The tumour was apparently very
loosely connected with the textures around it. Mr. Syme saw the man
eighteen years before, and told him that it might not trouble him
if he let it alone. "When first seen by Mr. Spence, the tumour was not
so large as it had becojne at the time of removal, and was exhibited to
the society. It was movable, bound down by the tissues to the scapula,
but apparently not connected to the bone. The man came into the
hospital in bad health, took erysipelas, recovered, and was dismissed for
a time. When he came back there was a change in the tumour. The
pain was very great at night, and the pulse was quickened. The growth
was still apparently movable and smooth on the surface, but from the
appearance of the skin and of the patient Mr. Spence was of opinion
he would have to remove the scapula. He made a preliminary incision,
and the tumour felt so loose he thought it would come away, but when
he came to a deeper part he found a soft mass involving the glenoid
cavity. Accordingly he proceeded to perform excision of the tumour
with the scapula. After examining the part, carefully, he found a series
of prismatic bodies of milk-white appearance and opaque. He removed
them, and they turned out to be lymphatic glands. He thought the
growth malignant. The man recovered well. One difficulty in the
after-treatment was found to consist in the tendency of the head of the
humerus to project through the line of incision. At this part, there
being nothing but skin, the head of the bone came against it and had a
tendency to protrude. When, during the operation, the clavicle is sawn
through, so as to expedite matters, the sharp section of bone projects
beneath the thin skin, and the overhanging arch is wanting. He would
be inclined, in future, to disarticulate the clavicle, and so leave the
rounded end of the bone. This would require less incision and less un-
covering of the head of the humerus, and would produce a better result.
The man was dismissed, cured, three months after the operation.
('Edin. Med. Journ.,' Aug. 1872, 178.)
Fibroma of the inferior costa of the scapula, 8fc. ; removal with part of the
scapula; result not stated. (Mr. Hill, 'Path. Trans./ xxii, 194.)
The pneumatic aspirator. — This instrument has been introduced into
practice by M. Dieulafoy for the purpose of preventing the access of
air during the tapping of any tumour suspected to contain fluid — of the
bladder, chest, &c. It has been improved by Weiss and others. It
232 REPORT ON SURGERY.
was described by M. Dieulafoy, at a meeting of the Academy of Medicine
in Paris, on April 19, 1870. ("De I'aspiration pneumatique sous-
cutanee,methode de diagnostic et de traitement, par le Dr. Georges Dieu-
lafoy.") Claims of priority were made by MM. Langier and Jules
G-uerin, the latter stating that he had had an instrument made on the
same principle thirty years ago.
The aspirator may be described, shortly, as consisting of a syringe
with an air-tight piston, capable of creating a vacuum, and a series of
fine, hollow needles (or a trocar and canula) fitting on to the syringe.
The latter is provided with an outlet as well as an inlet, each having a
stop-cock. The syringe is exhausted by drawing up the piston while the
taps are turned to prevent entrance of air. A needle is selected, or a
trocar and canula, attached to the syringe, and thrust a short distance
into the cavity to be emptied. The stop-cock is turned on, and the fluid
rushes into the vacuum in the syringe, without the possibility of air
entering the cavity tapped. If preferred, the syringe need not be ex-
hausted till the needle is thrust in, and thus the traction force can be
regulated. "When the syringe is full the inlet tap is shut, the other opened,
and the piston forced down. The fluid is conveyed by a tube into a con-
venient receptacle. Messrs. Khrone and Sesemann supply a form of
apparatus more convenient in some respects. It consists of a large, glass
jar, in the top of which is inserted a syringe and a tube. The syringe is
used to exhaust the glass jar. To the tube is attached a convenient length
of india-rubber tubing, to the end of which the needle or trocar and
canula can be attached. This apparatus is easier to work if there is a
large quantity of fluid to be removed. Considerable force is required to
draw up the piston of the ordinary syringe, and is tiring after a time.
Dr. Anton Lohmayer, of Esseg, a former assistant of Billroth, gives,
in the 'Wiener Med. "Woch.,' August 5 and 12, 1871, notes of 14
cases in which he used the aspirator ; cold abscesses, hydrops genu.,
tumor albus genu., &c. This paper contains an interesting, historical
summary of attempts made in the same direction as that of Dieulafoy.
Mr. Jessop gives illustrations of the surgical uses of the pneumatic
aspirator in abdominal tumours, a pelvic tumour, hernia, hydroce-
phalus, abscesses, efi'usion into knee-joint, &c. (' Brit. Med. Journ.,'
Dec. 7, 1872.)
See, further, Aspiration of intestine.
Cleft palate. — Mr. T. Smith narrates forty cases in which he has
operated for clefts of the hard and soft palates under chloroform. In
twenty-five cases, he closed the whole cleft at one operation. In nine
of these, a complete cure was effected ; in eight, there was only a small
central hole left ; in two, failure resulted ; in three, only the hard palate
united ; in one, the soft only, and, in two, a large hole remained in the
palate. If it is considered inadvisable to attempt to unite the whole
at once, Mr. Smith recommends that the part of the cleft should be
brought together, first, which seems most easily approximated, whether
it is the hard or soft palate. This proceeding, if successful, secures for
the most difficult part of the palate a larger supply of blood in the
subsequent operation. He figures a new form of gag, an improved
needle for wire, needles for silk, and a " catcher " for pulling the silk
CLE¥T PALATE — TUMOURS OF THE BREAST. 233
through. He only divided the muscles in a few cases, trustiuf^ to
ii>*J incisions. ('St. Barth. Hosp. Eep.,' vii, ij^s.) Mr. Francis Mason
describes a plan he has adopted for improving the voice after a cleft of
the palate has been closed. The operation may be performed at any
time after the closure. A narrow spatula is passed behind the soft
palate and then an incision is made in the soft palate on either side,
just at the inner side of the hamular process. The palate retracts by
muscular action and is converted into a loose, movable curtain, which
effectually shuts off the communication between the posterior nares
and the mouth. A diagram is given. Eleven cases have been
operated on. ('St. Thorn. Hosp. Eep.,' ii, 271.) Mr. Hulke
operated on a little girl, a?t. 2^, who had a cleft of the soft palate,
under the influence of chloroform, using Smith's gag. The sutures
were torn out at the end of a week in a fit of coughing. He operated
again at the end of thirteen months, using silkworm-gut sutures.
Perfect union throughout the whole of the cleft resulted. (' Lancet,'
Oct. 14, 1871, 339.) Dr. Whitehead records two cases in which he
operated successfully, the patients being anaesthetised. In several cases
he believes bone has been produced in the new palate. — (' Amer. Jour.
Med. Sciences,' Jan. 1872, 75.) A case of cleft of the hard and soft
palates operated on successfully at one operation, in a man of thirty-
five, is recorded by Dr. Whitehead. A special gag and various instru-
ments, which are figured, were employed. The patient was relieved.
(* Amer. Journ. Med. Sciences,' July, 1871, 114.)
Scissors for removing sutures — Mr. Thomas Smith uses a pair of
Bcissors with a fine hook at the end of one blade, and there are flat
surfaces on each blade, behind the cutting edge, to seize the suture fast
when divided. (* Lancet,' May 13, 1871, 645.)
Improved gag for use in operations on the mouthy Sfc. — In a clinical
lecture on epithelioma of the tongue Mr. Wood describes and figures a
gag somewhat similar to Mr. Smith's, acting on both sides, but without
a tongue-piece, very strong and having a transverse connecting piece
passing under the chin. (' Lancet,' Sept. 28, 1872.)
Removal of tumours of the breast. — The results of Mr. Syme's practice
in the removal of tumours of the breast show, that of fifty-five opera-
tions which he performed, for simple tumours, recovery followed in all.
In 147 cases of carcinoma, death followed in 10. Two of the patients
died of shock ; the others of erisipelas or of inflammatory affections of
the thoracic viscera. (' Edin. Med. Journ.' July, 1871, 32.)
Cancer of the hreast. — In the ' Lancet,' for Sept. 16, 1841, 398, is
a record of cases of cancer of the breast, with special reference to the
returnof the disease after operation (compiled by Dr. Andrea Rabagliati)
from the Bradford Infirmary. The following summary is given. Out of
10 patients, on whom 1 1 operations were made for cancer of the breast :
— 2 died of the operation ; 3 have died since, i of return of the disease
locally, and 2 died from constitutional return (of these i in the liver
and I in the lung) ; in 2 more the disease has recurred locally ; and in
3 there has been no recurrence of the disease up to the time of the
note. In the cases of the last 3 patients the longest interval between
the date of the operation and the time of the note was nine months,
L
234 REPORT ON SUHGERY.
in another, the interval was five months, and, in tlie last, the interval was
three months. The disease had recurred in every one of the cases in
which the axillary glands were involved at the time of the operation.
Excision of the mamma. — Dr. Joseph Bell advocates the employment
of three incisions instead of the two oval ones usually employed. They
are either curved, the convexities towards each other and leaving a
triangular space enclosing the nipple, or V-shaped with a cross piece at
the top (base) including the nipple, or, instead of the two lateral parts
of the V, the incisions may be curved, with their concavities towards
each other and the apex below the nipple, or, if more room is required,
they may be continued downwards after crossing, curving away from
each other. Figures are given. He also lays stress on removing all
the fat and glands from the axilla if the latter is affected, and, also, the
whole mass of subcutaneous fat lying in the line between the breast
and the axilla, and which contains the lymphatics extending from the
breast to the axilla. C Edin. Med. Journ.,' Eeb. 187 1, 687.)
Cystic tumours of the hreast. — Dr. James P. Goodhart has investigated the nature
and development of cystic tumours of the breast, and his results are published in the
* Ed. Med. Journ.,' May, 1872, p. 1015, with illustrations.
Myxoma of the breast. — Specimens by Mr. Forster and Mr. Henry Morris, * Path.
Trans./ vol. xxiii, pp. 261 and 274,
Subcutaneous division of the nech of the tMgh-hone. — Mr. W. Adams
points out the cases which he thinks adapted for performing sub-
cutaneous section of the neck of the thigh-bone. Six cases have now
been recorded ; five of them, for bony anchylosis, were successful ; one,
for fibrous anchylosis in a child, was unsuccessful. Mr. Adams enume-
rates the specimens of bony anchylosis which are preserved in the
various museums. In anchylosis after rheumatism, pyaemia, traumatic
inflammation, and strumous disease, arrested in an early stage, the
operation answers well. It is only in cases of severe, strumous disease,
with destruction of bone, that the operation is decidedly negatived.
(' Brit. Med. Journ.,' May 20, 1871.)
Statistics of operations. — Mr. Stokes publishes the statistics of 137 surgical opera-
tions performed by himself from Jan. 1870 to Dec 1871. (*Dub. Journ. Med.
Sci.,' 1872, 446.)
Paracentesis thoracis. — Dr. Evans contributes a paper on thoracentesis, giving
statistics and tables of results, &c. (' St. Thomas's Hosp. Rep.,* ii, 69.)
Tumour caused by the growth of a canine tooth within the antrum. — A
negro, set. 14, came under the care of Mr. R. W. McCoy for a swelling of
the left side of the face. As far as a history could be obtained it was
probable that the tumour had been growing for about two and a half
years. The tumour was punctured under the lip with a trocar and
canula, and half a drachm of a thin, glairy fluid drawn ofl*. The opening
closed and the tumour continued to increase in size. The whole of the
front wall of the tumour was then removed by operation. It was very
thin and lined, on its concave surface, with a thick, gelatinous substance
— mucous membrane morbidly thickened and degenerated. The cavity
of the antrum was found nearly filled with this substance. In the
centre was a space about the size of an almond, containing a little viscid
mucus, and projecting into it, from above, was a tooth. The tooth was
firmly imbedded in a socket, apparently growing from the nasal process
REMOVAL OF NASO-PHARYNGEAL TUMOURS. 235
or inner angle of the orbital process of the superior maxilla, and it
required some force to extract it with the tooth forceps. It was a fully
developed, sound, canine tooth. The gelatinous contents of the antrum
were, in great part, cleared out. The boy recovered well and with no
apparent deformity. The left, upper, canine tooth was wanting in its
natural place. (' Lancet,' Aug. 19, 187 1, 259.)
Distension of the antrvm of Highmore. — Mr, Warrington Haward brought cases
under the notice of the Chnical Society. (' Trans.,' v, 131.)
Myeloid tumour of the lower jaw ; removal through the m,outh without external wound.
— Mr. Maunder records a case and gives a photograph. ('Brit. Med. Journ.' Jan. 13,1872.)
Osteo-plastic resection for removal of naso -pharyngeal tumours. — It is
now several years since Langenbeck devised " osteo-plastic resection of
the upper jaw" for the removal of naso-pharyngeal tumours (see ' Year
Book,' 1862, &c.). In his operation the bone was raised directly
upwards or upwards and inwards. Oilier, of Lyons, opened the naso-
pharyngeal cavity by cutting through the nasal and superior maxillary
bones above, and turning the flap downwards. Another modifi-catioii
of this operation, having the same object, has been devised by Dr. von
Bruns of Tiibingen, and is described in the ' Berlin. Klin. Wochenschr.,'
Nos. 12 and 13, 1872. In cases where the external nose is thrust
towards the right cheek, a horizontal incision is made, through the upper
lip (avoiding the mucous membrane), from a few millimetres below the
right ala nasi to a point opposite the first, left, molar tooth. A second cut
is made in the direction of the naso-frontal suture, its ends lying about
a centimetre above and on the inner side of the angle of the eye ; and
a thirjl is carried from the left extremity of the upper incision obliquely
downwards and outwards along the side of the nose to the left end of
the lower incision. The periosteum is divided in the incisions. The
base of the anterior, nasal spine is now divided by a saw, and the
septum is cut through, horizontally, by bone forceps. A saw is now
inserted at the left, lower corner of the external nares, and the bone is
divided, first outwards, then upwards, then to the right ; the septum is
then divided obliquely, downwards, and backwards. This being done, a
chisel is inserted in the upper end of the lateral saw-cuts, so as to break
through the connection between the right nasal and the upper maxillary
bones, and the whole nose can be now turned over on the right cheek.
When only one half of the nose requires to be raised, the horizontal
incisions are carried only a little beyond the middle line ; the anterior
nasal spine, the septum, and the nasal bone, on the sound side, are left
untouched, and the nasal bones are separated along their line of
junction. If the tumour cannot be at once removed, a tampon may be
introduced to prevent union, and the operation completed afterwards.
Dr. von Bruns has performed the operation on three patients, all the
cases being successful. In one instance it was necessary to keep the
nose displaced for three weeks, but union readily took place at the end
of that time, after freshening of the edges. The advantages of this plan
are said to be, that the removal of the tumour is facilitated, more direct
and extensive access to its base being gained ; that the haemorrhage is
easily arrested ; that the surgeon has the opportunity of keeping the
part accessible, so as to perform further operations if necessary ; and
that healing takes place readily, without any disturbance of function.
236 EEPORT ON SURGERY.
Removal of pharyngeal polypi hy the galvanic cautery. — MM. Corradi
and Gozzini ('Lo Sperimentaie,' 1871), describe a case of pharyngeal
tumour which they removed by means of the galvanic cautery. The
tumour was round, very hard, smooth, and was attached by a broad
pedicle to the pharynx, the upper part of which it occupied. A Belloc's
sound, introduced through the nostril, was passed between the tumour and
the uvula ; one end of a silk thread was, by means of the sound, carried
into the nose, and the two ends of a platinum wire, about two feet long
and one twentieth of an inch thick, were fastened to the other end. The
silk thread was drawn through the nose, and, by manipulating the
wire loop in the motith, it was placed as high as possible on the pedicle
of the tumour. The ends of the wire were then placed in connection
with the battery (G-renet's) ; the circuit was kept closed for twenty
seconds, traction at the same time being made on the wipe. The current
was now interrupted, and the loop, which had cut into the tumour, was
placed more accurately on the pedicle. The circuit was again com-
pleted, and the tumour was cut through at its base and removed through
the mouth by means of the fingers. It measured nearly two inches
longitudinally and an inch and a half transversely. The patient felt no
sensation of heat during the operation ; it was not followed by pain,
haemorrhage, or any discharge.
Nasal polypus. — Dr. Lichtenberg records a case of fibrous polypus,
high up in the nose, which he removed, from the outside, by making a
flap and sawing through the nasal process of the superior, maxillary
bone, &c. A detailed description and a figure of the operation are
given. ('Lancet,' Nov. 30, 1872.)
Naso-pharyngeal polypus; extraction through the anterior nares; brain symptoms;
death. — Mr. Forster, 'Clin. Soc. Trans.,' iv, 159.
Removal ofhronchocele. — Dr. Grreene has removed large bronchoceles,
successfully, in three instances. The first patient was a woman, set. 45.
The bronchocele was very large (a sketch from a photograph is given).
A fatal result was anticipated, quickly, if nothing were done, and the
patient was anxious for an operation. A long incision was made
through the skin, and the fascia divided on a director. Several veins
were wounded in dividing the fascia immediately investing the tumour.
Their walls were so thin no ligature would hold. He only used his
fingers in cleaning the surface of the tumour and separating it from
surrounding structures, but the haemorrhage was fearful. He soon
reached the pedicle, which contained three, large arteries whose pulsa-
tions were very distinct and which served as guides for dividing the
pedicle into three parts, which was accomplished with the fingers. Each
part was tied separately ; adhesions to the sheath of the carotid vessels
were found at one place, and their division was followed by copious,
venous haemorrhage. This came from the internal jugular, which was
tied. The patient recovered well. The second patient was forty years
of age. The tumour was connected with the oesophagus. There was
not so much haemorrhage as in the former case. Two vessels were found
at the base ; a blunt needle was passed between these and the pedicle
tied" in two halves. She recovered well. The third patient was thirty-
five years of age. The growth was very large, and the surface of it
pulsated everywhere. The haemorrhage was very alarming. The base
REMOVAL OF BRONCHOCELE. 237
was reached as quickly as possible, regardless of the bleeding, and tied
in two halves. The inferior thyroid, of the left side, is mentioned as of
the size of the common carotid in its normal condition. The patient
did well. Dr. Greene says these are the only cases he has attacked,
jind though they turned out so successfully he is not anxious to deal
Avith another ; at the same time he would not hesitate in a similar case,
as the possibility of extirpation, even in the worst cases, is established.
The several steps in the operation are — (i) exposure of the tumour by
linear incision of ample length, avoiding most sedulously any wounding
of the tumour or of its fascia propria ; (2) division of the fascia propria
upon a director ; (3) the reflection and the enucleation of the tumour
with the Jingers and the handle of the scalpel, paying no attention to
lic'emorrhage, however profuse, but going as rapidly as possible to the
base of the gland and compressing the thyroid arteries ; (4) transfixion of
the pedicle, from below upwards, with a hlunt, curved needle, armed with
a double ligature, and tying each half; or, when practicable, dividing the
])edicle into as many portions as there are main arterial trunks, and
tying each portion separately ; (5) excision of the gland and subsequent
dressing of the wound as in ordinary cases. " It is and always will be
exceedingly rare that any such interference is warrantable ; never for
relief of deformity or discomfort merely, only to save life." " If it is
beyond all question determined, in any given case, that such an opera-
tion gives the only chance for snatching a fellow-being from an untimely
grave, be it remembered that accurate, anatomical knowledge and a per-
fect self-control, under the most trying ordeals through which a surgeon
can pass, are indispensable to its best performance." (' Am. Jour.
*Med. Sciences,' Jan. 1871, 80.)
Dr. Morell Mackenzie writes on the treatment of hronchocele
(* Lancet,' May 4, 1872). In " simple or adenoid bronchocele " he uses
iodine, blisters, iron, &c. For the " fibrous" he employs a seton passed
through the substance of the gland. The seton should be of twine (six
to twelve threads, according to the size of the tumour). In " cystic
bronchocele" he uses injections of perchloride of iron. The cyst should
first be emptied and then a solution of perchloride of iron (two drachms
of the salt to an ounce of water) is injected through the canula, which
is then plugged and fastened in. The injection is repeated every two or
three days till suppuration is established. The tube is then withdrawn
and poultices are employed. Figures of patients before and after opera-
tion are given. Other varieties of the disease are considered.
Congenital, cystic tumour of the neck successfully extirpated. — Dr.
Hardie records the case of a baby, set. 5 months, who had a congenital
cystic and solid tumour of the neck. After various methods of treat-
ment had been tried, as the child seemed likely to die if nothing further
was done, an operation was performed. Haemorrhage was checked as
he proceeded. The baby on several occasions seemed nearly dead. Both
sterno-mastoids were divided. The operation took an hour and five
minutes. The child recovered perfectly and remained well. (* Lancet,'
Nov. 9, 1872, 667.)
Removal of a cystic tumour of the neck. — Dr. Walter F, Atlee removed
a cyst, of the size of a goose-egg, from the neck of a young man. Various
238 REPORT ON SURGERY."
attempts had been made to procure contraction of the cyst without
avail. The patient recovered. " The chief interest, in this case, i
derived from the fact that it appears to show, that encysted tumours (^
the neck may have their origin in certain changes taking place in tli
lymphatic ganglia, as suggested by M. A. Kichard (' Memoires de la Sor
de Chirurgie,' iii). Another reason for calling attention to the case is
the fact that English, surgical literature is most remarkably barren ou
the whole subject of tumours of the neck. In this respect Holmes's
' System of Surgery' is quite deficient.'' ('Am. Jour. Med. Sciences,'
April, 1872, 411.) (The notice in Holmes's 'System' may not be in
sufficiently large print or detail, but is hardly " quite deficient." See
" E-egional Surgery," v.)
Sanguineous tumour of the nech. — A case in which a sanguineous
tumour of the side of the neck was tapped, then laid freely open and
syringed out, daily, with Condy's fluid, is noted in the ' Lancet,' Sept.
30, 1871,467. The patient was uuder the care of Mr. Savory. Oa
the ninth day a sudden gush of blood occurred. It was stopped imme-
diately and the common carotid artery ligatured, but the patient died.
The external carotid artery had given way.
Removal of a tumour of the palate. — A young man, set. 28, came under
the care of Dr. King, of Hull, for a large tumour of the left side of the
palate, which filled up nearly the whole of the arch of the fauces,
the tonsil being tightly stretched over it. He had only been aware of
it for three months, but when he discovered it, he said, it was of consi-
derable size. The man's symptoms were urgent, and so he consented to
the removal being attempted. A ligature was first of all passed round
the left carotid so as to be ready for being tightened if necessary. An
incision was then made from the angle of the mouth to the inferior
maxilla, a little above the last molar tooth, and the ends of the facial
artery tied. The last two molars of the upper jaw were extracted
and the incision was carried back across the masseter to the posterior
edge of the inferior maxilla. Some difficulty was then experienced
owing to the tumour falling back on the glottis. It was held up, how-
ever, and the ramus of the lower jaw divided about an inch above the
angle and the lower portion forcibly drawn down. Eoom was thus ob-
tained to deal with the tumour. An incision was made to the right of
the uvula, and the soft palate detached from the hard palate : two in-
cisions were made through the mucous membrane, one behind, the other
in front, enclosing the tonsil between them, and the fingers thrust
forcibly behind the tumour. The latter could now be drawn out be-
tween the divided portions of the lower jaw. On making a final in-
cision to remove the tumour a terrific gush of blood occurred. The
ligature on the carotid was tied and the haemorrhage ceased. An
artery on the right side of the palate required a ligature. The tumour
was found to be of a fibrous character. Dr. King thought that the
haemorrhage proceeded, simply, from vessels supplying a rapidly growing
tumour, and that no artery of any size had been divided. He con-
sidered the preliminary ligature of the carotid unnecessary and should
not again practise it. The chief danger was from suff"ocation. The
man did well after the operation, as far as its immediate dangers were
REMOVAL OF TUMOUES OF THE PALATE. 289
concerned, but succumbed to an attack of erysipelas six days later.
'riie power of swallowing was restored, the wound in the face had all
bat healed ; the division of the inferior maxilla could not be looked on
as hazardous ; no secondary haemorrhage had occurred ; from the time
of leaving the operating table till his death he did not lose one drop of
blood. ('Lancet,' Feb. 25, 187 1, 204.)
Removal of jptery go-maxillary tumours hy the mouth. — A man, set. 21,
was admitted into the Liverpool Eoyal Infirmary, May, 1871, under the
care of Mr. Bickersteth, for a tumour of the left side of the palate.
Eighteen months, previously, his attention was drawn to a slight swell-
ing over the left parotid region, which kept slowly increasing in size,
but did not cause him any pain or inconvenience. Probably the
Uiraour had existed much longer. There was considerable enlarge-
ment in the left parotid region, which evidently pushed the parotid
outwards. The left, ascending ramus of the lower jaw was so pushed
outwards that its condyle was seen and felt to project beneath the skin
(iutside the back of the zygomatic arch, while the right was at least half
an inch deeper than this process. On examination from within the
jnouth, a firm, dense tumour was found springing from the left ptery go-
maxillary region, and pushing the lateral wall of the pharynx inwards.
The tonsil was thrust inwards and downwards, and the uvula rested
against the anterior pillar of the opposite side. The boundaries of the
mass were well defined except externally. When pressure was made
externally, the tumour was plainly pushed inwards. There was clearly
no attachment to the bone. It was evident the tumour could not be
attacked externally without division of the lower jaw and extensive
mutilation of the soft parts. On the other hand, to attempt extirpa-
tion from within the mouth appeared hazardous and the result doubtful,
both on account of the size of the mass and the risk of wounding any
large vessels. Nevertheless, relying on the mobility of the tumour and
the certainty that it was enclosed in a distinct capsule, Mr. Bickersteth
attempted the latter plan. Chloroform was not given. Firm pressure
was made by an assistant. A direct incision was then made from
behind the left, posterior piUar of the fauces forwards and upwards,
through the structures of the soft palate, as far as its junction with the
hard palate. This incision, which at once exposed and opened the
capsule of the tumour to an extent of not less than two inches, was
crossed by another at right angles. With the handle of the scalpel the
flaps were now pushed back and reflected so as fully to expose the
whole of the portion of the tumour which projected into the mouth.
This was seized with forceps. The growth was of so friable a nature,
however, that it crumbled under pressure. Keliance was, therefore,
placed solely on the use of the forefinger aided by pressure from the
exterior. By a little perseverance the whole was turned out after some
difficulty. Not more than a drachm or two of blood was lost, and no
vessel required ligature. On putting the finger into the chasm from
which the tumour had been extracted, it was found to pass behind the
articulation of the jaw, and there appeared to be nothing, except the
skin and fascia, between it and the exterior The great arteries of the
neck and the styloid process and pterygoid plates were easily felt, the
240 REPORT ON SURGERY.
latter being laid bare but not denuded of periosteum. The patient was
discharged, cured, in eight days. The tumour was about three and a
half inches in its longest diameter, and weighed between three and ;i
half and four ounces. It was enveloped in a distinct, investing capsul
and microscopic examination showed that it was mainly composed
very perfect cartilage with a good deal of fibrous tissue intermixes
Figures of the man's condition before and after operation, and of the
tumour, are given. ('Lancet,' July 29, 187 1, 156.) In the number
for August 5, 186, Mr. Bickersteth remarks on the cases of Dr. King
and Dr. Watson,* and observes — "When it is remembered that all innocent
tumours, properly so called, are enclosed in a complete and distinct invest-
ing capsule, which is separated from the surrounding parts by a simple
layer of condensed, cellular tissue, surrounding the capsule proper, it
appears to be often unnecessary, in order to remove them, to do more
than make an aperture large enough to admit of their passage exter-
nally, and then they are capable of being easily shelled out, by the aid
of the finger or some blunt instrument, with much better precision and
much less risk, than by the most elaborately conducted dissection. This
observation is specially appropriate with regard to tumours occupying the
position we are now considering." " The deep and almost inaccessible
position of such growths secures them from the accidental agencies
liable to excite inflammation and consequent adhesions in tumours situ-
ated more superficially. If it is clearly ascertained that they admit of
as much movement as the confined space in which they are lodged per-
mits, I believe they may generally be easily and safely removed by the
method I have described, and without any external excision or any
elaborate dissection." In Oct. 1864 a woman, set. 35, was admitted
sufiering from great difiiculty in swallowing and from occasional attacks
of dyspnoea, caused by a growth of firm, fibrous consistence on the right
side of the pharynx. The tumour bulged over to the left side, but did
not project externally as the former one did. The tonsil was stretched
over it, but could be moved on it and was not adherent to it. In every
direction, except below, its limits could be defined, but it passed down-
wards into the lower part of the pharynx beyond the utmost reach of
the finger. The tumour had been observed for some years, but had
latterly increased rapidly, and the unfortunate woman was emaciated
by starvation and in imminent danger of suffocation. Incisions were
made similar to those described above, the flaps separated and turned
up, and the tumour seized with vulsellum forceps. By the aid of the
finger the whole growth was very quickly enucleated. It proved to be
of the size of a moderately sized, ripe fig and of purely fibrous struc-
ture. The patient left, in ten days, cured.
Removal of an exostosis from the first rib. — The patient, a female, set.
20, was under the care of Mr. Birkett. She had noticed a swelling on
the side of her neck for four months. There was a hard swelling felt,
deeply placed, on the left side of the neck, close to the main artery,
and with the cords of nerves going to the brachial plexus passing over
it, so that they could be felt roUing over the tumour. The external
jugular vein coursed along the anterior margin, and the incision was
* See 'Ketrospect/ 1869-70, 308.
ENCHONDROMA OP THE filBS. 241
made behind the growth, parallel to the vein. As little use was made
of the knife as possible when once the superficial incisions had laid bare
the nervous cords. The carotid artery was found to lie in a groove on
the anterior surface of the tumour, and had to be cautiously moved
aside. The tumour could be felt to spring from the surface of the first
rib, close to the margin of the scalenus. It was removed in two pieces.
Mr. Birkett remarked that the rough surface would soon be smoothed
down. He had never known a growth of this sort to recur. The
growth itself seemed of ordinary, cancellous bone, with a thin layer of
investing cartilage. (' Med. Times and Gaz.,' May 27, 1871, 602.)
Mnchondroma of the ribs; operation; death — Dr. Menzel relates
(* Wien. Med. "Wochensch.,' No. 15, 187 1) the case of a man, SBt. 2>^,
who was admitted into the hospital in Vienna, under Dr. Billroth, in
October, 1870, on account of a tumour under the right clavicle, which
he had first noticed in .the preceding January. It was five inches by
four in diameter, and reached from the lower border of the clavicle to
the third rib, and from the sternum beyond the line of the nipple. Its
surface was smooth, and it was firm and hard. The skin was not
affected. The tumour was immovable on the ribs, and was covered by
the pectoral muscle. It did not pulsate, nor could any bruit be heard
in it. There was no displacement of the heart nor any sign of disorder
of the circulatory or respiratory organs. With regard to the question
of operation, it was considered, on the one hand, that if the tumour
were left it might endanger the patient's life by outward growth and
consequent ulceration and sloughing, or even by inward growth and com-
pression of the lungs and large vessels ; while, on tlie other hand, its
removal might be attended with danger from opening the cavity of the
pleura. It was accordingly determined to cut down the tumour to the
level of the chest-wall, and this was accordingly done on October 27.
The wound was dressed with carbolic acid. On the third day the
patient became very feverish (temperature 104° Fahr.), and stated that
on deep expiration fluid escaped from the wound. On examination it
was found that the remaining portion of the enchondroma had sloughed
away, leaving an opening through which an india-rubber catheter could
be passed downwards as far as the lower part of the upper lobe of the
lung. Adhesions had formed round part of the ^opening. The pleura
was syringed every two hours, first with warm water, and then with
solution of hypermanganate of potash (five grains to the pint). From
Nov. 2 to 9 the patient went on well ; but the perforation had been
enlarged, partly spontaneously and partly by the removal of necrosed
portions of the second and third ribs. On Nov. 9 dulness on percus-
sion was noticed at the lower part of the right side of the chest, and
rapidly increased upwards. On account of the increasing difficulty
of breathing, paracentesis, by means of Dieulafoy's aspirator, was per-
formed between the eighth and ninth ribs, and 1400 cubic centimetres
of yellowish-green serum were removed. The patient was relieved for
three days, but the effusion then recurred, and was again removed to
the amount of 1350 cubic centimetres; it was newfound to contain
pus. After the second operation there was relief for a time, but the
patient was attacked with bronchial catarrh and cough, during the
16
242 BEPORT ON SUllGERY.
paroxysms of which the lung became torn by the edges of the riba,
giving rise to slight hseniorrhage into tlie thorax. Death took place on
November 30. On post-mortem examination there were found to be
extensive adhesions of the whole upper part of the right lung with puru-
lent exudation below. The mediastinum contained some enchondroma-
tous masses having a gelatinous appearance.
Removal of tumours from hone. — Sir James Paget is convinced that
the operation of simply removing a tumour from the place in which it
lies is as sufficient for the cure of one growing in a bone, as for that of
one growing in connective tissue, and that the instances are very few in
which it is right to disturb the continuity of a bone in order to remove
from it any innocent tumour. He selects the following cases : — i. He
removed a cartilaginous tumour from the head of the tibia of a lad,
set. 16. He reflected a semilunar flap and gouged. 2. He removed a
similar tumour from the lower jaw of a lady, set. 45. 3. He removed
a cartilaginous tumour from the radius of a woman, set. 40. 4. He
removed a fibrous tumour from the walls of the antrum. 5. Mr.
Wrench removed a myeloid, pulsating tumour from the end of the
radius of a woman, set. 43. 6. He enucleated a bony tumour from
the angle of the lower jaw of a patient, set. 15^. The tumour should
be freely exposed, and then turned out with the finger or the gouge.
For help to the diagnosis of fitting cases he suggests — i. The tumour
is probably cancerous if its growth commenced before puberty or after
middle age, unless it be a cartilaginous or bony tumour, on a finger or
toe or near an articulation. 2. If a tumour has existed on or in a bone
for two or more years, and is still of doubtful nature, it is probably not
cancerous or recurrent, and this probability increases with the increasing
duration of the tumour. 3. If the tumour on or in a bone has doubled
or more than doubled its size in six months, and is not inflamed, it is
probably cancerous or recurrent, and this probability is increased if,
among the usual coincideuces of rapid growth, the veins over the tumour
have much enlarged, or the tumour have protruded far through ulcerated
openings, and bleeds and profusely discharges ichor. 4. If with any
such tumour, not being inflamed, the lymph-glands near it are enlarged,
it is probably cancerous, and still more probably if the patient have lost
weight and strength to amounts more than proportionate to the damage
of health by pain or fever or other accident of the tumour. 5. A
tumour on the shaft of any bone but a phalanx is rarely innocent, and
so are any but cartilaginous outgrowths on the pelvis, or any but the
hard bony tumours on the bones of the skull. If on the concurrence
of these characters or on other grounds it is in any case concluded that
a tumour connected with a bone is not cancerous or recurrent, the
question whether it is growing on or in the bone may be made probable
by attending to the following points : — When the wall of the bone can
be traced over the surface or any part of the surface of the tumour, its
growth from within is nearly certain, and so it is when, on the surface of
the tumour, portions of bone can be felt among portions of more yielding
substance. General smoothness of surface is usually significant of a
tumour growing within a bone and expanding it, unless in the case of
cartilaginous tumours, which, after growing within bones, have pro-
TUMOURS. 243
truded through some of their expaoded walla. Pulsation in a non-can-
cerous tumour connected with bone is a nearly certain sign of growth
within bone, except in the case of certain specimens of myeloid epulis,
and when such pulsation is felt it is no indication that severe bleeding
will ensue in the removal of the tumour, for it is only derived from the
arteries in the walls of the bone-cavity lodging the tumour. When
these means of diagnosis are insufficient an exploratory puncture or
incision may be made ; and generally in cases of doubt it may be well
to attempt the simple removal of the tumour, and in case of failure to
proceed at once to its excision, or to resection, or to amputation.
(* Med.-Chir. Trans.,' liv, 253.)
On deefly seated atheromatous tumours of the necTc. — Dr. Max Schede,
in the *Archiv fiir Klin. Chir.,' xv, relates three cases in which the
tumour lay on the sheath of the large vessels ; in one it was attached
to the styloid process. In two of the cases, the inner wall of the sac
was formed of cells arranged in from six to ten layers, superficially,
resembling large, flattened epithelium, and, in the more deeply seated
parts, becoming gradually elongated into spindle-cells standing per-
pendicularly on the cyst-wall. Outside the cellular layer was a sac of
connective tissue, the inner part of which consisted of close, concentric
layers of fine, fibrillar tissue, interspersed with a homogeneous, finely
granular substance. Further outwards, loose connective tissue was
met with. There were no traces^ of glands or of hair-follicles. In a
third case iodine had been injected before the removal of the cyst.
The epithelial cells here showed pale nuclei, and the capsule of con-
nective tissue presented signs of inflammatory infiltration, and con-
tained a large amount of young tissue. On the outer part, the
capsule presented the structure of a lymphatic gland ; this appearance
was found, on close examination, to be due to the incorporation of
lymphatic glands with the wall of the sac. Schede believes that these
cysts have their origin in branchial fistulas. In one of the cases the
patient's twin-sister had persistence of branchial clefts. The extirpa-
tion of such cysts is attended with difficulty ; puncture, followed by
injection of iodine, is more likely to be useful.
Congenital, fihro-cellular tumour in the huttocTc. — Mr. Bryant removed
a tumour of this nature from the buttock of a man, set. 50. He had
always had it, he said, but it had only caused inconvenience for two or
three years, and been really troublesome for two months. (' Lancet,'
Sept. 30, 187 1, p. 468.)
Congenital fibrous tumour. — Mr. Waren Tay removed a tumour
(probably congenital) from a child's arm, close to the axilla. The
growth seemed to be of the simplest character, hypertrophy of the
connective-tissue elements of the subcutaneous fatty layers, and to be
allied to the solid portions of the cystic tumours of the neck and other
parts ; of the nature of Mr. Holmes's " Congenital Innocent Tumour or
Hypertrophy." (' Path. Trans.,' xxiii, 250.)
Removal of a large, scrotal tumour. — Mr. Bickersteth narrates a very
interesting case of a large, scrotal tumour which he removed, saving the
testes. The mass was, chiefly, hypertrophied, scrotal skin and sub-
cutaneous tissue. Embedded in this was the original growth (which
244j report on surgery.
had been said to slip up and down), about the size of a 32-lb. shot,
enclosed in a firm capsule. It was fibro-cartilaginous in structure.
From its upper part a firm band had passed upwards. This was met
with in the operation as a pedicle of the thickness of the thumb, and
tied before being cut. The man recovered. He was a tailor, and had
noticed the tumour about seventeen years. A figure of the enormous
tumour is given. ('Lancet,' Aug. 5, 1871, 187.)
Medullary carcinoma in the axilla. — Mr. Durham removed an encepha-
loid tumour of the armpit from a man aet. 48. The tumour had been
growing about five months, and was secondary to a small growth in a
mole above the elbow. (' Med. Times and G-az.,' Aug. 12, 1871, 189.)
Osteoid cancer. — An interesting but somewhat obscure case of
osteoid cancer of the ulna, &c., is detailed by Dr. Joseph Bell. (' Edin.
Med. Journ.,' May, 187 1, 1006.)
Multiple lymphoma treated hy arsenic. — Billroth describes in the
'"Wiener Medezin. Wochenschr.,' No. 44, 1871, the case of a woman
who was affected with universal hyperplasia of the lymphatic glands.
On each side of the neck was a tumour as large as a fist, and in the
fauces lay one (proceeding from the tonsils) as large as a hen's egg.
As this produced dyspnoea, it was removed by the galvanic cautery.
There were also tumours, as large as apples, in the axillae and groins,
and as large as hens' eggs in the bend of the elbow. The mesen-
teric glands were felt to be enlarged, and the spleen was double its
normal size. There was no leukaemia. B,ecovery took place in four
weeks under the use of Fowler's solution. In such cases, Billroth
remarks, subcutaneous injection and electrolysis have not been found
to have any effect in reducing the size of the tumour.
Bectilinear ecraseur. — Dr. Nott describes and figures a rectilinear
ecraseur. It may be compared to a pair of scissors. The blades
short, strong and'serrated — to crush — and the handles long, strong, and
provided with a screw, by means of which the crushing power is
exerted. In treating external haemorrhoids the pile is crushed and
then cut off. In internal piles the ecraseur is applied, removed,
and then a ligature is tied in the groove formed by the crusher for
safety. The crusher may be used in any case in which an ecraseur
is deemed advisable. The tissues are squeezed together and then a
cut is made in front of the ecraseur, or after this is taken off,
through the line of indentation.- In amputation of the penis no
bleeding occurred, and the tissues quickly united. He removed a
finger by crushing through bone and all. The end soon healed over.
(' Amer. Journ. Med. Sci.,' April, 1872, 378.)
Treatment of tumours hy subcutaneous injection. — In a paper on this
subject, read before the Surgical Congress in Berlin, in 1872, and
published in the ' Archiv fiir Klinische Chirurgie,' xv, Dr. Heine
remarks that the high expectations which were formed when Thiersch
and Nussbaum called attention to injections into the parenchyma, as a
means of destroying tumours have not been realised. We believe
that, hitherto, surgeons have not had clear ideas as to the object to be
attained, and that they have acted rather empirically in regard to the
choice of the fluids to be injected and to their strength. Again, the
TREATMENT OF TUMOURS BY SUBCUTANEOUS INJECTION. 245
cases, in which the treatment has been tried, have been those in which
operation appeared unadvisable, and in which, therefore, no convincing
]osult could be expected. In primary cancer, the treatment ought to
be tried at the earliest stage of the disease. In his paper, Heine
referred to cases in which, after the injection of a watery solution of
carbolic acid, cancer of the parotid and indurated syphilitic ulcers and
])apul8e were said to have been reduced. In his experiments on cancer
he modified the operation by injecting the fluid chiefly into the
])criphery, so as to act on the youngest proliferating cells, to bring
their growth to a standstill, and to prevent the escape of the cancerous
(dements into the neighbouring lymphatic glands. A woman, set. 48,
1 he mother of three children, had had a tumour of the right breast for
a year, and one of the left for six months. Their external appearance
and an examination of excised portions showed them to be carcinoma-
tous. From the left breast an indurated cord of lymphatics led to an
enlarged axillary glaud of the size of a chestnut, and in the neigh-
bourhood of the same breast several small, hard nodules were embedded
m the skin. A solution of chloride of zinc (o*^ to i per cent.) was
injected in the neighbourhood of the breast several times (the quantity
used being from five to seven charges of Pravaz's syringe), but
})roduced only severe pain, without any efi'ect on the size of the
tumour. On October 31 Dr. Heine began to inject a solution of i
per cent, of hydrochloric acid in quantities represented by from two to
live charges of Pravaz's syringe, at intervals of twelve or fourteen
days, the injections being made between the breast and the axilla.
At the end of eight months a notable reduction in the size of the
tumours was observed. The enlargement of the axiUary glands and
the indurated, lymphatic cord disappeared in a month from the com-
mencement of the injection. One gland, only, was removed for the
purpose of microscopic examination, and showed that the cancer-cell
masses were broken down into a homogeneous, finely granular material.
The pain produced by the injection was slight. After the third injec-
tion fever set in and lasted three months ; in Heine's opinion it could
be only regarded as an absorption-fever. It was treated with quinine,
and with carbolic acid in eight-grain doses in pills, with the efi'ect, only,
of temporarily reducing the temperature about 3^° Fahr. The number
of white corpuscles in the blood was increased. At the end of the
treatment, the reduction had amounted to 4f centimetres, transversely,
and 4|-, vertically, in the left breast ; in the right, to ^ centimetres
transversely, and only ii vertically. On one occasion, when the injec-
tion was omitted for a time, the right breast increased in size. At
the end of the eighth month the woman was in good health, the fever
having for some time left her. In two other cases, one of ulcerated
mammary cancer in a woman and one of secondary ulcerated cancer of
the inguinal region in a male, injection of hydrochloric acid produced
febrile symptoms, molecular melting down of the tumour, and partial
shrinking. In two instances, Dr. Heine endeavoured to reduce hyper-
trophy of the prostate by injecting solution of iodine, made by mixing
60 parts of tincture of iodine* and 8 parts of iodide of potassium in
* As Dr. Heine practises at Innspruck, he probably refers to the Austrian tincture.
246 llEPORT ON SURGERY.
1 80 parts of water. The fluid was thrown in yer rectum by means of
Pravaz's syringe. The first patient died a fortnight after the treat-
ment was commenced, of old-standing cystitis and pericystitis, with
pulmonary oedema. The injection did not appear to have had any
effect on the prostate. In the second case the solution used for injec-
tion consisted of 60 parts of iodine and 4 of iodide of potassium in 102
of water. It produced prostatic abscess, which spread into the rectum,
and the patient had epididymitis for some days. The lobe of the
prostate, which was enlarged to the size of a walnut, was entirely
reduced in size. In the discussion which followed the reading of Dr.
Heine's paper (see ' Berliner Med. Wochenschr.,' July 8, 1872) Dr.
Billroth said that he had tried parenchymatous injections in the treat-
ment of tumours, but the result had been negative, and he for some
months desisted from their use. Having heard, however, of the
injection of bronchocele and lymphoma with tincture of iodine by Liicke,
of Bern, and of the observations made by It. Demene, of Bern, he
determined to give the plan another trial. His late assistant, Dr.
Czerny, made a number of experiments on the injection, in cases of
strumous enlargements, tumours of the lymphatic glands, and cancer,
of solutions of nitrate of silver, chloride of gold, perchloride of iron,
carbolic acid, gastric juice, &c. The result, sometimes, was the forma-
tion of a small abscess, which left a little scar, but had no influence on
the growth of the tumours. In some instances, the result was a rapid
increase of the tumour, and, in others, no result at all was obtained.
Billroth also related a case in which a single injection of alcohol in a
case of strumous disease of the lymphatic glands was followed by
sloughing and death.
Supra-sternal luxation of the clavicle. — Prof. R. "W. Smith records the
following case, accompanied by two illustrations. A man, aet. 60, fell
down from and was run over by a vehicle he was driving. He was found
to have sustained a compound luxation of the astragalus of the right foot
outwards. The bone was easily replaced. The sternal end of the left
clavicle was dislocated. The shoulder had fallen in, towards the mesial
line, so far that the end of the clavicle was pressing strongly on the
trachea, causing a very great amount of dyspnoea. It formed a very
striking projection in front of the trachea, giving to the sternal portion
of the mastoid muscle an arched line ; it was a complete luxation. In
a sitting position the dyspnoea and dysphagia were extreme. When
the man was placed in a recumbent position the bone no longer pro-
jected, but it still remained above its proper level. The man died on
the eleventh day. When the integuments were removed from the
sternal region, the end of the left clavicle was seen lying above the
sternum, beyond the centre of which it had so far passed as to be in
contact with the inner edge of the right sterno-mastoid muscle. The
sternal portion of its own muscle crossed in front of it at some distance
external to its articular surface, was arched forwards and in a state of
tension, while the clavicular portion was relaxed. Posteriorly, the bone
rested on the sterno-hyoid muscles and the front of the trachea. The
which, according to Squire, contains one part of iodine in seventeen of rectified
spirit.
DISLOCATIONS. 247
anterior and posterior ligaments of the joint were, of course, ruptured,
as were, likewise, the inter-clavicular and rhomboid ligaments. The
inter-articular cartilage was torn from its attachment to the sternum
and cartilage of the first rib, and was carried upwards and inwards ahmg
with the clavicle. The only deviation from its normal state observable
in the subclavius muscle was that it appeared relaxed and altered in
direction. Dr. Stokes then gives an account of seven other cases
already published, and remarks — " It will be seen from the preceding
rSsume, that the archives of surgical science, previous to the publication
of the present case, contained only seven examples of the injury under
consideration. The case I have described constitutes the eighth, and is
peculiarly valuable as being the first (as far as I am aware) in which the
anatomical characters of the injury were accurately established hj post-
mortem examination, for the account given by Du Verney is totally des-
titute of value as a dissection of the injury. It is a luxation of neces-
sarily rare occurrence, for it not only requires for its production that
the force applied should be very great, but that it should also act on the
shoulder in an unusual direction, viz. downwards, inwards, and probably
backwards. The result of this threefold impulsion is that the clavicle,
converted into a lever of the first order (the fulcrum of which is con-
stituted by the first rib) is forced, at its sternal extremity, upwards
and inwards." ('Dub. Journ. Med. Sci.,' Dec. 1872, 450.)
Dislocation of both ends of the clavicle. — Dr. Stanley Haynes records
the case of a girl, set. 13. Spontaneous dislocation forwards of the
sternal end of the clavicle and partial luxation upwards of the acro-
mion one occurred while she was washing the back of her neck one
morning. The bone could easily be replaced, but it was difficult to
retain it in place. In a note Mr. Erich sen states there are three cases
on record, two recorded in his own work, and one by Mr. Hamilton.
('Brit. Med. Journ.,' Jan. 27, 1872.)
Paralysis of the arm after dislocation of the shoulder-joint. — Dr.
Bernhard relates in the ' Berliner Klin. Wochenschr.,' !No. 5, 1871,
two cases in which dislocation of the head of the humerus was followed
by paralysis. In one of the cases reduction was effected eight days
after the injury, in the other the dislocation was reduced on the day of
its occurrence. In the first case there was slight power of extension of
the wrist, and the supinator longus became very distinct in the attempt
to bend the arm; sensibility was increased in some parts, but was
diminished somewhat in the forearm. In the second case the forearm
could be bent on the arm and the head could be moved slightly, while
voluntary power over the muscles of the shoulder was completely lost.
Sensibility was impaired over the three outer, metacarpal bones and
fingers. The electric irritability of the muscles had almost entirely dis-
appeared and was repaired in but a very slight degree at the end of
more than four weeks, although the voluntary power over the muscles
had become increased.
Reduction of an old dislocation at the shoulder. — Mr. Callender records
a case in which he reduced a dislocation of the huinerus, of one month's
standing, under choloform. After rotating the head of the bone so as
to break down adhesions, the arm (the right) was forcibly drawn
248 REPORT ON SURGERY.
upwards, across the sternum, the elbow being raised almost to the level
of the axilla. In this way the head of the bone was depressed, the
trunk being fixed, the arm was then forced outwards by pushing against
the elbow, the forearm being flexed and at the same time movements of
rotation were made, the arm being occasionally lowered from the level
of the axilla. Reduction was soon eff'ected. The manoeuvre consisted
in raising the elbow across the chest, forcing the raised arm outwards,-
rotating the arm in so doing, and, lastly, whilst still rotating, somewhat-
depressing it. Practically this plan avoids all risks of injuring the great
vessels. (' Clin. Soc. Trans.,' iv, 196. See also previous ' Bien.-
Eetrospects.')
Extravasation of Mood after the reduction of a dislocation of the
shoulder. — Mr. C. De Morgan records the case of a man, set. 54, who
came under care a fortnight after the reduction of a dislocation of the
shoulder under chloroform and with the heel in the axilla. Extravasa-
tion of blood occurred and increased. The man's strength failed and
he had rigors. Mr. De Morgan laid open the swelling and turned out
clots, &c. The man gradually sank. At the post-mortem it was impos-
sible to detect the source of the hssmorrhage. (Clinical lecture, ' Brit.
Med. Journ.,' Jan. 6, 1872.) Mr. Eivington records the case of
a man, aet. 71, who died in consequence of haemorrhage from a
traumatic, axillary aneurism, resulting from the reduction of a disloca-
tion of the humerus. ('Brit. Med. Journ.,* April 20, 1872.) In the
' Brit. Med. Journ.,' May 18, 1872, is recorded the case of a man, set.
38, who dislocated his humerus and had it reduced. He was then
admitted into the Northampton Infirmary. Gangrene of the arm
ensued and the man died. Fracture of the coracoid process, chipping
of the head of the humerus, and rupture of the axillary artery, were
found.
Dislocation of the wrist. — A case has been under the care of Mr.
Erichsen. The accident had occurred long before. The carpus was
displaced on to the palmar aspect of the bones of the forearm and to
the ulnar side, and the trapezium could be distinctly felt in front of and
to the ulnar side of the end of the radius. After manipulation the
position of the parts was much improved. (' Med. Times and Gaz.,'
Oct. 14, 1871, 470.)
Congenital dislocation of the wrist. — Specimen from an old woman
brought to the dissecting-room. (Mr. James Adams, ' Path. Trans.,'
xxii, 197.)
Complete, simple, anterior luxation of the semilunar bone. — Dr. Chisolm
narrates the following case. A sailor, set. 25, fell from the yard-arm on
to the deck, a distance of about twenty-five feet. He fell on the right
side with his right hand doubled under him. Ten days later he came
under Dr. Chisolm's care. There was comparatively little swelling.
The axis of the hand was perfectly in a line with that of both radius
and ulna. A large, hard, rounded, subcutaneous prominence existed on
the front of the wrist, directly over the site of the semilunar bone.
This was so firmly fixed as to exhibit not the slightest motion when
manipulated with force. The point of a couching needle thrust, to the
depth of an inch, into the back of the wrist showed, by the freedom of its
DISLOCATION OF THE BONES OE THE PELVIS. 249
lovement in every direction, that a vacant cavity existed where, normally,
Ithe compact semilunar bone is found. The constant pressure kept up
by the luxated bone caused forced and painful flexion of the fingers and
wrist. All attempts at reduction were useless. Three weeks after the
injury Dr. Chisolm removed the bone through a single incision, two
inches in length, in the median line. The operation was more tedious
than was expected. The bone was rotated so that the concavity for the
reception of the rounded head of the os magnum looked directly up the
arm, whilst the convex surface belonging to the radio-carpal joint was
fibcing the fingers. All the ligaments were not torn through, but the
bone was forced amongst them, twisted and stretched over it so that it
was tied down firmly in its new position. Its reduction would have
been quite impossible, owing to the irregular surfaces of bone in contact.
A small fragment of the scaphoid was found attached to the semilunar,
torn off at the time of the injury. ('Lancet,' Oct. 28, 1871, 605.)
Dislocation of the bones of the pelvis. — Dr. Sallerou contributes an
elaborate memoir on the subject to the ' Archives Generales de Mede-
cine, for July and August, 1872. During a period of forty years, there
have come under his notice, in the military hospitals, more than thirty
cases of severe injury of the pelvis, most of them being instances of
fracture with dislocation, often complicated with other severe injuries,
and rapidly fatal. In three cases, there was simple dislocation without
fracture. In one of these, a man, set. 26, fell from a height of twelve
metres, and dislocated the left iliac bone, upwards and backwards ; the
second piece of the sternum was also dislocated upwards and forwards,
on the first. Reduction was readily eff'ected by fixing the pelvis,
applying steady extension, by a towel placed round the thigh, and push-
ing the posterior, superior, iliac spine downwards and forwards.
Attempts were made to reduce the dislocation of the sternum, but
without effect. The patient left the hospital, able to walk without
crutches, about seven weeks after the receipt of the injury. In another
case, a Zouave, set. 0^6, dislocated the right iliac bone forwards and
slightly upwards, by a fall from a height of five or six metres. On
placing him on his back, the right antero-superior spine of the ilium
was seen to be ten or twelve millimetres higher than the left, and the
right pubic bone projected forward, beyond that of the other side. The
crista ilii was nearer to the false ribs on the right side than on the left.
There was no impairment of the movements of the hip-joint. On
turning over the patient, in order to make a further examination, Dr.
Salleron felt a sudden movement, accompanied by a sound which was
heard by the bystanders. The patient at once felt relieved, and the
manipulation of the pelvis became less painful than it had been. On
again placing him on his back, the projection forwards of the right
autero-superior iliac spine had nearly disappeared, and the right pubic
prominence quite so. The patient was discharged, convalescent, nearly
seven weeks after the accident. In a third case, a man, set. 28, was
injured by a mass of lime-stones falling on him, from a height of four
or five metres. The left iliac bone was dislocated forwards. The signs
of the injury were distinct, although less marked than in the case just
related, and the patient was unable to lie on his back without pain. As
250 REPORT ON SURGERY.
the patient was in a state of nervous excitement, and the displacement
vs as not very strongly marked, Dr. Salleron deferred any attempt at
reduction. On the fifth day, while the patient was turning himself in
bed, he felt a sudden shock in the pelvis, accompanied with a noise
which his neighbour (no doubt with exaggeration) described as
being as loud as a pistol-shot, but which was distinctly heard
by a man in the third bed from the patient. Immediately after this
he was able to lie comfortably on his back. When he went out of
hospital, three months after the receipt of the injury, he could walk
tolerably well, but the right thigh was somewhat atrophied. Its con-
dition had improved, somewhat, when he was seen twenty days after-
wards. In a subsequent portion of his memoir Dr. Salleron treats,
at length, of the pathology, symptoms, diagnosis, prognosis, and treat-
ment of dislocations of the pelvis. Pathology. — In disjunction of the
pubic symphysis, the interarticular cartilage is not (except, perhaps, in
exceedingly rare cases) torn through its central part, but is separated
from the bone on one or the other side. This has been noticed by
Malgaigne, Backer, and Cloquet, as well as by Dr. Salleron. The
fibrous ligaments surrounding the symphysis are more or less torn.
The inferior ligament is generally detached from the interarticular
fibro-cartilage, and torn away from its attachment to the descending
ramus of the pubic bone that is detached. Its lower edge seems
to be usually uninjured, but its upper border is irregularly torn
to a greater or less extent, especially at the sides, where it is
attached to the bone. Lacerations of the perinaeum and rupture of
the urethra or of the bladder, although produced simultaneously with
the dislocation, are not produced by it. Bupture of the bladder
generally arises from direct pressure. The wound in this case is linear,
and has well-defined edges, while in perforation of the bladder by
fragments (which, in rare cases, takes place in cases of dislocation com-
plicated with fracture) the edges of the wound are irregular. Reten-
tion of urine or dysuria may occur in consequence of the deviation of
the prostatic portion of the urethra to one or tlie other side. The
precise mechanism of this displacement requires to be explained by
post-mortem examination ; but Dr. Salleron believes that it arises from
the manner in which the pubo-prostatic ligament, on the side of the
dislocation, is affected. When it is merely stretched, the prostate and
the urethra with it are drawn towards the affected side ; when it is torn
through, the prostate and urethra are displaced towards the opposite
side. This displacement of the prostate has been noticed in one case
by Eicherand, and in two by Dr. Salleron. In displacement of one of
the pubic bones directly forwards, there is no injury of the triangular
ligament and no deviation of the urethra from its course. Simple
luxation of the sacro-iliac articulation may be partial or complete. In
the partial form, the ligaments uniting the ilium to the sacrum are
torn, while the ilio-lumbar ligament is only partially lacerated. The
ilium becomes somewhat tilted, so that its upper portion is carried
somewhat forwards, and its lower part correspondingly backwards. The
tuberosity, which lies behind and a little below the posterior, superior,
iliac spine, passes beyond the posterior edge of the articular surmce of
DISLOCATION OF THE BONES OF THE PELVIS. 251
he sacrum, and becomes entangled on it. If the ilium be thrown a
ittle higher up, this tuberosity lodges in the digital fossa of the sacrum,
bud the displacement may now be regarded as complete. In both
legrees of this dislocation, the ilium is rotated from within outwards
,nd from before backwards, to a degree proportionate to the amount of
he laceration of the soft parts ; its posterior border thus approaches the
niddle line, while the internal, iliac fossa is turned more or less directly
orwards, and the external one backwards. The ischiatic spine, in the
irst degree of this dislocation, is carried backwards and inwards
;owards the edge of the sacrum, and the tuberosity of the ischium
pproaches the coccyx. When the dislocation is complete, which rarely
)ccurs, the upper half of the ilium is carried backwards and the lower
lorwards ; the ischiatic spine and the tuber ischii pass considerably in
ront of the edges of the sacrum and coccyx. M. Salleron believes
:hat the condition described by Key, in which the finger could be intro-
iuced into the space between the sacrum and ilium, must be of extremely
^re occurrence, and must, if it occur, be attended with very great dis-
turbance. In most cases the bones remain in contact. In the forms
)f dislocation of the ilium here described, the pubic bone of the affected
dde is carried outwards and a little forwards, never inwards. When
;he ilium is dislocated directly forwards, the upper half is tilted forwards
md the lower backwards. In the less complete degree of this disloca-
}ion, the iliac tuberosity lies on the articular surface of the sacrum,
[)ut, in the more complete form, it is thrown on the anterior edge of the
irticulating surface. In the more simple forms of dislocation forwards
[)r backwards, the soft parts are more or less lacerated, giving rise to
extravasation of blood alongj the courses of the large vessels and nerves.
in the second degree the large vessels and nerves, though stretched,
may remain entire, but if the displacement be great they may be lacerated.
Causes and mechanism. — Considerable violence is necessary to pro-
duce displacement of the pelvic bones, on account of the size and extent
of the articulating surfaces, the strength and shortness of the ligaments,
and the very limited amount of motion in the parts. To produce dis-
ocation of the sacro-iliac joint upwards and backwards, the displacing
brce must act along an axis passing through the tuber ischii or the
acetabulum, and ending in the centre of the sacro-iliac synchondrosis.
In luxation of the ilium forwards, the traumatic cause must act along
n axis passing through the posterior, superior, iliac spine and the centre
f the sacro-iliac articulation. To produce dislocation of both iliac
bones backwards, the force must act on the spinous processes of the
sacrum, at the apex of an angle of which the sides pass forwards and
outwards through the centre of the sacro-iliac articulation. Dislocation
of the pelvic symphysis is produced by force acting on the tuberosities
of the ischium or on the acetabula, so as to increase the distance between
xhem. Symptoms and diagnosis. — Dislocation of the pubic symphysis is,
when the displacement is considerable, attended with much pain in con-
sequence of the rupture of the ligaments. The existence of the displace-
ment can generally be recognised by digital examination. In luxation
of the sacro-iliac articulation upwards and backwards, the antero-
superior spine of the ilium is placed relatively higher and situated
252 REPORT ON SURGERY.
further back than that of the other side. The crest of the ilium is
nearer the false ribs than is normal ; the postero-euperior spine can be
felt (if there be not too much contusion and ecchymosis) projecting more
or less backwards, and lying nearer the middle line than that of the
other side ; the hollow of the sacrum is increased. The pubic bone on
the side of the injury is raised above the other, and is carried more or
less outwards and forwards, according to the extent of displacement and
rotation of the ilium. The displacement outwards is the result of the
approximation of the postero-superior iliac spine to the middle line.
Tavignot has recorded a case where the pubic bone, of one side, was dis-
placed in such a way as to ride over the other ; Dr. Sailer on, however,-
believes that there must be some error in the description, especially,
from the ready recovery of the patient, there is no reason to suppose that
there was also fracture. The leg of the affected side appears shortened,
but it is only apparently so, and the measurements from the antero-
superior, iliac spine to the malleolus are the same on both sides. In
consequence of the rotation of the ilium, the foot is generally everted,
sometimes to such an extent as to imitate fracture of the neck of the
femur (as in cases described by Enaux andGerdy). In luxation of the
iliac bone forwards, the transverse diameter of the pelvis is increased,
and the displaced bone forms a visible projection. The antero-superior,
iliac spine is thrown forwards and, generally, a little downwards — some-
times, however, upwards. The postero-superior, iliac spine is depressed,
and cannot, often, be readily felt ; the sacral hollow is more or less
obliterated. The limb nearly preserves its normal length and direction ;
the foot may be more or less inverted. The symphysis pubis is little, if
at all, injured, but, sometimes, the sensibility of the part is very great.
In both forms of dislocation there is deep-seated pain in the pelvic and
ilio-sciatic regions, increased by the slightest, passive movement, and
especially by pressure with the fingers. Active movement of the limb
is abolished, or is restricted to slight flexion of the toes. If, however,
the limb be well supported it can be flexed and extended to a limited
extent without pain. In luxation upwards and backwards, in conse-
quence of the laceration of the subpubic ligament, there is stretching or
deviation of the urethra and a resistance to the passage of a catheter ;
in the luxation directly forwards, there is little disturbance in the pubic
region, and the flow of urine is free. In luxation upwards and back-
wards, there is no compression or laceration of the nerve-trunks to such
an extent as to produce numbness or paralysis ; in the dislocation
directly forwards, the sacral nerves may become stretched, producing
more or less marked and persistent disorder of their functions. When
the luxation is unaccompanied by fracture, the bladder and urethra are
generally uninjured. Occasionally, however, rupture of the bladder has
occurred in such cases, probably as the result of direct pressure during
the accident. Except when the coccyx is dislocated forwards, there is
no disturbance of the rectum. In the three cases of simple dislocation,
observed by Dr. Salleron, the displaced iliac bone was completely
immovable. Key has described an instance where the ilium was dis-
located backwards and the finger could be laid in the sacro-iliac joint.
In this, however, the bone must have been displaced outwards. When
REDUCTION OF OLD DISLOCATION OP THE FEMUR. 253
both iliac bones are dislocated backwards, and especially when there^ is
also luxation of the pubic symphysis, the severity of the injury and of
the symptoms, generally, renders the diagnosis easy. In cases where the
local injury and the visceral lesions are not so severe or complicated as
to involve immediate danger, the use of anaesthetics will probably enable
the surgeon to make his diagnosis more accurate ; when, however, the
injuries are so severe as to be obviously fatal, at a more or less early
date. Dr. Salleron thinks that the surgeon should abstain from minute
examination, and make, merely, a general diagnosis. Prognosis. — Even
ill the more simple cases the prognosis requires to be carefully made,
and in the complicated cases it is very unfavorable — the bladder being
often lacerated, the urethra ruptured, and large vessels being torn,
giving rise to extravasation into the pelvis and sometimes into the
j)eritoneum. Together with these lesions there are almost always
injuries of the head, chest, and spine. Other complications, of which
the observation of cases has shown the possibility, are contusion of the
sciatic nerve, concussion of the spinal cord, intra-pelvic suppuration,
&c. The prognosis is especially unfavorable in cases of dislocation of
both iliac bones backwards, or of the sacrum forwards, on account of
the great disturbance of the parts which this lesion produces. Treat-
ment.— Dr. Salleron advises immediate attempts at reduction in all cases
of dislocation of the pelvic bones, whether fracture be also present or
not. The patient must be kept lying'on the back in a state of absolute
I'est, and any complications that arise must be treated according to
their nature.
Reduction of a dislocation qftlie femur after five and a half months. —
Dr. M'Kee records a case. The patient was a woman who was thrown out
of a trap on the left knee. She was at a distance from any advice. After
five and a half months the dislocation was diagnosed and reduced by
manipulation under chloroform. There seemed to be some tendency in
the other hip to become dislocated during pregnancy. Great difiGculty
was experienced in keeping the femur in its place after reduction. It
slipped out once, but returned with an audible snap. ('Am, Journ.
Med. Sciences,' Jan. 187 1, 281.)
Dr. James Norton notes a case of dislocation of the femur backwards
and upwards, with fracture of the acetabulum, which was reduced after
three months. (' Brit. Med. Journ.,' May 27, 187 1.)
Unreduced dislocation of the femur. — Mr. MacCormac describes a
specimen of unreduced dislocation of the femur. The patient was a
man, set. 70. A weight of metal casting fell on him ; his abdomen was
injured extensively. The symptoms of the dislocation were inversion of
the limb, the thigh was flexed and rigid, the amount of shortening was
difficult to make out. As the patient lay in bed the knee rested above
the patella of the sound thigh. The head of the bone could with diffi-
culty be discovered lying near the sciatic notch. The trochanter was in a
plane somewhat posterior to the normal situation. The head of the femur
was found to have been displaced almost directly backwards ; it rested
behind the acetabular ridge opposite the middle and upper part of the
great sciatic foramen. The anterior part of the capsule remained intact.
The tendon of the obturator internus was below the head. The specimen
254 REPORT ON SURGERY.
cojifirmed most of Bigelow's views. An illustration is given. (' St.
Thomas's Hosp. Bep./ ii, 142.)
Simultaneous dislocation of hoth femora. — Mr. AVilliam Pollard records
a case in a man, set. ^;2^. The right was thrown into the thyroid foramen
and the other on the dorsum. Reduction was effected by manipulation.
Two months later, he could walk perfectly. His recovery was delayed
by an attack of gout in the left foot. (' St. Barth. Hosp. Rep.,' viii, 105.)
Rip and shoulder dislocations and their reduction without traction, by Rushton
Parker. ('Brit. Med. Journ.,' Sept. 7, 1872.)
Dislocation of the knee. — A man, set ^o, slipped from a ladder and
severely lacerated the soft parts of the calf of the left leg and the skin
of the popliteal space, and also dislocated the left tibia outwards and
slightly backwards. After two months he came under the care of Mr.
Erichsen. At that time the leg was fixed nearly at a right angle and
was quite useless. With the aid of chloroform the reduction was
effected without any great difficulty. ('Med. Times and Gazette/
Oct. 14, 187 1, 470.)
Simultaneous dislocation of the three cuneiform hones. — An instance
of this extremely rare injury is quoted in the ' Gazette Med. de Paris,*
Dec. 30, 187 1, from the * Gaz. Med. de I'Algerie.' It is described by
Dr. Bertherand. The subject was a man, set. 2>h ^^ infirmier, who fell
on the soles of his feet from a height of four metres. After being
under treatment for some time, he left the hospital completely disabled
by lameness. When M. Bertherand saw him, the right foot was
strongly flexed on the leg, especially on the inner side. Tlie first three
metatarsal bones, with the cuneiform bones, were raised, forming a
higher plane than that of the dorsal surface of the foot. On the ex-
ternal side of this elevation was a vertical surface consisting of the
outer surface of the third cuneiform bone detached from its articulation
with the cuboid. On the inner side was a depression, increasing con-
siderably in this direction the normal concavity of the plantar arch.
Behind, there was another depression, the upper surface of the sca-
phoid lying lower than the back of the cuneiform joint. In this cavity
the tendons of the tibialis anticus muscle, on the inner side, and of the
extensors of the toes, on the outer side, were felt very distinctly. The
foot was atrophied ; the tarso-metatarsal joints were nearly ankylosed,
and the length of the inner border of the foot was shortened to the
extent of about 15 millimetres. The patient walked on the heel of the
affected foot, it being impossible to bring the first three toes to the
ground.
Suhastragaloid dislocation of the foot. — A case of dislocation of the
foot inwards from beneath the astragalus came under the care of M.
Gosselin in January, 1872. The foot was turned inwards, with the
under border looking upwards ; there was a rounded projection on the
exterior side of the foot, in front of which a depression could be felt,
and, on the inner side, was a depression having an antero-posterior
direction, at the bottom of which the inner malleolus could be in-
distinctly felt. Reduction was readily accomplished under chloroform.
(' Gaz. des Hopitaux,' 10 Fevrier, 1872.)
APPLIANCES IN FRACTURES. 255
Compound dislocation of the foot. — Mr. Spencer Smith gives a clinical
lecture on two cases of compound dislocation of the foot, complicated,
in one of them, with compound fracture and dislocation of the astra-
galus. Eecovery in both instances, with useful limbs. One patient was
a man, set. :i'], the other a married woman, set .28. ('Brit. Med.
Journ.,' Eeb. 17, 1872.)
Flastic apparatus in surgery, especially plaster of Paris. — Dr. St.
John writes an elaborate paper on the employment of plaster of Paris
splints in the treatment of fractures. He enters, at length, into the
history of the employment of plastic apparatus, the advantages of such
apparatus, the method of applying the splints, and the cases in which
he has himself used this mode of treatment. He tabulates his results.
A great deal depends on the manner in which the apparatus is put on.
In fracture of the femur, ether is administered, and extension is kept
up by a traction apparatus while the plaster is applied. The limb is
padded with blankets. The plaster should be cut up the middle soon
after its application ; he generally makes two cuts, one on each side of
the middle line, and thus removes a strip an inch wide. He prefers a
sharp, shoemaker's knife as the most useful instrument for doing this.
He sums up as follows. He has endeavoured (i) to show that the
results are at least equal to those of any other instrument, and, in some
fractures, better. To support this ground he adduces 192 cases of simple
fracture (50 being of the femur) and 26 cases of compound fracture.
(2) That union is not delayed by this splint, as alleged by some. On
this point he appeals to the records of 313 cases, 192 of the gypsum
apparatus and 121 of the starch, felt, leather and pasteboard. (3) That
the splint may, with safety, be applied, at once, in fractures of all bones.
In support of this point there are 176 cases in which this splint was
applied within forty-eight hours from the date of the accident, of which
69 are simple and 23 compound fractures (gypsum apparatus), 23 are
simple fractures (felt splint), and 61 simple fractures treated with gyp-
sum splints, of which he could not get complete details as to results,
the patients having been discharged from the hospital wearing the splints,
<fec., but whose records are given beyond the date, when wq may be sure
that no untoward result could arise, dependent upon the early appli-
cation. (4) To show that great contusion of soft parts, swelling or
extravasation of blood, do not, of necessity, contra-indicate even its imme-
diate application. Here belong 32 cases of simple fracture and 23 of
compound fracture thus described. (' Am. Journ. Med. Sci.,' July, 1872,
75— II2-)
Spiral, spring extender. — Mr. Holthouse advocates the employment
of a spiral spring in order to produce extension in diseased joints, frac-
tures, &c. ('Lancet,' June 8, 1872, 789.)
Incomplete fractures. — Dr. B. W. Smith describes and figures speci-
mens of incomplete and green-stick fractures of the radius and ulna,
taken from a young man (set. 18) who was whirled round and crushed
by machinery. The fracture had occurred about two inches above the
wrist-joint. There was also a complete fracture higher up, which
showed the mechanism of the "green-stick or sally fracture." He also
describes and figures a specimen of complete fracture of the fibula, in
256 REPORT ON SURGERY.
which, though the bone was broken across, the fragments were so dove-
tailed into one another that they were held firmly in a curved position,
separated at the convexity o£ the curve, jammed together at the
concavity. This specimen was noticed on a former occasion, but
it was not then sketched. (' Dub. Journ. Med. Sci.,* April,
.1872,351.)
A simple method of removing^ silver wire when employed in cases of
ununited fracture. — Mr. Mason invites attention to a modification of
the plan of transfixing and holding the fractured ends in apposition with
twisted wire. He operated on an ununited fracture of the ulna and
radius. The smooth surfaces of the ends of the ulna were sawn off
diagonally, so that when placed together the new surfaces accurately
corresponded. A hole was bored obliquely through them, and a needle
was passed through the hole. The needle was then encircled with a
loop of wire, the ends of which, having been firmly twisted on them-
selves, were made to emerge, together with the needle, from a small inci-
sion in the skin, placed at right angles to the larger wound. By re-
moving the needle the wire would be at once disengaged. The radius
was treated very similarly. The wire was finer and carried round the
needle in a figure of eight. Mr. Mason suggests that it is possible that the
division of the fibrous bond of union may be dispensed with, the needle
and loop of wire being alone employed ; that the needle may be shorter,
so as not to press on the neighbouring structures ; that ivory or other
material may be used in the place of the needle ; and, lastly, that the
wire, being released, may be left to work its way out, its removal, if
required, being eff'ected at any time by traction. (' Med.-Chir. Trans.,'
liv, 313-)
A clinical lecture on delayed union and non-union of hones by Mr.
Callender will be found in the ' Brit. Med. Journ.,' Nov. 30, 1872. He
alludes to obstructed venous circulation as a cause of delayed union.
He mentions a case in which union was delayed for ten months — fracture
of the thigh-bone. In the case of a soldier the humerus did not unite
for two years and a half. In another case the femur did not unite for
two years. At St. Bartholomew's there has been but one case in two
thousand five hundred fractures. He alludes to abscess of the bone,
foreign bodies between the ends, want of apposition, fractures near a
joint, &c.
Wrist-drop from paralysis of the musculo-spiral nerve in fractures of
the humerus. — Prof. Erichsen remarks that injury to the musculo-spiral
nerve in fracture of the humerus must be of rare occurrence, for he has
met with no instance recorded in any standard work. He had himself
seen three instances quite recently. When the main trunk is injured
complete wrist-drop is produced. When the posterior interosseous
division is injured, the loss of supination and of extension is not so
complete. The supinator longus and extensor carpi radialis longior,
being supplied by branches from the main trunk, are not paralysed, and
thus a certain, though very limited, movement in the sense of supination
and extension is preserved, though the forearm and hand fall naturally into
state of pronation and flexion. The first case was that of a woman, aBt.
29, who fell and fractured her humerus about the middle ; ten weeks
MlACTURli! OF OLTHCRANON — ATROPHY OF MUSCLE. 257
afterwards, she had marked wrist-drop. The symptoms are given at
length. There was a difference of temperature, on the two sides, of 5°
or 6°. The thumb and index-finger were numb ; when the fingers were
completely flexed, she could extend the joints between the first and
second, and second and third phalanges. This was evidently accom-
plished by means of the interossei and lumbricalcs (figures of the hand and
fingers are given). When the forearm was flexed, a slight, supine move-
ment could be made by the patient, probably due to the action of the
biceps. The second case was that of a woman, sdt. 30, who fell on her
elbow, and was found to have sustained a compound fracture of the
external condyle of the humerus. She could not raise the wrist or the
fingers when the hand was pronated. There was some power of supi-
nation and also of extension, probably due to the extensor carpi radialis
longior and to the supinator longus. The muscles supplied by the
posterior interosseous nerve were paralysed, the radial had escaped.
She could feel in the fingers and there was no loss of temperature. The
third case was one of fracture of the lower epiphysis of the humerus,
wrist-drop from paralysis of the posterior interosseous nerve and tonic
contraction of the fingers. The patient was a girl set. 7. She had
fallen over a croquet hoop and the lower part of the right humerus was
fractured. She had very marked wrist-drop, but could easily extend
her wrist, her hand was pronated and could be but imperfectly supi-
nated. The fingers were flexed and drawn into the palm of the hand.
She could use the interossei and lumbricales ; the flexor tendons were
much contracted ; the arm was smaller than the other. There was a
difference in temperature, on the two sides, of 8° or 9°. (' Lancet,' July i,
1871,1.)
Fracture of the olecranon in each arm; atroyhy of muscle. — Mr. Hutchin-
son notes the case of a man, set. 27, who was admitted into the London
Hospital, who had fractured the olecranon process on each side, and (as
he stated) ruptured the tendon of his calf. These accidents had all
happened several years before. Two years before admission, he fractured
the right olecranon, by falling on his elbow from the rigging of a ship,
a height of about ten feet. He had the arm put in splints in a straight
position for three weeks. Since that time he had had no power to lift
the arm straight in the air above his head ; the forearm falls into extreme
flexion as soon as its centre of gravity gets to the proximal side of the
elbow. The triceps of the right arm was found to be wasted and quite
flabby ; when he tried to straighten the arm, that muscle did not act in
the least. The upper fragment of the olecranon was separated, by at
least an inch, from the lower one. Five years later, he fractured the left
olecranon by a somewhat similar accident, falling about four feet. The
arm was kept straight in splints for six weeks, after which time he soon
regained perfect use of the limb. The upper fragment was found to be
movable on firm pressure, but he had perfect use of the triceps and his
muscle was apparently quite strong. The fracture appeared to have
been oblique and there was strong, fibrous union. He met with a third
accident, about eighteen months before, in which he probably ruptured
the tendo Achillis on the right side. He jumped off a table, and on
alighting felt as if something had struck his right calf. On examining
17
258 UElPORT ON SURGEEY.
it he found a little " dent " into which he could put his finger. After
rest in bed for a time, he could walk as on admission. There was found,
on careful examination, a slight swelling at the junction of the lower
and middle thirds of the calf, or perhaps rather higher. The right calf
measured half an inch less in circumference than the left. The wasting
was quite perceptible to the touch and seemed to involve, chiefly, the
inner part of the gastrocnemius, for, when the calf muscles were put in
action, it was that part which remained flabby, while, apparently, the
soleus could be felt to act beneath it. Possibly the rupture had involved
only the tendon of the gastrocnemius before its junction with the soleus.
The calf of this leg was considerably weaker than that of the other, so
that he could not stand on tip-toe on the corresponding foot ; he limped
with the left foot. Mr. Hutchinson remarked that no cause was
assignable for the occurrence of these injuries. The health was good ;
no fractures of any other bones had occurred. The diff'erence in the
condition of the two arms was probably due to the too early use of the
right one. He thought it was not difficult to obtain close union after
these fractures, although very difficult to get actual bone. It was of
interest to note that absolute atropy of the triceps on the right side by
no means disabled the arm. In this respect the case was parallel to
what happens after atrophy of the quadriceps extensor of the thigh.
The man could use the arm well, except in extension, and followed a
laborious occupation without discomfort. The reason why a muscle
should atropy in consequence of non-union of the bone into which it is
inserted is not quite obvious ; but Mr. Hutchinson has repeatedly
noticed this result after badly united fractures of the patella, and some-
times very good ones. He had never before noticed it after ununitec'
fracture of the olecranon. (* Lancet,' July 29, 1871, 159.)
Fracture of the head of the radius. — Specimen described by Mr. James Adai
('Path, Trans.,' xxii, 205).
Fracture of the ilium hy muscular violence. — A case of fracture of th(
anterior, superior, spinous process of the ilium from muscular violenc
is reported in the 'Am. Journ. Med. Sciences,' Jan. 1871, 277. Th(
patient was under the care of Drs. S. Joy and J. W. McWhinnie who]
recorded the case in the 'Canada Med. Journ.,' Sept., 1870. A verj
muscular youth, get. 17, in turning at a certain point while running ivA
a foot race, felt something snap in his right hip, walked a few steps an(
fell. " On examination distinct motion and crepitus could be felt b]
pressure over the process, also by placing the thumb over the origin of
the sartorius and rotating the thigh. The fracture extended into th(
notch below, but there was no great tendency to displacement save whei
the leg was abducted, thus placing the sartorius upon the stretch, th(
process doubtless being partially kept in place by the fibres of the tensoi
vaginsD femoris arising from this process on the one hand, and Poupart'
ligament on the other, when tension was taken off the sartorius." The|
patient was kept in bed with the thigh flexed and the shoulders raised.
In two weeks the patient made a good recovery without displacemeni
remaining.
Another case is recorded by Mr. Hyde (' Brit Med. Journ.,' JN"ov.1
9, 1872).
FRACTURE OF THE PEMURj ETC. 259
Ununited, extra-capsular fracture of the neck of the thigh lone, — Mr.
Lister, in the case of a man, set. 45, who had fractured his thigh eighteen
months before without union having occurred, cut down at the seat o£
fracture, felt the ends of the bones gouged them, and then dressed the
wound antiseptically, applying strong support. Bleeding occurred sub-
sequently and the wound had to be stuffed with lint (antiseptically).
Complete recovery resulted and the man walked well. (Address, ' Brit.
Med. Journ.,' Aug. 26, 187 1.)
Spontaneous fracture of the femur. — Mr. Durham records a case in a
man, set. 44. Ke-union occurred and the patient remained well four
years later. The pathology remained open to doubt. (' Clin. Soc.
Trans.,' iv, 6^.)
Vracture of the femur, — Dr. Montgomery writes on the impractibility
of restoring to its full length a thigh-bone shortened by fracture, as
apparently demonstrated by experiment. In a case of fracture of the
femur in a muscular man he tried reduction after death ; the fracture
was transverse with overlapping to the extent of one inch and a quarter.
The force employed by four men reduced the overlapping half an inch.
A weight of one hundred and twenty pounds was then applied over a
pulley and left for seventeen hours. The overlapping was then only a
quarter of an inch. *' I venture the opinion that in most, and probably
in all, cases of fracture of the femur whether transverse or oblique,
with shortening, the fractured ends of the bone cannot be placed in
exact opposition by any force which can be safely applied to living
tissue. It is admitted by most writers on surgery that shortening of
the limb in fracture of the thigh is to be expected and is generally found
after proper treatment. "Would it not be more correct to say it is
always found (when produced by a fracture), because a shortened
thigh-bone cannot be fully extended to its normal length after the
broken ends of bone have passed each^other ?" (*Am. Journ. Med.
Sci.,' July, 1872, 112.)
Ununited fracture oftlie tibia and fibula ; resection of the tibia. — Dr.
Edward Bennett records a case of ununited fracture of the tibia and
fibula in a strong man set. 34. The accident had occurred four months
previously ; the fracture was compound. On proceeding to operate, a
mass of tissue was found between the ends of the bones. The over-
lapping ends of the tibia were cut off and the union of the fibula
severed. No pegs were inserted ; the limb was put up straight and
firm union resulted. The leg was two and a half inches shorter than
the other (figures of the amount of the displacement are given).
('Dub. Journ. Med. Sci.,' April, 1872, 285.)
Fractures of the tibia. — In oblique fractures of the tibia near the
ankle Dr. Montgomery has successfully employed continuous extension
by means of a weight. He adopts a slight modification of the usual
plan of fixing the weight to the foot. (* Am. Journ. Med. Sciences/
April, 1871, o^t^^:)
Fractures of the odontoid process. — Dr. Stephen Smith has made
numerous experiments to show the mode of production of these
fractures. His conclusions are: — i. In a healthy condition of parts
the odontoid process has greater strength than either the anterior ring
260 REPORT ON SURG KEY.
of the atlas or the transverse ligament. 2. The odontoid process is
less liable to be fractured by external violence than the body of the
axis at the insertion of the process. 3. The odontoid process is not
fractured by being driven against the transverse ligament or anterior
arch of the atlas. 4. The odontoid ligaments have a combined strength
greater than the odontoid process. *' I am satisfied, however, that the
efficient agents in this fracture are the odontoid ligaments." He details
various cases under the heads of spontaneous fracture ; fractures from
direct violence ; from external violence applied to the forehead, the back
part of the neck, side of the head ; fractures with slight symptoms at
first; multiple fractures ; fracture followed by exfoliation and recovery ;
fracture aud recovery with the formation of a false joint. He dis-
cusses the various modes of death and the symptoms ; the chief being,
that the patient carries the head supported on his two hands. — (' Am.
Journ. Med. Sciences,' Oct. 1871, 338-58.)
Unilateral dislocation of the fifth cervical vertebra. — Dr. Key burn
records the case of a man, set. 24, who sustained a unilateral disloca-
tion of the fifth cervical vertebra by a weight falling on his neck.
Paralysis gradually came on. After nine weeks and two days reduc-
tion was effected with improvement in the symptoms. Death occurred
a fortnight later. There was no fracture. An abscess was fou7id in
the cord. Eemarks on other cases recorded are made. — (' Am. Journ.
Med. Sciences,' July 1871, no.)
fracture of the spine. — A case of fracture of the fifth cervical ver-
tebra, with laceration of the spinal cord, and complete paralysis below
the root of the neck, in which the patient lived for three months, is
recorded in the 'Am. Journ. Med. Sciences,' April, 1871, 590.
The relative onortality of analogous injuries in civil and military
practice. — Dr. E/. Yolkmann, of Halle, holds (' Archiv. fiir Klin.
Chirurg.,' xv) that the mortality after injuries and operations is not
greater in military than in civil practice ; on the contrary, that it is
even less. In 1699 gunshot fractures of the bones of the leg, occurring
in the wars of the last ten years, and the statistics of which were
collected by Billroth, there were 401 deaths, or 23 '6 per cent. ; and in
109 cases which came under Dr. Volkmann's notice, there were 25
deaths or 22 per cent. On the other hand, in 885 complicated frac-
tures of the leg, occurring in various German and British hospitals,
there were 339 deaths or 38^ per cent. In one hospital alone (St.
Bartholomew's) the mortality was lower than in military practice,
being 20 per cent. In most of the German hospitals the mortality
was 40 per cent. With regard to the cases of gunshot fracture of the
leg in which attempts were made to preserve the limbs, Volkmanu
finds that, in the Italian war, the mortality was 17 per cent. Among
the 109 patients under his care at Trantenau, amputation of the thigh
was performed in 1 8 cases, and 9 of the patients died ; while, in 9 1
cases in which he employed conservative treatment, the mortality was
16, or 17-5 per cent. Billroth, at Weissenburg, and Socin, at Stettin,
had a mortality of about 14 per cent, among the cases treated conser-
vatively ; and Stromcyer, in the Danish war, had a mortality of only
TO per cent. On the other hand, of 320 patients subjected to conser-
MORTALITY OF INJURIES IN CIVIL AND MILITARY PRACTICE. 261
vative treatment iu civil hospitals, 120 died, or 32.^ per cent. With
regard to complicated fractures of the femur, Volkmann has hitherto
been able to collect only a limited amount of statistics from civil practice.
Injuries of this kind generally occur in connection with railway acci-
dents, accidents with machinery, blasting of rocks, &c., and demand
primary amputation. Dr. Erankel has collected 140 cases in civil
practice which were, at least at first, subjected to conservative treat-
ment ; of these 8 j died, or 60 per cent. This rate of mortality is
about the same that has been observed in military practice after frac-
ture of the shaft of the femur by gunshot. In the more recent cases,
the rate of mortality has been even less. Volkmann himself had 44
deaths in 95 cases, or 46-3 per cent. Among the 88 j cases of compli-
cated fracture of the leg referred to as having occurred in civil practice,
there were 177 amputations; the percentage mortality after the
primary amputations was 60, and after the secondary, 77. On the
other hand, among the 3813 cases in military practice collected by
Billroth the death-rate was only 41.6 per cent.
Having given these statistics, Volkmann goes on to say that, in com-
plicated fractures in civil practice, the soft parts are most injured ;
while in military surgery the bones suffer most, being often very ex-
tensively fissured. The statistics, already referred to, show that the
injury of the soft parts has a much greater influence on the mortality
than that of the bones — an influence even greater than has generally
been suj)posed. Again, the result in gunshot fractures depends much
less on the extent of the injury of the bone than would be a priori ex-
pected. Volkmann has several times had the opportunity of examining,
after death, bones (including the femur) in which from twelve to twenty
fragments of various sizes had become consolidated, and where no
necrosis had occurred, no splinters had been removed, and the deformity
of the limb was no greater than after an ordinary fracture. The mere
extent of the fracture and the number of splinters, he, therefore, holds
not to aff'ord sufficient ground for primary amputation. Simple frac-
tures are very rare after bullet wounds. He has met with only two or
three instances among many hundred cases of such injuries. Grunshot
wounds of the joints, also, may heal without suppuration or necrosis.
Compound fractures of the leg occurring in civil life as the result of
indirect violence, and presenting but slight injury to the soft j)arts —
perhaps a clean cut-wound — appear (at least in the larger hospitals) to
be attended with a higher mortality than splintered fractures from gun-
shot. In cases of death after fracture of the leg, in civil practice, the
fatal event occurs, in 50 per cent., within the first fortnight. In gun-
shot fractures of the same part, on the other hand, death does not occur
(except in rare cases) until the third week. The cause of this marked
difference is thus explained : — In civil practice those patients who die
within the first fortnight are carried off by acute septic processes. After
gunshot wounds, on the other hand, the most acute and rapidly de-
structive, septic, phlegmonous processes are seldom or never met with.
Of sloughing phagedsena after a bullet wound, Volkmann met with no
examples ; in one case under his care, where gangrene occurred, he
found injury of the large vessels, with much extravasation of blood.
262 REPORT ON SURGERY.
Local reaction sets in later and more slowly after gunshot wounds, and
has not the same tendency to advance as after other injuries. A num-
her of patients, indeed, die of septicaemia after gunshot wounds ; but, in
these cases, there are almost always found purulent deposits around the
ends of the bones, presenting a much more limited character than the
diffused deposits met with after compound fractures in civil practice.
The comparatively small amount of injury of the soft parts, and the
less extensive, local reaction, must have a favorable influence on primary-
amputation in the field. But, leaving this subject, the difference in the
mortality after intermediate amputation in civil and in military practice
is noteworthy, and has been noticed by Billroth as well as by Volkmann.
Amputation performed as late as about the sixth day after the injury,
for gunshot wound, is in many cases as successful as primary ampu-
tation. But after this comes a period extending to the eighth week, in
which extensive inflammation prevails, and (at least as regards the
thigh) a patient operated on in this stage very rarely survives. The
discussion which followed the reading of Dr. Yolkmann's paper before
the Surgical Congress in Berlin is reported, at length, in the ' Berliner
Klin. Wochenschr.' for May 6, 1872. Dr. von Langenbeck, the pre-
sident, could not agree that infiltration of the wounded parts does not
occur to the same degree in military, as in civil practice. In extensive,
gunshot fractures of the femur, at least, swelling and aU the symptoms
of sepsis often appear within twenty-four hours ; so rapidly, indeed, as
scarcely to allow time for primary amputation properly so-called. To
this he was disposed to attribute the great mortality following the
operation. He agreed with Dr. "Volkmann that the different amount
of danger in civil and military practice was due to the relative amount of
injury of the bone and of the soft parts. Injuries from cannon baUs or
fragments of shells may very closely resemble certain injuries occurring
from accidents in civil life. But there is a great diff'erence in the result
between an entire separation or a mere crushing of the soft parts.
Laceration of the soft parts by splinters of shells are attended with
relatively small danger, even when the bones are not injured ; and,
when the bones are injured, death occurs at a later period than in civil
practice. Cases where the soft parts were contused by cannon balls
without a large open wound, were, in his opinion, much more liable to
septic infiltration than those in which the soft parts were extensively
laid open. Dr. Bardeleben thought that Dr. Volkmann attached too
little importance to the injury of the bones. Dr. Busch had already
noticed the greater mortality after severe injuries of the leg in civil
than in military practice. Eeferring to injuries of the knee, he
remarked that severe wounds from axes, &c., often occurred in civil
practice, and might be compared with gunshot wounds. As far as he
knew, more than half the cases of knee-joint injury treated conserva-
tively^ in military surgery were successful ; but this fell far short of civil
practice, where he could remember only two deaths in a number of
injuries of the knee that had come under his notice. He agreed with
Dr. Langenbeck as to the frequency of purulent oedema after gunshot
wounds, and had been struck with the number of cases of this which he
saw at Metz, even after resection of tlie elbow and shoulder joints. Dr.
GUNSHOT INJURIES. 263
Simon believed that necrosis was a much more common result of the
splintering of bone than Dr. Volkmann supposed. He could not call
lomind one instance of extensive splintering in which necrosis did not
occur. Several other surgeons also took part in the debate.
Gunshot wounds ; experience in the late war. — Mr. Sandford Moore,
A ssistant-Surgeon, 4th Dragoon Guards, gives his experience on certain
questions connected with the treatment of gunshot wounds, in the
' Lancet' (April 8, 1871, 476 and 502.) i. There are two operations
wliich the whole experience of the war goes to show should be aban-
doned, at any rate in field hospitals, or until all further necessity for
removing the patient is ended, viz. — {a) excision of the knee-joint;
(b) amputation by the flaj) method in the upper or middle third of the
leg. The first operation has been almost invariably followed by a fa,tal
result. The latter operation has the disadvantage that the posterior
flap becomes very heavy and separates from the anterior flap. If the
flaps are made of skin only, they take longer to make and do not offer
so good a covering to the bone, as that produced by a circular amputa-
tion. The Grerman surgeons have advocated leaving amputation of
limbs for gunshot wounds till the third day. Carbolic acid was used as
a disinfectant simply. Marine lint was very useful. Various matters
in connection with the surgery of the late war are noted by Dr. Murray
in " Four Days in the Ambulances and Hospitals of Paris under the
Commune." (' Brit. Med. Journ.,' May 20, &c., 187 1.)
Eemarks on the Prussian Siege of Paris, by C. A. Gordon, will be found in the
'Brit. Med. Journ./ Sept. 16, 1871.
Remarks on the instruments designed for exploring gunshot wounds to detect
bullets or other foreign bodies, by Prof. Longmore, will be found in the * Brit. Med.
Journ.,' Dec. 23 and 30, 1871.
Under the title of *' Kecollections of "Work done in an Ambulance,"
Mr. MacCormac relates many interesting cases of gunshot wounds. His
papers are illustrated. A statistical table showing the number of the
various operations performed, and the results of the same is given in
the last communication (March 11, 1871), ('Brit. Med. Journ.,' 1870
and 187 1.) See also a case of excision of the shoulder and elbow-
joints antea.
The Classification and Tabulation of injuries and surgical operations is dealt with,
at length, by Prof. Longmore (* Med.-Chir. Trans.,' vol. liv, p. 201-46).
The War Department of the United States has issued a report on
the surgical cases in the army from 1865 to 187 1. (' Circular,' No. 3.)
It contains an immense amount of valuable detail on all kinds of
injuries and statistics of proportion of recoveries, &c.
Three successful cases of amputation at the Tcnee-joint were performed,
, the condyles being removed.
8urgery of the arteries in gunshot wounds. — M. Verneuil communi-
cated to the Surgical Society of Paris five cases of injuries of large
arteries by balls and pieces of shell, in which haemorrhage was arrested
spontaneously. The performance of primary amputation allow^ed the
state of the vessels to be examined. The arterial coats were divided,
throughout, at the same level, as if they had been cut by a knife j and
264 REPORT ON SURGERY.
a clot extended for some way above the divided end of tlie vessel. In
two of the cases, the posterior tibial and the popliteal were the injured
arteries. (' Gaz. Med. de Paris,' July 22, 1871.)
Gunshot injuries of hone. — Specimens exhibited by Mr. Mac Cormac.
(' Path. Trans.,' xxii, 199.)
Fourf old y gunshot wound of the chest ; recovery. — Dr. Lorinser relates
in the 'Wiener Med. Wochenschr.,' for March 25, 1871, the case of a
man, set. 40, who for the purpose of committing suicide, discharged a
bullet from a four-barrelled revolver into the chest between the second
and third left ribs, a second between the third and fourth, a third be-
tween the fourth and fifth, and a fourth between the fifth and sixth
ribs. He was soon afterwards seen by Dr. Lorinser, who found him
lying dressed on a sofa, exhausted by iisemorrhage, and pale. He ob-
jected, at first, to examination and wished to be left to die in peace.
There was moderate hsemorrhage from the wounds ; the movements of
the chest on the left side could scarcely be perceived ; respiration was
laboured and stertorous; and the heart's action was weak. On the
third day, lie had recovered sufficiently to be undressed and put to bed.
A bullet was now felt lying under the skin below the angle of the left
scapula ; but as it caused no inconvenience, it was not removed. The
other balls could not be found. The patient went on well for about a
week, when he was suddenly attacked with repeated paroxysms of
dyspnoea, which were relieved by cherry laurel water and acetate of mor-
phia. For a time, again, there was improvement; but, on his attempting
to leave his bed, for a short time, in the third week, he was again seized
with dyspnoea, to which were now added loss of appetite and sleepless-
ness. This state continued tiU the eighth week, when he had recovered
sufficiently to leave his bed and go into the open air. Three months
after this injury, he went to the Tyrol where he spent the summer,
and returned in better health than he was in before the injury.
Chinshot wound of the neck ; retention of the hall for eight m&nths. —
M. Baumes communicated the following case to the Surgical Society of
Paris, in October, 1871. In the preceding January, an officer was shot
in the right submaxillary region. Haemorrhage occurred several times,
but was always arrested by plugging with charpie. Eor some days after
he received the wound, he was treated in the hosj)ital of La Pitie, under
Mr. Trelat. It was found necessary to perform tracheotomy, which was
attended with difficulty by reason of the general swelling of the neck.
After its performance, the breathing became free, and the swelling
diminished. The canula fell out easily ; the wound soon closed, and
the breathing remained normal. Still the part which had been wounded
remained enlarged, and fistulous openings presented themselves in the
neighbourhood. On introducing a probe, it struck against a foreign
body, but of its nature or size no idea could be formed. The patient
had an obscure notion that something was removed when he first came
under treatment after being wounded. At the end of eight months, the
parts remained indurated. An abscess now formed, and burst into the
mouth, allowing an examination to be made with ease. A hard body
was now felt lying deeply in the submaxillary region : it was removed
through an external incision, and was found to bo a musket-ball weigh-
TREPHINING FOR GUNSHOT. 265
ing 215 grammes (more than 7| ounces). (' Gaz. Med. de Paris,' 21
Oct. 1871.)
Trepliining for Gunshot, — A case is recorded in v?hich a soldier was
wounded in the forehead by a bullet. After ten days "a spot was
discovered, a little to the right of the occipital protuberance, that was
painful when touched, and had the appearance of being a very slight
portion of the occipital bone forced by some power from within out-
ward." The wound in front was examined more carefully. The frontal
bone had received a fracture of both tables, but in such a manner as to
allow the piece or pieces to spring into place again. A probe was
passed into this wound outwards to the " back part of the head in the im-
mediate neighbourhood of the lesion of the occipital bone, where it met
a hard, convex substance." The occipital bone was then trephined, and
a bullet extracted. The man recovered. (' Am. Journ. Med. Sciences,'
Jan. 1872, 120.)
Dr. Halstead records (' St. Louis Med. and Surg. Journal,' March,
1870) the case of a man, set. 17, who was shot in the head by the
breech-pin of his gun. The pin struck his forehead, smashed in the
bone, and stuck into the brain. The man pulled it out himself and
then rode on horseback for some distance. He afterwards became in-
sensible. Pieces of bone were found driven for two inches into the
brain. As many as thirty-eight pieces were removed, and also a tliree-
fourtJi inch screw. It was supposed that the breech-pin passed nearly
to the petrous bone, a distance of four and a half inches, it is said, from
the forehead, tearing the falx cerebri and opening the superior, longi-
tudinal sinus in its passage. The injuries, &c., are described in detail.
The man wholly recovered. He was not in any respect aware of any
difference, three months later, in his mental or physical condition, from
that before the accident. ('Am. Journ. Med. Sciences,' Jan. 1871,
301.)
Dr. Howard narrates the following case in detail. On April 6,
1862, a soldier, set. 19, was shot in the head by a Minie ball. He
staggered, fell back, and remained insensible till the next day. On
April 9 he was found sitting up, leaning against a tree, and sensible.
On April 15 he was carefully examined. There was a wound in the
left temple, and a probe passed obliquely across the most prominent
part of the forehead and emerged through a small incised wound, said
to have been made by a surgeon who extracted a ball, which the patient
saw. Just above this incision was a slight depression in the frontal
bone. The left leg was numb. After a few days " symptoms of com-
pression" came on. " Coma becoming almost complete," it was deter-
mined to explore. On April 21, a triangular depression was found in
the centre of the forehead, the apex of the depressed portion was
chipped off, leaving a small opening not admitting a probe. In this
was entangled a single hair. This at once suggested the presence of a
foreign body beyond. The trephine was applied. A Minie ball was
removed from a depth of two inches. The patient recovered. From
the appearance of the ball it seemed probable that a portion had
chipped off, remained under the skin, and had been removed by a
Burgeon. The remainder entered the skull and formed v^ trap-door
266 REPORT ON SURGERY.
aperture, the lid springing into place as soon as the ball passed. "Why
the ball should have entered the skull, at all, at a point beyond the
greatest convexity of the forehead, is not to be accounted for ; but the
ultimate recovery of the patient is the most remarkable feature in the
case. The narrator has failed to find another case on record in which
a missile out of reach and out of sight has been discovered and removed
from the brain by trephining — a permanent recovery afterwards
resulting. A diagram of the fracture is given and of the ball. (Ibid.,
Oct. 1871, 38J.)
Gunshot wounds of the lower extremity. — Mr. MacCormac writes a
very interesting paper on his experience of the treatment of gunshot
wounds of the lower extremity. He quotes statistics from English,
French, German, and American authorities. In the Anglo-American
ambulance, Mr. MacCormack and others treated in all, 47 cases of gun-
shot fracture of the femur. In 2 1 of these, amputation was performed ;
16 terminated fatally. Excluding disarticulation at the hip, the
mortality was 72*22 per cent. 26 cases were treated without amputa-
tion, many of them being in a hopeless condition. One half died. If
an attempt is made to save the limb it is better to avoid any strenuous I
efforts to remove the deformity. If amputation is determined on, it !
should be done within the twenty-four hours. In the ambulance, 57
cases of gunshot fracture of the leg were treated, with 23 deaths. 2 j
were treated conservatively, with 8 deaths, or 32 per cent. ; while 32
required amputation. Of these 13 died, or 40*6 per cent. Of the
oj)eration cases, 16 consisted of primary amputation, with 5 deaths, and
16 were secondary amputations, with 8 deaths. As regards injuries to
the hip-joint, the American statistics given in the Surgeon- G-eneral's
Circular JSTo. 21,869 ^^® referred to. (See last ' Eetrospect.') Injuries
of the knee- and ankle-joints are discussed. Mr. MacCormack sums
up — " The considerations detailed in this paper appear to me to afford
grounds for concluding against the universal application of amputation
in regard of gunshot fractures of the shaft of the femur. Sound, though
it may be delayed, union will often follow conservative treatment. I
think, for general guidance, we may, for the present, declare that, in
fractures of the lower half of the femur, the rule should be, when in
doubt, to amputate, while, in those of the upper half of the bone, the
converse should apply, namely, when in doubt to try to preserve the
limb." Two plates of illustrations of injuries to the femur and to the
tibia accompany the paper. (' St. Thomas's Hosp. Eep.,' ii, 43.) ,
Depressed fracture of the skull in a child, with deep laceration of the 1
hrain; no symptoms for six days ; death from convulsions on the eighth "
day.—Mx. W. Adams ('Path. Trans.,' xxiii, 184).
Compound, depressed fracture of the shull ; operation. — Dr. Meldon
records the ease of a boy, set. 7, who was kicked on the head by a horse.
Two compound, depressed fractures of the skull were found. On ad-
mission, he was " semi-conscious ; one pupil was contracted and the
other dilated." The depression was " an inch in depth." The bone
was elevated and pieces removed from each position. In one place the
dura mater was found lacerated. Hernia cerebri resulted from this
part, and was controlled by pressure. At the same time, however, there
INJURIES TO THE HEAD. 267
was a quantity of purulent discharge. At the end of three years " the
brain can be seen pulsating under the scalp in both the places where
the fractures existed." ('Dub. Journ. Med. Sci.,' April, 1872,295.)
Mr. Nicholson records the case of a child, aet. 5, w^ho had fallen down
stairs while playing with a marble. HsDmorrhage occurred from a cir-
cular wound in the temple. A hole could apparently be felt in the
skull. At the end of a fortnight a large marble was removed from the
temple. The child did well ; but the hole in the skull was not filled up
at the end often years (' St. Barth. Hosp. Rep.,' viii, 91). Dr. R. N.
Downs records a case oi punctured fracture of the sJcicll, in a boy, set. 12,
in which death resulted from the bursting of an abscess into the ven-
tricles, four months after apparent recovery ('Am. Journ. Med.
Sciences,' Oct. 1871, 429). A case of compound fracture of the skull
with protrusion and loss of hrain-suhstance, operated on by Mr. Wag-
staffe, and followed by recovery, is noted in * Lancet,' Aug. 17, 1872.
Mr. Annandale showed a patient to the Ed. Med.-Chir. Soc, who
had recovered from a severe injury to the head. On admission he was
found to have sustained a compound, comminuted fracture of the bones
of the skull, and to have hemiplegia of the right side. The depressed
portion of the skull was elevated and the fragments removed. One of
the fragments had wounded the brain, so that a portion of brain came
away. The patient had no other symptoms than those of hemiplegia ;
he was perfectly sensible and took his food. About the third day a
fungus of the brain made its appearance, and gradually increased till
it reached the size of a pigeon's egg. During the whole time the anti-
septic treatment, as recommended by Prof Lister, was carried out with
the antiseptic spray, and pressure was applied to the fungus. There was
no suppuration from the deep part of the wound. The pressure was
quite successful, and, gradually, the granulations arising from the fungus
adhered to those of the scalp, so that by keeping up steady pressure it
was gradually diminished, and the wound healed. An opening in
the bone- walls of the skull was left. Mr. Annandale said — " Having
watched many of these cases, where the antiseptic treatment was not
adopted, I think the treatment employed had much to do with the
satisfactory results. In many of these cases fatal results happen from
suppuration of the brain itself, but I believe the treatment prevented
that. The patient is recovering from the hemiplegia, and can now use
his right arm and leg." (*Edin. Med. Journ.,' Dec. 1872, 554.)
Mr. Stokes records the following interesting case : —A lad, set. 18, was
struck on the head and cut over the left temple five weeks before he
came under care. This occurred in England during haymaking. He
went on with his work. On the fourth day he suddenly lost all power
of speech. He was under the care of a practitioner for a fortnight.
His father was then sent for from Ireland. When the latter arrived,
the son could recognise him, and spoke to him in monosyllables. He
could walk about, and was quite sensible. For a fortnight more he
remained in the same state. At the end of four weeks and three days
from the receipt of the injury he had a violent attack of vomiting. They
then started for Ireland. At Liverpool, the father left his son for a
while, and on his return found him in a profuse perspiration and quite
^68 REPORT ON SURGERY.
insensible. After a while he improved, and was able to walk down to
the quay, a distance of 200 yards. On board he became, again, quite
insensible, and remained so. On admission he was quite comatose. On
examination a slight depression was felt under the cicatrix of the
wound in the temple. The pupil of the left eye was dilated, the right
contracted ; the pulse was 56 ; the respiration was stertorous ; the in-
sensibility complete ; touching the cornea with a feather did not pro-
duce the slightest irritation. His head was turned to the right side.
A stellate fracture of the frontal bone was found. A circular piece of
bone was removed with a trephine, and the inner table found to be de-
pressed. The dura mater was intensely congested, exceedingly tense,
and bulged, hernia-like, out of the opening. An incision was made into
it, letting out only turbid serum. Improvement followed. The respira-
tion ceased to be stertorous, the pulse rose to 64, the left pupil became
less dilated, and sensation was restored to the cornea). He soon re-
lapsed, however, and died about thirty-six hours after admission. At
the post-mortem, " on removing the calvaria the membranes were found
intensely congested, and a large abscess between the dura mater and
the bone was found pressing on the left hemisphere. It was a remark-
able circumstance that the abscess was not found immediately connected
with the portion of depressed bone. It is, I think, a circumstance
much to be regretted that the operation of trephining and elevating the
depressed portion of bone was not performed when the symptoms of
pressure first manifested themselves. (' Dub. Journ. Med. Sci.,' Dec.
1872,437-)
Trephining for abscess within the cranium. — Prof. N. B. Smitli relates
(* Baltimore Med. Journ.,' Dec. 1870) a case : — A clergyman received
a blow from a sharp stone over the left jiarietal bone. Separation of a
small sequestrum followed. There remained a fistulous opening, which
never closed during the long period of twenty years. When he came
under care, examination with a probe, through the fistula, showed a
cavity two and a half inches in depth between the bone and the mem-
branes of the brain. The sinus was smaller than a quill. Trephining
was proceeded with. The bone was found of ivory hardness, and much
thicker than common, and of unequal thickness. The operation was
proceeded with, however, without hesitation, as the membranes were
known to be far removed from the inner surface of the bone. "When
the piece was lifted up about three ounces of fetid pus escaped. No
cerebral disturbance followed. The patient "entirely recovered," and
remained well some time afterwards, (' Am. Journ. Med. Sciences,'
April, 1871,59^.)
Trephining in cerebral disease. — A paper, by Dr. "W. Pep])er, on this
subject, with the narrative of a successful case, will be found in the
'Am. Journ. Med. Sciences,' April, 1871, 411. The patient was a man,
8Bt. 21. He had suffered from constitutional syphilis, had febrile symp-
toms like tertian ague, intense headache, left hemiplegia, strabismus and
ptosis, increasing coma and stertor, and a node on the right frontal
bone. Anti-syphilitic treatment failed to give relief.
Injury to the brain.— Mr, Callender notes three cases of injury to the
brain and tabulates others, with the object of directing attention, first,
TUBERCLE OF Till] URINARY TRACT. 269
to the frequency with which convulsions or rigidity are associated with
paralysis of the left side of the body as compared with that of the right ;
secondly, to the occurrence of these symptoms in cases of injury or dis-
ease of those parts of the right cerebral hemisphere which lie above the
corpus striatum. ('Med.-Chir. Trans./ liii, 129.)
Affections of the lungs from injury to the base of the brain. — Dr. Brown-
Sequard, in the course of some experiments on guinea-pigs, was struck
by the frequency with which the lungs are altered consecutively to a
lesion of the brain. One of the most frequent causes of death was
pneumonia. He made special experiments to ascertain the immediate
effects of an injury to the brain on the lungs. " The results obtained
were startling. In almost all cases of injuries by crushing or section of
the pons Varolii ecchymoses were found in the lungs." Injuries to other
parts of the base were followed, sometimes, by the same effects, and it
is extremely probable that a slight pressure upon the pons by effused
blood is sufficient to produce it. Injuries to the medulla and spinal
cord rarely produced an effusion in the lungs. " Many experiments have
shown that it is not through the par vagum, but through the sympa-
thetic nerve, especially by its spinal roots, which throw themselves into
the first thoracic ganglion, that the peculiar influence of the irritated
pons Varolii exerts itself, producing a pulmonary haemorrhage." The
condition of the lung, as regards distension or collapse of the air-cells,
does not seem to influence the production of haemorrhage. It is not
essential that there be a continuation of breathing. Haemorrhage is
not the only result ; an amemic condition, oedema, and emphysema can
also be produced. The latter can occur when not a single respiratory
movement takes place after an irritation of the base of the brain, either
by crushing or cutting. (' Lancet,' Jan. 7, 1871, 6.)
Tubercular disease of the urinary mucous membrane. — Mr. Thomas
Smith writes on this subject, Avith special reference to the symptoms, &c.,
during life. He quotes various authorities to show what has been
already written respecting the disease, and then explains that his paper
refers to what is often called strumous or scrofulous disease of the
urinary, mucous membrane, and which commences as a tuberculous in-
filtration of the submucous tissue of some part of the genito -urinary,
mucous membrane (probably most often first in the kidney). To the
naked eye it first appears as a yellowish, cheesy deposit, though in its
earliest stage it is stated to be a deposit of grey or miliary tubercle.
Later on in the disease it is often associated with tubercle of the sub-
stance of the testis, the body of the penis, or the prostate. It mostly
affects those who are of a tubercular diathesis, and occurs before the
middle period of life. He describes the condition^ of the urethra,
bladder, ureters, and kidneys in advanced stages ; but we pass on to the
symptoms: — "Patients suffering with this malady are sure, some time"
in the course of the disease, to fall under the suspicion of being the
subjects of stone ; indeed, it would be true of almost all to say that the
early symptoms much resemble those of renal calculus, the later, those
of stone in the bladder. In the earliest stage of the disease the symp-
toms may be such as to excite but little attention, and for which medical
advice is not generally sought, being, perhaps, a slight aching in the
270 REPORT ON SURGERY.
back, a little blood in the urine, a transient pain in the testicle or glans
penis. By degrees the bleeding becomes more copious, the pain in the
back more severe, and symptoms of urinary irritation appear, in an in-
creased frequency of micturition, in pain in the glans penis, in the
bladder, or in the perinseum. In children there may be, before passing
water, shrieking, shuddering, and pulling the foreskin and pinching the
glans penis, the child sometimes finding a temporary relief after the
water has passed. In the later stages of the disease the pain in the
bladder and the urinary distress is most severe, and there is tenderness
in the hypogastrium. The urine, which from the first is usually alka-
line, may contain nothing abnormal but blood and broken-down epithe-
lial scales. After a time it comes to be loaded with pus, and to be
offensive. I have observed that the qualtity of the urine is liable to
great variations, that it may, at one time, be full of blood, at another,
free from it ; that the pus may disappear and again reappear. Ab-
scesses may form in the loins, prostate, vesiculsB, perina^um, body of the
penis, or testicle ; and these are preceded, in the last-named organs,
by deposits of tuberculous matter, which may be recognised as indura-
tions or lumps some time before the formation of matter. Urinary
abscess or extravasation is not rarely the result of these suppurations.
In a case (a boy) under Mr. Wormald's care, in addition to very severe
urinary symptoms, phosphatic deposits could be detected with a sound
in the mucous membrane of the bladder. The blood in the urine may
be bright coloured, as from the bladder, or coffee-coloured, as in stone
in the kidney ; it may be largely increased in quantity by exertion or
shaking, jarring movements of the body. As before mentioned, in some
stages of the complaint, the subjective symptoms are identical with those
of stone ; in no case, therefore, where tuberculosis is suspected, can the
diagnosis of the disease be confirmed until the non-existence of stone
in the bladder be ascertained by physical examination, and until, by
watching the progress of events, the existence of renal calculus is nega-
tived." He narrates the case of a man, set. 35, whose symptoms began
with pains in the back, followed by irritability of the bladder and fre-
quent micturition, with hsematuria. After eighteen months, " pain
commenced in the bottom of the bladder," followed by pain in the penis
and most acute pain in the glans, especially just at the moment the
bladder was being emptied. The tenderness in the periuseum was so
great that he could not sit. At this time the urine was bloody, puru-
lent, and full of mucus. No stone could be found. He died after
three years. Changes (detailed) were found in the kidneys, ureters,
bladder, and prostate. One patient was under observation many years.
Another, a boy, set. 4^, died in about four months. He had urinary
symptoms, and a tumour was felt below the right kidney. After death
this was found to be, probably, due to a deposit in the ureter. The chief
changes were in the kidneys. The case of a lad, set. 14, is noted. Mr.
Smith calls attention to the similarity between the symptoms and those
in pulmonary mischief On the one hand, suppuration, hemoptysis,
increased secretion of mucus, with the occasional recurrence of a spas-
modic, expulsive, muscular effort (in the form of cough). On the other,
suppuration, hsematuria, increased secretion of mucouS; with spasmodic
l''EVER AITER CATHETERI&M. 271
exjiulsive contractions of the bladder. Particulars of a case, in a man
xt 29, and in a girl, a^t. 2^, are also given. Treatment, — " From the
urgency and painful nature of the symptoms of this disease, it is
obvious that these must be treated as they arise, though it is necessary
and beneficial to use constitutional remedies. I believe opium or
morphia to be most useful for the relief of pain, astringent preparations
of iron and confection of black pepper to be most efficacious in control-
ling the bleeding, and cod-liver oil and iron to be the best as constitu-
tional remedies. (' St. Barth. Hosp. Eep.,' viii, 9^.)
Fatal, urethral fever after catheterism. — Mr. W. M. Banks writes on
this subject. The attacks may come on very quickly after slight inter-
ference with the urethra, and may terminate fatally in a few hours, or
may be deferred for a louger period, and death may not ensue for several
days. The afi'ection is essentially due to some shock to the nervous
system, possibly the sympathetic, nervous system. An interesting
feature is the non-secretion of urine in many cases. The patients retain
consciousness. He mentions a case in which a man died in a few
minutes after the passage of a catheter. He quotes the cases he has
found recorded in the medical journals for the last twenty -five years,
and details a typical case in which, after successive trials on different
days with small bougies, at last a No. 4 metallic bougie was passed into
the bladder. In half an hour the man vomited, then a rigor followed.
He continued to vomit, complained of pain in the region of the bladder
and loins ; the pulse became quicker. In six hours and a h alf he had
a sort of convulsive tremor, his appearance altered, he became uncon-
scious, and died in a few minutes. The autopsy revealed no special
lesions. ('Ed. Med. Journ.,' June, 1871, 1074.)
Improved, flexible catheter for retention in the lladder. — Sir Henry
Thompson employs the following modification. Into an ordinary, vul-
canised, india-rubber catheter, say about the size of 8, 9 or 10, or more,
according to the requirements of the case, a thin German silver tube
about four or five inches long, is introduced by the maker, so that the
last six inches of the catheter remain as flexible as ever, also about two
inches of the anterior part to form a spout or conductor outwards for
the urine, this being done, the calibre of the interior is still nearly
uniform, the thinness of the metal tube and the elasticity of the india-
rubber being so accommodated to each other as to accomplish this
object. The instrument is furnished with a silk cord to fasten it, which
owing to the metal tube cannot diminish the choke or diameter. The
advantages of this catheter are several ; (i) It is easier to pass as the
metal tube affords a handle. (2) When the loop of silk is loosely tied
behind the glans it is next to impossible for the instrument to escape,
the want of flexibility in the silvered part securing this. (3) The flexi-
bility and unirritability of the part remaining in the bladder is a great
advantage. ('Lancet,' Peb. 11, 1872, 185.)
A new, self-retaining catheter. — Mr. J. H. Wright describes and figures
a new catheter. It is made by Weiss. There are no wings, the open-
ing is in a convenient position for the escape of the urine, mucus, &c.,
from the bladder, and cannot be closed by the bladder. The catheter
is flexible, and is introduced pulled tight on a stylet. When it is in
%lt REPOllT ON SURGERY.
the bladder the stylet is removed, and a bulbous portion projects in the
bladder. (' Lancet,' Nov. 9, 1872.)
Vertebrated, 'prostatic catheter. — Dr. Squire advocates the use of a
silver catheter, the distal part of which is formed of joints. It is quite
flexible and is adapted for cases of enlarged prostate. A figure is given.
('Am. Journ. Med. Sciences,' Oct, 187 1, 393.)
Dr. Sayre figures and describes his vertehrated catheter and probe in
the •'Brit. Med. Journ.,' July 22, 1871. It is composed of a number
of segments, is introduced quite flexible and is then stiflfened.
Stricture of the urethra. — Mr. "W. Stokes records a hundred cases
treated either by gradual dilatation, external urethrotomy, internal
urethrotomy, or forced dilatation. He thinks the former the most
satisfactory mode of treatment when possible. His mode of performing
external urethrotomy was to pass a full-sized silver catheter down to the
stricture, make a median incision in the perin£eum,''reach the end of the
catheter, feel the stricture, divide it carefully, and then having reached
the dilated part of the urethra pass a flexible catheter into the bladder.
In order to bring the catheter through the anterior part of tlie urethra,
Mr. Porter suggested the following plan. Take the ivory head of the
flexible catheter away, pass a bougie down the urethra, bring it out at
the wound and fix it firmly into the catheter, and then withdraw the
bougie pulling the catheter with it. He has found internal urethrotomy
very successful. He uses Maisonneuve's instrument. A filiform
flexible bougie is passed through the stricture, and pushed on into the
bladder carrying after it a curved, grooved director on which is passed
the cutting instrument, so fashioned that the healthy urethra cannot be
cut, only the stricture. He thinks this plan far preferable to forcible
rupture of the stricture. Cases are given and figures of the instruments
employed. ('Dub. Quart. Journ.,' Feb. 1871, i.)
Stricture of the urethra ; orchitis ; pycemic symptoms ; perineal sec-
tion ; recovery. — A man was admitted under Mr. Hulke's care with
orchitis. He had repeated rigors ; a stricture was detected and perineal
section was performed. The man then did well. (' Lancet,' Nov. 9,
1872.)
A case of complicated stricture of the urethra treated by Mr. Syme's operatiou for
impermeable urethra, is recorded by Mr. Christopher Heath. (' Clin. Soc. Trans.,' iv,
121.)
Retention of urine from impassable stricture, treated by filiform bougies. IJy W.
P. Teevan. (* Clin. Soc. Trans.,' iv, p. 124.)
Sir Henry Thompson contributes a second lecture to the * Lancet '
(Dec. 7, 1872), on stricture of the urethra. He thinks Holt's operation
generally involves but little risk ; the benefit is not very enduring.
He describes a plan introduced by Dr. Corradi and figures the instru-
ment. Internal urethrotomy is said to give the best results of any plan.
He prefers Civiale's instrument ; the incision should be free. He has
performed two hundred operations.
A new stricture dilator. — Mr. Berkeley Hill describes a new stricture
dilator. The two halves of a split sound, which in juxta-position equal
the calibre of a No. 2 or 3 catheter, can be separated by thrusting
between them a segment of a cone fixed on a slender stem. It is of
OllCIllTIS FROM PROSTATIC INI'LAMMATION. ^t3
Biraple and cheap construction. Case3 treated are narrated. (' Brit.
Med. Journ.,' Sept. 23, 1871.)
Incontinence as a symptom of retention of urine. — Mr. Hutcliinson
writes on this point and mentions cases. (' Brit. Med. Journ.,' Jan.
21, 1871, 60.)
Persistent priapism. — See cases ' Bien. Eet.,' 1867-8, 317. Dr.
Mackie records the case of a gentleman, set. 70. After much treatment,
without effect, a free incision was made into the corpus cavernosum, com-
mencing at the corona glandis. Clotted venous blood escaped and
bleeding followed ; the patient was relieved. The acute symptoms had
lasted three weeks. Effusion of blood into the structure of the corpus
cavernosum was finally suspected. The treatment was so successful
that the author recommends its early adoption in like cases. (' Edin.
Med. Journ,,' Nov. 1872.)
Urinary fistula of the penis treated hy urethroplasty. — Mr. John Wood
publishes a clinical lecture on this subject. ('Brit. Med. Journ.,'
Aug. 24, 1872.) See also Mr. Pemberton's address on surgery ('Brit.
Med. Journ.,' Aug. 10, 1872), and a note by Mr. J. E. Lane on ante-
scrotal, urinary fistula. (' Brit. Med. Journ.,' Aug. 24, 1872.)
Epithelioma simulating hubo. — At a meeting of the K. K. Gressellschaft
der Aerzte in Vienna in January, 1871, Dr. Geber related the case of a
man, aet. 28, who had an epithelioma in the right groin. The patient
had excoriation after sexual connection, which was followed by enlarge-
ment and induration of the inguinal glands. Antisyphilitic treatment
was employed, and it was only when this failed and the disease con-
tinued to spread, that it was suspected that the case might be one of
epithelioma. Microscopic examination confirmed the latter opinion.
Dr. Geber also related another, similar case, in which the differential
diagnosis between syphilis and epithelioma was attended with difficulty,
and was only cleared up by microscopic examination. (' Wiener Med.
Wochenschr.,' No. 4, 187 1.)
Orchitis from irritation in the prostatic urethra. — In a clinical lecture
on this subject, Mr. Hutchinson details various cases in which orchitis,
terminating in suppuration and requiring incisions, occurred in con-
nexion with the passage of prostatic catheters, lithotrity, lithotomy, &c.
It is rare in connection with lithotomy, occurring once in about forty
cases. He then remarks, "these instances of inflammation of the testis
in association with some source of irritation existing in the urethra, are
of great clinical interest." We may have (i) inflammation of the vas
deferens only, as evidenced by deep-seated pain in the iliac fossa and
swelling in the inguinal canal. This may subside and the patient may
get well without any further symptoms. (2) In connexion with inflam-
mation of the vas deferens an abscess may form over its course, and
may require to be opened through the abdominal wall, or may present
at the external ring. (3) The inflammation may involve the whole vas
deferens and extend to that portion of the testis which is directly con-
tinuous with it, viz. the epididymis, leaving the gland itself unaffected.
In a fourth group of cases the epididymis, body of the testis itself, the
tunica vaginalis, and the cellular tissue of the scrotum are all involved.
In these cases the effusion is usually serum only and a speedy and com-
18
27d REPORT ON SURGERY.
plete cure by absorption may be expected ; but, in exceptional cases,
suppuration may occur in the cavity of the tunica vaginalis, and in
others, still more exceptional, in the body of the testis itself. He allude^^
to gonorrhoea as causing epididymitis, and then asks, " What is thi:
connexion between prostatic irritation and orchitis ?" He thinks it due
to the direct communication of the tube of the vas deferens with the
structures concerned ; he disbelieves in the mere sympathy theory.
*' I believe that whenever there is pain in the cord, that pain begins
before the epididymis is affected ; and I believe, further, that if the vas
deferens be carefully examined you will almost always find clear proof
that it is thickened and inflamed." In support of his view he insists
on the following facts : — (i) That, as already stated, in a vast num.ber
of cases there is conclusive proof that the vas is involved. (2) That in
a few cases the opportunity occurs for observing that the vas is
inflamed before the testis is involved. (3) That now and then the
inflammation begins and ends in an inflammation of the vas and never
gets to the testicle at all. (4) That according to the admission of all
surgeons the orchitis begins in the epididymis — i.e. in the part directly
continuous with the vas deferens — a fact which the theory of sympathy
cannot in the least explain. Against the theory of the direct exbension
is the fact of the extreme rarity of symmetrical orchitis. The aflfection
may alternate (" see-saw orchitis," Ricord) from one to the other testis,
but is very rarely seen in both at once. The subsidence of the discharge
on the appearance of the orchitis may be due to sympathy, or, as Dr.
Humphrey points out, to the efficient counter-irritation caused by the
orchitis. Mr. Hutchinson agrees with Dr. Humphrey that so long as
the discharge lingers the patient is liable to swelled testicle, and, there-
fore, treats the discharge vigorously in all stages. As regards treat-
ment of severe cases Mr. Hutchinson says, " when the pain is intense,
and when it persists in spite of the use of ice, I believe that the practice
of incisions is not only safe, but very valuable." In slight cases inci-
sions, if harmless, are unnecessary. In cases in which abscess is
threatened an incision cannot be made too early. " A free incision
into the tunica vaginalis leads to no ill consequence, whatever, excepting
the inconvenience of suppuration of the sac ; and if you chance to let
out the pus the relief is immense. A free incision through the tunica
albuginea into the testis itself does not lead to gangrene of the testis,
nor always, even, to fungous protrusion. When the testis is swollen it
appears to relieve pain, much with the same certainty that iridectomy
does in acute glaucoma, and my impression is that it is likely in critical
cases to diminish the danger of gangrene on the one hand, and of consecu-
tive atrophy on the other." (' Med. Times and Gaz,,' April 15 and 22,
1 87 1, 419, 447.) Dr. Garden mentions in detail cases in which orchitis
followed lithotomy in India. (' Med. Times and Gaz.,' July 29, 187 1,
126.) His proportion has been about one in fifty-two; the left side
seems more often afiected, in connexion with the incision. In five out
of sixteen cases mentioned it is noted that abscesses formed.
Mnlargement of the prostate gland. — Mr. Quain writes on some forms
of enlargement of the prostate gland. In one case, a patient, set. 68,
had very little trouble if he was careful to pass water frequently enough,
EXTROVERSION OP THE BLADDER. 275
but if he overstayed the time ho almost certainly had an attack of re-
tention. He finally died of idiopathic erysipelas. The bladder was
found to be in great part filled with a firm tumour which reached above
the pubes. A section of the whole having been made the tumour was
found to be the prostate gland enlarged in an unusual position, above
the urethra instead of below it, as is common. The upper end was
conical and inclined the urine towards the urethra. The bladder proper
was almost wholly within the abdomen. When he had attacks of re-
tention, during many years, one passage of the catheter relieyed him
till his next attack. No urine constantly remained behind in the
bladder, nor did the kidneys become afiected. Engravings are given
and notes of other cases. In one case, besides an enlargement of the
prostate, a large sac bulged backwards from the bladder. In another
case, general symptoms were occasioned by the accumulation of " resi-
dual urine." ('Med. Times and Gaz.,' June, 1872.)
uimputation of the penis for carcinoma. — Dr. Johnson narrates four
cases. In one, he saw the patient eleven years afterwards, and in ano-
ther three years afterwards, and no return had occurred in either case,
though the glands were more or less involved at the time of the opera-
tion. ('Edin. Med. Journ.,' Sept. 187 1, 242.)
Melanosis of the Penis ; Amputation. Mr. T. Holmes^ *Path. Trans.,* xxiil, 175.
Inversion of the Uadder. — Mr. Croft records a case of inversion of
tlie bladder. The patient was a female infant, ^t. 14 months. The
bladder was returned. The case did well. Three other cases recorded
are quoted. Mr. Croft's case was, in his opinion, complicated with a
slight rupture of the walls of the bladder, accompanied by the escape
of serous, peritoneal fluid. In the other cases no such accident occurred.
(' St. Thorn. Hosp. Kep.,' ii, 195.)
Extroversion of the urinary bladder. — Dr. E. E. Maury has operated
successfully on two cases. The patients were boys, set. 8 and 9 years.
In each there was a double hernia. His operation consisted in making
a curvilinear incision commencing on the outer third of Poupart's liga-
ment, carried down below the hernise and scrotum to the middle of the
peringsum, and thence along the opposite side to a point corresponding
to the commencement of the incision. This flap was carefully dis-
sected up, completely denuding the hernise of their cutaneous covering.
A valve like incision was made in one flap so as to allow the penis to
slip through. In this way one flap w-as obtained suflicient to cover in
the bladder, then an incision was made transversely across tlic abdo-
minal walls and a trap-door flap formed. The lower flap was then in-
verted so as to bring its cutaneous surface in contact with the mucous
wall of the bladder. The edges of the lower flap were bevelled, and it
w'as brought under the upper one and fastened by means of the tongue
and groove suture of Prof. Pancoast. One boy required two further
operations, the other only the first above described. The bladder is
now covered in, a small urinal can be used, some urine retained in the
recumbent posture, and the cicatrisation has cured the hernia. The
testicles are within the abdomen. (' Amer. Journ. of Med. Sciences,'
July, 1871, ij4.)
276 litlPORt ON SUEGEUT.
Dr. Ashliurst records a case in which he operated by "Wood's method.
The patient was a girl, set. 6^ years. The result was very satisfactory.
When lying down she could hold her water for two hours, when erect
she was obliged to wear some portable receptacle. The aperture which
had existed at the lower part of the abdomen instead of showing a raw
surface was now in a state of healed cicatrix. Eigures are given.
('Am. Journ, Med. Sciences,' July, 1871, 70.)
Successful lithotrity in a case of atony of the Madder. — Dr. Matie-
jowsky of Prague, relates in the ' Wien. Med. Wochenschr.,' Nos. 18
and 19, 1 87 1, the case of a gentleman, one of his colleagues in the uni-
versity, who came under his care in October, 1 868, on account of stone
in the bladder. The disease had been first detected in 1862, and the
bladder had gradually fallen into a state of complete atony. The
urine, which had to be drawn off entirely by the catheter, was bloody
and contained a large quantity of mucus. Under these circumstances,
it was considered that lithotomy was contra-indicated, and it was re-
solved to practice lithotrity, notwithstanding that it is generally said
to be attended with much danger when the bladder is in a state of
atony. The first operation was performed in October, 1868, and the
lithotrity was repeated at intervals on sixty-six subsequent occasions,
the last being on January ^th, 1870. The bladder was each time
washed out by injecting water into it. The result was that the bladder
was freed from stone ; the patient recovered from the vesical catarrh ;
and the urine became healthy. The atony, however, remained, de-
manding the habitual use of the catheter. Dr. Matiejowsky believes
from an examination of the fragments, that six calculi were broken u
and removed. They contained a large quantity of carbonate of limi
and phosphates of lime and magnesia, and some uric acid and mucus
Choice of operations for stone in the bladder. — Sir Henry Thompso:
has communicated a clinical lecture on this subject to the 'Lancet,'
July 22, 1 87 1. He had had twelve cases recently in the wards. In
four he performed lithotomy, in eight lithotrity. All the patients re-
covered. He thinks it most important to choose according to the cir-
cumstances of each case. It is unwise to cut all your patients or to
crush all the stones. In guiding your choice you must acquaint yourself
with — ist, the size of the stone, or the amount of the calculous matter
if multiple ; 2nd, its composition : 3rd, the age and constitution of the
patient ; 4th, the conditions of the local organs. A stone which mea-
sures i^ to i| in. in its longest diameter is amenable to lithotrity. A
stone of which any diameter is if in. is mostly too large. For a small
stone, at whatever the age, lithotrity is the operation. Enlarged pros-
tate rarely opposes any obstacle. Stricture of the urethra should be
treated first and then does not oppose any obstacle. If lithotomy be
performed, the lateral is always preferable. There were two children
amongst the twelve patients. One who had a large stone was cut.
The other had a small stone and this was crushed. It was about the
size of an orange pip. Sir Henry uses a tube if there be hemorrhage.
The last case was that of a man, a^t. 72, who was relieved of a con-
siderable lithic acid mass in eighteen sittings.
Miyh operation.— Dr. P. H. Watson operated on an adult male by
n ff
LITHOTOMY. 277
lateral lithotomy. He could not extract the stone. He then made a
supra-pubic incision and removed the stone by that means. It weighed
four and a half ounces. The patient recovered. (' Edin. Med. Journ.,*
Dec. 1871, 557.)
Lithotomy; hcemorrJiage. — A case, in a lad, ajt. i^, operated on by
lateral lithotomy, in which haemorrhage occurred on the sixth day, and
recurred till the eleventh is noted by Mr. Square. The bleeding camo
on and ceased suddenly. (* Lancet,' May 11, 1872, 648.)
In the case of a boy, set. 4^, under the care of the present compiler,
haemorrhage occurred on the fifth day. There had been no previous
complication ; the bleeding came on quite suddenly, after he had had a
violent fit of passion and crying ; it was so severe as to produce rather
alarming faintness, ceased as suddenly as it came on, and did not appa-
rently hinder the child's progress in any way.
Lithotomy. — A paper on Lithotomy in India will be found in ' Dub. Quart. Jouru.*
(May, 187 1, 311), by Dr. Curran. Four cases in which the stones were of unusually
large size are narrated by Mr. Teevan (' Clin. Soc. Trans.,' iv, 84). An analysis of
statistics of lateral lithotomy by Dr. Keith is continued and completed by the account
of the fatal cases in the 'Brit. Med. Journ./ Sept. 16 and 23, 1871. Seven cases are
recorded by Mr. Ensor, of South Africa. Notwithstanding the frequency of ha3ma-
turia and of renal calculi, vesical calculus is rare ('Lancet,' Jan. 27, 1872, 112).
Professor Erichsen gives an interesting clinical lecture on several cases on which he
operated for recurrent or multiple calculi ('Lancet,' March 18, 187 1, 369). A clinical
lecture on lithotomy, by Dr. Eben Watson, is given in the 'Lancet,' May 4, 1872;
of 47 patients operated on by him two only died ; he uses Buchanan's rectangular
staff. A clinical lecture, by Professor Humphrey, is given in the 'Lancet,' June i,
1872, and one by Mr. Forster on lithotomy and lithotrity in the 'Lancet,' Oct. 26,
1872.
Rupture of the female bladder. — "W. Stokes, m a clinical lecture on
rupture of the female bladder, says he could only find notes of five
cases (in Mr. Hoiiel's memoir). Two others occurred under the care
of colleagues of his own, and he adds one case. The patient survived
six days and fifteen hours. The rupture was at the anterior part of the
fundus. He discusses the diagnosis. He mentions two cases, recorded,
of recovery after rupture of the male bladder. (' Brit. Med. Journ.,'
March 23, 1872.)
Wound of the hladder in fracture of the pelvis ; recovery. — Dr. Bell
showed a lad who had fractured his pelvis. When he came under care he
could only pass water through a wound on the left side of the abdomen.
A probe went straight into the bladder. No catheter could be passed.
This was at last accomplished. No more urine came through the fistula
and the latter healed. Another case was mentioned where the fistula
was on the other side. (Edin. Med. Journ.,' Oct. 1872.)
Lithotomy ; removal of a piece of hone from the bladder, — Sir Henry
Thompson records the case of a patient on whom he operated for stone
in the bladder, and removed a calculus which proved to be bone en-
crusted with phosphates. The patient was a lad fifteen years of age.
Pour years previously he had been run over by a cart. On preliminary
examination with a lithotrite a piece of bone was removed, and at the
operation a larger piece was found. A somewhat similar case, in a man,
set. 40, occurred seven years before. Sir Henry removed fragments of
278 REPORT ON SURGERY.
bone and phospliatic matter by lithotrity. The bone had probably
necrosed from the os innominatum as the man had had abscesses about
tlie hip. Pigures are given and allusion is made to the other cases
recorded. ('Lancet,' June 22, 1872, 8ji.)
Calculus vesiccB in the female, — Dr. Watson removed a calculus
weighing 1120 grains from the bladder of an elderly woman by rapid
dilatation. She was able to retain her urine within twenty-four hours
of the operation. (' Edin, Med. Journ., 187 1, 6^0^.) Dr. Atlee removed
a stone weighing 220 grains, and measuring 3 j^yth inches, in its greatest
circumference, and 2y%ths, in its smallest, from the bladder of a female,
set. 73, by rapid dilatation of the urethra. He used Holt's dilator and a
pair of dressing forceps. The patient had no incontinence of urine.
(' Am. Journ. of Med. Sciences,' April 187 1, 424.) Dr. Long removed
a large stone from the bladder of a female, set. 0^^, by rapid dilatation.
Incontinence resulted for three days. The stone weighed 308 grains,
was four and a half inches in its longest and three in its shortest cir-
cumference.
A translation of the reports of two cases recorded in the Hospitah-
Tidende in which vesico-vaginal lithotomy was performed, is given by
Dr. Moore in the ' Dub. Journ. Med. Sci*.,* April 1872, ^^0,. The first
patient was thirty-five years of age ; symptoms had existed for five
years. A " large" stone was detected. Lithotomy was first attempted,
but owing to the hardness of the stone and the pain caused was unsuc-
cessful. G-uerin's old apparatus for lateral lithotomy was used (instead of
a round or straight director, passed along the urethra) to guide the
knife in incising the vaginal wall. The stone was easily removed. An
hour later the wound was united with ten silver wire sutures, which
were fixed with leaden plates. The urine was drawn ofi' every second or
third hour. On the seventh day, five of the sutures were removed.
The wound was healed. On the twelfth day the wires were removed.
No aperture whatever remained. The other patient was 32 years of
age. The stone was of a " tolerably large size." It was found im-
possible to crush it. The female blade of the lithotrite was employed
as a director. After three quarters of an hour had elapsed the wound
was closed with eleven sutures (silver wire), which were twisted. A
catheter was inserted. The vagina was washed out regularly On the
third day c^ptheterisation at regular intervals was adopted. On the ninth
day three sutures, and on the eleventh one, and on the fourteenth day
the other seven were removed. No gap remained. The nucleus of
the stone could not be crushed with the lithotrite out of the body, only
the outside crust. In the first case the stone had been crushed into
two parts by the lithotrite. Together they weighed 648-1 grains. The
length was six centimetres (2*4 in.), the breadth five centimetres (2*0 in.),
and the thickness two centimetres ( *8 in.). The second calculus was
one inch and a half in its longest diameter, and one and a third and
one inch in others. Its weight was 254*63 grains.
Bectal litJiotomy. — In the ' Vierteljahrschrift fiir die prakt. Heil-
kunde,' iii, 1872, Th. Schaffer describes two methods of performing
lithotomy through the rectum. He uses for dilatation specula like
Sims' s, but adapted to the rectum. The operations which he describes
CYSTINE CALCULI. 279
are the recto-vesical, and the lateral recto-prostatic. In the recto-ve-
sical operation, the section enters the bladder at the base of the pros-
tate between the seminal ducts, parallel to the long axis of the rectum.
lujurj of the spermatic ducts or of the peritoneum may be avoided by-
operating with care. In the lateral recto-prostatic operation, a nearly
semilunar incision with the convexity downwards is made along the
border of the prostatic and membranous parts of the urethra ; the flaps
are dissected from the prostate, and under the guidance of the sound,
the prostate is divided as in lateral lithotomy.
Calculous disease. — Sir Henry Thompson contributes a clinical lecture
on the prevention of calculous disease. His treatment consists chiefly
in careful dieting, avoidance of sugar, alcohol and fat, and the adminis-
tration of Friederichshalle and Carlsbad waters, saline purgatives. He
objects to the alkaline waters generally ordered. ('Lancet,' Jan. 13, 1872.)
Calculus- cJiolestearine. — Dr. Duncan showed to the Med.-Chir. Soc.
of Edin. a cholestearine calculus weighing 390 grains, which had es-
caped from the umbilicus of a young lady. No spinal symptoms were
noticed previously or subsequently. She had had constant discharge
from the umbilicus for three years, during which time the calculus
was making its way to the surface. (' Edin. Med. Journ.,' June, 1872,
1127.)
Cystine calculi.—Dr. K. Ultzmann describes in the ' "Wiener. Med.
Wochenschr.,' Nos. 13 and 14, 187 1, four cases of cystine calculus,
operated on by Dr. von Dumreicher in Vienna. The total number of
cases of stone among which these occurred was lojj. In three of the
cases, the calculus consisted entirely of cystine, and were single ; in
the fourth, there were three calculi formed of alternate layers of cystine
and earthy phosphates.
The first case occurred in 1847, in a healthy man, aet. 24. There had
been no hasmaturia. Lateral lithotomy was performed ; the stone was
broken during removal by the forceps. The patient was dismissed cured
on the eighth day. The calculus was of the size of an ordinary wal-
nut, somewhat flattened at the sides, and of a yellowish colour and
waxy aspect. It weighed twelve grammes (185 grains.) The second
case was that of a boy, set. 2 years. His mother noticed when he was
a year old that he had difiiculty and pain in passing urine. On Feb-
ruary 17th, 1 8^4, Dr. von Dumreicher operated by the lateral incision,
and removed a calculus of the size of a pigeon's egg. The child was
dismissed, cured, sixteen days afterwards. The calculus, in the dry
state, weighed 4*3 grammes {66^ grains). Its surface was of a yellow
colour, and was found on microscopic and chemical examination to con-
sist of cystine. Section of the calculus, however, disclosed in the
centre a waxy, yellow, glittering cystine nucleus of the size of a coff'ee-
bean ; this was covered by a layer a line thick, consisting of earthy
phosj)hate with traces of urate of ammonia ; over this lay a dark brown
thick layer of oxalate of lime, and over this again a layer of pure
cystine, one of earthy phosphate, and, finally, an external layer of
cystine. The symptoms of calculus returned three months afterwards ;
and the patient was operated on a second time in January, i8j6; on
this occasion, two calculi were removed. He was sent home, cured, two
280 EEPORT ON SURGERY.
days after tlie operation. The stones weighed, together, 9-^; grammes
(146^ grains). They were, like the former one, formed of cystine
nuclei followed by two layers of earthy phosphate and one of cystine.
The third case was that of a boy. set. 7, who three years previously
bad had hsematuria, unattended by any pain ; this soon diminished, and
a short time after its first appearance he passed ^er urethram, without
pain, a yellowish, firm substance of the size of a pea. Some time later
he became very restless at night, would spring out of bed if not re-
strained, and endeavour, but in vain, to pass urine. The next morning
he would have no recollection of what had occurred. He had also
violent itching over the whole body, which was reported to then have
a bronze colour. In the daytime bright coloured urine was frequently
passed in small quantities. In the summer his condition improved ; but
in the winter of 1863, irritation of the extremity of the penis set in.
His urine when examined in March, 1864, was found to be straw-
coloured, slightly turbid, of acid reaction, and to deposit a sediment
containing hexagonal plates of cystine. This, however, was not found
in the sediment on subsequent examinations. During the summer he
again improved ; but in the winter the symptoms became more severe ;
his faeces were frequently mixed with mucus and blood ; there were
alternate suppression and incontinence of urine ; and he was taken
into hospital in May, 1861;. On the day after his admission, Dr. von
Dumreicher removed, by the lateral operation, a stone about an inch in
diameter, weighing about ten grammes (1^3*4 grains) and consisting
entirely of cystine. The operation was followed by a severe attack of
cystitis and pericystitis, which, however, was subdued in the course of
ten days by inunction of mercurial ointment into the abdomen and
warm applications. The urine passed partly through the urethra on
the fifteenth day ; and the patient was discharged, cured, four weeks ■
after the operation. The fourth patient was a man, set. ^^^ who was,
admitted into hospital in November, 1870, having suffered for two years'
from pain in the bladder and other symptoms of stone ; for nine months
he had had constant dribbling of urine. None of his family were
known to have suffered from calculus. The patient was thin, and his
skin was almost bronze-coloured. The liver was not enlarged, nor
was there pain in the hepatic region. On sounding, a hard body,
which could not be pushed into the bladder, was felt in the prostatic
portion of the urethra. It did not give a very clear sound on
being struck, and its surface was felt to be rough ; a small portion
which followed the removal of the sound, was, on examination, found
to consist of cystine. The urine was of acid reaction, of spec. grav. 1007
it was cloudy and yielded a flocculent sediment of pus, together with
epithelial cells from the pelvis of the kidney and casts from the tubes
of Bellini. The quantity of colouring matter and uric acid in the
urine was much diminished ; the urea and salts were in normal amount ;
and there was a good deal of albumen. There was no cystine in
the sediment. The median operation of lithotomy was performed on
November 17th, and the stone was removed in three pieces with
a quantity of detritus; the whole was calculated to weigh forty-
five grammes (694^ grains). The patient went on well for some days j
TESTICLE IN THE PERINiEUM. 281
but, on November 30th, febrile symptoms appeared ; diarrhoea set in
four days afterwards; and he died on December 12th. The cause of
death, as far as the necropsy gave any indication, was general anaemia
and hypostatic pneumonia. There was some disease of the parenchyma
of the kidneys which had apparently come on subsequently to the ope-
ration, and did not seem sufficient to account for death. The supra-
penal capsules were healthy, so that the bronzed state of the patient's
skin was not connected with disease of these structures.
. Treatment of tuherculous testicle hy tlie actual cautery. — M. Verneuil,
in a communication to the Surgical Society of Paris, expresses his pre-
ference for the actual cautery over all other methods of treatment of
tuberculous testis. He introduces conical, or olive-shaped cauteries
into the fistulous openings, penetrating the indurated scrotal tissue,
and destroying the diseased structure of the testicle. Under this treat-
ment, he says, patients are enabled to leave the hospital in a few weeks.
The constitutional disease, however, is not eradicated, and the disease
is likely to return in the testis, and extend to the prostate. Cauteriza-
tion, however, relieves the patient for a year or two, and appears to
delay the recurrence of the disease. In the discussion on M. Verneuil's
communication, M. Legouest expressed an opinion in favour of castra-
tion being performed much more frequently than it is in such cases,
and at an early period of the disease. (' Gaz. Med. de Paris,' Novem-
ber 4, 1871.)
Testicle removed for neuralgia. — Mr. Annandale showed a specimen. The pain
had existed for six or seven years. No disease was found except slight thickening of
the epididymis ('Edin. Med. Journ.,' Sept., 1872).
Cancer of an imperfectly descended testis ; difficulty of diagnosis, — Mr. Henry
Arnott, 'Path. Trans.,' xxii, 182.
Transition of the testicle into tJie perinceum. — Mr. James Adams
narrates the case of a male infant, aged eleven weeks, who came under
his care for a misplaced testis. The right side of the scrotum was nor-
mal. On the left side was a pouch, but no testis in it. The left testicle
formed a smooth oval swelling in the perinseum, to the left of the middle
line, and half an inch in front of the anus. It was quite movable. The
cord could not be felt owing to a considerable thickness of fat. Mr.
Adams operated by making an incision about an inch and a half long,
from the external abdominal ring over the empty scrotal pouch, which
he carefully opened, thus preparing a bed for the testicle. He then felt
for the cord, and having found it, followed it down to the testis, taking
care not to injure the tunica vaginalis. On making traction on the cord,
it became evident that there was some firm adhesion between the lower
part of the testicle and the perineal pouch. This, Mr. Carling sug-
gested, was the gubernaculum. Mr. Adams dissected down to its
attachment, and divided it as far from the testis as possible. The testis
was then raised, in its uninjured tunica vaginalis, and placed in the
scrotal pouch. A catgut suture was passed through the gubernaculum
and fixed to the bottom of the scrotum. On the third day the edges of
the wound became sloughy, erysipelas followed, and the child died at
the end of a fortnight, apparently of exhaustion. Keference is made
to the other two cases ou record, and Mr. Adams remarks, the chief
282 REPORT ON SURGERY.
arguments adduced in favour of early operation are: — i. That the
scrotum will not develope on the empty side, and that in the course of
a few years it will become an impossibility to cover the organ with it.
2. That, as nearly all testicles found in abnormal situations are atro-
phied, there is a chance of the gland itself becoming useless. 3 . It has
been asserted that its position is inconvenient and painful, and that it
is liable to injury. The first of these propositions is undoubtedly true.
The gland, however, does not invariably atrophy, as in Mr. Ledwich's
case it was of normal size, and contained spermatozoa. The patient
may attain adult life without experiencing any inconvenience. He is
therefore of opinion that no operation should be undertaken during the
earlier periods of life ; first, because in very young children the wound
must almost necessarily be frequently irritated by the urine, and because
of the probability of the potency of the serous membrane ; and, secondly,
because the malposition may not prove to be of any inconvenience,
unless the patient is destined to become an equestrian. ('Lancet,'
May 27, 1871, 710.)
Treatment of gonorrhoeal epididymitis ly ice. — Dr. Borgioni, in a
paper published in * L'Imparziale,' for May i and 16, 1872, relates four
cases of gonorrhoeal epididymitis treated successfully by ice. He does
not bring forward the remedy as new, nor does he consider the number
of his cases sufficient to warrant his saying that it is always efficacious ;
but, as far as he can judge, he believes it simple of application, and
capable of efiecting an early cure.
GonorrJioeal or urethral rheumatism. — Dr. Bond writes on this subject*
He concludes with the following deductions, that urethral rheumatism
is a slow form of pysemic poisoning, due, not to a sudden absorption,
but to a gradual vitiation of the blood by progressive absorption of the
urethral discharge ; that the vitiated state is not maintained indepeni
dently of the local disease ; that when the discharge is thoroughly an(
permanently stopped, the rheumatism may soon be cured and has n<
tendency to return, except by the access of a fresh urethral discharge^
('Lancet,' March 23, 1872, 39^5.)
Vesico-vaginal fistula. — Dr. Joseph Bell records cases on which h<
has operated successfully. He uses a series of steel points, highb
tempered and curved, in various sizes, some not larger than one thirc
of the circumference of a sixpence, others bearing the same proportioi
to a shilling, but all welded to the silver wire in such a manner as tc
project no shoulder, and require no threading. These are easily managec
either with a Sims' needle forceps, or by an ordinary pair of dressing-
forceps, and setting the wire at a right angle to the needle and curving
it round the hand and arm, it is readily managed with great ease. He
also finds (Sims' ?) barbed hooks of great service. (' Edin. Med. Journ.'
Jan. 1872, 591.)
Imperforate hymen. — A case in which Dr. Barton operated success-
fully for retained menses, owing to an imperforate hymen is recorded.
('Dub. Quart. Journ.' Feb. 187 1, 62.) The patient was fifteeri]
years of age. The septum across the vagina was divided carefully, auc'
not very freely. It was of considerable thickness. Eeunion partiallyJ
occurred, but was obviated by retention of a piece of oiled lint.
EPITHELIOMA OF THE TONGUE — GALVANIC CAUTERY. 283
Epithelioma of tJie tongue treated ly the galvanic cautery, — Dra.
Andrea Gozzini and Peleo Puccioni relate, in ' L'Imparziale,' (Nos. 15
and 16, 1872) a case in which an epithelioma of the toDguo was re-
moved by the galvanic cautery. The patient was Signer Mazzoni, a
gentleman aged 64, who had always enjoyed good health, until, in
October 187 1, he observed an excoriation on the upper part of the left
side of his tongue. In course of time, this presented the ordinary cha-
racters of epithelioma ; and, an operation being decided to be neces-
sary, it was determined to apply the galvanic cautery. The operation
was performed on April 10, 1872, in the presence of Senator Prof.
Burci and Drs. Casctti and Billi. The tongue was drawn out of the
mouth by a double hook passed through the healthy portion, and held
by an assistant. The end of a needle was then introduced, which had
been made for the purpose ; it was in the form of the letter S, chan-
nelled on its surface, and carried at one end a platinum wire \\ milli-
metre in diameter, and 50 centimetres loug. It was introduced into
the fold of mucous membrane which is reflected from the base of the
mouth on the inferior surface of the tongue, as nearly as possible at a
point which left three-fifths of the base on the left side, and tw^o fifths
on the right. AVhen the eye of the needle appeared on the upper sur-
face of the tongue, the platinum wire was seized with a forceps, and,
having been freed from the needle, one end was drawn out of the mouth
and placed in contact with the other end, the needle having been with-
drawn in the reverse direction to that by which it entered. The ends
of the wire were then fastened down by a serre-noeud on the apex of
the tongue. The loop was then heated by the galvanic cautery, and in
twenty seconds the parts with which it was in contact were distinctly
cauterised. The wire was now allowed to cool, and was again tightened ;
after which the cautery was applied as before. By proceeding in this
way, the longitudinal division was effected in eight minutes. The
tongue being held aside well out of the mouth, and the angle of the mouth
and the cheek held by a blunt hook, and pieces of wood being placed
between the molar teeth, the wire was applied transversely, as far back
as possible ; and the division in this direction was completed in seven
minutes. The whole operation occupied seventeen minutes ; it was
unattended either with haemorrhage or with flow of saliva. After the
operation, the patient rose from the chair on which he had sat, and
walked to his bed without assistance. Ice was given him to suck, and
he was allowed soup and wine, which he swallowed slowly, but without
much difficulty. On the fifteenth day the eschar fell off, after which
the salivation, which had become profuse, diminished and soon ceased ;
and the patient became able to eat solid food. On the eighteenth day
after the operation. Signer Mazzoni was able to walk out. During the
whole time he had been able to attend to his professional duties as a
lawyer, conveying his instructions for some days by means of writing.
Microscopic examination proved the epitheliomatous character of the
tumour. When the case was reported, three months after the opera-
tion, there were no signs of recurrence.
New onethod of removing the tongue. — Mr. Purneaux Jordan success-
fully removed the tongue of a patient suffering from carcinoma, by the
284 EEPOllT ON SURGERY.
mode of incision recommended by Macleod, of Q-lasgow, combined with
a novel mode of using tbe ecraseur. He made the incision by thrusting
his knife through the cheek in front of the ramus of the jaw, and then
cutting towards the angle of the mouth. The vessels were secured by
torsion. He thus obtained free access to the root of the tongue. " The
tongue was then seized close to its root between the finger and thumb
of one hand, while the other carried under the tongue a strong curved
needle, threaded with four pieces of ligature. These drew back through
the channel made by the needle the chains of two ecraseurs, one after
the other. One was fixed so as to divide the tongue near tlie larynx,
the other was to separate it from the floor of the mouth. The instru-
ments were worked simultaneously, and in about seventeen minutes
clean removal was efi"ected, absolutely without haemorrhage. (' Lancet,'
April 20, 1872, 540,)
Mr. Annandale removed the right half of a woman's tongue by Buchanan's modi-
fication of Syme's operation. The patient was 71 years of age. At time of note she
was 72, and there was no recurrence (' Edin. Med. Journ.,' Aug., 1872, 678). A suc-
cessful case in a woman, aged 62, under the care of Mr. Canton, is noted in the
'Lancet' (Jan. 20, 1872, 80). The tongue was drawn down below the maxilla, and
divided by an ecraseur. Mr. Lee records a case. He divided the jaw, and passed
ligatures, in a special manner, through the base of the tongue before cutting it away.
No haemorrhage occurred. The patient recovered. (' Clin. Soc. Trans.,' iv, 114.)
Abscess of the Tongue. — Dr. Pooley records a case of abscess of the tongue in a
girl seven years old ('Am. Journ. Med. Sci.,' April, 1872, 385).
Congenital liypertrophy of the tongue. — A case was shown to the
Clinical Society by Mr. Lawson. (' Trans.,' v, 158.)
In a case under the care of Mr. Simon removal of portions ivith the
Ecraseur was practised and death followed. Eeport of the case by Mr.
Arnott. (• Path. Trans./ xxiii, 109.)
In a case of congenital hypertrophy of the tongue which came under
the care of Mr. Pairlie Clarke he used the ecraseur with success. The
patient was. four months old. The protruding portion only was re-
moved. (* Lancet,' March 30, 1872,433, and 'Path. Trans.,' xxiii, 11 1.)
l^atty masses in a ranula — adipocere.—ln a case of apparently ordinary
ranula, Mr. Waren Tay evacuated five masses, like lumps of firm butter,
from a cyst under the tongue. Dr. Tidy pronounced them, from che-
mical examination, probably in the condition of adipocere. They were
not ordinary fat. (' Path. Trans.,' xxii, 258.)
A fatty tumour under the tongue resembling ranula is recorded by
Mr. Churchill who gives a resume of other cases. (* Path. Trans.,' xx,
iii, 234.)
Fibrous tumour of the tongue. — Dr. Pooley records the case of a
young woman (set. 23), who came under his care for a tumour of the
tongue of twelve months' duration. It was hard to the touch, and
placed far back. It had a broad base. Bleeding occurred occasion-
ally. It was removed with wire ecraseur with some difficulty owing to
its density. There was no bleeding. The patient soon recovered.
After removal the tumour was as large as a bantam's egg perfectly
spherical in form, with a pedicle an inch in diameter, had several stellate
cracks or fissures extending through the mucous membrane with which
it Wfis covered^ which were undoubtedly the source of the repeated hae-
SPASMODIC STRICTURE OP THE ESOPHAGUS. 285
inorrhages. In structure it was a firm fibroid and resembled accurately,
as it did also in its symptoms, the well-known fibroid polypi of the
Litems. One case is quoted from Paget, another from Cooper's
' Dictionary/ and one from * Boston Med. Surg. Journ.,' all the author
could find. The patients were young men. (' Am. Journ. Med. Sci.,'
April, 1872, 385). Dr. Titts records the case of a woman, aet. 30.
In examining her throat and while depressing the tongue he noticed a
tumour rising up at its base, of about the size of a filbert. It was
situated in the median line, so far back tbat it was difficult to pass the
finger behind it. It was exceedingly hard, incompressible and im-
moveable. It was not apparently pedunculated. In a few months the
growth steadily increased in size, and almost filled the whole of the
fauces. Prof. Bigelow operated. He removed the tumour with the
ecraseur. It was pronounced fibrous or fibro-recurrent. At the end of
two years there was no recurrence. ('Am. Journ. Med. Sci.,' July,
1872, 122.)
Hysteric or spasmodic stricture of the oesophagus. — Sir James Paget
considers this condition the homologue, in the pharynx or oesophagus,
of that want of harmony between the organs of speech and respiration
which produces stammering and appears to depend on a want of per-
fect concert between certain involuntary muscles and muscles acting
under the control of the will which are designed to act in harmony.
In the latter case the muscles of respiration do not act in time and
unison with the organs of speech ; in the former, instead of the normal
contraction of successive portions of the upper part of the alimentary
canal from above downwards which transmits the food regularly from
the mouth to the stomach, there occurs an unruly contraction of certain
fibres which, as long as it continues, bars the passage of food as com-
pletely as if some permanent obstruction existed. The degree of this
contraction varies in difi'erent cases ; in some it only compels the
patient to take his meals apart or inconveniences him whenever his
attention is in any way directed to the act of swallowing : while, in
others, it produces contraction so obstinate and comj)lete that the
maintenance of life by means of gastric digestion is wholly prevented.
In these cases recourse must be had to enemata, and it will be found
necessary to make use of something more than beef tea and brandy,
and by injecting preparations containing fats, starches, sugars, and
vegetable as well as meat juices, to supply all the ingredients which
are contained in a natural diet, and are essential to the building up o£
the various tissues of the body. Of the fact that vegetable juices
could thus be eff'ectually introduced into the system, he had recently
had very satisfactory proof in the case of a patient with whose nutritive
enemata some of the essence of water cresses proposed by Mr. Wyatt
had been introduced. At the end of a few days the patient had begged
that the quantity of the essence might be diminished, because the
flavour of the vegetable in his mouth had become so strong and so con-
stant as to be extremely disagreeable. ('Lancet,' Jan.7, 187 1, 11.)
Resection of the oesophagus. — In an article in the ' Archiv fiir Klin.
Chirurg.' (Band xiii, 6^), Dr. Billroth suggests that this operation may
be found practicable in cases of cancer of the oesophagus. He remarks
^86 REPOET ON SURGERY.
that the disease is generally limited to one part, and that attempts at
dilatation often only increase the evil by tending to ulceration. H©
suggests that after removing the diseased portion (if the cancer be
situated sufficiently high), the resulting cicatrix would be capable of dis-
tension by bougies ; and that the healing powers would be analogous
to that which takes place in the urethra atter the loss of a portion of
this canal by ulceration, sloughing, or injury. Prom a large dog, Bill-
roth removed an inch and a quarter of the oesophagus, and united the
lower end of the tube to the skin by two sutures, so as to allow the
introduction of a tube through which milk was to be conveyed into the
stomach. On the fifth day, it was found possible to introduce a tube
through the mouth ; at first it had to be guided along the wound by
means of the finger, but afterwards this became unnecessary. The
sutures were removed a week after the oj^eration. There was at first a
great discharge of mucus through the wound ; this gradually decreased,
the oj^ening became smaller, and in two months entirely closed ; and
an oesophageal bougie of the size of a large index finger could be
readily passed. The dog was fed with meat, potatoes, &c., and throve
well. A little more than two months after the operation, it was killed ;
the cicatrix was found to be annular, scarcely half a line wide, and
readily distensible.
Foreign bodies impacted in strictured ozsopliagiis : cssopliagotomy. —
Dr. Menzel relates, in the 'Archiv fiir Klin. Chirurg.' xiii, 678, the
cases of two children, patients in the Greneral Hospital in Vienna, in
whom stricture of the oesophagus had been produced by swallowing
irritant fluids, and in whom also foreign bodies subsequently became
impacted in the strictured portion. The first patient was a boy aged
6, who, a year previously, had swallowed some strong lye, in conse-
quence of which great narrowing of the oesophagus occurred. He was
brought into hospital on account of having swallowed a breeches button.
Dr. Billroth removed this by cesophagotomy, and the patient was dis-
charged, with the external wound healed, on the twenty-first day after
the operation. The second patient, a girl, had strictured oesophagus,
the result of swallowing nitric acid, and was unable to swallow solid
food. She was brought to the hospital on account of having been for
ten days unable to take any food whatever through the mouth. A
slender oesophageal tube, however, was passed, through which some
milk was introduced. After this, the condition varied; sometimes
deglutition was tolerably easy, sometimes quite impossible; on some
occasions a bougie of moderate size could be passed, while on others this
could not be done, and it occasionally seemed as if a foreign body were
struck, though this could not be distinctly made out. The child gradually
lost strength, became feverish, and died on the forty-eighth day after
admission. At the necropsy, there was found in the oesophagus a semi-
lunar aperture leading into a cavity in the submucous tissue, in which
lay a blue glass bead, of the size of a pea. A narrow, fistulous canal led
from the bottom of the cavity to a collection of pus in the mediastinum.
There was also purulent efi'usion in the right pleural cavity. Dr. Pean
relates in the 'Tribune Medicale,' January 21, 1872, the case of a boy,
aged 8, who had a peach-stone impacted in the oesophagus beneath the
Wound of cesophagus — iiyEMorauiAOE — operation. 28t
manubrium sterui. Q^^sopliagotomy was performed, but the foreign
body could not be reached. The connective tissue between the oeso-
phagus and trachea was carefully torn by the finger to the extent of
about 3 centimetres, till the mediastinum was reached. The sharp end
of the peach-stone was now felt, and the foreign body, having been
brought into a favorable position, was pushed into the oesophagus and
removed. The wound in the cesophagus healed within a fortnight.
Removal of an artificial plate with false teeth from the oesophagus. — A
lady in an epileptic fit swallowed a tooth-plate. At first it could not
be felt from the mouth, but after some time could just be detected. At
the end of about twenty-four hours Dr. Matthews succeeded in tilting
up one end as it lay across the oesophagus, and then extracting it.
('Lancet,' May 13, 1871, 643.)
Passage of an artificial tooth-plate along the alimentary canal. — Mr.
Henry Smith was called to see a corpulent butcher who had swallowed
an artificial plate, with two teeth, and projecting hooks on each side.
J\Ir. Smith tried to withdraw the foreign body which he could just feel,
but failed in his attempts, and therefore decided to push it into the
stomach. This he accomplished. Nine days later the plate passed per
anum. ('Lancet,' April i, 1871, 440.)
Haemorrhage from internal loound of ossophagus — operation. — Mr. Ann-
andale records the following case : — A lady, aged ^2, while dining, swal-
lowed a bit of bone which she felt lodged in her throat. A few streaks
of blood were noticed to pass by the mouth. The day after a small
swelling formed over the inner border of the left sterno-mastoid, about
the middle of the neck. On the fourth day this was still evident, hard
to the touch, and about the size of half a small walnut. An ivory-
headed probang passed down the oesophagus struck against some hard
substance on the left side, immediately opposite the swelling in the
neck. This hard substance could not again be felt. The pain and
difficulty in swallowing had vanished. The next day only a slight sore-
ness was felt in swallowing. On the twelfth day haemorrhage occurred
suddenly from the mouth. The blood brought up was arterial and un-
mixed, except with a little saliva and mucous. The haemorrhage re-
curred after some hours and it was decided to cut into the neck, with
the hope of discovering and removing the source of the haemorrhage,
which appeared to be connected with the lodgment of the foreign body
in the oesophagus. An incision was made on the left side of the neck,
as if for tying the common carotid below the omo-hyoid, and the artery
having been exposed, a ligature of catgut was4)assed loosely round in
order to be in reserve. A careful dissection was then made to the inner
side of the artery, so as to lay bare the oesophagus, with the result of
exposing a wound of this canal. The wound was a quarter of an inch
in length, situated in the left side, and passed completely through the
walls of the canal ; its edges were somewhat ragged, and a continuous
oozing of arterial blood occurred from them. A very foetid odour was
noticed. No foreign body could be detected. A small artery was found
entering the oesophagus close to the wound. This artery passed up-
wards from underneath the carotid, and was, from its situation and
direction, considered to be a branch of the inferior thyroid artery. A
SB8 REPORT ON SURGERY.
ligature passed round tliis small branch at once stayed the bleeding.
The margins of the wound were freely touched with tincture of muriate
of iron, and the edges of the wound in the neck were brought together
with sutures. The patient was fed by a tube. The wound became un-
healthy looking, slight haemorrhage occurred, checked by iron. The
patient gradually became weaker, and died nine days after the operation.
No post-mortem was allowed. Mr. Annandale remarks, " The history
of the case, the detection of the foreign body by means of the probang,
and the condition determined at the operation are, I think, sufficient
proof that a sharp fragment of bone had lodged in the oesophagus, and
wounded its walls. This wound had been followed by ulceration,
which, in its progress, had involved the arterial branch and caused the
haemorrhage. It seems probable that my first introduction of the
probang displaced the bone, and that this accounted for the relief of
the symptoms and the disappearance of the inflammatory swelling in
the neck. Had the bone remained in its original position, an abscess,
pointing externally, would have been the result. From the fact that
no difficulty in swallowing was experienced after the introduction of
the probang, it is likely that the bone passed down into the stomach.
Had I not possessed a clear history of this case, and had I not also dis-
tinctly felt the bone and ascertained its position, operative interference
would scarcely have been justifiable; for although the blood was evi-
dently coming from the pharynx or oesophagus, it was impossible to be
certain as to its exact source." " The discovery that the wounded vessel
was not a branch of the carotid, but of the subclavian artery, is an ex-
cellent, but, at the same time, rare illustration of the important prin-
ciple in the treatment of wounded arteries, namely, to search for the
bleeding-point itself and secure it, if possible. Ligature of the carotid
artery, in this case, could have had no influence in restraining thej
haemorrhage from the bleeding vessel." The progress of the case, foi
the first few days, was all that could be desired. The fact that thi
patient had been hemiplegic for some time on the left side, and was nol
in a good state of health, tended to diminish her chance of recovery^
The bleeding after the operation was only from the sloughy edges of the
wound in the neck, not from the oesophagus, and blood never came bi
the mouth. ('Edin. Med. Journ.,' April, 1872, 880.)
^Radical Cure of Inguinal ffernia. — Professor Fayrer records cases (• Med. Time
and Gaz./ April 6, 1872).
Herniotomy. — Mr. Erichsen operated on a male infant, aged six weel
for strangulated inguinal hernia. The child recovered from the opers
tion, but died a month later from pleurisy and peritonitis. (' Lancet,^
May 18, 1872.) Mr. J. D. Hill performed herniotomy in a case of
congenital scrotal hernia in an infant eighteen months old. Stranguh
tion had existed twenty-four hours. The sac was not opened. Th«
baby recovered. ('Med. Times, and Gaz.,' April 8, 1871, 395.)
Sir James Paget has contributed Clinical Lectures on Strangulated Sernia to tl
•Brit. Med. Journ,,' i and ii, 1872.
Direct Inguinal Sernia in the Female.— Mr. Squire, 'Path. Trans.,' xxii, 148.
Strangulated Femoral Hernia; reduction in masse. — Reported by Air. Morfia
under the care of Mr. Lawson. ('Path, Trans./ xxii, 148.)
ASPIRATION OF STEANGULATEB INTESTll^E. ^^9
Catgut sutures to the tendinous openings in Tiernia. — Mr. Lister has
successfully employed catgut sutures in stitching up the tendinous
openings in operating on ventral and umbilical hernise. (Address,
*Brit. Med. Journ.,' Aug. 26, 1871.)
Strangulated Umbilical Sernia; operation; sac opened; recovery, — Dr. Arnison
mentions two cases. ('Lancet,' Nov. 2, 1872.)
Incarcerated scrotal hernia; operation; artificial anus: recovery. —
The case of a man, set. 6^, under Mr. Hutchinson's care for hernia
presented features of interest. The hernia was incarcerated from im-
paction of faeces ; there was an absence of strangulation, and yet the
bowel was sloughing. There was no vomiting and no constipation, but
the prostration was extreme. Great relief followed the operation.
The right scrotum was enlarged, swollen, tender, and of dusky red hue.
On incision, the hernial sac was found distended and fluid was let out.
The neck was quite free. The intestine contained a large mass of
faeces of almost stony hardness and was sloughing at one part. The
mass was turned out and the margins of the bowel stitched to the
edges of the wound. The artificial anus gradually closed. (* Lancet,'
Aug. 24, 1872.)
Treatment of strangulated hernia hy puncture of the intestine. — In the
'Med. Times and Gazette,' April 20, 1872, Mr. Bryant records the
case of a man, set. 71, the subject of strangulated scrotal hernia and
upon whom he performed herniotomy. It was necessary to expose the
bowel in order to return it. Owing to the restlessness of the patient,
however, the gut again descended in a few hours, and all attempts to
reduce it failed, until the large intestine was punctured in four or five
places with a grooved needle and a quantity of flatus let out. The
patient recovered without any bad symptom. Mr. Bryant advo-
cates puncturing the intestine in certain cases of hernia. He thinks
it possible that some hernise may be reduced without any cutting oj)e-
ration at all. He intends trying puncture in large scrotal and umbi-
lical hernise, and thinks the plan adapted for all cases of acute internal
strangulation, due possibly to bands or twists. In the ' Med. Times and
Gaz.' for Aug. 3, 1872, two cases of strangulated hernia treated success-
fully by puncture are referred to.
tfseofthe aspirator for puncture of the intestine in hernia. — Dr. Leon
Labbe records a case of strangulated inguinal hernia in a man, set. 70,
in which aspirating puncture of the intestine was employed. Fluid
and gas escaped, immediate reduction was effected, and the patient
was cured. (' Lancet,' July 20, 1872, 78.)
M. Demarquay related to the Academy of Medicine, in May, 1872,
the case of a young man, to whom he was called, suffering from stran-
gulated congenital hernia. M. Demarquay saw him on the second
day after the symptoms of strangulation had set in, and attempted to
reduce the hernia by the taxis, but without effect. He then applied
Potain's aspirator, and withdrew from the intestine about 120 grammes
of liquid. After waiting for a few minutes to see whether the swelling,
which had gone down, would return, he easily replaced the intestine in
the abdomen by pressing gently from below upwards. The patient was
treated by rest, small doses of opium, and low diet ; and made a good
19
290 ItUPORT ON SUEGEKY.
recovery, tlie only disturbance of any kind being inflammation of the
testis in consequence of the pressure to which it had been subjected.
M. Demarquay says that the treatment of hernia by aspiration is in-
dicated in the following circumstances : — i. In all congenital herniae,
or in recent hernise which have become strangulated at the moment
of their formation ; 2, in old hernise that were perfectly reducible a
few days before strangulation took place ; and in recently strangulated,
large, umbilical hernise. The operation, he says, should be performed
only at an early period, when there is reason to believe that the intes-
tine has not yet undergone any destructive change. (' Bull. General
deTher.,' 13, 1871.)
Mr. Jessop says, "I remember the late Mr. Teale, in i860, while
introducing an acupuncture needle twenty or thirty times through the
abdominal walls in a case of excessive tympany following herniotomy,
remarking to the students around him that, in his early days, he had
been accustomed, under similar circumstances, to use the trocar after
the manner of veterinary surgeons ; but that, of late years, he had pre-
ferred the acupuncture needle as being at the same time less dangerous
and equally ef&cient.'' Mr. Jessop has used the aspirator with satis-
factory results on several occasions. (* Brit. Med. Journ,,' Dec. 7, 1872.)
Diaphragmatic hernia. — Dr. A. Popp, in the 'Deutsche Zeitschr. fiir
Chir.,' Band i, has collected forty-two cases of diaphragmatic hernia,
adding two observed by himself. He arrives at the following conclu-
sions : — The oesophageal opening very rarely gives passage to the hernia ;
in most cases, there is an abnormal cleft in the oesophagus, either con-
genital or the result of injury. The hernia is generally on the left
side ; an aperture on the right side being covered in by the liver. The
causes of injury were, stabs in twenty-one cases ; gunshot wounds in
three ; falls in ten ; and in three, the causes were, respectively, violent ex-
ertion, a fall with a violent twist of the body, and the being run over
by a carriage. In most cases, the hernia was formed of the stomach,
transverse colon, or a portion of the omentum. In five cases, the hernia
was in the right pleural cavity, in thirty-two, in the left. The dia-
gnosis is difficult, but may be aided by the history of the case and by
auscultation and percussion.
J. Sargent relates a case of diaphragmatic hernia in the 'Boston
Med. Surg. Journal' for February 22, 1872. In 1851, a woman,
named S — , was injured by the handle of a hay-fork, which entered the
vagina and broke the first rib on the left side. She recovered, and died
in 187 1 of peritonitis. At the necropsy, the left pleural cavity was
found to contain, besides the compressed lung, the stomach, the trans-
verse colon, several inches of the descending colon, and a considerable
portion of the small intestine. In the left half of the diaphragm was
an irregular opening four inches in diameter.
Ohturator hernia. — Dr. Chiene describes the conditions found by him
in the body of a woman, set. 73, in the dissecting room. On opening the
abdomen, a portion of the ileum was found strangulated in the opening
at the upper part of the obturator foramen. On dissecting down-
wards, among the adductor muscles of the thigh, a sac, the size of a
pigeon's eg^, was exposed. It was brought fully into view by cutting
OBTURATOR HERNIA — HERNIA OF THE OVARY. 291
through the pectineus and dissecting off a layer of fascia derived from
the muscular fascia of the obturator externus. It had passed through
the obturator canal displacing, in its outward passage, the upper fibres
of the obturator externus muscle. The artery lay between and was
separated from the sac by a ligamentous band. The nerve lay in front.
The sac contained the outer two thirds of the Fallopian tube and two
inches of the ileum. The bowel was gangrenous and had given way.
The round ligament passed in front, above the opening. The ovary was
compressed against the wall of the pelvis immediately below the open-
ing. The sac was formed of the broad ligament. Dr. Chiene's expla-
nation of the occurrence of this hernia is, " In the broad ligament of
the uterus, in health, a slight cul de sac will be observed between the
round ligament and the Fallopian tube ; a knuckle of bowel pressing
downwards in this position had caused a separation of the layers of the
broad ligament ; the pressure being continued, the bowel had passed
through the obturator canal, necessarily pushing before it a sac formed
of the peritoneum of the broad ligament, the Fallopian tube being
carried into the sac along with the peritoneum. On the opposite side
were two obturator hernise, an anterior sac formed of parietal perito-
neum, the opening admitting the tip of the little finger and passing
in front of the round ligament, and a posterior one, similar to that on
the other side, containing the outer half of the Fallopian tube. A
sketch of the parts is given. The points of interest are that it was a
case of triple obturator hernia, and that in two of the heruiae the sacs
were formed of the peritoneum of the broad ligament. Dr. Miller
gives some particulars of the patient's clinical history. He had ope-
rated on her, rather less than twelve months before, for strangulated
femoral hernia, successfully. At the post-mortem examination, detailed
above, very little trace of this could be found. He was called to see
her again shortly before her death. He could find no hernial tumour,
but she had symptoms of abdominal obstruction and was very ill. She
had delayed sending as she dreaded another operation. The idea of
gastrotomy suggested itself, but was dismissed owing to the patient's
great age and low condition. ('Ed. Med. Journ.,' Jan. 1871, 601-3.)
A case is noted ('Lancet/ June 22, 1872) under the care of Mr.
Erichsen. There were no symptoms to lead to the diagnosis. After
death, with symptoms of obstruction, a small hernia was found. De-
tailed notes are given.
Hernia of the ovary. — Dr. J. Englisch describes (' Jahrbiich. der K.
K. Gesellsch. der Aerzte in "Wien,' 1871) three cases of ovarian hernia,
and makes some remarks on the afiection. Exclusive of the cases in
which the uterus has been found displaced along with the ovary, there
are on record thirty-eight cases of ovarian hernia, twenty-seven in-
guinal, nine femoral, one sciatic, and one obturator. In one third of
the cases of inguinal ovarian hernia, the displacement was on both
sides. In seventeen cases, the hernia was congenital ; in all these it was
inguinal, and all the cases of double hernia were also inguinal. From
these facts, Englisch concludes that congenital ovarian hernia arises
from an abnormal descent of the ovary, analogous to the normal
descent of the testis in the male. Ovarian hernia is frequently combined
29:2 EEPOET ON SUHGEliY*
with other malformations of the genital organs. Those cases of ovarian
hernia which come on at a later period of life must be accounted for by
some such conditions as excessive length of the ovarian ligament, bend-
ing forward of the uterus, too great an inclination forward of the pelvis,
or the drawing down of the ovary with a hernial sac. In congenital
hernise, the ovary and Fallopian tubes are generally present, while
acquired hernia usually contains the ovary alone. The uterine end of
the Fallopian tube has been found obliterated inmost of the cases that
have been examined. The displaced ovary was, in fifteen cases, normal ;
in seventeen, inflamed ; in five, it had undergone cystic, and in one, can-
cerous degeneration. In five cases the hernia also contained intestine.
Ovarian hernisa are generally pear-shaped, the neck of the protrusion
being very narrow, especially where the organ has undergone degenera-
tion. In the femoral form, the hernia is rounder. It is rarely that
any information as to diagnosis can be obtained from the form or the
consistence of the swelling. It has been alleged by some observers
that the pain produced on pressure extended to the umbilicus, and in a
number of cases included uterine colic and pain in the external genital
organs. The healthy ovary is always tender. Of the fifteen con-
genital hernisB, thirteen were irreducible ; while, of fifteen cases of
acquired hernia, in three only could the ovary not be returned into the
abdomen. In some cases pain is described as having been produced by
dragging on the uterus, when the patients lay on the side opposite to
that of the hernia. In single ovarian hernia, the uterus is generally
inclined towards its aff'ected side. The symptoms produced during
menstruation are very striking, and afl'ord important aid in the dia-
gnosis. In some cases, however, these have been wanting, and here the
uterus has been absent. Before the menstrual discharge commence.^,
the patient feels pain in the hernia, which also increases in bulk. In
many cases there have been also eructation and vomiting, nearly lead-
ing even skilful surgeons into the error of supposing that they had to
deal with strangulation. In one case, in which pregnancy occurred,
the changes in the hernia at the menstrual periods were arrested during
this condition. Inflammation of ovarian hernia may be traumatic, or
may accompany menstruation. Englisch observes that even in omental
and intestinal hernia the period of strangulation often coincides with
that of menstruation ; and he believes that the congestion, which aflects
not only the ovary but the peritoneum, may in certain cases give rise
to the phenomena of incarceration. When an ovary that has under-
gone cystic degeneration becomes gangrenous, it may readily be con-
founded with gangrenous intestine. The vomiting which often accom-
panies inflammation of a displaced ovary, is ascribed by Englisch to
a sympathetic aff'ection of the intestine, and not, as has been supposed
by Miilert, to compression of the intestine against the overstretched
edge of the broad ligament. In inflammation of an ovarian hernia,
the abdomen is usually less distended, and the countenance less anxious
than in ordinary strangulated hernia. When an ovarian hernia suppu-
rates, the abscess very rarely bursts into the abdomen. When there
is strangulated intestine, at the same time with the ovary, in the hernia,
the symptoms are increased in severity. The condition of the stools
SCIATIO HERNIA — INTESTINAL OBSTRUCTION. ^93
\\ ill give the most certain aid in the diagnosis ; which, however, is often
very difficult. Of twenty cases in which syjnptoms of incarceration were
[ present, a correct diagnosis was formed in seven only ; in the remainder,
the nature of the hernial contents was not ascertained until the sac
had been opened. The prognosis in ovarian hernia is favorable as re-
gards life, but unfavorable as regards the function of the organ.
Attempts should be made to reduce the displaced ovary, if possible, by
the same proceedings as are followed in other hernia). If the hernia
be irreducible, a concave truss should be worn. If the tumour be-
come very painful, extirpation is indicated. When inflammation occurs,
the patient must rest ; cold applications are to be used in the trau-
matic, and warm in the menstrual form. If abscess occur, it should be
opened ; or it may be evacuated by means of an aspirator. The opening
of the peritoneal sac for the purpose of replacing an irreducible healthy
ovary is condemned by Englisch. Of the cases in which extirpation
of a healthy irreducible ovary was performed, one half died of sub-
peritoneal inflammation and its results.
Sciatic hernia. — Dr. Marzolo of Padua has described the case of a
female who was first seen by him in 1847. She was then thirty years
old, and for ten years had noticed a small tumour in the right gluteal
fold, which disappeared on lying down, and again protruded and gra-
dually increased while she was erect. The patient had been pregnant
five times ; on four occasions she miscarried, and once bore a healthy
child at the full term. The hernia now formed a large swelling, the
base of which covered part of the nates, and reached as far as the tro-
chanter and the pubic arch. It was 60 centimetres in length, and 118
in its greatest and 80 in its smallest circumference. It apparently con-
tained a large part of the intestines, as the belly was retracted, the
abdominal wall lying in contact with the vertebral column. On lying
down or sitting, most of the hernial contents returned into the abdo-
men, the patient was accustomed to sit upon the hernia. Defsecation
and coitus were interfered with. The patient came under treatment
again in 1871. There was no great change in her condition; but the
hernia had now become quite irreducible, and at the lower part the per-
cussion sound was dull and fluctuation was distinctly felt. Marzolo
now made a puncture and drew ofi" nine quarts of fluid ; severe diar-
rhoea soon set in, and the patient died. A post-mortem examination
could not be made. (' Wien. Med. "Woehenschr.,' July 6, 1871.)
Intestinal ohstritction ; injection ; kneading ; cure. — Dr. Hilton Fagge
records the case of a man, set. 40, who was attacked with great pain in
the abdomen quickly followed by severe vomiting. This was Oct. 22,
1871, in the evening. He came under the care of Mr. Brookhouse
Oct. 23. His face had an anxious expression ; he was crying out with
pain, a little to the right of the median line of the epigastric region,
increased by pressure. On the fourth day Dr. Tagge saw him. The
vomited matters were not stercoraceous. On Oct. 28, the seventh day,
in the evening (that is after six days' strangulation, according to the
dates given, but five days according to the heading), a copious in-
jection was given and the abdomen was kneaded. The injection waa
repeated next day. The man recovered. Dr. Hilton Fagge remarks ;
294 REPORT ON SURGERY.
— " In this, as in so many other cases of intestinal obstruction, it wag
not possible to determine accurately the cause of the disease. The
history of the attack pointed to a sudden closure of the calibre of the
bowel, and probably to the small intestine as its seat ; while the fact
that mucus and blood were passed on the third day was in favour of the
existence of an intussusception, and of its having become strangulated
as soon as formed. The remarkable feature in the case, however, is the
success of the energetic treatment which Mr. Brookhouse adopted. It
can hardly be doubted that the life of the patient was saved by the
kneading of the belly carried out by his medical attendant, and so
satisfactory an issue in this case may well encourage other surgeons to
adopt a similar procedure. Tet it cannot be denied that such forcible
manipulation of the abdomen would, in many instances, involve great
risks of tearing through parts softened by inflammation, or even
sloughing, and might thus counteract the curative processes of nature.
It can scarcely be said that there was anything in the symptoms in Mr.
Brookhouse's case that indicated the special applicability of kneading ;
nor does the success of the treatment enable a more accurate diagnosis
as to the nature of the intestinal lesion to be given than had been given
before it was tried. The case still remains very obscure in this respect."
(' Lancet,' July 27, 1872, in.) A case is recorded which came under
the care of Mr. "Waren Tay, at the London Hospital. A man, set. 49, who
was apparently in good health, was seized while in the street, at five
o'clock in the morning, with acute pain in the epigastrium. He soon j
vomited and continued to do so. Thirty-six hours later the vomiting
became stercoraceous, and seven or eight hours later he was admitted.
He continued to vomit stercoraceous matter repeatedly ; he was in great
pain (referred to the right side and above the umbilicus), and appa-
rently in an urgent condition of collapse. No hernia could be ascer-
tained. There was no local swelling or tenderness to aid in the
formation of an accurate diagnosis. There was no history of any pre-
vious attack of any sort. Some sudden displacement or knotting ol
intestine seemed indicated. The man's symptoms were so urgent thai
the question of gastrotomiy had been entertained. It was not though!
he would live through the night. Three washhand basinfuls of injectioi
were thrown up, and then chloroform was given, the abdomen kneadedj
and the man was also inverted and shaken. When he recovered froi
the chloroform he said he was relieved. Owing to the urgency of th<
previous symptoms, a consultation was held a couple of hours later ; if
was then manifest, however, that he was much better; no furthei
vomiting occurred (save slightly once), and the man quickly and thoi
roughly recovered. The nature of the case did not admit of an]
diagnosis being made ; but the case is important from the urgency
the symptoms, which were so rapidly relieved. The enema visibly dij
tended the abdomen, and the obstruction could not have been in tht
large intestine. ('Med. Times and Gaz.,' Dec. 14, 1872.)
intestinal obstruction, — Mr. Bryant writes on this subject (' MedJ
Times and Gaz.,' March 16, 30, April 29). He details a numbei
of very interesting cases. Mr. Bryant relates cases in which he h£
performed lumbar colotomy, and remarks on the kind of cases adaptec
STRANGULATION OF INTESTINE WITHOUT VOMITING. 295
for this procedure ('Med. Times and G-az.,' May i8 and June i^,
1872.) Mr. Steele records cases ('Brit. Med. Journ.,' Sep. 7, 1872).
Dr. Taylor narrates a case in which a portion of the ileum was found
iu a knot, at the post-mortem, which might have been unravelled had an
operation been performed. A figure of the knot is given. (' Brit.
Med. Journ.,' July 29, 1871 ; Edin. Med. Journ.,' Aug. 1871, 126.)
Biliary concretion in the ileum causing intestinal obstruction. — Mr. Le Gros Clark
records a case and figures the concretion ('Med.-Chir. Trans./ Iv, i).
Cases of intestinal obstruction^ at the seat of a congenital constriction
of the gut, and at the point of departure of a diverticulum., probably the
remains of the omphalo-mesenteric duct, are recorded by Dr. Southey.
One patient was a lad, set. 16, the other was a girl, aet. 13 1-. (' Clin.
Soc. Trans.,' v, 159 and 162.)
Mr. Bell and I)r. Croom narrate the case of a man, about ^o years
of age, who was under care for obstruction of the bowels with peculiar
features. He was in good health and had never had any previous attack.
He lived from Eeb. 4th till Eeb. loth, suffering from obstinate obstruc-
tion without any nausea or vomiting during the whole time. The ab-
domen was swollen, on the whole, resonant on percussion. There
was no marked tenderness anywhere, but the pain was localised,
chiefly, in the right iliac fossa, rather above the position of the ileo-
caecal valve, and, at this spot, careful, deep pressure gave the sensa-
tion of several coils of intestine matted together and distended chiefly
with air. A tumour, which could not be moved out of its place, but
was as if moored to the back of the abdomen, could be felt. It was
lobulated and resonant. The diagnosis of a twist of the small in-
testine, probably quite close to the caecum, was made. An operation
was proposed, but the suggestion was not agreed to. After death
evidence of general peritonitis was found. In the right iliac fossa there
were several coils of small intestine matted together. A portion of one
coil had burst. For three inches from the iliac valve, the intestine was
absolutely contracted and empty up to a distinct twist, rather more
than half a turn, which evidently was the seat of the obstruction. The
points of diagnosis were arrived at by exclusion. The pain was not
sharp enough for gall-stone, nor in the right place. As the enemata
had passed well into the colon the seat|of obstruction was probably on
the right side ; secondly, the absence of vomiting made the ileum more
probable than the jejunum; and lastly, the tumour in the right iliac
fossa seemed probably ileum low down. Had it been higher up it
would have been more likely to have changed its position at times. There
was also a peculiar coiling, lobular movement to be felt in the afi'ected
portions of the intestine such as is described by Brinton. The ques-
tion of the pathology of the affection is entered into, whether the peri-
tonitis precedes the twist, or whether, more probably, the twist forming
accidentally first, the peritonitis occurs as a secondary condition. The
question of treatment is also discussed. After medical means have
been fully tried gastrotomy affords the only chance. In this case, the
coil could have been untwisted. Colotomy would not have been of any
use. Grreat relief had been afforded to the patient by tapping the
intestine and letting air out. (' Edin. Med. Journ./ May, 1872, 971.)
296 EEPORT ON SURGERY.
Intestinal ohstruction ; formation of artificial anus in small intestine.—^
Mr. McCarthy records a case of obstruction of the bowels caused by-
cancerous disease, in which he made an incision in the abdominal wall,
opened the first piece of intestine which presented and stitched it to
the edges of the wound. The patient lived for forty-eight days having
been much relieved by the operation. Death was caused immediately
by failure of the heart. The carcinoma had originated in the cardiac
end of the stomach and had involved the splenic flexure of the colon.
There was not the slightest evidence of peritonitis. Mr. McCarthy
remarks on the absence of peritonitis. It is stated by authorities to be
almost inevitable after such an operation. Another point of interest
was the fact of there being very fluid, but otherwise normal, faecal
matter in the portion of the bowel between the artificial anus and the
obstruction. It is also noteworthy that the patient recovered. (' Med.-
Chir. Trans.,' Iv, 267.)
Gastroto7ny for intestinal ohstruction. — Dr. Buchanan operated on a
young woman who had symptoms of acute intestinal obstruction, sue-
cessfully. The patient was 29 years of age, in good health. The
symptoms began with severe pain in the abdomen followed by vomiting.
On the third day, stercoraceous vomiting occurred. On the fourth day,
Dr. Buchanan saw the patient. The voice was husky ; her counte-
nance was anxious and pale ; the extremities were cold ; her pulse was
weak ; and she was restless and uneasy in whatever position she lay.
The abdomen was distended with flatus. The most careful examination
failed to detect any point which could be referred to as the seat of the
obstruction. An incision was made from the umbilicus downwards
for about four inches. As soon as the peritoneum was opened a quan-
tity of turbid serum flowed out and was collected, altogether about a
pint. It had very much the appearance of whey, with flocculi, like
pieces of curd, floating in it. It was very acrid, smarting the skin whea
it came in contact with the hands. The intestines were glued togetherj
and one coil was sharply bent on itself. The right hand was intrc
duced into the abdominal cavity and a thorough exploration madeJ
The intestine was removed from the pelvis with slight jerks to liberate
any portion possibly strangulated. An assistant kept the bowels froi
protruding from the abdominal cavity. The pelvis was sponged OutJ
The wound was secured with deep and superficial sutures. The patieni
did well afterwards. She had an attack of swelling of the left lower ex^
tremity resembling phlegmasia dolens. Dr. Buchanan alludes to case
of spontaneous recovery in intestinal obstruction, but remarks thai
there are few, if any, in which stercoraceous vomiting has gone on un«
interruptedly for more than forty-eight hours which have not terminatec^
fatally. The cause of the stercoraceous vomiting he supposes to have
been the twist of the intestine held down by adhesions or else the acric
peritoneal fluid. Mr. Hancock, in 1 848, performed a somewhat similai
operation and let out a quanity of greenish, flocculent serum witl
decided relief of the symptoms and ultimate cure of the patient. Ii
a paper which Mr. Hancock read before the Medical Society, he advo-
cated opening the peritoneum in other cases of peritonitis in " casea
where the eflTused fluid destroys rather by its character than its quani
GASTROTOMY FOR INTESTINAL OBSTRUCTION. 297
tity. . . . where the sinking and typhoid symptoms depend on the pre-
sence of the offensive fluid in the peritoneum." Dr. Buchanan, after
the experience o£ his own case, was inclined to make the same sugges-
tion before he became aware that such had already been done. (' Lancet,'
June lo, 1871, 777.)
Mr. Hulke publishes a clinical lecture on the following case : — A
man, set. 32, in good health, after a hearty meal of fish, was seized with
pain in the belly— he thought it colic — shortly followed by vomiting.
The pain left him, but the sickness continued. On the tenth day Mr.
Plulke found his belly uniformly swollen and hard, so hard that no rea-
sonable pressure dimpled it. He often vomited a pea-soup-like fluid
having a faecal smell, which gushed copiously from his mouth with but
little heaving. The only pain and tenderness in the belly, and this was
very slight, he referred to a spot rather above and to the right of the
navel. His pulse was small, quick and weak. By a process of
exclusion well described by Mr. Hulke, " it became likely that the
obstacle was either a twist, or the entanglement of a piece of small
intestine in a hole in the mesentery or omentum, or an adventitious,
constricting band. A negative reply to repeated questions whether he
had any previous abdominal ailment weighed rather against the suppo-
sition of a band, and favoured volvulus or entanglement with strangu-
lation, because an adventitious band necessitated a previous peritonitis,
and of this there was no history ; but then a very limited and sub-acute
peritonitis might have passed unnoticed ; it might have been, so to say,
latent, just as the post-mortem theatre teaches us daily with regard to
pleurisy and periorchitis, revealing adhesions ot the costal and pulmo-
nary pleurae, and of the testis and parietal tunica vaginalis in the bodies
of persons in whom during life these maladies had not been suspected."
The abdomen was opened by a cut in the median line midway between
the navel and pubes, through which the hand was passed and an empty
piece of small intestine sought for, by tracing which Mr. Hulke hoped
to be led to the obstruction. The distension of the small intestines
caused great difficulty. Many feet of intestine had to be drawn out
and returned again. The obstacle remained undiscovered. The howel
was tapped with a very fine trocar. Much stinking gas hissed out, but
only a few inches of bowel collapsed, and on pulling out the canula
thin pea-soup-like faeces oozed through the prick. An attempt to tie
up the opening resulted in its becoming larger. ^\^q punctured gut was
slit up and stitched securely to the skin : a large panful of fluid faeces
immediately ran out. The relief was prompt and remarkable ; the
vomiting ceased and the belly became soft ; he had no pain, and his
temperature was not raised; this, however, was not conclusive as to the
absence of peritonitis. Fifty-three hours after the operation the
patient died exhausted. At the post-mortem the intestine and peri-
toneum were found inflamed ; the sigmoid flexure of the colon had a
very long and lax meso-colon, which allowed it to stretch in an angular
loop across the pelvis from left to right. At the apex of the loop, a
long epiplooic appendage, issuing from the free border of the gut, gave
attachment to one end of a thin, glistening, tendinous band, the other
^nd of which crossed and tightly tied dowji the ileup^ Jibout three inches
298 REPORT ON SURGERY.
distant from the csecum, and lost itself on the peritoneal lining of the
pelvis near the right sciatic notch. The band might have been easily
reached and safely cut had its seat been discovered during the ex-
ploration. The lessons drawn from the case are, that " notwith-
standing its fatal issue, the ascertained practicability of cutting the con-
stricting band is an encouragement to operate again under similar
circumstances. Next, the acute and general enteritis and the ulceration
at the constriction, already present when the operation was done, show
how much danger grows with delay. Again, we learn that the plan of
puncturing inilated intestines for the purpose of letting off gas is safe
only when the gut does not also contain fluid faeces; and when,
unspoiled by inflammation, its muscular coats can shrink and close the
puncture, assisted by a slight sliding of the mucosa ; but where the gut
is damaged by inflammation, and contains also fluid faeces as well as
gas, tbe hindrance to the search caused by tight packing of the
inflated intestine, will be more safely dealt with by a freer section of
the walls than by puncture. We are taught, also, that fixed tenderness
and pain are very uncertain guides to the seat of an obstruction, for
here that situation pointed to the upper end of the small intestine,
while the obstruction was close to the caecum. Lastly, in traumatic
peritonitis we may expect a low temperature, and are not to be thrown
off our guard by the absence of a high one."
Mr. Thomas Annandale narrates a case in which he performed
gastrotomy on the fourth day of obstruction of the bowels, and divided
a band of lymph. T'm patient died about eighteen hours after the
operation. He was r man aged 5^, who was taken suddenly with
severe pain in the abdomen. Faecal vomiting rapidly set in, showing
that the obstruction was complete. Mr. Annandale sums up (i) when
the symptoms of sudden and complete intestinal obstruction are
present, and the ordinary means of treatment have failed to give relief,
the operation of gastrotomy is justifiable and advisable. (2) That the
operation should not, if possible, be delayed beyond forty-eight or
thirty-six hours after the first symptoms have appeared. (3) That the
abdomen should be opened in the middle line ; and, that during the
operation and after it every precaution should be taken to lessen the
risks of peritonitis. (4) That when the abdominal cavity is opened
the best guide to the seat of obstruction is the contracted or dilated
condition of a portion of the intestine. (5) That if the intestine be
gangrenous, or the obstruction not removable, its canal should be
opened as near the obstruction as possible, and an artificial anus
established. ('Edin. Med. Journ.,' Feb. 1871.)
In the 'Brit. Med, Jour.,' March 23, 1872, is an abstract of a
case recorded in ' Lo Sperimentale' for March, 1872. The patient was
a man aged 2^, who had double inguinal hernia. Synjptoms of internal
strangulation came on while both hernise were reducible. On examin-
ing one, by operation, and passing the finger into the abdominal cavity
a knuckle of intestine was found tightly strangulated by a hard fibrous
band. This was divided. The patient left the hospital^ cured, in a
month.
Opening the stomach for cancer. — Three cases in which the stomach
OPENING THE STOMACH — COLOTOMYj ETC. 299
was opened for disease are related by Mr. Smith and Mr. MacCormae:
In the case under the care of Mr. Smith the patient lived seven days.
In one of Mr. MacCormac's cases the patient lived six days. It seems
doubtful whether in any case yet recorded the operation has prolonged
life. It seems to relieve suffering. In the cases which have survived
for three days, peritonitis has always been present. (' Clin. Soc. Trans.,'
Vol. v., 236 and 242). Dr. Lowe relates the case of a woman suffer-
ing from scirrhous cancer of the oesophagus, in which he opened the
stomach. Considerable relief followed. She died on the third day
rather suddenly (about sixty hours after the operation). ('Lancet,'
July 22, 1871.) A case in which Dr. Troup opened the stomach of
a man suffering from cancer is noted in'Edin. Med. Journ.,' July
1872, 36. The patient lived for three days afterwards and was greatly
relieved.
Wound of abdomen with injury of the intestine ; recovery. — The wound of the
abdomen was a lacerated one ; omentum protruded and the peritoneal coat of the
jejunum was damaged. Mr. Horton ('Brit. Med. Journ.,' Sept. 28, 1872).
Becto-vesical Ustula treated ly colotomy. — Mr. Bryant records two
cases. In 1869 he recorded another case (see 'Eetrospect '). His
present cases were very successful. The ulcerated action which caused
the fistula was in all probability of a simple nature, and commenced in
the rectum. In both the relief afforded was complete. The ulcera-
tive action ceased if it did not heal. The escape of urine into the
rectum showed that the fistula remained open, but faeces did not
escape into the bladder. The cases corroborate remarks made by Mr.
Holmes in connection with a similar case and noted in a previous
'Eetrospect.' ('Clin. Soc. Trans.,' v. 131.)
Colotomy. — Cases of colotomy for stricture of the rectum under the
care of Mr. Hulke will be found noted in * Lancet,' July 20 and fol-
lowing nos., 1872.
Imperforate Anus. — Dr. A. Stern relates in the 'Wiener Med.
Wochenschr.,' No. 21, 1872, a case of successful operation for im-
perforate anus in a newly born child. No bulging could be perceived
in the perinaDum when the infant cried. An incision was made, and
the blind end of the rectum was reached at the depth of an inch and
a half. It was laid open, giving exit to a quantity of meconium : and
the edges were brought down and fastened by sutures to the external
skin. The hssmorrhage was very slight. The wound was dressed witli
lead lotion and carbolic acid, and healed by granulation. The child
was in good health six weeks after the operation.
Stricture of the rectum. — Cases of stricture of the rectum treated in
various ways, one of them by electrolysis, are narrated by Dr. White-
head ('Am. Jour. Med. Sci.,' July, 1872, 114). He also records a
case of fibrous stricture of the rectum in a married woman, aged 38,
which he treated with deep incisions and gradual dilatation afterwards.
The dilatation was effected by means of an india-rubber, conical bag
into which water was injected through a pipe provided with a stop-
cock. The water is used warm. To prevent the sphincter being too
much pressed on, the pipe which is embraced by the sphincter should be
300 EEPORT ON SURGERY.
at least an inch and an quarter in length. The pipe should also be pro-
vided with an india-rubber flange to prevent its passing too far in. The
pipe terminates inside the bag in a sort of rose which is surmounted
by a delicate, flexible, hard-rubber probe four inches long, and to which
the capote, or bag, is attached superiorly. The probe is screwed into
the pipe at its bulbous end and may be replaced by others of difi'erent
lengths and flexibility. He alludes to opinions of authors on the
rectum in relation to syphilitic stricture and considers that sufficient
attention has not been called to this form of stricture. The seat of
the stricture is at the junction of the dilated part with the sphincter,
about one inch and a half from the anus. The patients, with very rare
exceptions, are women. Fissures and fistula3 in ano and in perineo, or
fistulous tracts opening into the labia, sometimes complicate stricture
of the rectum, and condylomata about the anus are frequent. The
stricture may be partly fibrous, tight and unyielding, the fibrous con-
striction being from half an inch to two thirds of an inch in extent, or
the stricture, while forming, may produce the sensation to the finger
of irregular elevations or of crescentic folds which readily break down
from pressure of the finger. The intestine sometimes four or five
inches above the stricture is ulcerated and the extensively ulcerated
surface is terminated superiorly by a festooned border. There is con-
siderable purulent secretion and the contraction of the sphincter
favours its accumulation in the ampulla. It lasts for months or years,
before the formation of a stricture. The mucous membrane may be
BO softened that a bougie easily penetrates it and may enter the
peritoneal cavity. If the ulceration is low down pain on defaecation
is complained of, if higher up there may be no pain. The patients
are generally between 17 and 40 years of age. Owing to the anatomical
relations of the ano-genital region of the female, the chancrous matter
of the syphilitic sores, nearly always present on the vulva, infects this
region, occasioning rhagades or fissures of the anus. The ulceration
extends to the ampulla of the rectum, where it remains long after the
healing of the external sores and on cicatrising causes a tight, fibrous
stricture. The stricture is lower down than in cancerous disease. An
antisyphilitic treatment is worse than useless. It does harm by de-
bilitating. When the stricture is fibrous, it should be very treely
divided with the knife or scissors and kept properly dilated. Chloride
of zinc or carbolic acid sufficiently diluted should be applied to the
ulcerated part above. ('Am. Journ. Med. Sciences,' Jan. 187 1,
Memoval of a portion of lone from the rectal fossa. Dr. Thompson
relates the case of a man, aged 70, who, twenty years previously, had
begun to suflfer from pains in the back and pelvis. After five years
he consulted a surgeon, who could not find anything the matter.
When he came under Dr. Thompson's care he complained of " piles.'*
On examination an almost raw surface was found extending two inches
round the anus and a zone of erysipelatous blush four inches in
breadth. On the left side, about an inch from the anus, there was a
small opening, through which appeared a small black point. This was
geized and drawn out by slightly enlarging the orifice and proved to
bvARtotoMf. sol
be a piece of bone tbree quarters of an inch square. No piles were
found. A probe passed through the opening entered the rectum a
short distance above the sphincter, and a considerable cavity remained
Avhere the bone had rested. The following day two other small pieces
oi:' bone were removed. The fistula was subsequently slit up. The
patient declared that he felt more comfortable than he had done for
twenty years. He regained his former activity. The pieces of bone
were examined and were possibly portions of the scapula of a rabbit.
The patient thought it had been "in him all those years," if so, it must
have lodged in some part of the. intestine, ulcerated its way out and
gradually reached the pelvic opening. There was no history of any
injury to the spine or sacrum. (' Lancet,' Aug. 26, 1871, 289.)
" Ovariotomy. — Mr. Alcock oj)erated on a child three years old. The
tumour was universally adherent. The patient died at the end of
forty-eight hours. ('Lancet,' Dec. 16, 1871, 850.)
Dr. W. Barker has operated on a child aged six years and eight
months. The case was one of dermoid cyst of the right ovary. The
patient recovered. (' Philadel. Med. Times,' Nov. i, 1871, and 'Am.
Journ. Med. Sci.,' Jan. 1872, 285.)
A case of ovarian disease on which Dr. Newman operated, using
antiseptic ligatures and dressing, is narrated in the ' Med. Times and
Graz.,' Feb. 17, 1872, 184. Haemorrhage occurred into the peritoneal
cavity and the wound was opened (under carbolic spray) on the tenth
day. About three ounces of " dark coloured and slightly oftensive
blood" was let out. The patient recovered. Dr. Newman regretted
he had not used a clamp instead of the catgut ligature.
Mr. Spencer Wells publishes further tables of hospital cases in the
'Med. Times and Gazette,' Feb. 18 and March 25, 1871, 187 and 337.
A fourth series of 100 cases of ovariotomy are recorded by Mr. Wells
in the ' Med.-Chir. Trans.,' liv, 263. Of the first too cases, 34 died ; of
the second 100, 28 ; of the third 100, 23 ; of the fourth, 22. Eemarks
are added on the diagnosis of uterine from ovarian tumours. Mr.
Spencer Wells has contributed a fifth series of 100 cases of ovariotomy,
with remarks on the results of 500 cases to the ' Med. Chir. Soc.,' Nov.
26, 1872 (abstracts in 'Med. Journ.'). In the ' Brit. Med. Journ.,'
May 18, 1872, is a short editorial, grouping together various statistics
of ovariotomy .
A case of unilocular ovarian tumour, with pelvic and intestinal
adhesions, operated on successfully by Dr. W. L. Atlee, is given. In a
second case of multilocular tumour, with extensive adhesions, death
occurred. ('Am. Journ. Med. Sci.,' April, 1872, 389.)
Dr. W. L. Atlee records Jive cases of ovariotomy. Three patients
recovered and two died. In one of the successful cases there were
extensive adhesions, in the two others there were none. In one
case there was a pervious urachus. In each of the fatal cases there
were extensive adhesions. All were multilocular. (' Am. Journ. Med.
Sci.,' July, 1872, 127.) Dr. W. L, Atlee records further cases (Oct.
1 87 1, 409). In one in which recovery occurred a ligature had been tied
round a detached portion of peritoneum. When this came away an
artificial anus was found to exist. This gradually closed. During its
302 UEPOUT ON SURGERY.
existence the bowels acted regularly. In two other cases death
followed.
Ten cases of ovarian disease operated on at the Hospital for "Women
are detailed in the 'Lancet,' 1871 (March 2, 9, and 16). In all the
cases the pedicle was tied and dropped in. A double ligature was
passed through the centre of the pedicle and tied on each side, and then
one of the ligatures encircled the whole pedicle and was tied again.
The abdominal cavity was always thoroughly cleansed out with sponges
on holders, wrung out in warm water before the sutures were inserted.
When the wound was brought together a broad strip of strapping was
placed across the abdomen tightly from hip to liip, and a large linseed-
meal poultice with a drachm of laudanum was applied and changed
every four or six hours and continued for six or seven days. Seven of
the patients recovered, three died.
Dr. W. F. Atlee records a successful case of ovariotomy, and also a
case in which he successfully removed an enlarged uterus lohicJi was
considered to he an ovarian tumour. Dr. W. L. Atlee's clamp was used
in each instance. ('Am. Journ. Med. Sciences,' July, 1871, "i^Ci^
Dr. Packard relates a somewhat similar case. The tumour was not
removed. The patient died (Oct. 1871,433). (See previous ' Bien.
Eetrosp.' also.)
Mr. Keith records a tliird series of ^o cases. Of the last 100 cases
there have been 84 recoveries. Eight of the last 50 patients died : 2
from obstructed intestine, i from acute septicasmia, and 5 from perito-
nitis. In 2 of these the adhesions were considerable, in i moderate,
while, in 5, the tumours were non-adherent. In 6 of the fatal cases,
the clamp was used ; in i, catgut ligatures to one ovary and clamp to
the other ; in another the long ligature of Dr. Clay. In nearly one
third of the cautery cases, bleeding took place from large vessels and
ligatures were necessary. (' Lancet,' Nov. 16, 1872.)
Treatment of suppurating ovarian cysts and pelvic adhesions in
ovariotomy. — Mr. Holmes remarks on a case of ovarian disease in which
after a preliminary tapping, apparently revealing a single cyst without
complications, suppuration of the cyst ensued. The patient com-
plained of constant pain in the right iliac fossa, and became very
emaciated. She was sent to a convalescent home at Wimbledon.
When she had improved as much as she was likely to do, Mr. Holmes
operated. A large quantity of pus was let out. Many adhesions
were found, but all were separated till the brim of the pelvis was reached;
here there were very firm adhesions. The remains of the cyst were
pulled out as far as possible, the intestines returned into the belly
and the lower portion of the cyst clamped. The wound was united ;
next day there was a little oozing of blood from the walls of the cyst,
which were nearly half an inch thick. A strong ligature was passed
through the mass above the clamp, and the exposed edges of the cyst
were seared with the actu'al cautery. The clamp was removed on the
third day. The sloughing stump gradually receded and tympanites
became developed. She recovered gradually, but completely.
Mr. Holmes remarks, " The internal inflammation which leads to
suppuration will, I should suppose, usually, if not always, be accom-
SUPPURATING OVARIAN CYSTS^ ETC. 303
panied by external peritoneal inflammation. The first question we
have to decide is whether it is possible to distinguish the symptoms
of suppuration from those of peritonitis. When occurring in the acute
form after the operation of tapping, I believe the diagnosis may be
made with moderate certainty, from the rapid refilling of the cyst,
with rigors, sweats, high temperature and general fever. But few
such cases would, I imagine, afford any opportunity for surgical treat-
ment. Mr. Spencer Wells has recorded one successful case of ovario-
tomy during acute suppuration in a lecture in the ' Med. Times and
G-azette.' It is more important in a surgical point of view to inquire
into the symptoms and treatment of that chronic form of suppuration
which is more common and more tractable that the former." Quota-
tions from authors on this subject are given. Mr. Holmes says " I
much regret that the thermometer was not used in the case I have
related, but the heat and dryness of the skin were certainly not present,
nor was the tongue of the character described by Mr. Wells. In fact,
the patient was so free from any indication of general fever that it
never occurred to me to take thermometical observations, nor is it
likely that a very elevated temperature could have coexisted with
symptoms otherwise so ill-defined. The sickness which came on shortly
after the abdominal pain and tenderness was of no value as a diagnostic
sign, since equally troublesome sickness occurred before the tumour
had been meddled with in any way, and when the fluid was certainly
not purulent. No rigors were observed at the time, and on question-
ing the patient afterwards she said she had never had any. There
remains the rapid and extreme emaciation combined with a peculiarly
feeble pulse. It is difficult to convey in words an idea of the strange
oppressed pulse in this patient ; it really seems to me that this ema-
ciation and this peculiar pulse were the only general symptoms which
ought to have attracted our observation, and on which a diagnosis could
in future be founded. But I would also call attention to the fact of the
patient having complained of acute tenderness when the cyst was pressed
upon in various parts." " I think I might say that in another case
in which this general tenderness to pressure coincided with symptoms
of low peritonitis, with rapid emaciation otherwise unaccounted for,
and with a very feeble and somewhat rapid pulse, I should be disposed
to conjecture the occurrence of chronic suppuration within the cyst,
and that this conjecture would be confirmed if the rise of temperature,
mentioned by Mr. Wells, were observed." W^hat is the surgical in-
dication? Mr. Bryant and Mr. Wells are quoted. Mr. Holmes
thinks the best plan is at least to attempt the operation of removal of
the suppurating cyst. The question of opening the cyst freely and
attaching it to the abdominal wall in case the adhesions are found
invincible, must be kept before the surgeon's mind. " Another in-
teresting question in ovariotomy, illustrated by this case, is how to
manage cysts which are so adherent in the pelvis that they cannot be
pulled out without too much danger. In this instance any persistent
attempt to have dissected or torn away the mass from the pelvic outlet
would probably have ended in laceration of the ureters or great veins,
and might, after all, have been futile. The alternatives are to pull the
oOi feEtOlit OK SXJUGfiiii'.
cyst as far as possible out of the abdomen and apply a clamp to its
neck ; or to apply a clamp temporarily, cut away the cyst, sear the
cut edges with the cautery and return the mass into the abdomen ; or
instead of the cautery to use ligatures for the purpose of restraining
haemorrhage from the cut edges of the cyst ; or, finally to stitch the
edges of the cyst to the wound in the abdomen and leave the cavity of
the cyst exposed. I have no doubt of the superiority of the first
method when it is practicable, that is, when the neck of the cyst is
thin enough to be embraced in the clamp. The internal surface of the
cyst is thus brought into contact and may adhere and obliterate the
cavity, as seems to have occurred in our patient. If this does not
take place, at any rate the resulting inflammation during the healing of
the wound will probably exclude the mass from the peritoneal cavity,
just as effectually as if the edges were stitched to the wound ; whilst
the plan is free from the dangers incurred by leaving the remains of a
suppurating cyst free in the pelvis, and those resulting from the
irritation of ligatures in the pelvic cavity." Mr. Wells relates a case
in which the ligatures set up mischief. " The case before us was an
example of complete, and, I must allow, unexpected success. I ex-
pected that when the clamp and pins had been removed a suppurating
sinus would be left proceeding from the interior of the cyst, which
would only gradually dry up, if at all. Such a result would not, how-
ever, be inconsistent with good health and activity." At the end of a
year the patient remained quite well. The cicatrix was quite sound
and free from irritation, with no perceptible swelling beneath it.
(*Med. Chir. Trans,,' Iv, 195.)
Feritoneal inflammatory cyst resemhling an ovarian tumour. — Dr.
"W. L. Atlee records the case of a married woman, who at her last con-
finement, five months previously, had been discovered to suffer from a
tumour on the right side of the uterus. Some days after childbirth
she was seized with rigors followed by fever and supposed peritonitis,
and a rapid development of the tumour, with great constitutional dis-
turbance and emaciation. When Dr. Atlee saw the patient she was
larger than a woman at full term. Notwithstanding the case was very
unfavorable for operation, in consequence of the acuteness of the original
attack, the rapidity of the development, the pelvic complication, the dis-
placement of the uterus, and the general condition of the patient, it was
determined to make an exploratory operation, as it was believed at the
time that the tumour was ovarian. An incision was made, and a cyst
found, which was not oVarian, but came from the pelvis. The cyst was
laid open, and fifteen pints of greenish pus and numerous large, stringy
clots of fibrinous matter let out. The patient died on the third day.
" After the operation T supposed that the original tumour was a pedun-
culated, uterine fibroid tumour, that inflammation had supervened, and
that an abscess had formed within it, which had caused it to partake
of the characteristic signs of a unilocular ovarian cyst. Subsequent
experience, however, satisfied me that this last opinion was erroneous,
and that the tumour originated in the pelvis through inflammation
localised in the peritoneum, agglutinating the serous surfaces, and
forming pockets wherein to receive the resulting fluids of this inflamma-
OVARIOTOMY — CLAMPS, ETC. 305
tlon, forming what I denominate, in my book on the diagnosis of
ovarian tumours, vl peritoneal inflammatory cyst.''^ ('Am. Journ. Med.
Sci.; July, 1872, 133.)
Large ovarian cyst; tapping; inflammation; great prostration;
ovariotomy ; recovery. — Mr. John Clay records the case of a patient
who was in extreme prostration resulting from inflammation of an
ovarian cyst after tapping, when he performed ovariotomy with success.
('Lancet,' Sept. 7, 1872.)
Cases of ovariotomy, under the care of Dr. "W. L. Atlee, are given.
('Am. Journ. Med. Sci.,' Jan. 1872, 113.) In one case the cyst was full
of pus, and was everywhere adherent. Neither clamp nor ligature was
used, the vessels of the pedicle having been destroyed by inflammation.
A second case was one of cyst of the broad ligament. A third was mul-
tilocular with extensive omental adhesions. All the patients recovered.
A case is also recorded which was under the care of Dr. John L. Atlee.
The cyst was multilocular, there were slight adhesions, and the patient
recovered, (p. 118.)
Wound of intestine during ovariotomy, with recovery. — Mr. C. Heath
records a case in which he operated for ovarian disease, and, in enlarging
the abdominal wound with scissors, cut a piece of intestine which became
entangled between the blades. He stitched the intestine to the ab-
dominal wound, and so formed an artificial anus. After some time he
applied the actual cautery to induce the opening to contract. It never
quite closed ; but the patient became fat, and a pad and belt sufficed
to prevent all extrusion of faecal matter. Mr. Heath remarks that he
believes no similar case is on record, and it will serve as a warning to
surgeons to be on their guard against adherent intestine. If such an
accident should occur he thinks the plan he adopted the best which
could be carried out. (' Clin. Soc. Trans.,' v, 3^.)
New clamps, ^c. — Dr. W. L. Atlee describes and figures a new
clamp, constructed so as to ensure a parallel grip, and admitting adap-
tation to a narrow or wide pedicle. (' Amer. Journ. Med. Sciences,'
April, 1 87 1, 370.) At p. 398 of the same journal he narrates seven
cases of ovariotomy. Two of the patients recovered, five died. Purther
cases are given July, 1871, 128. They are three in number. The
patients recovered, but in one, the tumour was not removed.
Dr. Dawson has invented a new clamp. It is oval. One limb lifts
away from the other, the pedicle is included, the limb fixed, and then
an inner V-shaped piece is screwed down on the pedicle. This may be
cut through with the clamp if desired. (' Am. Journ. of Obst,,' Aug.
1871, quoted 'Am. Journ. Med. Sciences,' Oct. 1871, 583.)
Division of pedicle in ovariotomy. — Dr. Macleod, of Glasgow, suggests
twisting off" the pedicle in ovariotomy, and returning the stump wholly
within the abdomen. He uses strong forceps with stirrup-shaped
blades, the straight ends answering to the straight cross-bar of the
stirrup fit into one another when closed. The pedicle is grasped with
these, then the tumour is cut off at a like distance from the forceps,
and the cut extremity seized by another pair of forceps, and slowly
twisted ofi". In one case in which he tried this plan it succeeded per-
fectly. There was no hsemorrhage. He returned the stump within
20
306 REPORT ON SURGERY.
the abdomen and closed the wound. The patient made a rapid
recovery. Pigures of the forceps are given. (' Lancet,' Jan. 28,
1871, 108.)
Dr. Beebe records cases in which he severed the pedicle gradually,
and twisted each vessel as it bled, afterwards returning the stump into
the abdomen, and closing the wound carefully. Five cases in succes-
sion treated in this way recovered. Also another in which he applied
a single catgut ligature to the pedicle, and returned the stump, after
cutting away the tumour, within the abdomen. (' Am. Journ. Med.
Sciences,' April, 187 1, 3^3.) See also Dr. Nott's rectilinear icraseur.
Ccesarean section. — Dr. Philip Poster records a case in which he
performed Csesarean section successfully, as far as the mother was
concerned. ('Lancet,' June i, 1872, 753.)
Dr. Harris has collected cases of Csesarean section performed in the
United States, and tabulated them. They are seventeen in number.
Twelve of the women recovered, and fourteen of the children were
saved. The operations " were performed during or at the close of the
first day of labour, showing the value of timely surgical interference.
In all of the cases but one the child was removed alive." (' Am.
Journ. Med. Sci.,' July, 1872, 290, from * Am. Journ. Obstet.')
Vaccino-sypJiilis, — A case was brought before the Clinical Society by
Mr. Thomas Smith ('Trans.,' iv, ^^). Subsequently two series of cases
were brought before the Medico- Chirurgical Society by Mr. Hutchin-
son, and were reported on by a Committee. First series, synopsis : —
Twelve persons, mostly young adults, vaccinated from a healthy-looking
child. Satisfactory progress of the vaccination in all. Indurated
chancres on the arms of ten of the vaccinated in the eighth week.
Treatment by mercury in all. Eapid disappearance of the primary
sores. Constitutional symptoms in four of the patients five months
after the vaccination. The vaccinifer showing condylomata at the age
of six months. Second series, synopsis : — Unquestionable symptoms of
constitutional syphilis in nine children who had been vaccinated from
the same patient. Suspicious symptoms in six others, and entire
escape of a certain number. Yaccinifer a fine healthy-looking child, but
with slight, local symptoms, indicative of inherited syphilis. (' Med.-
Chir. Trans.,' liv, 317.)
Reinfection with constitutional syphilis. — H. Kobner, in the ' Berliner
Klin. Wochenschr.,' No. 46, 1872, remarks that Eicord had asserted
that syphilis can be contracted once only during life ; a new infection
cannot take place. This doctrine has been generally accepted, espe-
cially by the dualists ; but Kobner calls it in question. He relates a
number of cases of repeated infection which he has observed, among
which is the following: — A man, set. 40, had, in May, 1866, a sore on
the penis, roseola, and sore throat, for which he was treated with mer-
cury ; in November, 1868, he had syphilitic sarcocele on the right side,
and a node on the manubrium sterni. He was now treated by Kobner
with iodide of potassium and mercurial ointment to the scrotum, and
at the end of the year was able to resume his work. During the next two
years he sufiered occasionally from pains in the limbs and sternum, for
the relief of which he took iodide of potassium, but did not seek medical
BONE DISEASE IN CONGENITAL SYPHILIS. 30 7
advice. The patient's wife was treated by Kobner, in the spring of
1867, for tubercular and ulcerative syphilides of the limbs. In Octo-
ber, 187 1, the male patient had a very indurated shallow sore, with
sharply defined edges, on the glans penis ; the affection of the sternum
also returned, and the right testis became enlarged, and in parts very
much indurated. The induration on the penis disappeared in six weeks
under the use of calomel ointment and iodide of potassium, the other
symptoms remaining unchanged. The patient remained under observa-
tion eleven months, during which time he was treated for acute nephritis
and symptoms of spinal irritation ; no further symptoms were observed
and no change was noticed in the residual symptoms of the first attack
of syphilis. Kobner repudiates the idea that the induration ob-
served on the penis was the result of a gummatous deposit, and calls to
mind a number of instances in which several infections have been alleged
to have taken place after the complete removal of all the symptoms of
the first attack of syphilis. In 45 cases of repeated infection the only
symptom, in 22, was indurated chancre ; in 23, constitutional symptoms
followed; these were severe in one case only. The constitutional
affection was removed in the course of about eight weeks by appropriate
treatment ; and, except in one case, relapse did not occur. Kobner
arrives at the following conclusions: — (i) Constitutional syphilis is
perfectly curable, for it is only when the disease has been completely
removed that the system becomes liable to infection, as in a healthy
person. (2) Many inveterate, so-called tertiary affections, such as sar-
cocele and exostosis, are only local products or remains of an attack of
syphilis that has run its course, and are not to be regarded as signs
that the whole system is still infected. Parents with tertiary products
of this kind may beget healthy children. (3) In more than two thirds
of all the cases observed, the cure of the first attack of syphilis was
effected by mercury, used sometimes in the form of inunction, but in
most instances given internally.
Bone disease in hereditary syphilis. — G. Wegner has published some
interesting observations on this subject in ' Virchow's Archiv.' He
has examined forty children affected with intra-uterine syphilis, which
were either still-born or died soon after birth. In almost all the cases
Wegner found pathological changes in the bones in the forms of
ossifying periostitis, and of a peculiar disease of the bone at the point
of transition from the diaphysis to epiphysial cartilage. This last-
named disease was found in three forms, which "Wegner regards as
three stages of the same affection. In the first, between the cartilage
and the soft spongy bone is found a layer about two millimetres in
thickness, shining, sometimes with a level surface, sometimes bulging.
He believes it to be the result of increased proliferation of the cartilage-
cells, with retardation or arrest of the conversion of cartilage into bone.
In the second stage this layer has become doubled in thickness ; there
is considerable proliferation of the epiphysial cartilage-cells ; together
with progressive hardening and calcification of the intercellular sub-
stance and cells near the upper surface of the joint, and some evident
retardation in the neighbourhood of the spongy bone-substance of the
ossification of the cartilage. The third stage presents the following
SO^ UEPOET ON SURGERY.
appearances at the point of transition from the diaphysis to the epi-
physial cartilage. There is first a layer of hyaline cartilage, then comes
an indented layer of mortar-like substance about four centimetres in
thickness, and, finally there is a soft, pus-coloured layer, sometimes
irregular, defined at the upper part, which gradually passes into the
diaphysis. These three stages may be observed in different bones of
the same individual. Wegner regards the disease as an irritative
osteochondritis arising from syphilitic condition of the blood. The
long bones, and the epiphyses of those which contribute most to growth,
were specially affected. Along with these changes in the bones, fatty
degeneration of the cells and vessels of the medulla is often found in
syphilitic children, the marrow assuming a reddish-yellow or light
yellow instead of a red colour. (' Wiener Med. Wochenschr.,' No.
8, 1871.)
Dr. Taylor's essay (reprinted from ' Am. Journ. Syph. and Derm.,'
Jan. 1 871) on dactylitis syphilitica, that is on late syphilitic affections
of the fingers and toes, is a useful contribution to our knowledge of this
rare form of disease, which has been generally overlooked by writers on
syphilis. He has added to several published cases two that came
under his own observation and has constructed a short, but valuable,
essay. The disease consists of gummy infiltration of the subcutaneous
connective tissue, the ligaments, periosteum, and bones of the pha-
langes. By this morbid process, irregular enlargements are produced
in both fingers and toes, sometimes forming rounded swellings of the
bone and periosteum near the first phalangeal articulation, which
strongly resemble enchondromatous tumours. In other instances the
enlargement spreads chiefly in the sheaths of the tendons and connec-
tive tissue, forming a dull, red, brawny thickening of the whole digit.
These affections yield readily to specific remedies. The essay contains
all the cases hitherto recorded of this peculiar affection and forms an
important contribution to syphilitic pathology. (' Med.-Chir. Review,'
July, 1 87 1, 129.)
Subcutaneous injections of mercury in sypTiilis. — Dr. Sigmund, of
Vienna, writes on this subject in the (' Wien. Med. Wochenschr.' for
Sept. 9, 1 87 1.) He first examines the disadvantages which, accord-
ing to the opponents of the proceeding, attend it ; viz. the formation
of subcutaneous deposits ; inflammation, abscess, and their results ;
the pain attending the process of injection ; the difficulties of the pro-
cess ; the disturbance which it produces in the circulatory and respi-
ratory systems ; stomatitis and salivation ; and, finally, the small
amount of success attending subcutaneous injections as compared with
other plans of treatment.
The formation of subcutaneous infiltration at the seat of injection
no doubt occurs ; but, under rest and care of the affected parts, com-
plete absorption of the deposited material gradually takes place. The
occurrence of inflammation and abscess is, no doubt, very troublesome
and interferes with the cure ; but it depends entirely on the manner in
which the injection is made, on the strength of the solution used, and
on the management of the patient after the operation. Sigmund has
MERCURIAL INJECTIONS IN SYPHILIS. 309
used subcutaneous injections in more than 200 cases of syphilis in
hospital and in private practice, and has twice only met with abscess as
a result. The patients were of both sexes, of various ages and con-
stitutions, and affected with syphilis in very various stages. Some
patients had as many as thirty injections ; usually one daily, sometimes
one every second or third day. The parts chosen for injection were
generally the trunk, sometimes the arms, care being taken to avoid
parts that were liable to be lain upon, or to be subjected to movement
or pressure. The process of injection was performed with great care,
and the patients were required to protect the parts well and keep
them at rest. The solution used in almost all the cases was that re-
commended by Lewin — four grains of bichloride of mercury in an
ounce of distilled water. If patients are allowed to go heedlessly to
their ordinary occupations immediately, or two or three hours after the
injection, the occurrence of inflammation and abscess must be ascribed
to this and not to the operation.
The pain attending injection in Sigmund's cases varied much, but
was usually very slight and of short duration ; in most cases, it was at
once allayed by cold applications. In a few cases, the pain was severe
and lasted for some time, no matter at what part or with how much
gentleness the injection was made. Patients in whom this occurs are
not fit subjects for subcutaneous injection ; in them even the addition
of hydrochlorate of morphia to the solution does not prevent the occur-
rence of the pain.
The details and difficulties of the operation are scarcely worth con-
sideration. Grood instruments are easily procured, and can be easily
kept in good order. The operation is not a difficult one, and even if it
occupy a good deal of the surgeon's time, that time is not lost if the
result be successful.
Stomatitis and ptyalism occur frequently if the patients do not cleanse
their mouths carefully and often. Dr. Sigmund has very seldom met with
even slight affections of the gums in his patients, but he uses prophy-
lactic measures. He has never met with disturbance of the circulation
and respiration, or any other general disorders of any importance
attributable to the mercury. The methodically continued use of all
mercurial preparations is attended with a moderate increase of the
heart's action and of the temperature : gastric disturbances often
occur, but are to be attributed generally rather to the dietetic condi-
tion of the patient than to the treatment. The secretions of the skin
and kidneys are but rarely disturbed in cases which must be regarded
as exceptional. The chemico-vital processes in the blood and secretions
which lead to the improvement or cure of the various forms of syphilis,
go on without any remarkable functional disturbance ; and if any such
occur, it is probably due to other causes than the injection.
There has been a great difference of opinion as to the absolute and
relative value of the subcutaneous method in the treatment of syphilis.
It would be impossible to arrive at a conclusion from the observations
of a few patients during a limited time, for the disease recurs at inter-
vals in a variety of forms, continues long even in favorable cases, and at
intervals manifests itself so feebly that it appears to have disappeared.
310 REPORT ON SURGERY.
There is also tlie difficulty, even when a patient is kept under observa-
tion for a number of years, of knowing whether he confines himself to
the prescriptions of his medical adviser, or uses sometimes those of other
persons. The question as to the value of subcutaneous injection in
syphilis is not yet ripe for decision; a prolonged series of clinical
observations is required.
One of the alleged advantages of subcutaneous injection in syphilis
is the possibility of allowing the patient to move about and foUow his
ordinary occupation. This advantage, however, is limited ; for the
wound made in the operation demands rest and care for a time at least,
and it is often necessary simultaneously to apply local treatment to the
genital organs, mouth and throat. In the treatment of syphilis, Sig-
mund insists most strongly on the importance of pure air and exercise ;
but when injection is used much care is required.
An essential advantage of subcutaneous injection, and one which
cannot be overrated, is its precision. The surgeon knows when, how
much, and where he introduces the medicine into the system, and can
determine with the greatest accuracy the place, the time, and the
repetition of the dose. Again, there is no immediate disturbance of
the digestive organs. Perfection in the details of the operation, and
attention to the hygienic and dietetic conditions of the patient are the
most important points to be observed in a long and varied inquiry made
with the view of arriving at a conclusion as to the value of the process.
In Dr. Sigmund's opinion, no one as yet possesses the facts on which
an absolute conclusion may be founded. Subcutaneous injection must
be regarded as a valuable addition to our resources, inasmuch as — un-
fortunately not rarely — cases are met with which resist all the ordinary
methods of treatment. As far as Dr. Sigmund has observed, its good
effects are most readily obtained, and are apparently permanent in the
simple papular, pustular, and squamous syphilides, in simple faucial and
laryngeal catarrh, in diffuse inflammation of the muscles and tendons,
of the periosteum and perichondrium and of the joints, and in neuralgic
affections. It may also be used empirically where other methods have
failed, or where, for special reasons, they cannot be carried out. To
cases of the kind here referred to, Dr. Sigmund would limit the use of
subcutaneous injection in private practice. Clinical observations, on
the other hand, must embrace a wider range. As far as Dr. Sigmund
has observed, he finds that he cannot support one of the assertions of
the advocates of subcutaneous injection, viz. that it prevents secondary
symptoms when employed in the initial stage, or that of induration.
In all the cases which he has thus treated, the consecutive, cutaneous
and mucous syphilides have appeared, just as if the disease had been
treated locally or not at all.
Subcutaneous injection possesses an advantage in common with
friction and fumigation, namely, that internal remedies, such as quinine,
iron, preparations of iodine, cod-liver oil, &c., can be given at the same
time. Dr. Sigmund attaches much importance to this fact, since such
combination of treatment is often of high value.
In concluding. Dr. Sigmund insists on the necessity, in order to
arrive at an estimate of the value of subcutaneous mercurial injection
TEAUMATIC FEVER. 311
in syphilis, of observations, continued for several years, as to the efiecfc
of the treatment on all the various forms in which syphilis manifests
itself. Hitherto, he has found mercurial inunction to produce the most
favorable results; but he could abandon it if a better remedy were
found.
TraumatiG fever. — The thirteenth volume of the ' Archiv fiir Klin.
Chirurg.,' contains an essay by Dr. Billroth on the pathology of trau-
matic fever, supplementary to those which he has already published on
this subject. On the present occasion he treats of — i. Fever following
injury in man. 2. The temperature in man during the first hours after
operation. 3. The temperature of the rectum in healthy dogs. 4. The
influence of muscular motion on the temperature in man and dogs. 5.
The direct influence of various injuries. 6. The continued mechanical
and chemical irritation. 7. Of irritation of the vaso-motor nerves on
the temperature of the rectum in dogs. 8. Septicsemic fever in dogs.
9. PysBmic fever in dogs. 10. The efiect of the injections of water,
blood-serum, and the fluid of hydrocele, on the temperature of the
rectum in dogs. 11. Critical remarks on the results of the experiments
detailed in the foregoing chapters. 12. How does the inflammatory
process give rise to fever ?
I. In his first chapter, Billroth repeats the statement made by him
in the second volume of the ' Archiv,' " that in a large number of cases,
even of severe injury, there is no fever ; fever is, then, not a necessary
result of injury, but rather an accident." Further, in the ninth volume,
he remarked that it was not only in slight wounds that fever was
absent, for he had met with cases of amputation of the limbs (including
even the thigh), of excision of the breast and axillary glands, ovariotomy,
extirpation of the upper jaw, &c., in which little or no fever followed.
Changes connected with fever may occur in a wound at any time from
its origin to its perfect healing. As a general rule, fever sets in within
the first two days, mostly on the second, and then lasts till the
seventh day. The duration of the fever is more variable than the
period of its appearance. Of 45 cases of removal of the breast and ax-
illary glands one was unattended with any fever; in 10 patients the
fever commenced on the first day, in 28 on the second, in 4 on the third,
and in 2 on the fourth day. In none of them did the fever com-
mence after the fourth day. Analogous results were found in the
observation of seventeen cases of removal of the breast alone, and
nineteen cases of amputation of the arm and forearm. "When he com-
menced to investigate the subject of traumatic fever, Billroth accepted
the doctrine of Schonlein, that the fever was the result of reflex irrita-
tion of the nerves of the injured part. The absence, however, of any
constant relation between the extent of injury and the severity of the
fever rendered this idea very improbable, and his investigations led him
to the conclusion that there was a relation between the amount of de-
struction of the tissues and the amount of fever. Still, however, some
points required explanation ; the course of the fever presented remark-
able variations, especially with regard to temperature. By further ob-
servation, Billroth has been enabled to eliminate certain elements which
complicated the question, and to arrive at a general theory of fever,
812 REPORT ON SURGERY.
which maybe called "humoral," although in it the nervous system still
has a place, especially in the explanation of disturbances of motility,
such as rigors. 2. With regard to the temperature in man during the
first hours after operation, Billroth recalls the fact that, in his first
essay on traumatic fever, he stated that the temperature at first falls
and then soon commences to rise rapidly. His examinations at that
time were made on each case for three or four hours only ; subsequently,
however, he has noted the temperature continuously for periods varying
from eight to twelve hours. He finds that the cases (twenty-one in
number) can be arranged in three principal classes, i. Those (ten) in
which the temperature remained below the normal (100° Fahr.) ; 2,
those (six) in which the temperature rose slowly above the normal ;
and, 3, those (five) in which it rose rapidly, sometimes reaching, in a
few hours, even 104° Fahr. In most of the cases the rise commences
from half an hour to two hours after the operation, being, in rare in-
stances, preceded by a fall, which probably often occurs before the
observation commences, and escapes notice ; while in some instances
the rise of temperature is attended by intercurrent falls. These differ-
ences cannot be accounted for by the nature of the injury and its im-
mediate effects on the tissues ; the state of the temperature depends on
other circumstances, which may be called accidental. G-reat loss of
blood lowers the temperature. This has been proved experimentally
by "Weber, Erese, Kettler, and Bergmann. Chloroform also has the
same effect, as was pointed out in 1848 by Dumeril and Demarquay ;
and the observation has been confirmed by Scheinesson, of Dorpat, by
experiments described in an unpublished thesis, which Billroth has had
an opportunity of reading. Pain, perhaps, also lowers the temperature,
but in some cases it was attended with a rise. Rapid section of the
large nerves, and their more or less abrupt laceration, as in the removal
of tumours, may produce a depressing influence on the temperature, as-
is observed in shock. The exposure of the patient unclothed to the
air for too long a time, especially in winter, in the operating theatre, is
liable to produce a fall of temperature. To this, Spencer Wells attaches
much importance in ovariotomy ; and Billroth remarks that, since his
attention was directed by Mr. Wells to the necessity of not allowing
the temperature of the operating room to fall below 77° Fahr., he hs
never seen such marked collapse during and after ovariotomy as he
formerly met with. In two cases observed by Billroth a temporary fallj
in the temperature, which had been high or rising, was produced by!
haemorrhage : and in another instance of fever, daily variations were ob- '
served, which corresponded with those normally occurring in the healthy '
subject, there being a fall between 5 and 7 p.m. 3. In the third
chapter, Billroth describes a series of researches on the ordinary tem-
perature of the rectum in dogs. He found it to manifest frequent oscil-
lations, which were proved, by the use of specially protected thermo-
meters, not to be dependent on muscular action. 4. The influence of
muscular action on the temperature is discussed in the fourth chapter.
Very slight changes, if any, are produced in the temperature of healthy
men by muscular exercise ; in animals, however, the effect is greater.
The artificial production of tetanus in a limb gives rise, as shown by
TRAUMATIC FEVER. 313
Ley den, to an increase of temperature in the part. 5. In the fifth
chapter, Billroth examines the influence of various injuries on the tem-
perature of the rectum in dogs. He finds that even severe lesions, such
iis the ligature of arteries, or long incisions through the skin, have no
c onstant efiect on the temperature in the rectum within three hours,
even when the experiments are performed on animals that have been
suffering from illness. 6. The application to the extremities of the
nerves of mechanical and chemical irritants, such as injection of air or
\vater into the subcutaneous tissue, irritation with croton oil or with
ammonia, &c., had no constant effect in elevating the temperature in
dogs, even when continued for two or three hours. 7. The influence
o£ irritation of the vaso-motor nerves on the temperature has been
studied by Billroth by means of (a) the introduction into the vessels
of canulae or pieces of tangle, which produced no , result ; (h) the
introduction of purely mechanical embola, such as starch or powdered
charcoal suspended in water. The injection of these into the systemic
arteries was followed by a fall in temperature rather than a rise ; when
they were introduced into the jugular vein, and thus reached the pul-
monic circulation, fever was not a constant result, but the temperature
presented a remarkable series of tolerably regular falls and rises, such
as had already been noticed by Albert and Strieker. 8. In the eighth
chapter Billroth speaks of septicaemic fever in a dog. A filtered in-
fusion of putrid muscular tissue, swarming with vibriones, when injected
in large quantities into the arteries, veins, or subcutaneous areolar
tissue, rapidly produced death ; when injected in smaller quantities (five
centigrammes or less) it produced fever of a remittent type, lasting
several hours. 9. Regarding pysemic fever in dogs, experiments are
described in the ninth chapter, the result of which was that the injec-
tion of pure pus, or of pus diluted with water, was sometimes followed
by fever, sometimes not. 10. A similar inconstancy of results attended
the injection, in a similar manner, of water, of serum, and of the fluid
of hydrocele. 1 1 . In commencing, in the eleventh chapter, a critical
examination of the results described in the preceding part of his essay,
Billroth says that their great variety is one of the principal obstacles
to their use in forming a theory of fever. Two phenomena only are
constant — the rise of the temperature after muscular action, and after
the injection of putrid matters. Beferring to the eff'ect of muscular
action, he says that the artificial tetanization of limbs and the effect of
voluntary muscular movements can be accepted as starting-points in the
inquiry only so far as they show that an elevation of temperature is
produced through irritation, direct or reflex, of the muscles. It is,
however, not proved that a similar elevation of temperature can be
exerted reflexly by the irritation of sensory and vaso-motor nerves. The
curves presented by the temperature in the various experiments are
next commented on. In some instances there was steady and tolerably
regular rise ; after the injection of water there was a single marked
rise ; and in other instances, especially after the injection of putrid
fluid, pus, and starch or charcoal, there were two marked elevations.
It is probable that in all the experiments the same cause produced the
rise, and that this was in all cases called forth and regulated by the
k
314 REPORT ON SURGERY.
same means. Eor some time, in the cases where the double rise of
temperature was observed, Billroth attributed the first elevation of
temperature to the irritation directly produced by experiment, and the
second to the supervention of a secondary inflammatory process. This
double rise, however, did not follow the injection of serum or of hydro-
cele fluid. This double elevation of temperature Billroth suggests may
be explained by assuming a defect in the regulation of the production
of heat. If the regulating apparatus be regarded as nervous or mus-
cular, it may be supposed to become exhausted by excess of work ;
that then the rapid effect of the pyrogenic action will be held in check
by the renewed energy of the regulating apparatus ; and that, this again
becoming exhausted, the progressive influence, though there is no new
formation or increase in quantity of it, again produces a rise of tempera-
ture. In Billroth's opinion injections of water (with or without embolic
matters), of putrid fluid, of pus, of blood serum, of hydrocele fluid, &c.,
all give rise, alike, to pyrogenic action ; but the time of appearance and
the duration of this vary. Putrid matters and some forms of pus (as
well as other substances) depress and even destroy the regulation of
heat, and hence arise the longer duration and greater intensity of the
elevation of temperature after the injections of these than after that of
water. If the respiration and insulation be greatly lowered at a time
when the pyrogenic action is still powerful, death is attended with a rise
of temperature. If, on the other hand, the pyrogenic agent paralyse
the regulating apparatus of temperature before the heart and lungs fail,
then the temperature falls rapidly, and there ensues a state of vita
minima recognisable only by a few respirations and by diminished
action of the heart, the temperature of the body falling to a level with
that of surrounding objects. 12. In the last chapter Billroth discusses
the question. In what way is fever excited by inflammatory processes ?
According to Zimmerann, the combustion in the seat of inflammation
is the source of the excess of heat which becomes distributed over the
body. According to this hypothesis the heat of the inflamed part should
always be greater than that of the blood, which, however, according to
Mosengeil and Billroth, is not always the case. Traube and Senator
suppose the increase of temperature to be due to a diminished expendi-
ture of caloric, while Leyden and Liebermeister hold that there is an
exaggerated production of heat in fever. Another hypothesis is that
the septic substances introduced into the blood serve as materials for
combustion ; the production of fever by the injection of water or of
serum, however, renders this improbable. If the ordinary doctrine be
accepted, that increased temperature in fever is due to an exaggeration
of the normal calorific process, the question arises, How is this brought
about ? — in what way does the local inflammation exert an influence on
the apparatus which regulates the production of heat ? In spite of the
experiments of Breuer and Chrobak, Billroth does not admit that irri-
tation of the sensory or of the vaso-motor nerves produces fever by
reflex action. The hypothesis which appears to him more probable is,
that matters are carried from the inflamed or sloughing part into the
blood, and act on the nervous system in such a way as to impair its
power of regulating the production of heat. Billroth does not admit
TRAUMATIC FEVER FROM GUNSHOT WOUNDS. 315
that tliere is any difference, except in degree, between tlie products of
inflammation and those of putrefaction. The opinion has been main-
tained that the introduction of septic or of inflammatory products into
the blood or areolar tissue gives rise to fever by first exciting inflamma-
tion. This, however, is opposed to the fact that fever may follow the in-
jection of water, serum, or hydrocele fluid, where, without inflammation,
an influence is produced on the nervous system through the medium of
the blood. It is, therefore, rational to suppose that pus and putrid
matters act, not through inflammation, which is not always present, but
rather indirectly on the nervous system through the blood. In con-
clusion, Billroth expresses his renewed conviction that that hypothesis
of traumatic fever is the most probable which assumes that materials
are absorbed into the blood from the focus of inflammation, and give
rise to fever, probably by acting on the nervous system. This hypothesis
he considers to be applicable, not only to inflammatory and traumatic
fever, but also to the initial form of infectious diseases before the
appearance of local symptoms.
This subject has been investigated in its relation to gunshot wounds
by C. HueterX' Volkmann's Sammlung Klin. Yortrage,' No. 22), and
by von Eecklinghausen ('Yerhandl. der Physikalisch. Mediz. Gresellsch.
in Wiirzburg').
Hueter treats of traumatic fever in its relation to gunshot wounds.
"Wounds made by small bullets, and regular in shape, often heal
without any fever. On the other hand, severely lacerated and con-
tused wounds are often accompanied with much fever. This difference
in the course depends essentially on the amount of decomposition of
the secretions from the wound, induced by vibrionic germs. In cases,
especially where the tissues are moist and albuminous, and not charged
with oxygen, the vibriones multiply immensely and bring about destruc-
tion of the highly complex albuminous substances, the products of
the healing up of which become sources of fever and increased tempera-
ture. Traumatic fever is at first essentially septicsemic. The vibrionic
germs are, perhaps, introduced into the wound with pieces of clothing
carried with the projectile, or by the use of dirty charpie at the first
dressing. The treatment must then consist in the prevention of the
introduction of septic matter and of its absorption from the wound, and
in the subdual of inflammation and fever. The septic process is best
obviated by careful organisation of the hospital and local disinfection
of the wound. As, however, the former is not always within the
control of the surgeon, he must give more attention to the latter.
Hueter recommends irrigation of the wound with permanganate of
potash, which, he says, destroys vibriones. The wound is then to be
dressed with charpie soaked in an oily or watery solution of carbolic
acid. To prevent the absorption of septic matter, the escape of the
secretions of the wound must be assisted by caoutchouc or metallic
drainage tubes. The products of decomposition produce, not only fever,
but also inflammation and suppuration. Traumatic fever setting in
with the commencement of suppuration is of a septicopysBmic cha-
racter ; with the cessation of the putrefactive process and the advance
of suppuration, it becomes pysemic. But the pus itself must be
316 REPORT ON SURGERY.
protected against putrefactive changes. As soon as the pus passes
beyond the immediate limit of the wound, forming a phlegmonous
abscess, this must be opened ; and, on the escape of the pus, the local
swelling and the fever diminish. This opening cannot be made too
soon, as it is impossible to know whether the case is to be one of
simple phlegmon or of rapidly spreading gangrene. No other compli-
cation in the ordinary course of a gunshot wound points to an intense
poisoning so strongly as the acute septic phlegmon. When the track
of the wound is lined with granulations, these form a barrier against
the absorption of putrid matters ; under such circumstances, however,
it may be broken through, giving rise, in the course of the healing of
the wound, to the complication described by Billroth as secondary
fever. In nearest relation to the septicopyasmic fever stand the com-
plications arising from putrescence of pus. Hueter believes that
diphtheritic disease of the wound (including hospital gangrane) and
erysipelas arise from this source. In the early stage of progress of a r
wound, vibriones are probably the cause of the putrefactive process.!
They cannot exist in fluids rich in oxygen (of which the action of per-
manganate of potash gives proof) . Their action on the living tissues
is probably prevented by the oxygen contained in these. In pus
containing oxygen there appear animal organisms belonging to the
genus Monas crepusculum ; in a chemical sense, these are sources of
putrescence, inasmuch as they cause the breaking up of the more complex
combinations. These monads produce irritation and inflammation of
the living tissues. As they can live in oxygenated fluids they may
penetrate in vast numbers through the finest lymphatic passages into
the blood, and may even appear in the urine. Hueter believes that
traumatic diphtheritis and erysipelas are produced by the wandering of
these monads into the living tissues. These speculations of Hueter
derive increased importance from the researches of von Eecklinghausen,
who, at a meeting of the Physico- medical Society of Wiirzburg in
June, 187 1, ascribed to the development of parasitic organisms the
presence of multiple small purulent deposits in the lungs, kidneys,
spleen, liver, heart, brain, and eye, which correspond with what had
been described by Yirchow as capillary embola. The organisms were
those described by botanists as schizomycetes, zoogloea, or micrococcus ;
and are distinguished from the detritus of tissues by their unchange-
ability in acetic acid, glycerine, and solution o£ soda. They seem in all
essential characters identical with the organisms described by Buhl,
Oertel, and Nassiloff as occurring in diphtheria, and by Klebs in
pyelonephritis. They occur, not only in the blood-vessels, but also in
the alveoli of the lungs and in the urinary tubules. They were much
less abundant in the arteries than in the veins. The absence of
changes in the endocardium contradicted the idea of an embolic origin.
Eecklinghausen showed these purulent deposits with micrococci in
pyssmia, typhus, and phthisis, with hectic occurring four weeks after
delivery, in cases, therefore, where previous lesion of tissues had
afforded an opportunity for the introduction of germs. Small myo-
cardial and nephritic deposits with micrococci were found in the body
of a boy, eleven years old, who died at the end of three days with
FEVER AFTER SURGICAL OPERATIONS. 317
symptoms of articular rheumatism, without any injury of the tissues.
According to Hueter the most simple result of the decomposition of
pus is ulcerative destruction of the granulations, which manifests itself
as diphtheritis, and, in an extreme stage, as hospital gangrene. Diph-
theritis in its mildest form may be successfully combated by the use of
carbolic acid in the proportion of one part in] twenty, applied four
times daily. Hueter prefers the watery to the oily solution. In
diphtheritic inflammation attacking the areolar tissue, spreading
rapidly with redness and swelling, and leading to the formation of
foetid pus, incisions must be made and the tracks of the wound freely
irrigated. In the pulpy and gangrenous form of traumatic diphtheria
Hueter prefers the actual cautery to all other treatment. He believes
that while the cautery destroys the monads, its action extends beyond
the tissues that are burnt. Much may be done, in Hueter' s opinion,
to prevent erysipelas by the use of disinfectant dressings. He praises
tar as a means of arresting the extension of erysipelas ; it is applied
in the form of an ointment consisting of two parts of tar and one of
lard, which is energetically rubbed in with the hand for four hours, and
repeated two or three times. Other observers, however, have failed to
find this method efficacious even though the inunction has been repeated
twenty times.
Fever following surgical operations. — Mr. Spencer "Wells has given
some clinical lectures on this subject (' Med. Times and Gazette,' Jan.
27 and April 27, 1872). In the first lecture he mentions three cases
in which high temperature and other signs of fever were clearly due
to inflammation and suppuration of ovarian cysts, or to decomposition of
the fluid contents of the cysts, where the fever subsided almost imme-
diately after the removal of the cysts, and the patients completely re-
covered. In all these cases the fever was of the type now commonly
termed pycemic. He then mentions a case of what might be termed
urcemic fever in a patient, set. 16, admitted with what appeared to be
an ovarian tumour. An exploratory incision was made, and Mr. Wells
at once came upon the csecum, its appendix and the ascending colon
which had been pushed forwards by the cyst behind. He then knew
(what was suspected before) that it was a case of hydronephrosis. The
cyst was tapped and twelve pints of fluid removed. The opening in
the cyst was fastened to the abdominal wall. Before the operation
the temperature was 97*4°; afterwards it rose to ioo'2°, 101*3°, and
io2'4° at the end of ten hours — a rise of 5° in ten hours. The morn-
ing after the operation the temperature was lower and she seemed
better, then it rose again, more fluid was let out and a glass tube was
inserted. On the second day, the temperature rose to 104" 2° in the
morning, and ioj"4° in the night. The third day in the afternoon it
rose to io8*4° and at night it was 110°. She lived till noon of the
fourth day, her temperature for some hours having been upwards of
1 1 1°. Mr. "Wells says, " Two very puzzling questions follow — First,
how did the operation check the elimination of urea in this girl and
lead to its presence in excess in her blood, or to the ammonia resulting
from the decomposition of urea ? and secondly, how does uremia lead
to fever heat or hyperpyrexia ?" The post-mortem showed the left
I
318 REPOET ON SURGERY.
kidney was almost useless, and tlie right kidney was converted into
a cyst holding twelve pints of fluid. " Why no symptoms showed them-
selves before this cyst was emptied, why they came on almost imme-
diately afterwards, and why they continued (although a free discharge
of urinous fluid was kept up from the cyst) I cannot explain." " We are
led to the suspicion that the opium which was given to relieve the
pain, or possibly the chloro-methyl by which anaesthesia was kept up,
may have been the cause of the first stoppage in the elimination of
urea, or else that some injury to the nerves of the kidney may have
been the first step in the fever process." The second question is
answered by appealing to the consideration of the influence of the nervous
system upon the production and regulation of heat.
Traumatic erysipelas. — Wilde states (' Deutsches Archiv fiir Klin.
Med.,' x) that he was led, on the recommendation of Yolkmann, to ex-
amine the effect of subcutaneous antiseptic injections in the neigh-
bourhood of the aff'ected part. He used for this purpose a solution of
one part of sulphocarbolate of soda in twelve of water; from three
to five injections (each 38 grains) of this solution were made, either at
different points around the diseased part or even directly into it. In
five cases, on the first day, the temperature did not rise much in the
evening ; on the next day (two injections having been made) there was
a fall, and the erysipelas had begun to disappear. On the third day,
oedema alone remained. (' Wien. Med. Wochenschr.,' 1872, No. 35.)
Hospital gangrene. — During the Franco-German war, those among
the wounded in the hospitals of Berlin who were attacked with hospital
gangrene were transferred to special barracks, which were placed under
the care of Dr. Jacob Heiberg, of Christiania. Dr. Heiberg has pub-
lished in ' Yirchow's Arch.,' liii, the result of the observations made by
him from September i, 1879, *o March 15, 187 1. In all the Berlin
cases the gangrene was of the ulcerative form ; it was always of local
origin, although there were cases where the aperture of entry was
small, in which the disease commenced in the deep-seated parts, and
produced constitutional disturbance before it was detected. In an
open granulating wound the granulations would break up over round
or angular patches, which gradually increased, and at last became con-
fluent. The wound assumed a yellow grey colour ; and here and there
were spots of a clear red, or brownish-red colour, the result of eff'usion
of blood into the granulations. The whole surface became ex-
cavated; the destructive process then seized on the subcutaneous
and intermuscular connective tissue, and the skin was often deeply
undermined to a much greater extent than was visible externally. The
skin swelled first at the margin, becoming tender and red. In a cica-
trix the process of destruction went on in small segments. The
muscles, nerves, bones, and arteries were at last laid bare, covered with
a firm greasy mass, or with a yellow-green stinking pulp. The large
cavities of the body were not found invaded in any case, and gangrene
seldom appeared on the trunk. In eighty-nine cases under observa-
tion, secondary haemorrhage occurred in seven. In six of these it took
place from arteries, and in one it was capillary. In two cases repeated
arterial ligatures were applied, but both died. In the remaining cases ^
i
HOSPITAL GANGRENE — TRACHEAL TAMPON, 319
tlie bsemorrliage was treated successfully by cauterisation and plugging.
The fever was always secondary, and presented the type of fever arising
from absorption of morbid matter. It always occurred in cases where
the gangrene spread irregularly into the deep parts ; when the gan-
grene was superficial, it was observed only in exceptional cases. The
temperature presented no special type, the curves, Dr. Heiberg says,
" were as irregular as the Alps." In the treatment, gastric disturbance
was allayed by low diet and iced water ; beyond these, no internal
remedies were used. The treatment was throughout local, and con-
sisted almost exclusively in cauterisation with chloride of zinc. Per-
manganate of potash was found by Heiberg to be of no use. It is
alleged by American surgeons that very mild cases heal readily under
the use of water dressing and fresh air ; but Heiberg doubts whether
such can be cases of true hospital gangrene, which spreads mercilessly
under such treatment. The granulations in the neighbourhood of a
necrosed piece of bone may undergo a process of destruction, bearing a
close resemblance in appearance to incipient gangrene. The manner of
extension of the disease is the only trustworthy ground of diagnosis ;
and Heiberg daily marked, with coloured chalk, on an iron wire network
the extent of the disease, so as to observe its progress accurately.
"When the diagnosis was clearly made out chloride of zinc was at once
applied. It was dissolved in a small quantity of water, so as to form a
mass of the consistence of oil, in which small pads of cotton-wool were
dipped ; these, having been gently pressed, were laid over the whole
surface of the sore. If the gangrene had spread deeply, free incisions
were made ; the more extensive these were, and the more the sore was
laid open, the sooner was the gangrene arrested. Chloride of zinc has
the advantage over nitric acid of being less dangerous to clothes, hands,
and instruments. After the cauterisation the sores were dressed with
oil for twelve hours ; after this, lukewarm water dressing was applied
four times daily. The scars often remained till the eleventh day, and
it was found that attempts to remove them by mechanical means pro-
duced bleeding and pain, without being successful. Paralysis and
anaesthesia were not met with, notwithstanding the depth at which the
caustic was sometimes applied. Under this treatment one death only
occurred, and in this instance the patient died under chloroform, when
the caustic was about to be applied. There were six deaths from
pyaemia in patients in whom the gangrene had been arrested.
An elaborate paper on this subject by Dr. Jones will be found in the ' Surgical
Memoirs of the War of the Rebellion/ published for the TJ. S, Sanitary Commission,
and a review of the same in the 'Am. Journ. Med. Sciences/ Oct., 187 1, 456.
Use of tJie tracheal tampon. — Dr. Junker writes on the employment
of the tracheal tampon, as advocated by Dr. Trendelenburg and prac-
tised by Langenbeck and others. The danger of suffocation from the
passage of blood into the trachea in operations about the face, &c.,
while the patient is under the influence of chloroform, suggested to Dr.
Trendelenburg the plan of administering chloroform through an opening
in the trachea, the latter being at the same time plugged. After
various trials the canula and tampon are now made in one. " The tampon
consists of a delicate, double-walled india-rubber tube, of about 3*4
L
320 REPORT ON SURGERY.
centime trea in length (1-36"). The walls of the tube are united at
their extremities, so as to form a cavity, which is inflated by means of a
small tube opening into the external wall. The internal wall closely
embraces the vertical portion of the tracheotomy-canula. This tampon
when inflated within the trachea, thoroughly plugs the space between
canula and and the windpipe." The air can be let out to withdraw the
plug. " A small india-rubber balloon, with an ivory nozzle, fits into
the inflating tube. After inflation the tube itself is closed by means
of a small metal clamp. The point of the canula is furnished with
a raised shoulder of about one millimetre ('04") in thickness. A
similar shoulder exists above the plug, so that the latter is firmly re-
tained between these two shoulders. By this arrangement the tampon
is prevented from slipping when passing through the wound." The
tracheotomy is performed, a sujficiently large opening being made, the
canula and tampon (collapsed) inserted, and then the latter is inflated.
The anaesthetic is administered by a funnel-shaped instrument of
japanned tin. Its outlet is furnished with an india-rubber tube, stiff"-
ened by a spiral wire, which, by means of a cone-shaped nozzle, fits into
the external aperture of the tracheotomy-canula. Over the inlet of the
funnel a raised, wire frame covered with dimity is placed, and on this
the anaesthetic is dropped. A circle of small holes drilled round the
edge of the funnel assists the admission of fresh air. After the opera-
tion, before the removal of the plug, the larynx should be washed out
with warm water, and the clots removed through the upper angle of the
incision by means of a syringe with a fine nozzle. A common tube is
inserted till all danger of haemorrhage has passed way. (' Med. Times
and Graz.,' May 4 and 25, 1872.)
In the 'Berliner Klin. Wochenschr.,' for September 2, 1872, Dr.
Heiberg, of Christiania, relates a case, in the practice of Dr. Schoenborn,
in which this plan was followed with good results. The patient, a man,
set. s6, had cylindroma of the upper jaw. By following Dr. Trende-
lenburg's method, it was found possible to maintain complete anaes-
thesia throughout the operation. In this case, however, the india-
rubber tampon was not sufficient to prevent the entrance of blood into
the larynx, and it was necessary to introduce plugs of wadding from
the mouth. The patient was discharged cured on the twentieth day
from the operation.
Bronchotomy. — Mr. Prescott Hewett gives a clinical lecture on the operations on
the windpipe. (' Brit. Med. Journ.,' Jan. 27, 1872.)
Laryngotomy for removal of a half sovereign impacted in the larynx. —
Mr. H. Smith records the case of a tipsy shoemaker, who put a half
sovereign in his mouth and it disappeared. Dr. Johnson saw it with
the laryngoscope impacted between the vocal cords transversely, its
reverse looking upwards. It was found impossible from its position
to grasp its edge. Mr. Smith performed laryngotomy, and, after a
little trouble, extracted the foreign body. A view of it, in situ, is
given. ('Brit. Med. Journ.,' Jan. 7, 1871, 7.)
Foreign lody in the larynx ; removal.- — A female child, set. 18 months,
had been suddenly seized with difficulty of breathing five days pre-
viously. It was not known that a foreign body had entered the larynx,
t-OREiaN BODIES IN THE LARYNX — TRACHEOTOMY. 321
but tracheotomy was performed high up. Something was felt, and on
cutting through the cricoid cartilage a dress-hook was found attached
to one of the vocal cords. After much trouble the hook was removed.
The child died on the seventh day, probably owing to the damage neces-
sarily caused by the removal of the awkwardly and firmly fixed hook.
The patient was in the Ormond Street Hospital. (* Lancet,' Sept. 30,
1871,468.)
A case in which a foreign body was removed from the larynx of a
child eight years old is recorded by Dr. Bennett. The child had swal-
lowed a plum-stone. Tracheotomy was performed, but the stone could
not be found, notwithstanding careful search with probes by himself
and Mr. Butcher. After some days it was clear it was impacted be-
tween the cords. The thyroid cartilage was divided and the stone
removed, about three weeks after the child first came under care. The
child recovered voice, &c. (' Dub. Quart. Journ.,' Aug. 1871, 29.)
Mr. Teake records the case of a man who, while drinking, sucked a
thin 'plate of lone into Ms larynx. Examined with the laryngoscope the
bone was seen to be a long, thin piece, impacted between the thyroid
cartilage in front and the arytenoid behind. It was seized with forceps
by Mr. Teale, but it could not be removed. Tracheotomy was then
performed. Eepresentations of the bone are given. ('Brit. Med.
Journ.,' Jan. 7, 1871, 7.)
Mr. Stokes says, " As I am not aware of any case in which the diffi-
cult and hazardous operation of tracheotomy, performed twice on the
same subject, has been recorded, the particulars of the following one
must, doubtless, be considered of much surgical interest :"
The patient was a woman, set. 30, who suffered from syphilitic dis-
ease of the larynx. Fifteen months previously she had had tracheotomy
performed. The tube was only worn a short time, the wound healed,
and the patient became free from all laryngeal distress. Six weeks
previously the difficulty of breathing had returned. A second operation
was performed, but with great difficulty. Mr. Stokes found Langen-
beck's double tracheotomy-hook of great service. She continued to
wear a tube afterwards. (' Dub. Journ. Med. Sci.,' Dec. 1872, 436.)
Dr. Buchanan, in the * Brit. Med. Journ.,' March 4 and 25, 187 1,
gives an abstract of results of thirty-nine cases in which he performed
tracheotomy.
Dr. Eben Watson narrates two cases for chronic laryngeal disease.
In one, the patient fainted during chloroform inhalation, and was
brought round with difficulty; he fainted without chloroform, and
finally was found dead in bed, probably having fainted when no assist-
ance was at hand. Dr. Watson points out the bearing of such cases in
the administration of chloroform. In the second case no special com-
plication existed. Dr. Watson does not lay much stress on the part of
the trachea opened, but he recommends sparing use of the edge of the
knife after the skin has been divided. He remarks on the length of
time the tube should be worn. ('Lancet,' Aug. 3, 1872, 145.)
Tracheoto7ny-tube removed from the trachea. — A case, in which a tube
slipped into the trachea, owing to the separation of the shield, is re-
corded in the 'Lancet,' Jan. 27, 1872, 113. It was removed by Mr.
21
322 REPOUT ON SURGEEY*
Holtbouse, by enlarging the wound and placing the patient in a prone
position.
Dr. J. W. Ogle and Mr. H. Lee record a case of tracheotomy in
which the tube, having become detached from its shield, escaped into
the trachea, and was removed by a second operation fourteen months
afterwards. ('Med. Times and Gaz.,' Sept. 21, 1872, 324.)
Parotitis ; tonsillitis ; tracheotomy. — Dr. Packard records the case of
a child, aged four years and nine months, on whom he performed
laryngo-tracheotomy, on account of dyspnoea from tonsillitis, compli-
cating mumps. Bleeding occurred just as he opened the trachea. The
child survived eight hours. (' Amer. Journ. Med. Sci.,' April, 1872, 404.)
Opening the larynx for the removal of morhid growths. — Mr. Durham
read a paper on this subject before the Med.-Chir. Society. He
details 5 cases which have come under his own care, or under that of
his colleagues, in which section of the cartilages of the larynx has been
performed for the removal of growths. The first case was that of a
girl, nine years of age, who was admitted into Guy's Hospital with
urgent dyspnoea. Tracheotomy was performed. In the course of the
next four years she was repeatedly seen, but no laryngoscopic exami-
nation could be satisfactorily carried out. But at the end of that time
Mr. Durham succeeded in obtaining a view of the larynx and found it
blocked up by warty growths. Shortly afterwards, chloroform having
been administered through the tracheotomy canula, an incision was
made, with a curved, sharp-pointed knife, straight through the super-
ficial structures, the crico-thyroid membrane and the mucous mem-
brane of the larynx, and then directly upwards in the middle line,
through the thyroid cartilage, &c., thus dividing all the structures by
one incision as high as the thyro-hyoid membrane, which was only
slightly cut. The cricoid cartilage was subsequently divided in order
to give more room. When the edges of the wound were drawn apart
it was seen that the whole larynx was studded with growths. Only a
few small ones were below the vocal cords. All were carefully re-
moved ; some were cut off with scissors, others were twisted off with
forceps. The wound was closed with sutures and strapping. The
next day the patient could breath through the larynx and could
produce audible sounds. On the seventh day the wound had healed.
On the tenth the canula was removed after having been worn for four
years. More than four years after the operation the patient was a
fine, thoroughly healthy woman, breathing, speaking, and singing as
though she had never had anything the matter with the larynx. The
second patient was a lad, aged seven years. Tracheotomy had been
performed nine years previously. An incision was made gradually from
above downwards, through all the structures as low as the opening in
the trachea. The whole larynx was full of growths, which extended
above and below the vocal cords. All were removed. He recovered,
and nine months afterwards was reported breathing well and the con-
dition of the voice was satisfactory. Difficulty was experienced in
closing the old tracheotomy wound in this case. It was finally accom-
plished after paring the edges. The third patient was a girl, aged
eight years. Four years before, tracheotomy had been performed. A
REMOVAL OF GROWTHS FROM THE LARYNX. 32^
similar proceeding to tliat adopted in the last case was carried out.
The fourth patient, under the care of Mr. Bryant, was a boy, aged three
years. Tracheotomy was first performed and then, by means of a
curved bistoury, an incision was made upwards from the opening in the
trachea. Some haemorrhage, as in the other cases, then occurred, but was
quickly stopped by exposure, torsion of vessels, &c. In the course of
a fortnight the canula was removed, and in three weeks the wound was
entirely healed. More than a year later he was in excellent condition.
The fifth patient, under the care of Mr. Davies-Colley, was a boy, four
years of age. Tracheotomy was first performed and then, on a subse-
quent occasion, an incision in the middle line was made through the
cartilages and upper rings of trachea. The growths were most exuberant.
A month later the tracheotomy tube was discontinued in the day time,
but subsequently its use had to be resumed. A second operation was
performed seven months later and has apparently been quite successful.
In the second, third, and fifth cases nitrate of silver was applied after
the removal of the growths, in the fourth perchloride of iron was used.
Appended to the paper are notes of all the cases in which similar
operations have been performed of which the record is accessible. The
cases are 32 in number ; including his own, 3 7. In at least 19 of these
the operation was completely successful, in 7 partially successful, and in
4 temporary heneflt resulted. (In a note 2 other successful cases are
mentioned.) In 3 cases the result was negative. Five cases were not
completed but were progressing favourably. In 2 cases death appears
to have resulted from the operation. Dr. Mackenzie, in his monograph
on 'Growths in the Larynx,' gives 9 out of 28 as the proportion of
deaths, but Mr. Durham considers that 7 of these deaths occurred from
circumstances unconnected with the operation. He gives the facts of
the cases. Mr. Durham remarks on the difficulties attending the
operation. First, with regard to haemorrhage. If the incision be kept
strictly to the median line it is impossible that any large vessel can be
wounded. Any wounded vessel is fully exposed. The wound being
hept well open, if blood pass down the trachea it is soon coughed up again.
Bleeding from the interior of the larynx is easily controlled by pressure
or styptics. The introduction of a canula, if not already in position,
and the insertion of a small piece of sponge into the trachea above the
canula may afford material aid in securing free respiration and hinder-
ing the flow of blood down the air-passages. The spasmodic move-
ments of the larynx and the paroxysms of cough often cause delay, but
these generally subside after a time. Division of cartilages. — If the
opening is commenced below and a grooved director passed up between
the vocal cords, their safety may be absolutely ensured, but such a
proceeding seems to Mr. Durham unnecessary. He prefers dividing
the cartilages by cutting through them from without inwards and from
above downwards, and separating, slightly, the al89 of the thyroid
cartilage, before actually penetrating the mucous membrane. In the
removal of the growth no great difficulty will be experienced unless
some important part of the larynx is involved, then so much as is
necessary must be removed with the growth. As a general rule it is
probably best to begin by dividing the thyroid cartilage and crico-
324 REPORT ON StjUGERt.
thyroid membrane and subsequently to continue the section upwards
and downwards as far as necessary. Cases in which extensive inci-
sions have been made have proved as successful as those in which the
thyroid only has been divided. It is advantageous, if tracheotomy have
not already been performed, to insert a canula during the operation
and leave it in for a few days at any rate. If the growths be few, in
certain cases, it may not bo necessary to leave the tube in. The result
of Mr. Durham's consideration of the subject shows, ist., that the
dangers and difficulties attending operative procedures are neither so
numerous nor so considerable as have been represented and commonly
supposed ; and, 2ndly, that the success hitherto achieved has been so
marked and so indisputable as to justify and encourage, in any such
case as may seem appropriate an earlier, bolder, and more ready resort
to this method than has hitherto prevailed. (' Med. Chir. Trans.,'
vol. Iv, 17 — 90.)
In a most^complete monograph, well illustrated, Dr. Mackenzie enters
thoroughly into the consideration of the whole subject of laryngeal
growths. He details 100 consecutive cases treated by himself, and
also gives a resume of cases treated by others. Of 93 of his cases in
which growths were removed j^er vias naturales, in 72 a cure resulted.
Stricture of the trachea. — In an article on operations on the air-
passages, in the * Archiv fiir Klin. Med.,' xiii. Dr. Trendelenburg re-
lates the case of a girl, set. 19, who came into hospital in Berlin in
June, 1867, suffering from dyspnoea and complete aphonia; she had
for several years had hoarseness, difficulty of swallowing, and shortness
of breath. On the 27th, Dr. Trendelenburg opened the trachea below
the thyroid body, on accountof an urgent attack of dyspnoea. In perform-
ing the operation he noticed that the peritracheal tissue was much thick-
ened and indurated. Eour months later an ulcer formed at the point
where the canula pressed, and increased rapidly. A second tracheotomy
was accordingly performed above the thyroid body, but it was now found
that the canula would not pass, in consequence of a stricture, which would
only admit a very fine urethral bougie. An attempt had been made at
first to examine the parts with the laryngoscope, but had failed in con-
sequence of the diseased state and faulty position of the epiglottis. A
long, slender canula was introduced with an india-rubber plug, into the
lower opening ; the plug was inflated, and pressure was exercised on
the granulations surrounding the opening, so that they now disappeared.
Attempts were now made to treat the strictured portion by internal
incision ; but the only result was to produce emphysema of the neck.
Dr. Trendelenburg accordingly, on March 19, 1870, laid open the
trachea from the cricoid cartilage to the lower opening ; the tissue cut
like cartilage. Conical pieces of tin, gradually increased in size, were
introduced. The patient, who had been unable to speak, was able to
utter sounds at the end of five days, when the canula and pieces of
tin were removed. After three weeks, the strictured part was found to
be dilated to the extent of i'2'j centimetre; the wound in the trachea
was nearly healed, but respiration through the glottis was still very
imperfect. On examination, it was found that the obstruction was
caused by the epiglottis, which was ulcerated and much swollen and
DISEASES OF JOINTS, ETC. 3^5
inclined backwards. A portion of it was removed with good effect ;
the breathing, however, did not become quite free, as there was paresis of
the vocal cords, which yielded, however, to the application of elec-
tricity continued for some time. The canula could not be removed, as
this was in a few hours followed by renewed shortness of breath. The
patient, however, gained the power of walking and ascending stairs
with the canula closed ; and in time she learned to introduce bougies
herself through the glottis.
Joint disease, necrosis. — Mr. Treves narrates some interesting cases
of necrosis of the ends of bones leadiog to joint disease, and in which
after the removal of the sequestra the latter subsided. A boy, set. ii,
was admitted with disease of the left knee following necrosis of the end
of the femur. He also suffered from necrosis of the lower end of the
right tibia. The disease probably followed on an attack of rheumatic
fever eleven months previously. The knee was much swollen, was
contracted, and there were sinuses. After five months' residence in]^the
hospital at Margate, Mr. Treves made an incision below and on the
inner side of the joint, and removed in three fragments a large seque-
strum, which had become separated from the lower end of the femur.
It was between two and three inches long, and about an inch in
diameter, and corresponded to the lower third of the shaft of the
femur ; passing downwards it had been discharged through the con-
dyles and the knee-joint. Eecovery with useful limb followed.
Sequestra had previously been removed from the tibia on the inner
side. A boy, set. 7, had disease of the knee and a sinus in the popliteal
space, probably of twelve months' duration. After about nine months'
residence, Mr. Treves removed a sequestrum from the back of the outer
condyle of the femur. The boy was discharged able to walk on the
limb. A boy, set. 10, was admitted with disease of the hip. A sinus,
on the front and outer side, led to bare bone. At the end of about
nine months a sequestrum was removed from the inner side of the
joint, the sinus having passed under the femoral vessels and opened on
the inner side. The child did well. A boy, set. 7, had disease of the
ankle. After seven months a sinus on the outer side was enlarged,
and a small sequestrum, which had separated from the lower end of the
tibia towards its fibular side, and lay in contact with the joint, was
removed through the joint. Eour months later the child could walk
with ease. The average time required for the separation of the
sequestrum was about eighteen months. (' Lancet,' Nov. 18, 1871,
712.)
Disease of joints from continued rest. — Dr. Menzel writes on this
subject in the 'Archiv fiir Klin. Chirurgie,' 1871. He remarks that
Cloquet and other authors observed some time ago that ankylosis was
sometimes the result of prolonged disuse of joints. The earlier stages
of the condition, of which ankylosis is the termination, were first
observed by Teissier and Bonnet, in the examination of six individuals
who had suffered from fractures of the lower limbs, and had thereby
been prevented for long periods from using the joints. They found in
the joints bloody synovia, swelling, serous infiltration of the synovial
membrane, and ulceration of the cartilages. Mendel has tested th©
326 REPOKT ON SUKGEUY,
correctness of these observations by experiments on dogs and rabbits,
the extremities of which were encased in plaster of Paris, and examined
at periods varying from one to ten weeks. In most cases, at the end
of ten weeks, the same appearances were found in young rabbits as had
been described by Bonnet and Teissier. In one case there was crepi-
tation in the joint. The synovia contained numerous red corpuscles
and epithelial cells ; and the cartilages were found to have undergone
proliferation of the nuclei, with conversion into a fibrous tissue rich in
spindle-shaped cells. Menzel concludes that the retention of the
articular surfaces in contact by means of the surrounding elastic
structures has a mischievous effect ; and that the ulceration of the
cartilages is analogous to bedsores, arising as it does from the constant
pressure of the same points against each other.
Sip-joint Disease. — A clinical lecture by Dr. Sayre on the treatment of hip-joint
disease with a description and figure of his own splint for keeping up extension will
be found in the 'Brit. Med. Journ.' July 22, 187 1, also *Med. Times and Gazette,'
July 29.
Dr. Morton publishes a lecture on the subject of excision in disease of the hip
('Brit. Med. Journ.,' Jan. 20, 1872).
Chronic Eheumatic Arthritis. — Numerous specimens have been exhibited by Mr.
Hutchinson (* Path. Trans./ xxiii, 194).
Loose Cartilages in the knee-joint. — Mr. Square records twenty-four consecutive
and unselected cases, cured, without anxiety or accident, by subcutaneous incision
(' Brid. Med. Journ.,' Sept. 23, 1871).
Mr. Lister speaks of the removal of loose cartilages under the antiseptic dressing
('Brit. Med. Journ.,' Aug. 26, 1871).
Spina bifida treated ly tapping and pressure. — A child, set. 25 days,
was brought into the San Jose Hospital, in Lisbon, under the care of
Dr. Camara Cabral, on November 21, 187 1. It had spina bifida in the
lumbo-sacral region ; the tumour was 40 centimetres in circumference,
and measured 17 centimetres, longitudinally, and 10 transversely. It
was transparent and fluctuated, but appeared to contain solid matter as
well as fluid. Convulsions were not produced by manipulating the
tumour, nor was there any paralysis or other sign of injury of the
nervous system. On the 29th it was tapped by means of Dieulafoy's
aspirator, and 409 grammes of yellow, transparent fluid, containing
much albumen, were removed. Compression by means of adhesive
plaster was employed. Some vomiting and loss of appetite were the
only symptoms that followed the operation. The tumour refilled in
the course of a few days, it was therefore again tapped, 2^0 grammes
of fluid being removed, and on December 14th, 425 grammes were drawn
off. On two subsequent occasions 17^ and 125 grammes were removed
by the aspirator ; the fluid had become more albuminous than it was
at first. The last two operations were followed by meningitis, which
yielded to remedies. The child recovered, and was exhibited by Dr.
Cabral at a meeting of the Lisbon Medical Society, on February 17.
(* O Correio Medico de Lisboa,' March i, 1872.)
Dr. Morton records a case cured by injections (' Brit. Med. Journ.,' April 6, 1872).
Vlceration of the jugular veins. — Dr. Gross writes an elaborate paper
on ulceration of the jugular veins, communicating with an abscess or
an open sore. ^ He also alludes to the cases which have been recorded,
in which arteries have been opened by ulceration, &c., and to Mr. Bir-
ULCERATION OF THE JUGULAR VEINS. 327
kett's case of abscess of the neck opening the arch of the aorta. He
says that erosion of the blood-vessels is by no means to be anticipated
in cases of abscess, &c., of the neck, as they are strengthened by fibri-
nous deposits outside, and often coagula inside. The pressure of an
abscess on a vein often causes its obliteration, whereas arteries appear
more disposed to ulcerate. Having met with a case of fatal hsBmorrhage
from perforation of the internal jugular vein, in consequence of difi'use
or gangrenous cellulitis, after an attack of scarlatina, he turned his
attention to the subject. He gives the details of twelve cases, from
which it would appear that ulceration of the jugular veins attacks the
two sexes with equal frequency, and to be eminently a lesion of early
life, since lo of the 12, in which the age is noted, occurred between the
second and thirteenth year, the average being the sixth year, while in
the remaining 2 the patient had attained the age of maturity. The
efficient cause of the destruction of the coats of the vessels was, in 1 1
instances, diffuse cellulitis following their course, and that disorder must
be regarded, in at least 10 of the cases, as one of the secondary expres-
sions of the morbid poison of scarlet fever, developed immediately after
its termination or during convalescence from it. When the cellular in-
flammation has culminated in an abscess which has been opened by the
surgeon, or has opened spontaneously, hsDmorrhage from perforation of
the jugular veins may be looked for within the first week. In 2 of the
cases the bleeding was immediate ; in i it was deferred until the seventh
day ; but the average date of its appearance was the fifth day. After
hsBmorrhage has once occurred, investigation of the cases narrated
shows that a fatal result may be anticipated. In 3 instances it occurred
immediately, 2 being found dead in their beds ; i was fatal in a few
hours ; while in 6 other cases, in which the date is recorded, it varied
from thirty hours to the fifth day after the first hsemorrhage, the average
being the third day, and then from repeated recurrence of the loss of
blood. Three distinct pathological processes are probably included in
the perforation of the vein. In i case there was probably a limited
necrosis from cutting off of the vascular supply, an eschar of upwards
of an inch in extent having plainly been visible before death. In
another the vein gave way from the loss of the support of an abscess.
In all the other cases the ulceration was due to progressive inflamma-
tory changes or diffuse (suppurative) phlebitis. In only 2 was there
thrombosis of the affected vessels. In one case the coagulum was of a
limiting nature, in the other the thrombus had softened, and led to
secondary obstructions and metastatic deposits. The appearance of
the ulcer is noted in 1 1 instances. In i the external jugular vein was
" perforated like a sieve, in a space three quarters of an inch in extent."
In another there were two openings in the internal jugular vein, one of
about the size of a pea, and a second in the form of a slit half an inch
in length. In all the others the opening was single. In 2 it was cir-
cular, while in the others it was of an oblong or ovoidal form, and varied
from four to twelve lines in length. In only i was there any inflam-
matory appearances about the margins of the opening or of the internal
coat of the vessel. In only 2 cases were the edges of the ulcer irregular
or jagged. In the remainder it appeared as if the walls of the vein had
328 REPORT ON SURGERY.
been removed by a sharp scalpel. In only 2 of the cases did the
contents of the vein communicate with a closed abscess, and blood
flowed at once upon an incision being made into it. It is scarcely pos-
sible to diagnose such a condition. In 2, however, there were sus-
picious symptoms. In i there existed " a certain tremor, which was
perceptible by the hand, and noise which could be heard with the ear,"
while, in the other, pulsation was very evident, and it could not be de-
termined whether it was resident in the tumour or communicated to it
by the carotid artery. In both cases there were no signs pointing to
the presence of venous blood, but a careless examination might have
given rise to the supposition of an aneurism. Introduction of air was
only met with in one instance. A month before the death of the
patient, while dressing her neck, there was slight bleeding, followed by
a gurgling sound, &c., and alarming syncope, from which she gradually
recovered under the use of stimulants. " The practical lessons to be
deduced from the study of the facts contained in this paper are,— Pirst,
that acute, destructive inflammation of the tissues of the neck and
deeply seated abscess, which has existed for some time and suddenly
takes on acute action, may, if unchecked in their progress, lay bare and
perforate blood-vessels, and that this result is to be feared more particu-
larly when difl'use cellulitis follows grave forms of scarlatina or other
acute specific diseases. Secondly, that scrofulous abscesses and ulcers
are not always indolent, but may, under favorable circumstances, that
is, in an enfeebled, broken-down condition of the system, rapidly assume
a phagaedenic condition, and lead to the same complication. And thirdly,
that the large arterial and venous trunks are more liable to be involved
than their branches." Incisions should be made early to check the
inflammation. If the surface of the sore be unhealthy, chloride of zinc
in solution, &c., may be used. Poultices should be avoided. If the
gangrenous action be extensive and spreading, the hot iron may be
lightly applied. The general condition of the patient must be attended
to. As to the treatment of the haemorrhage little can be said, as all
the cases proved fatal. In all the cases in which it is possible to apply
a ligature, and the disorganized condition of the parts does not contra-
indicate its employment, it should be resorted to in preference to other
haemostatic agents. It is perfectly safe, and is not open to the objec-
tions which can be justly urged against compression.* In the cases
detailed the latter was utterly inefficient. If it be tried it should be in
the following way :— An assistant's finger should be placed above the
wound, a small piece of sponge should be held in contact till it adheres to
the orifice, and should then be supported with a compress and adhesive
strips. Instead of the sponge, a piece of lint dipped in dilute solution of
persulphate of iron may be employed. This will exercise a beneficial
influence in checking gangrenous action and correcting the ofiensive
discharge. ('Am. Journ. Med. Sciences,' April, 187 1, 337.)
Intrabuccal resection of the inferior maxillary nerve. — Dr. A Menzel,
of Vienna, describes in the * Archiv fiir Klin. Chir.,' xiii, two cases in
which resection of the lower maxillary nerve was performed by him and
* See 'Retrospect,' 1867-8, p. 283, and 'Am. Journ. Med. Sciences,' Jan. and
April, 1867.
HESECTION OP NERVES, ETC. 829
by Dr. Billroth in the manner proposed by Paravicini, of Milan, in
1858. The corner of the mouth being held wide open, an incision three
centimetres long, running obliquely from within outwards, is made
along the anterior border of the ramus of the jaw through the skin and
the anterior fibres of the internal pterygoid muscle. The connective
tissue between the pterygoid and the periosteum is then torn through
with the finger, the nerve is easily reached at its entrance into the
dental canal, and a portion is removed. The lingual nerve is easily
avoided by taking care to trace the nerve to its entrance into the bone.
In Menzel's case the nerve was raised on a hook, and a piece four lines
long was excised. The bleeding was very slight. Billroth raised the
periosteum from the bone, and having surrounded the nerve with a
thread, cut out a piece ten centimetres long. Menzel says that the
intrabuccal method of excision of the lower dental nerve is attended
with less extensive injury and is less dangerous than the other plans ;
that it leaves no disagreeable results — such as scars, facial paralysis, or
salivary fistula ; that the nerve is readily rendered accessible, and may
be excised even to the extent of ten centimetres ; that the haemorrhage
is slight ; and that the operation is not difiicult of performance. Dr.
Menzel refers to a case described by Dr. Meusel, of Gotha, in the
* Deutsche Klinik' for November, 187 1, in which the intrabuccal
operation was performed, but both the dental and the lingual nerves
were divided. He believes that this is the first case in which the
operation has been performed on the living subject. Paravicini
operated only on the dead body, and up to a recent date his proposal
had no supporters, but several opponents.
Spasm, Sfc, of the arm; operation; exposure and extension of the
nerves of the hrachial plexus; recovery. — In the 'Lancet,' Nov. 30,
1872, will be found a detailed analysis of an account of a bold opera-
tion performed by Prof. Nussbaum, which resulted in a physiological
triumph. The patient was a soldier who had been injured in the war.
He suffered from spasm of the arm, from anaesthesia, and from pain.
Having once given relief by stretching the ulnar nerve in a case of
spasm of the inner fingers. Prof. Nussbaum determined to operate on
the present case, having first of all received a report from Prof. Voit as
to the probable seat of the mischief. He laid bare the ulnar nerve and
stretched it, then the nerves around the axillary artery and stretched
them, and lastly the cords of the brachial plexus. These were in-
dividually and vigorously pulled. The man was cured by the operation.
Dr. Grartner has operated on another patient.
Transfusion of blood. — Dr. Hildreth writes on the kind of cases in
which it is useful. Defibrinated blood should always be used, human,
if possible ; but successful cases have occurred with the blood of calves,
lambs, sheep, &c. The instrument he uses consists of an india-rubber
hand-ball in the centre of two feet of tubing. To one end is attached
a funnel-shaped, metallic vessel, double cased, with a tube through
which hot Avater is to be poured between the cases, and also a con-
venient handle. To the other end is attached a metal, capillary point
to enter the vein. About five inches from the point is inserted a short
segment of glass tubing, in order that it may be knowii wheii the
830 REPORT ON SURGERY.
supply of blood is exhausted, and to avoid injecting air. If the funnel
is held up, the blood will usually flow ; if not, the hand-ball can be used.
(Am. Journ. Med. Sciences, Jan. 1872, 10^.)
Dr. "Winants records a case in which he employed transfusion. The
carotid artery of a lamb was opened to supply the blood, which was not
defibrinated. The patient decidedly rallied, and survived for a fort-
night. At the time he appeared moribund. (Ibid, Jan. 1872, 108,)
Dr. Aveling records a successful case of immediate transfusion in
haemorrhage after parturition. A man employed as coachman furnished
the blood. A tube was inserted into a vein in his arm, and the india-
rubber portion of the apparatus filled with water affixed, another tube
having been inserted into a vein in the patient's arm, as was thought.
It proved to be only in the cellular tissue, and was then properly inserted.
Sixty drachms of blood were injected. The patient recovered com-
pletely. A diagram of the whole method of operating is given. A
bevel-pointed, silver tube is inserted into a vein of the patient, and this
tube is filled with water, and the thumb is kept on the open end. An
assistant prepares the blood-donor's arm, and inserts a round-pointed
tube in a direction towards the fingers. An india-rubber tube with a
ball in the middle and a tap at either end is filled with water and fitted
to the two tubes. The taps are turned on, the india-rubber tube com-
pressed on the donor's side of the ball, and the ball squeezed to send
the water on into the patient's vein. Next the tube is compressed on
the other side of the ball, and the latter filled. The process is repeated
as at first. Defibrination is not necessary. (' Lancet,' Aug. 3, 1872, 147.)
Modification of Syme's rhinoplastic operation. — Mr. Stokes operated
on a man, set. 39, a Scotchman, who was suffering from complete de-
struction of the nasal bones as well as the nasal processes of the supe-
rior maxillary bones, and the soft structures covering them. There
was a large opening, through which three fingers could be easily intro-
duced into the nasal cavity. Fortunately the soft parts constituting
the tip of the nose remained intact, and the tissues around the opening
appeared healthy. Mr. Stokes adopted a modification of several pro-
cedures. He made two triangular flaps, with their apices above, at the
nasal process of the os frontis and their bases below and having freely
vivified the edge of the large, oval-shaped opening he transplanted the
two triangular flaps towards the middle line so as completely to cover
the opening and united them in that situation with fine entomologist
pins and twisted, glass silk sutures. The bases of the triangular flaps
were in like manner united to the upper margin of the lower portion of
the nose. In order to fill up the defect at each side of the inner
portion of the cheek, where, namely, the flaps had been taken, another
plastic operation was performed. The flaps were made of a somewhat
quadrilateral form and were taken from the soft parts covering tho
malar bone. The result was satisfactory. A woodcut of a photograph
is given. ('Dub. Journ. Med. Sci.,' Dec. 1872, 442.)
Zeis' cJieiloplastic operation. — Mr. Stokes records a case in which he
performed this operation. He remarks that it is best adapted for cases
where the disease extends across the whole or greater portion of the
red border of the lip. Its advantages are simplicity and facility of
TREATMENT OF CICATRICES FROM BURN, ETC. 831
performance and slight cicatrices left afterwards. An illustration is
given. The disease is removed by a quadrilateral-shaped incision.
Srom the outer (and inferior) angles of the defect, incisions should be
made downwards and outwards to the lower border of the inferior
maxilla, terminating at about one inch and a quarter from the sym-
physis. From the apex of the chin two other incisions, united above,
should be made, parallel to the first ones, but underneath the chin, and
each of them from half to three quarters of an inch in length. The
soft parts included within these four incisions should then be dissected off
the inferior maxilla as far as the inferior extremities of the two lower
incisions (those, namely, beneath the chin) and these latter then permit
the soft tissues of the chin to be pushed upwards, so as completely to
fill up the defect made by the removal of the morbid growth. (' Dub.
Journ. Med. Sci.,' Dec. 1872, 444.)
Treatment of cicatrices from hurn. — Dr. Buck records the case of a
child affected with extensive cicatrices of the front of the neck, &c., on
whom he operated successfully. A broad band extended from the chm
to the sternum, approximating them to within two inches of each
other. At both lateral edges of the band, the adjacent, continuous,
sound skin receded, and formed a deep pocket behind the band itself,
BO that the fingers pressing from opposite sides were easily made to
meet, with the skin only intervening. A photograph is given showing
the great width of the band well. The patient being under the
influence of ether, the entire cicatricial band was divided into three
serrated, irregular flaps, interlocking each other. One of the three
was central, with its apex upward at the symphysis menti ; the other
two were lateral, with their apices downward, and resting on the
clavicles. They were formed by two diverging incisions carried from
the symphisis downward and outward to either edge of the band at the
clavicles. From these terminal points an incision was made along
either margin of the band, upward and outward, to the edge of the
jaw. The three flaps were then dissected up from the subjacent,
loose, connective tissue, from their apices towards their bases. The dissec-
tion was carried beyond the limits of the scar. The flaps were adjusted
to the raw surfaces. A thick nodule of scar was removed. A long
incision was made to remove tension. Strapping was used as well as
sutures. The flaps sloughed. The granulations were treated thoroughly
with nitrate of silver and caustic potash. As cicatrisation advanced
lines of cicatrix formed and were notched. The chin was elevated by
means of an apparatus which is described in detail and figured. Two
parallel bars were fixed along the back from the pelvis to the top of
the neck. A cross piece was fixed opposite the shoulders and bands
passed from this under the armpits. A steel ring or collar was fixed
to the highest part and passed under the chin. It had a joint at the
side. When the child wanted to move the head he was obliged to lift
the chin above the collar, thus further stretching the cicatrix. By
means of a screw behind, the chin could be elevated or depressed. The
patient recovered satisfactorily. A woodcut of his final appearance is
given. In the course of some remarks Dr. Buck insists on the value
of the removal of the indurated cicatrised parts by sloughing, &c.; and
33a REPORT ON SURGERY.
the free detachment of the remainder from the subjacent parts ; on the
fact that the apparatus was kept on for a very long time (it was taken
off at night) ; the repression of the granulations ; and the free division of
the new cicatricial tissue forming in bands. Dr. Buck refers to other
cases and apparatus. (* Am. Journ. Med. Sciences,' Jan. 1872, 53.)
Treatment of cicatrices. — Mr. Lister advocates division of cicatrices,
stretching of the edges of the wound by india-rubber bands and the
careful employment of antiseptic dressing. The latter consisting in
applying folds and bandages of gauze (antiseptic) with a piece of water-
proof material interposed next the skin as a "protective." Underneath
the outmost fold also a piece of waterproof material is inserted to make
any discharge travel through a quantity of the gauze. The gauze
admits air freely, but removes the septic germs. Q Edin. Med. Journ.,'
Aug. 1871, 145.)
Ossification of the marrow of tones. — At a meeting of the Academy
of Medicine in Paris on January 9th, 1872, M. Demarquay presented
a specimen of ossification of the medulla of the humerus. It was
taken from a young man, set. 20, who had had his humerus fractured
by a gunshot a year previously. An attempt was made to preserve the
the limb, but the wound did not heal ; numerous abscesses formed on
the chest, and the arm became greatly swollen, and presented, through
its whole extent, fistulous openings leading to diseased bone. The
patient's health being much impaired, disarticulation of the limb was per-
formed. The humerus was divided longitudinally, and it was then found
that the periosteum had formed a layer of new bone covering the whole
shaft, but leaving openings through which the dead bone could be
reached. The whole of the shaft had undergone necrosis. The
medulla had undergone ossification at the ends of the diaphysis, its
periphery being transformed into bone, and the central part destroyed.
Scapulo-Jivmeral periarthritis. — Dr. Simon Duplay gives an elaborate
description, in the ' Archives Generales de Medecine' for November,
1872, of an affection which is, he says, very common, but has scarcely, if
at all, been thoroughly described in surgical works. Jarjavay, how-
ever, in a paper on displacement of the tendon of the long head of the
biceps, published in the * Gazette Hebdomadaire,' in 1867, gives a very
accurate account of the early stages of the disorder. He says that con-
tusions of the shoulder and sprains of the arm are very often followed
by inflammation of the subacromial synovial bursa, producing the fol-
lowing symptoms : — A sensation at the time of the accident as if some-
thing were displaced ; tumefaction of the shoulder ; pain, preventing the
movements of the arm, especially abduction ; flexion of the forearm on
the arm, and rigidity of the biceps muscle ; increased pain,, with crepita-
tion beneath the acromion when the arm is raised and abducted, and
disappearance of the pain and return of the power of movement after
rest and the use of a sling, with the application of lotions to the
shoulder. This description of Jarjavay is applicable to the acute form,
but Dr. Duplay has extended his researches also to the chronic form of
the affection. After describing the symptomatology, diagnosis, pro-
gnosis, and treatment, and giving several cases, he sums up in the fol-
lowing conclusions : — (i) Direct or indirect injuries of the shoulder are
SCAPULO-HUMEEAL PERIARTHRITIS. 333
very frequently followed by inflammation of the tissues surrounding
the scapulo-humeral articulation. This periarthritis is more especially
localised in the subacromial synovial bursa and the subdeltoid areolar
tissue, and gives rise to thickening and induration of the areolar tissue
and of the walls of the subacromial bursa, and also to the formation of
adhesions and fibrous bands, which impede or entirely prevent the head
of the humerus from gliding on the concavity of the acromion and the
inner surface of the deltoid. (2) Periarthritis is distinguished from
disease of the interior of the shoulder- joint by the absence of deformity,
and if there be any swelling, it is only in the acute stage, when it is
limited to the summit of the shoulder. The characteristic symptoms of
periarthritis are the following : — (a) The movements of the shoulder are
impeded, sometimes to such an extent that the arm cannot be extended
horizontally. In all the movements of the joint the relations of the
humerus to the scapula remain unchanged, and the latter bone plays
round its clavicular attachment. In some cases these movements are
accompanied by crepitation, (b) There is pain on moving the arm, not
at the level of the articulation, but beneath the acromion, at the attach-
ment of the deltoid to the humerus. Pain is also caused by pressure
below the acromion, at the level of the coracoid process. Sometimes,
also, there is a sensation of tingling and of numbness along the limb as
far as the hand, (c) The forearm is sometimes semiflexed, and at-
tempts to extend it produce pain in the fold of the elbow and in the
neighbourhood of the coracoid process. (3) Periarthritis of the
shoulder must be carefully treated at its commencement, if we would
avoid the rigidity to which it gives rise. G-ymnastic exercises of the
limb, electricity, douches, and shampooing, are the best methods. (4)
In cases of chronic periarthritis the only means of procuring a rapid
and complete cure is at once to break down the adhesions and the
fibrous bands. The use of chloroform is indispensable for this opera-
tion, which may require to be repeated if the result be not satisfactory.
(5) After the adhesions have broken, the patient must be placed for
some time under a course of gymnastic exercises, electricity, douches,
&c., until the limb has regained its power of movement.
Periostitis of the temporal lone. — In an interesting clinical lecture
on this subject, in relation to a case in the London Hospital, Mr.
Hutchinson calls attention to the fact that the bone is not covered on
its opposite surfaces by the same periosteal membrane. Necrosis is
very common in the long bones, but of the temporal bone it is compa-
ratively rare. We have periostitis of this bone accompanied by con-
siderable suppuration, and yet followed by complete recovery without
the death of any portion of bone. This may be due to the copious
supply of blood which it obtains. The comparative immunity of the
inner surface of the bone from inflammation may possibly be attributed
to the absence of continuity between the dura mater and the external
periosteum. The treatment resolves itself, mainly, into the possibility
or impossibility of opening the abscesses which form in connection with
the inflamed periosteum. This can be accomplished over the mastoid
process, but not if the abscess point in the meatus or in some part of
the pharynx. ('Med. Times and Gaz.,' Nov. 25, 1871", 641.)
334 REPORT ON SURGERY.
Treatment of persistent inflammation. — Mr. Jolin Marshall writes on
the employment of solutions of the oleates of mercury and of morphia in
the local treatment of " persistent" inflammation. They consist, essen-
tially, of solutions of oxide of mercury in oleic acid, being, in reality,
the oleate of mercury dissolved in oleic acid, but to these solutions is
added a certain quantity of morphia, which, in its uncombined state, is
readily soluble in, and doubtless unites with, the oleic acid. The oxide
of mercury precipitated by caustic potash or soda from a solution of
the metal in nitric acid (which is a yellow impalpable powder) is, when
recently made and well dried, readily soluble in oleic acid, especially
when aided by a temperature of about 300° Eahr. The solutions are
named according to the amount of oxide they contain. The ^ per
cent, is a perfectly clear, pale, yellow liquid. They should not be
rubbed on the skiu, but merely smeared on. As a rule, from ten to
thirty drops are sufficient for one application. This should be repeated
twice daily for four or five days, then at night only, then every other
day. In a case of chronic inflammation of the knee-joint treated,
twenty to thirty drops of the ^ per cent, solution also containing a grain
of morphia in the drachm were applied night and morning for about ten
days, and then at longer intervals. A piece of linen was kept on the
joint, then a layer of cotton wool, and over this a bandage from the
foot to above the knee. The patient could walk at the end of a month.
The 5 per cent, solution with the addition of an eighth part of ether is
useful in sycosis, chloasma, and other forms of tinea. It destroys
pediculi and their ova. In congenital syphilis a drop of the 20 per
cent, ointment, about the size of a pea or bean, placed in the child's
axilla night and morning for five or six days is an eff'ective and cleanly
means of treatment. (' Lancet,' May 25, 1872, 709.)
Treatment of epistaxis. — Dr. F. Klichenmeister, of Dresden, proposes
to treat epistaxis by an instrument which he calls the "rhineurynter,"
and which is, in fact, an imitation of the " colpeurynter." It consists
of an india-rubber tube about 20 or 24 centimetres long, with a dia-
meter of half or three-fourths of a centimetre, and ending in a bulbous
extremity about i\ centimetre long and from i to i-J centimetre wide.
The tube is guided into the nostrils by means of an ordinary sound,
and, the latter being withdrawn, air or water is injected so as to distend
the bulb, which thus fills the naso-pharyngeal cavity and presses against
the walls of the nares. (* Oster. Zeitschr. fur prakt. Heilk.,' No. 22,
1871.)
ITasal mucous membrane used in uranoplasty. — M. Lannelongue com-
municated to the Surgical Society of Paris, in May, 1872, the history of
the case of a lad, set. 17, who had congenital fissure of the hard and
soft palate. He had also harelip on the left side, which was remedied
by operation. The cleft in the hard palate was a centimetre in breadth,
and to its right border was attached the septum narium. This suggested
to Lannelongue the idea of transplanting the nasal mucous membrane.
He accordingly made two perpendicular incisions in the membrane,
before and behind, joined the upper ends by a transverse cut, loosened
the flap thus formed, and fastened its free border to the left edge of the
fissure after paring the latter. Union followed, and a fortnight after
SKIN GRAFTING, ETC. 335
the operation the membrane retained its original appearance, and con-
tinued to secrete mucus, though in diminished quantity.
Removal of foreign todies from the external ear. — J. Gruber (* AUge-
mein. Wiener Medizin. Zeitung,' Nos. 42 and 43, 1872) recalls attention
to the old, but hitherto much neglected fact that foreign bodies are best
removed from the external auditory meatus by syringing, and if they
become impacted in consequence of swelling of the canal, they do less
harm than the attempts made to remove them. He has lately made
experiments for the purpose of ascertaining the effect of astringent
solutions in reducing the size of peas, &c., which are often introduced
into the ear by children, and he finds that the only agents which pro-
duce this result are a solution of sulphate of zinc and diluted lime-
water. He therefore advises that, in cases of the introduction of foreign
bodies, these fluids should be dropped into the ear. He relates the
following case : — A carob bean had been pushed by a schoolfellow into
the ear of a boy eleven years old. Attempts were made to remove it,
but without effect. When Gruber saw the boy, five weeks aftewards,
he had febrile symptoms, and was therefore placed under antiphlogistic
treatment. The foreign body lay deep in the ear, and water, when in-
jected, flowed out through the nose, showing that the tympanum was
perforated. After the febrile symptoms had abated the meatus was
dilated, and solution of zinc dropped in. At the end of about three
minutes the bean was removed by injection. Previously to the intro-
duction of the bean the boy had been suffering from purulent discharge
from the ear ; this, however, ceased some weeks before the foreign body
was removed, and after the removal of the latter the membrana tym-
pani was seen to present a cicatrix, but no perforation.
SJcin-grafting . — M. ^Oilier, of Lyons, in a communication to the
Academic des Sciences, on March 18, 1872, states that the method which
he employs to promote healing of ulcers consists in the transplantation,
not of small portions of epidermis, but of pieces of skin 4, 6, or 8 square
centimetres in size. These may be taken from the patient himself or
from another person, the part having been first rendered insensible by a
freezing mixture. In most cases M. Oilier has obtained these from
amputated limbs. Any adipose tissue that may be present on the
under surface of the flap must be removed before its application. By
this process, M. Oilier says, a thick, stable layer of skin is formed, in
place of thin, delicate, and unstable cicatrix which follows the operation
of epidermic grafting.
Mr. Anderson writes a paper on the theory and practice of epidermic grafting.
('St. Thomas's Hosp. Rep.,' ii, 165.)
Dr. Macleod writes on the subject, and figures a pair of scissors and forceps com-
bined, which he uses. ('Brit. Med. Journ.,' April 1, 1871.)
Dr. David Page makes further observations on the true nature of the so-called
skin-grafting. ('Brit. Med. Journ.,' May 27, 1871.)
Unilateral atrophy of the tongue. — Mr. Pairlie Clarke relates the case
of a woman, set. 45, who had a tumour removed from her right breast
February 16, 1870. On October 3rd the patient was seized with a deep*
seated pain on the right side of the head, of aperiodic character, return*
ing each night, between i and 2 a.m., and rendering her for some hours
3^6 llfePOET ON SURGERY.
incoherent and unmanageable. There was great turgescence of the
vessels of the right side of the neck. On the 4th of December the pa-
tient was so much better as to require no further attendance. It was
at this time that the atrophy of the right side of the tongue was first
noticed, though it was not then so marked as it afterwards became.
On March 29th, 1871, the patient was found to be suffering in an aggra-
vated degree, and, in addition, there was an alarming dysphagia, toge-
ther with paroxysms of suffocative cough, which recurred about three
times in the twenty-four hours. She could only put the tongue out
very slowly, and seemed unable to do so at all at first. The tongue
was crimped and puckered along its whole right side from base to apex,
but these appearances were most marked in the anterior two thirds,
and an actual loss of substance had taken place, so that this half of the
organ seemed small and wasted. The loss of substance was bounded by
the median raphe, and the contrast between the plumpness of the left
side and the shrivelled aspect of the right was very striking. The
tongue was soft throughout ; there were no hard nodules on it. No alter-
ation was noticed either in the common sensation of the organ or in its
special sense of taste. When the tongue was protruded there was no
deviation to either side. The paroxysms of dyspnoea became more
frequent and more severe, and on the 7th of June, in one of these pa-
roxysms, she died. There was no post-mortem. Two published cases
are quoted, one recorded by M. Dupuy tren, and the other by Sir James
Paget. Mr. Eairlie Clarke remarks that in his case he thinks there
was good reason for supposing that the affection depended on the in-
volvement of the right hypoglossal nerve in a secondary cancerous
growth, either inside the cranium or at the upper part of the neck. The
facts which lead to this conclusion are — the existence of an undoubted
cancerous tumour, which was removed sixteen months before death,
after it had been growing about a year ; the general cachexia ; the in-
tense and deep-seated pain on the right side of the head and neck ; the
fulness and turgescence of the vessels on the right side of the neck,
denoting an obstruction to the circulation ; the frequent attacks of
dyspnoea and dysphagia, which probably depended on pressure on
the pneumogastric and glosso-pharjngeal nerves. These symptoms,
together with the absence of paralysis of the extremities and the clear-
ness of the intellect, seem to indicate that the disease was not in the
brain or medulla oblongata, and make it probable that there must have
been an adventitious growth pressing upon the right hypoglossal nerve,
and implicating more or less the pneumogastric and glosso-pharyngeal
nerves. The different situations in which such a growth might be
placed are discussed, and the evidence which exists to show that the
condition of the tongue might depend on an affection of the nerve itself
is considered. An experiment on a rabbit is detailed. In an appendix,
cases more or less similar are alluded to. An illustration of the state
of the tongue is given. (' Med.-Chir. Trans.,' Iv, 90.)
[Abstracts of various papers on Cancer, Tetanus, Electrolysis,
Treatment of Deformities, etc., etc., have been unavoidably omitted.]
REPORT
OPHTHALMIC MEDICINE AND SURGERY.
BY
EGBERT BRUDENELL CARTER, F.R.C.S.,
OPHTHALMIC SITEGEON TO ST. aEOEGE'S HOSPITAL.
The years 1871 and 1872 have been marked, like those immediately
preceding them, rather by writings of a fugitive character, devoted to
matters of detail, than by accounts of any researches or facts of
striking novelty. The International Congress of Ophthalmology held
its fourth quadrennial meeting in London, in the first week of August,
1872, but the report of the meeting has not been published at the
time when this summary is passing through the press, and the papers
read must be noticed on a subsequent occasion.
In the course of the two years death has taken away five ophthal-
mologists of eminence. Dr. Heymann, of Dresden, best known in this
country by his ingenious aut-ophthalmoscope ; Professor Gioppi, of
Padua ; Professor Erederic Jaeger, of Vienna ; Dr. Pamard, of Avignon ;
and Professor Stoeber, of Strasburg. Of these, the first two have
died in the prime of life ; the last three were veterans, already resting
from their labours.
In England the literature of ophthalmology has been extremely
scanty. Messrs. Churchill have published, in their manual series, a
second edition of Macuamara's treatise.* Mr. Streatfeild has re-
written the chapter on diseases of the eye for a new edition of Erich-
sen's ' Science and Art of Surgery ;' the ' Ophthalmic Hospital Reports'
have appeared irregularly ; and various papers have been published in
the journals or read before the medical societies.
In America the 'Archives of Ophthalmology and Otology' have been
continued, and a second volume has been completed. The ' Trans-
actions of the American Ophthalmological Society' have been issued
irregularly.
In G-ermany Dr. Hirschberg has commenced the publication of an
annotated edition of von Graefe's ' Clinical Lectures ;t Dr. Schmid
* * A Manual of the Diseases of the Eye,' by C. Macnamara.
t Prof. A. von Graefe's 'Klinische Vortrage iiber Augenheilkunde. Herausgegeben,
erlantert und mit Zusatzen versehen von Dr. J. Hirschberg,' Berlin, A. Hirschwald.
22
338 EEPOUT ON OPHTHALMIC MEDICINE AND SURGEUY.
has issued a treatise on the lymph-follicles of the conjunctiva ;* Dr.
Salomon has written a tract on the diseases of the lenticular system,t
founded on v. Grraefe's teaching ; Dr. Otto Becker has collected and
edited Heinrich Miiller's writings on the anatomy and physiology of
the eye ; J Woinow, of Moscow, has published at Vienna a treatise on
ophthalmometry ;§ and various tracts and inaugural dissertations have
appeared. Dr. Nagel has commenced a yearly record of ophthalmo-
logy, || which is to embrace the scientific work of all countries. Prof.
Th. Leber has been added to the editorial staff of the ' Archiv fiir
Ophthalmologie,' and the * Klinische Monatsblatter' of Prof. Zehender
have appeared as usual.
In Prance Dr. de Wecker has issued a Prench edition of Jager's
* Ophthalmoscopic Atlas,' with the original plates, and with a disserta-
tion of his own upon the diseases . of the deeper parts of the eye ;^
Glalezowski has completed his systematic treatise,** and has com-
menced, in conjunction with Dr. Piechaud, the issue of a monthly oph-
thalmic journal.tt In Holland the usual scientific papers have been
added to the annual reports of the Netherlands Ophthalmic Hospital.
In Belgium the * Annales d'Oculistique,' and in Italy the ' Giornale
d'Oftalmologia Italiano' have been continued with regularity.
{a) Anatomy and Physiology.
Ocular tension. — MonnikJJ has published the opinions of Donders
with regard to the principles of tonometry of the eyes, and the results
of his own observations with an improved tonometer. Donders points
out that when we determine the ocular tension, either by the finger
or by a tonometer, we estimate the force required to make a certain
impression upon the tunics of the eye. The tension of the eye de-
pends upon several conditions, and we cannot estimate simply and
directly the hydrostatic pressure of the contained fluids. The pressure
that we exert upon the eyeball from without diminishes its internal
space, and displaces a portion of its contents, for which, the con-
tents being incompressible, room must be found elsewhere. This
room is afforded {a) by extension of the remaining parts of the ocular
tunics, an effect that will vary with their elasticity and with the
* * Lymphfollikel der Bindehaut des Auges. Histologische Studie, von Dr.
Schmid,' Wieii, 187 1, Braumiiller.
t * Die Krankheiten des Linsensystems, von Dr. Max SalomoD,' 1872, Brunswick,
Vieweg.
X Heinrich Miiller's * Gesammelte und hiaterlassene Schriften zur Anatomic und
Pliysiologie des Auges. Zusammengestellt und herausgegeben von Otto Becker,'
Band, i, 1872, Leipsic, Engelmann.
§ ' Ophtlialmometrie, von Dr. M. Woinow,' 1872, Wien, Braumiiller.
II ' Jahresbericht iiber die Leistungen und Fortschritte im Gebiete der Ophthal-
mologic,' Erster Jahrgang, 1872, Tubingen, Laup.
IF * Traite des Maladies du Fond de I'CEil et Atlas d'Ophthalmoscopie,' par L. de
Wecker et E. de Jaeger, Paris, Delahaye.
** • Traite des Maladies des Yeux,' Paris.
ft ' Journal d'Ophthalmologie de Paris.*
XX 'Tonometers en Tonometrie,' Dissert inaug., Utrecht, 1868; 'Bijbladen, lode
Verslag, Nederl. Gasth.,' v. Ooglijders, 1869; "Ein neuer Tonometer und sein
Gebrauch," *Arch. f. 0.,' xvi, i, 49.
ANATOMY AND PHYSIOLOGY. 339
absolute size of the eyeball, since a larger surface will yield more than
'd smaller one ; (b) by an alteration in the shape of the eyeball, which
Iro 111 being spheroidal will become more nearly spherical; (c) by the
exit of blood and lymph from the vessels of the eye. It is only after
estimating the value of these several factors that a sound judgment
upon the actual degree of tension can be arrived at. The new instru-
ment of Monnik is so contrived as to measure the force that is re-
quired in order to indent the coats of the eyeball to the depth either of
one fourth or of one half of a millimetre, and the inventor states that
this force is about two grammes greater near the corneal margin than
at the equator. In his final observations the tonometer was applied at
an intermediate part, 6 mm, from the cornea. The tension of normal
eyes was found to differ within rather wide limits, and Monnik defines
normal tension as that in which a depression of ^th of a millimetre
was produced by a pressure of between lo and i^ grammes. He calls
the eyes soft that require less than lo grammes, and those hard that
require more than 15. From a small number of observations it would
seem that tension naturally increases with advancing life ; that there
is frequently a small difference between the two eyes of the same
person ; and that the same healthy eye, tested at different times, may
exhibit a difference as great as three grammes. In moderate degrees
of myopia the tension was slightly below the normal, in high degrees
slightly in excess, in hypermetropic eyes normal. Excess of tension
was found in almost all cases of anterior synechia, especially when
complicating corneal ulcers or keratitis ; in congestive amblyopia, in
some cases of cataract, and in glaucoma. Diminished tension was
found in all forms of iritis except the sympathetic, in some cases of
cataract, and in detachment of the retina. In sympathetic iritis a
reduction of tension followed the extirpation of the primarily injured
eye. The effect of atropine upon tension was not satisfactorily
determined. The instrument used in the researches was made by
Yerlaan, of Utrecht.
Coccius* practises palpation of the globe by placing the tips of
the index fingers, first moistened with lukewarm water, directly upon
the sclera, while the patient looks upwards. He believes that he can
thus better estimate, not only the degree of tension, but also the thick-
ness of the coats of the eyeball.
Congenital colohoma of the iris. — Dr. Pontif presented to the
Medico- Chirurgical Conference of the University of Parma one of his
own children, aged seven years, the subject of congenital fissure of the
iris of the left eye, in a direction downwards and a little inwards, as
far as the ciliary ligament, where the two margins of the fissure met
by convergence. The ciliary processes appeared to be wanting in this
region. The eyeball was a little flattened in the direction of the
inferior rectus, and the cornea seemed less convex in the segment
20
corresponding with the coloboma. Vision was perfect (S= — , No. i
Sn, read at i'). There was no photophobia, although it had existed
* ' Bericlit iiber die Heilanstalt fur arme Augenkranke.'
t 'Annales d'Oculistique,' 1872, ii, 19.
340 EEPOUT ON OPHTHALMIC MEDICINE AND SURGERIT.
during the first years of life. The media and fundus showed nothing
abnormal. The author related that, seven months before the birth of
this child, his mother assisted at an iridectomy inwards and downwards
on the left eye of a little girl. He thought it possible that the im-
pression thus arising might have produced the coloboma. He also
cast doubt upon coloboma being occasioned by an arrest of develop-
ment, and gave reasons for attributing it to a process of intra-uterine
inflammation.
The diagnosis of colour blindness. — M. "Woinow * brought before
the Heidelberg Congress of 187 1 a simple and easy method of dis-
covering colour blindness. It rests on the fact that all the tones,
including white, that are distinguishable by an eye which is blind for
one of the three elementary colours, may be obtained from the other
two. Thus, if the eye be affected with auerythropsia, all the colours
it can distinguish, including white and grey, may be obtained from
violet and green. If it be blind to green, all the colours it can dis-
tinguish may be obtained from red and violet ; or if to violet, from
red and green. The author constructed a top, carrying four super-
imposed concentric discs, each smaller than the one below it. The
largest and lowest is coloured violet and green ; the second, violet and
red; the third, red and green; and the fourth, black and white, or
grey. When the top is rapidly rotating the discs present a grey centre,
surrounded by three variously coloured rings. The patient is asked
whether any of the three rings seem to him to be grey, like the central
disc. If one should present this appearance, the patient is blind as
regards the colour absent from that disc.
Retinal pulsation in aortic disease. — Dr. Beckerf read, before the
Heidelberg Congress of 1871, an account of his investigations on
arterial (retinal) pulse in cases of aortic insufficiency. He had
observed, in concert with Dr. Sichting, that under such circumstances
a spontaneous arterial pulse was visible with the ophthalmoscope in the
direct image. At first he thought the observation new, but found
afterwards that he had been anticipated by Quincke, who had pub-
lished two articles upon the subject.^
Further and careful examination showed that in every case of
insufficiency of the aortic valves, not complicated with other valvular
disease, the arterial pulse was plainly visible, and the more plainly the
more considerable the consecutive hypertrophy of the left ventricle. It
was absent when valvular insufficiency was combined with very pro-
nounced anaemia or with fatty degeneration of the heart. The pulse
was visible, not only upon the papilla, but over the retinal surface,
wherever it was possible to follow the arteries with the ophthal-
moscope.
The phenomenon is wholly different in its character from the
so-called arterial pulse of glaucoma, in which, on account of the
resistance to be overcome, blood only enters the central artery of the
retina at the acme of each successive pulse wave. The visible pulse of
* 'Annales d'Oculistique/ 1872, i, 112; 'Arch. f. O./ xvii, 2.
t * Annales d'Oculistique,' 1872, i, 275.
X *Berl. Klin. Woch.,' 1868, No. 34; 1870, No. 21.
ANATOMY AND PHYSIOLOGY. 341
aortic insufficiency presents all the characters that can be recognised
at the wrist by touch. It allows the observer to count on the retina
the beats of the heart, to see the rhythmical distension and elongation
of the artery, to recognise the distinction, during each pulsation,
botween the turgescence of the artery, its relaxation, and the pause ;
in other words, it displays to view all the characters of the pulse, its
frequency, its force or weakness, its sharpness or softness. By means
of the ophthalmoscope the eye can follow on the retina, as on the table
of a sphygmograph, all the undulations of the curve described by the
arterial wave.
The observation of the phenomena is not equally easy in all cases, or
in all parts of the same retina. The distension of the arteries is best
seen at a bifurcation, their elongation in those which present curves in
the form of an S. During the arterial diastole the curves of the S in-
crease, and return to their former position during the arterial systole.
Sometimes the rhythmical and vermicular movements of the vessels
communicate to the whole fundus of the eye a strangely animated
appearance. It is well known that similar conditions may be observed
in the mesentery of a frog. When a drop of water is suffered to fall
on the exposed intestine, the muscular coat, by its contraction, in-
creases the resistance offered to the arteries on their passage from the
mesentery to the intestine, and their vermicular movements assume an
almost spasmodic character.
Dr. Eecker has observed that, in a certain distribution of vessels on
the papilla, spontaneous arterial pulsation may be found even in the
normal eyes of healthy persons. He has also observed a case of
detachment of the retina, in which the arteries, on their passage over
the displaced portion, performed very manifest vermicular movements.
But his most interesting observation was in a case of aneurism of the
transverse aorta, in which the phenomena of visible pulsation were
apparent in the left eye and entirely absent from the right. This
condition could only be explained by reference to the seat of the
aneurism, which must have been so situated as to involve the origins of
the left carotid and subclavian, leaving the innominate free. The con-
clusion to be drawn from this is that, in certain cases, the appearance
of a retinal arterial pulse might assist in determining the precise seat
of an aneurism of the transverse aorta.
In the discussion which followed. Dr. Weber, in reply to Dr. de
Wecker, gave an account of the retinal circulation at and immediately
after dissolution. Dr. Schmidt, who had taken part in Quincke's
observations, confirmed the general accuracy of Dr. Becker's statements,
adding, however, that the force of the pulsations varied from time to
time with the degree of cardiac excitement. Dr. Becker rejoined that
he was so well aware of this that he was in the habit of administering
a stimulant to render the pulse more visible. He was entirely in
accord with Quincke except on two points. That observer said that
the pulse might be manifest at certain moments and quite invisible at
others. He also claimed to have seen, besides the arterial pulse, a
rhythmical coloration and pallor of the disc, which he attributed to a
capillary pulse. In spite of the most careful and conscientious exami-
342 EEPORT ON OPHTHALMIC MEDICINE AND SURGERY.
nations, he had not been able to verify either of these statements. Dp.
Schmidt observed that he had witnessed both phenomena. Dr. Becker
did not doubt him, but regretted that he could not himself say
the same thing.
Befraction. — Dr. E. Erismann, of St. Petersburgh, publishes* a very
full and detailed account of his investigation of the state of refraction of
the eyes of 4358 scholars or students of both sexes, and of ages ranging
from 10 to 24 years.
Cohnf brought before the Heidelberg Congress the results of his
examination of the dioptric state of the eyes of 240 village school
children, after the instillation of atropine. He commenced by some
observations on the paper of M. Erismann mentioned above, and stated
his intention of analysing this paper fully on a future occasion. At
the time he would only refer to some expressions in it which he
thought a little too bold, and especially to this, that the use of concave
glasses was hurtful to the sight of young myopes. Nothing could be
more difficult than to determine, a priori, whether, given a certain
degree of myopia, such or such a glass would be hurtful or not. In
order to answer such a question it would be necessary to have a number
of persons all with the same degree of myopia, all occupied in the same
manner and during the same hours, and to give glasses to half of them
and not to the others. Under such conditions, and after several months
of observation, it would be possible to determine the influence of spec-
tacles upon myopic vision.
The chief interest that Dr. Cohn found in the paper of M. Erismann
was the proof it afforded of the great frequency of facultative hyperme-
tropia. Among the children attending school at St. Petersburgh
44 per cent, were manifestly hypermetropic, and it might have been
found that many others were really so if atropine had been employed.
The author wished to fill this void in all previous researches ; and he
had been enabled, by favorable circumstances, to apply atropine to the
eyes of 240 children at the school of Schreiberhau. He selected 142
boys and 98 girls, all who were old enough for his purpose, and first
examined them for facultative hypermetropia without atropine, and
found Hm. in 77 per cent. After atropinization he found H in 99 per
cent., and in the following degrees :
H = T- in 26 per cent.
I .
80
in 23
I
40
I
in 9
I
— in 6 per cent.
30 ^
— in 4
24 ^
I
■— in 2
I
36
so that the extremes were -^^ and -}^, and the most frequent grade
* *Arcliiv. f. Ophth.,' xvii, i, i — 79.
t 'Annales d'Oculistique/ 1872, i, 89.
I
SURGERY. 343
was ■^-^. He concludes that the normal eye among children from 6 to
13 is not emmetropic, but presents a slight degree of hypermetropia.
Cohn's paper is published in full in the ' Archiv fiir Ophthalmologie ;'*
and the same journal contains also (p. 292) his promised review of
Erismann. The details are such that they scarcely admit of con-
densation. Maklakofff has examined the refraction of the eyes of
scholars twice, after an interval of a year, and his results generally
agree with those of Erismann. He found that both the number per
cent, of myopes and the mean grade of the myopia increased in the
more advanced classes. Among 759 scholars, 284 were of the junior
classes. Of these —
208 ('js^ per cent, were emmetropic.
69 (24i »> ) » myopic.
7 ( 2i „ ) „ hypermetropic.
307 were in middle classes. Of these —
189 (61 f)er cent.) were emmetropic.
"I (36 „ ) „ myopic.
7(2^ „ ) „ hypermetropic.
168 were in advanced classes. Of these —
86 (514 per cent.) were emmetropic.
73 (43i » ) » myopic.
9 C Sf » ) » hypermetropic.
He also found myopia more common among girls than among boys, a
circumstance which he attributes to such occupations as sewing, which
require the close application of the eyes.
Test ti/pes. — Burchardt has published J a set of test objects, which he
calls international, originally suggested by the test dots given in the
* English Army Medical Eeport for i860.' His introduction is trans-
lated, and specimens of the tests are given, in the ' Annales d'Ocu-
listique.'§ He enumerates the well-known disadvantages of types as
tests of the acuity of vision, and proposes to substitute for them
groups of black dots or circles, variously arranged and of graduated
sizes. The intervals between the dots are equal to their diameters,
and vision is tested by the distance at which the dots of a given group
can be seen and counted as distinct objects. Eor astigmatism he has
black circles intersected by white lines in several directions, correspond-
ing to the lines of Dr. Pray's test types. He professes to be able by
these tests to determine the state of refraction in each meridian, or i^
the eye as a whole, without the aid of lenses. It is worthy of remark
that the principle of using dots instead of letters is not new, but was
suggested by Dr. Giraud-Teulon to the Ophthalmol ogical Congress
of 1862. The author makes no reference to this circumstance.
(b) Surgery.
Cataract extraction. — Dr. Mazzei, of Florence, in a letter addressed
* xvii, 2, 305.
t ' Societe Phys. Med. de Moscou,' 187 1.
X ' Cassel, Verlag von A. Freyschmidt,*
§ i, 187 1, 25 etsec^.
844 REPORT ON OPHTHALMIC MEDICINE AND SURGERY.
to Dr. Charles Delstanclie,* enters at length into his method of cataract
extraction, for which he claims a large proportion of success. He dis-
penses with a blepharostat, and never administers an ansBsthetic. He
does not use the upper section except for prominent eyes, and prefers
the lower wherever the orbital fat is absorbed, or the eye, from any
cause, deeply seated. He entrusts the upper lid to the care of an
assistant, who is told not to elevate it too much, and himself steadies
the globe with two fingers of the right or left hand, according to the
side operated upon. He then introduces a knife, of the general model
of that of Grraefe, but twenty-four millimetres long instead of thirty,
and three broad instead of two and a half, at the junction of the lower
with the middle third of the outer corneal margin, and carries it into the
anterior chamber directed towards the pupil, or at an angle of 40° with
the lower horizontal tangent of the cornea. When the widest part of
the blade has fairly entered the chamber he changes the direction of the
point in such a manner as to make a counter-puncture opposite the
puncture, the cutting edge being turned directly downwards. The
counter-puncture being fully made, the cutting edge is turned forward
till the flat of the blade makes an angle of 45° or 50° with the iris, and
then the corneal section is completed by a gentle sawing movement.
The capsule is next lacerated, and an attempt made to extract the lens
by simple pressure and counter-pressure. If this should not succeed,
or if the iris should protrude before the advancing lens, an iridectomy
is performed, and the necessary pressure again employed. The external
incision may be enlarged if necessary. Six hours after the operation
the writer drops in solution of atropine, and repeats the application
every twelve hours, the lightly compressive bandage being changed
each time. After three days the bandage is laid aside, but the atropine
is continued for twelve days longer. The writer claims for his method
the great simplicity of the operation, the almost constant preservation
of the integrity of the iris, and a smaller degree of pain and distress to
the patients, on account of the non-employment of blepharostat or
fixation forceps. ISTo statistics of the method are given. Dr.
Martin, chef de clinique to Dr. de "Wecker, publish esf a statistical
report of the operations performed at the clinique during the second
half of 1 87 1. Among these were ninety-five for cataract, of which
eighty-six were for spontaneous, five for traumatic, and four for con-
genital cases. The spontaneous and the traumatic cases were all ope-
rated upon after the method of von Grraefe, with modifications as
regards the section of the sclerotic and as regards the manner
of opening the capsule. The section is based upon the fol-
lowing rule: — The puncture and counter-puncture are made in the
sclerotic tissue, a millimetre heyond the corneal houndary, upon a hori-
zontal line two millimetres helow the upper corneal margin. The knife
is made to cut its ivay out at the level of the superior corneal margin. In
this way a flap is obtained, the summit of which corresponds exactly to
that of the cornea, while its base, situated two millimetres lower,
measures the whole width of the cornea at that level, with the addition
* 'Annales d'Oculistique,' 1871, ii, 202.
t Ibid., 1872, i, 157.
SURGERY. 846
of two millimetres (one on each side) from the sclerotic. If the cornea
be of twelve millimetres horizontal diameter, the section thus made will
be of eleven or eleven and a half millimetres, while that of von Graefe
never exceeded ten or ten and a half
This enlargement of the section is not necessarily attended by a large
excision of the iris. A large coloboma may be avoided by not drawing
out too much iris prior to excision ; and, when the excision is made, it
is always possible, if the iris should tend to lock itself into the angles
of the wound, to replace the extremities of the sphincter by slight
movements over the cornea with the convexity of the caoutchouc spoon.
It is an important point in De "Wecker's section that the same rule
suffices for all cases and persons, and, unlike Graefe's, requires no modi-
fication for very large or very hard lenses, or for eyes of small corneal
diameter.
The division of the capsule is effected by a forceps resembling iris
forceps, but furnished with a screw to regulate the extent of separation
of the blades, and with a point on each blade to serve as a cystitome.
The forceps being introduced closed and horizontal, until it reaches
the inferior margin of the pupil, is then turned into a vertical position,
BO that its points perforate the capsule. The blades are then allowed
to expand, so that the two points incise the capsule horizontally at the
level of the pupillary margin. Still expanded, they are drawn towards
the section, making two parallel incisions in a vertical direction.
When nearly at the margin of the lens the blades are closed, the points
making the second horizontal incision, and thus cutting out a square
portion of capsule, corresponding to rather more than the pupillary
area. As the blades are closed this portion is seized between the for-
ceps teeth, and is withdrawn altogether from the eye. The forceps
cystitome should on no account be introduced until the cut margins of
the iris are restored to their proper position. After the operation both
eyes are covered by circular pieces of fine linen, over which are pads of
unglazed wadding, so placed as to fill all the space between the orbital
margin, the bridge of the nose, and the prominence of the cheeks. These
pads are retained by a binocular flannel bandage, which exerts slight
pressure over the eyes and renders the lids immovable. On the evening
of the operation a dose of chloral hydrate is administered, and on the
following morning, if the pupil is sufficiently dilated and free from cortex,
no atropine is used. It is only employed when the aqueous is a little
turbid, when cortical masses remain, or when the iris is threatened with
inflammation. The foregoing observations are followed by a table
giving full details of each case and of the results obtained.
Extraction without opening the capsule. — Dr. Hermann Pagenstecher*
gives the results of the more recent experiments of his brother. Dr.
Alexander Pagenstecher, in this method of operating, which, during the
last few years, he has applied to 140 cases. Careful observation has led
to the conclusion that the method is specially applicable to certain
groups of cataracts, while others are more successfully removed by
opening the capsule. The delicacy of the latter in certain cases, and
its intimate union with the zonula, contra- indicate the general adoption
* 'Aunales d'Oculistique,' 1871,11, 126,
346 REPORT ON OPHTHALMIC MEDICINE AND SURGERY.
of the proceeding. On the other hand, it seems to be especially ad-
vantageous when the resistance of the capsule is greater than that of
the zonula. In the latter category may be placed nearly all senile cata-
racts, whether they are regressive and hard, or soft, as well as those in
which, after the slow development of opacity, certain portions of the
cortex remain permanently transparent, and never attain maturity.
Such are, in general, of small dimensions, and the attachment of the
capsule to the zonula offers but little resistance. Most frequently the
cortical layers are in a regressive condition, and the cataract is conse-
quently somewhat flattened. A third group well suited for the pro-
ceeding comprises the cataracts which supervene upon irido-cho-
roiditis or iritis, and which coexist, with circular posterior synechiaB.
In such it is, of course, necessary to detach the adhesions, and this may
be done with a small blunt silver hook. The fourth group comprises
the cataracts that accompany iridodonesis, a state which depends either
upon regression of the lens or upon diminution in the bulk of the
vitreous body. The method is especially to be recommended for the
cases comprised in the last two classes, in which there is a tendency
to inflammation, and in which it is very important to protect the
iris from debris of cortex and of capsule. There is a last and rare
indication in those cases in which, prior to laceration of the cap-
sule, there is escape of vitreous humour. On account of these it is
desirable, even when intending to open the capsule, to be always ready
to employ the scoop.
Besides arriving at these indications, MM. Pagenstecher have much
modified their original method of operating. They now make a linear
incision upwards, instead of a flap, and a large iridectomy. In a few
cases, as soon as this is done, and the eyeball well fixed and turned
downwards, a slight pressure on the lower border of the cornea will
cause the lens, enclosed in its capsule, to present itself at the incision.
G-enerally, however, it is necessary to employ a scoop, specially con-
structed for the purpose by Messrs. Weiss and Sons. The scoop is
carefully carried behind the equator of the lens, and made to glide
over the posterior capsule until it reaches the equator on the opposite
side. To facilitate this manoeuvre it is necessary to make slight pres-
sure with the fixation forceps against the lower border of the lens, and
thus to push the opposite margin upwards. After a slight rota-
tion, produced by change in the direction of the scoop, such that its
handle passes from the centre towards the inner angle of the wound,
the lens is drawn upwards, the handle of the scoop being at the same
time depressed towards the orbital margin. Thus there is produced
a slight pressure of the lens against the cornea, which forbids the former
to slip out of the concavity of the scoop. Its exit is at the same
time promoted by a slight pressure on the lower part of the cornea by
a caoutchouc curette, which is made to follow the advancing lens from
below upwards.
Anaesthesia from chloroform, which was always employed when the
flap section was made, is now only practised at the especial request of
the patient. Experience has shown that extraction with the capsule
may be performed as easily through the linear as through the flap in-
SURGERY. 347
cision. The author also finds that loss of vitreous occurs both less
frequently and to a less extent than before.
The subsequent treatment is the same as after other forms of opera-
tion. The advantages claimed by the author are —
The extraction of the lens within its capsule removes all predispo-
sition to iritis. In 200 cases operated upon there has not been one of
primitive iritis.
The method excluded all secondary operations. The visual acuity
is greater after this operation than after any other. In 12 per cent,
of the cases S= i.
Notwithstanding these advantages, it is not attended by a larger
proportion of lost eyes than ordinary linear extraction.
The defects consist in the difficulty of execution, and in the diffi-
culty in certain cases of arriving at an exact diagnosis. Loss of
vitreous occurs pretty frequently, but has never been found to interfere
with the union of the section.
It is necessary to observe that after these operations it is compara-
tively frequent for the anterior portion of the vitreous body to become
turbid. "Without considering whether the same thing does not occur
in other methods, it need only be said that such turbidity completely
disappears after a while. It most usually appears after loss of
vitreous, but seems to bear no relation to the quantity that may
escape.
Astigmailsm after cataract oiyerations. — "Woinow* has been engaged
with Eeuss in the study of astigmatism in aphakial eyes. He has
arrived at the conclusion that the cylindrical glasses employed for
ordinary astigmatism, and based upon ophthalmometric data concern-
ing the curvatures of the cornea, will not always neutralise aphakial
astigmatism, and that other glasses are to be preferred, of different
forms and w^ith their axes differently directed. Hence he believes that
aphakial astigmatism is not due to the cornea, but that it is seated in,
and due to the curvatures of, the posterior pole of the eyeball. He
finds also that many aphakial astigmatics require a different cylinder
and a different direction of the axis for vision of near objects, and he
explains this by the supposition that a certain rotation of the globes
takes place during convergence.f
Glaucoma. — Prof. QuaglinoJ publishes an account of some expe-
riments intended to determine what is the value of iridectomy in the
treatment of glaucoma, and leans to the conclusion that the incision in
the sclerotic is the essential element in the operation. He has prac-
tised sclerotomy upon several eyes already lost from glaucoma, and has
found a permanent diminution of tension and a clearing of the media
as the result. Since then he has used sclerotomy also in progressive
cases, and has been well satisfied with it. He operates with a lance
* *Prot. de la Soc. Phys. Med. de Moscou,' 1871.
t This seems subtle ; but surely the ordinary cause of astigmatism after cataract
operations is the alteration in the curvature of one meridian of the cornea, due to
the incision and the consequent cicatrix. Astigmatism thus produced not uncom-
monly follows simple iridectomy. — K. B. C.
X « Annali di Oftalmologia,' 187 1.
348 REPORT ON OPHTHALMIC MEDICINE AND SURGERY.
knife, as if for iri<iectomy, and withdraws the blade very gently, pressing
upon the iris as he does so. If prolapsus should still take place he
waits until the protruding portion is distended by the resecretion of
aqueous humour, and then punctures it in the direction of the radial
fibres. After this the prolapsus may generally be readily replaced.
Dr. de "Wecker, at the Heidelberg Congress of 1871,* referred to
Quaglino's results, and stated that he had himself made trial of
sclerotomy in a somewhat different manner. He introduces a G-raefe's
cataract knife, by puncture and counter-puncture, as if to make a flap
two millimetres in height, the point passing through the sclerotic very
near the corneal margin. He then divides the sclerotic for two thirds
of the distance between the punctures, leaving the central third undi-
vided, and retains the knife in the chamber until the aqueous has
escaped, when it is slowly withdrawn. In this way he avoids prolapse
of the iris. His cases seemed to him to establish the value of sclerotomy
in reducing tension, and to show that a cicatrix of filtration was the
condition essential to a cure.
Ulcus serpens cornece. — Pagenstecherf strongly supports Saemisch's
treatment ot creeping ulcer of the cornea. The treatment previously
employed at Wiesbaden consisted of atropine instillations, with warm
poultices and compression, and it often yielded good results. But com-
plete or nearly complete loss of vision was sufficiently common to render
a trial of Saemisch's method desirable. The results were —
1. The ulcerative process was restrained within its existing limits,
and thus the size of the eventual leucoma reduced to a minimum.
2. The base of the ulcer became clean and less turbid, and the sur-
rounding infiltration wholly disappeared in the course of a few days.
3. The pus or turbid matters in the anterior chamber were in great
part evacuated, and the absorption of the remainder much promoted.
The risk of occlusion of the pupil by the organization of false mem-
brane was thus greatly diminished.
4. The tendency to iritis rapidly diminishes, and complete dilatation
of the pupil is soon produced.
5. Existing ciliary neuralgia is commonly completely relieved, either
immediately or after the lapse of a few hours.
The precepts laid down by Saemisch were rigorously followed in the
making of the incision. The after-treatment consisted in the appli-
cation of a moist compress, the instillation of atropine, the application
of a pressure bandage at night, and the frequent reopening of the
incision. This last, however, was not continued for so long a time as
by Saemisch, but only for from five to eight days.
Corelysis. — Dr. de "WeckerJ entirely condemns operations for
detaching posterior synechise, either by corelysis or by Passavant's
method. He thinks that all such operations are usually followed by
anterior synechiae, the peripheral part of the iris becoming united to
the corneal wound. The way in which this wound is irritated by
passing hook or forceps through it, and the necessary dilatation of the
*= 'Aimales d'Oculistique,' 1872, i, 87.
t * Klinische Monatsblatter fiir Augenheilkunde.'
X ' Aniiales d'Oculistique,' 1872, i, 70.
pupil afterwards, combine to render such union probable ; and the
anterior adhesions are as perilous to the eye, if not more so, as
those which they supersede. Dr. de Wecker relates the case of a
gentleman who had a single, very fine band of anterior adhesion in his
left eye, passing from the inner and lower portion of the pupillary
margin to the small circumscribed scar of a nearly central corneal
ulcer. Several ophthalmic surgeons attributed frequent attacks of
peri-orbital pain to the presence of this adhesion. Nothing seemed
more easy than to detach it, and the attempt was made, without success,
first by Prof. v. Hasner, then by Prof. Knapp, and, lastly, by Dr. de
Wecker himself. Dr. de Wecker made a small incision at the margin of
the cornea, allowed the aqueous to escape slowly, and seized the iris
near the adhesion with forceps. He found, however, that he tore the
tissue of the iris instead of breaking the adhesion, and desisted after
three attempts. - Every operation was followed by union of the iris to
the corneal wound, so that the patient gained three fresh synechisB
without losing the old one, and without losing the pains for which
he had sought advice. Dr. de Wecker recommends, in all such cases,
the excision of the portion of iris that is adherent.
Suture of the eyelids. — Yerneuil* related to the Societe de Chirurgie
de Paris some cases in which he had pared the edges of the eyelids and
united them by suture, in order to prevent ectropion after the extirpa-
tion of an epithelioma of the lower lid, and after other injuries likely to
be followed by a contracted cicatrix, and also for the cure of ectropion
actually established by such contraction. In one case he maintained
the union of the margins of the lids for fourteen months. The results
in all his cases were very encouraging, and he advocates the employ-
ment of his method in preference to plastic operations, which are
usually only imperfectly successful. f
BurowJ confirms Passavant's account of the excellent qualities of the
so-called marine grass (obtained in China from the spinning organ of
the silkworm) for sutures. The threads produce no suppuration, even
if they are suff'ered to remain for weeks, and are especially adapted for
plastic operations about the eyelids. In the same paper he refers to
his use of threads soaked in collodion for twisted sutures. As soon as
the collodion is dry the pins may be removed. He uses English sewing
needles with broad points (glovers' needles ?) and floss silk.
Warlomont§ mentions a method suggested to him by the elder
Desmarres for removing suture pins without dragging upon the cicatrix.
The operator casts a loop of thread over the head of the pin to be
withdrawn, and steadies the soft parts by traction upon this loop with
the left hand, while the pin is withdrawn by the forceps held in the
right.
Gunshot wounds. — A contribution to ophthalmic surgery of entirely
* *Gaz. Hebd.,' 1871, 473.
t Union of the lids has been employed in this country by Mr. Bowman, by the
writer, and by others, and the power of healing extensive wounds by skin grafting
now renders a long period of occlusion unnecessary. — E. B. C.
X "Zur Lehre von der Wuuduaht," 'Berlin klin. Wochenschr./ 1871, 155.
§ 'Ann. d'Oculistique,' 187 1, i, 73.
L
350 EEPORT ON OPHTHALMIC MEDICINE AND SURGERY.
unprecedented and most important character has been made by Dr.
Hermann Cohn, of Breslau, who has recorded* his experience of the
cases of injury to the eyes treated at the Lazareths of Eorbach, Heinitz,
and Neunkirchen, during and after the Franco- German war, and his
paper is so novel and so important that it deserves a full notice. He
commences by stating that the literature of gunshot wounds of the eye
is extremely scanty, probably on account of the attention of military
surgeons having been directed almost exclusively to the wounds of
vital parts ; that even the statistical records of injuries to the eye are
very imperfect, and that military ophthalmic surgery can hardly be said
to exist, although the value of the organs implicated renders this branch
of the art worthy of all attention. Estimating the superficial surface
of the body at 15 square feet, and that of the eyes at 4 square inches,
we might expect one injury to an eye in every 500 wounds. Demme,
in the Austro -Italian war of 1859, saw, in all, 55 cases of shot wound of
the eyes, among which 19 produced blindness of both. Stromeyer,
among 714 invalids from the Schleswig-Holstein campaign, found losa
of eyes in 13 cases, but has not recorded in how many of these both
were lost. Williamson states that among the wounded from the last
Indian campaigns there were 1 1 cases of loss of one eye, and a single
case of loss of both. Erom the Crimean war there were 42 cases of
destruction of a single eye, and 2 cases of loss of both. In the Austrian
war of 1866 Niemetschek saw 9 and Mooren 4 cases of shot wounds of
the eyes, and beyond these there are, within Dr. Cohn's knowledge, no
statistics upon the subject. No conclusion can be drawn from the
number of soldiers invalided as blind, since the lists would exclude all the
cases in which injury to the eye had been followed by partial or complete
recovery. Even in the Franco- Q-erman war it was impossible to arrive
at the facts with any certainty, since in a large number of lists of
wounded the nature of the injury was not stated at all, and in others it
is probable that eyes were involved in many cases entered as injury to
the face, head, or brain. The only statistical guidance of any value is
that furnished by Dr. Eischer,t who has based a comparative estimate
of the relative frequency of wounds of different parts of the body upon
109,698 cases recorded from the annals of modern warfare. His table
is entitled to weight on account of the large numbers on which it is
based, and he gives 7*4 as the average percentage of wounds of the
brain and head, and ^'^ as the average percentage of wounds of the
face. There are, therefore, 10*7 per cent, of injuries in which one or
both eyes are liable to be implicated. If we assume that they will be
actually implicated in 10 per cent, of such injuries, an estimate that is
probably not much short of the truth, then the 100,000 wounded of
the Franco- German war would furnish 1000 cases of eye injury. The
care of the wounded was divided among at least 400 G-erman, French,
and foreign surgeons, and, especially at the beginning of the war, the
cases of injury to the eye were scattered among the several military
hospitals, along with all other cases that would bear removal, instead
of being sent to the numerous ophthalmic hospitals of Germany. It
* Contribution to Fischer's ' Kriegschirurgische Erfahrungen,' Erlangeu, 1872.
t * Uelier Kriegschirurgie,' Erlangen, i868.
SURGERY.
851
follows that scarcely any single surgeon enjoyed opportunities of
observing many cases of injury to tlie eye, and hence Dr. Cohn has felt
himself bound to make public the histories and results of 31 such
cases that came under his own treatment. "While on duty at the
railway station at Saarbrucken, Avhere hundreds of wounded passed
daily, it was his custom to select the cases of injury to the eyes for
treatment in his hospital at Heinitz ; and his colleagues, Drs. Fischer,
"Waldeyer, Spiegelberg, Fmne, Priinkel, and Busch, selected cases for
him in the same manner at Forbach, Neunkirchen, and Ottweiler. In
this way 14 cases were obtained, and the remaining 17 were seen for
the first time after the close of the war, some at his own eye hospital
at Breslau, others at a barrack hospital in Berlin. He treated 8 cases
at Heinitz, 4 at Eorbach, i at Saarbrucken, i at Neunkirchen, 6 at
Berlin, and 7 at Breslau. Among the 3 1 shot wounds there were 2 of
the brain, 16 of the eye only, 9 of the face, and 4 of the cranium.
Among the 16 wounds of the eye the eyeball was ruptured in 8 cases
and grazed in 2. In 5 the lids were wounded by fragments of shell,
and in I a fragment had penetrated the ciliary body. Of the 9 wounds
of the face ^ implicated the superior maxilla and 4 the zygoma, and of
the 4 wounds of the cranium i was of the temporal and 3 were of the
frontal bone. The right eye was wounded in 15 cases, the left in 14.
In one case double blindness and in another double nystagmus were
produced by injury to the brain.
In the 31 cases the following 70 conditions were observed. Dr.
Cohn has stated them, some in G-erman, some in Latin, and some in
phraseology hybrid between the two languages, so that his original
words are quoted when his meaning does not seem to be absolutely
clear :
Total loss of the eye {Totaler Defect des Auges)
Wasting of the eyeball
Extensive wound of the eyeball (Vulnus jperfectum bulhl)
Foreign body in eyeball
Opacity of cornea ....
Hasmorrhage into anterior chamber
Iritis .....
Partial loss of iris {Defectus iridis partialis)
Iridodyalysis ....
Traumatic mydriasis
Opacity of anterior capsule
Hemorrhage or opacity in vitreous body .
Rupture of choroid
Hsemorrhage in choroid
Contraction of field of vision without visible change
Cicatrix in retina ....
Chorio-retinitis with exudation
Hsemorrhage at yellow spot
Disease at yellow spot
Detachment of retina
Atrophy of optic nerve
Complete amaurosis
Inflammation of optic nerve
Amblyopia without visible change
Sympathetic affection without visible change
Weakness of internal recti
m
REPOltT ON OPHTHALMIC MEI)1CINE AND SURGER"^.
Weakness of external recti . . . . i
Monocular weakness of accommodation . . , i
Nystagmus . . . . . .1
Sympathetic blepharo-spasm . . . .1
Ptosis . . . . . . .4
Lag^ophthalmus . . . . . .1
Cicatrix of lid . . . . . .2
Foreign body in lid . . . ., .2
Pterygium ...... i
In a case of wound inflicted by a waggon-wheel passing over the eye
there was laceration of the upper lid, followed by defective union ; and
a case of bayonet wound of the orbit was followed by paralysis of the
rectus internus, complete ptosis, and pterygium.
The operations performed in the 3 1 cases were enucleation of the
eyeball in 5, and in 3 the excision of splinters of shell that had pene-
trated the lids. The following cases are among those given in detail :
Two cases of injury to the Irain.
I. — Juschkat, 8Bt. 27, was injured in the brain by a chassepot ball
before Metz, on the 14th August, 1870, and was struck down stone
blind, but without loss of consciousness. The wound of entrance was
situated an inch and a half above and behind the concha of the right
ear, in a line with a prolongation of the palpebral fissure, and therefore
in the lower and posterior portion of the right parietal bone. When
the patient reached Eorbach, on the 1 7th of August, a portion of brain
the size of a walnut had escaped from the wound, and was adhering to
the shirt collar. There was no wound of exit, and the ball was found
lying about 2" behind and i^' below the wound of entrance, a little to
the right of the occipital eminence, from which position it was immedi-
ately removed by Prof. Fischer. Perception of light returned the same
evening, and on the following day the patient could discern the (white ?)
clothing of the nursing sister who had charge of him. A small quan-
tity of brain tissue mixed with pus escaped daily from the wound, which
was only gently syringed. The patient had perfect freedom of movement,
and his taste, smell, and hearing were normal. There was no paralysis
of either extremity. Dr. Cohn saw the case for the first time on the j
22nd of August, eight days after the injury. The eyes were then, as ■
they had been from the beginning, quite normal in external appearance.
In the right eye the pupil measured 2V", and promptly contracted to
I \"' under lateral illumination or direct lamplight. When looking at
the illuminated face of the observer it discerned movements of the
hand outwards, upwards and outwards, and downwards and outwards,
but in no other parts of the field. Colour perception was lost, but the
power of distinguishing whether large objects were bright or dark re-
mained, and, although movements of the hand were seen, the fingers
could not be counted. The ophthalmoscope showed perfectly clear
media, the retina nowhere detached. The optic nerve was much
swollen, its margins obscured, its surface exhibiting a radiating stria-
tion in the course of the fibres, the veins distended and winding, the
arteries very small, and a number of fine vessels were visible, such as
are never seen in the healthy state. The whole surface of the disc was
SUUGEEt. S53
very red, with a greyish tone. Eetina healthy. In extreme abduction or
adduction of the eye there were slight pulsatile movements of the globe.
Tension seemingly normal. Left eye: — Pupil 3''' in diameter, con-
tracting very little at the close approach of a flame. No perception of
light in any direction. Aspect of nerve the same as in the right eye.
The patient slept and felt well, and answered intelligently all questions
put to him. All functions were naturally discharged. Pulse full, 50.
Dr. Cohn gave a doubtful prognosis, and advised two leeches to be ap-
plied to the inner angle of each orbit. The local circumstances pre-
cluded treatment in a dark room, and when Dr. Cohn next visited
Porbach, on the 2^th of September, the patient had been sent away. The
notes in the journal were : — " August 26, abscess in the neighbourhood
of wound and removal of splinters of bone after incision. Sept. 4,
sudden acute headache and a rigor. Sept. 14, vision much improved,
wound healing. Discharged."
Dr. Cohn remarks that this case presents many features of great in-
terest. It is another illustration of the well-established fact that large
quantities of brain substance may be lost without disorder of the intel-
ligence. Secondly, it shows that even total traumatic amaurosis may
terminate in recovery. Thirdly, that sudden increase of pressure on
the brain may produce double stauungspapilla, with sudden loss of
sight. That the blindness was not the result of concussion of the retina
seems to be proved by the ophthalmoscopic examination, since such
concussion is never attended by visible changes. It must be admitted
that in gunsliot wounds of the brain we never have symptoms of pure
compression, those of concussion and contusion being always added.
But in this case everything shows the predominance of compression ;
the slow full pulse on the eighth day, and the circumstance that per-
ception of light was restored to the right eye on the eighth day, imme-
diately after the projectile was removed. It is well known that V.
Grafe, in 1866, sought to explain the occurrence of stauungspapilla
in intracranial tumours, by obstruction to the flow of blood through the
cavernous sinus. He believed that the passive congestion of the retinal
vein thus occasioned was multiplied by the constriction of the sclerotic
foramen. Sesemann, however, in 1 869, proved by careful injections that
the retinal vein always communicates with both the superior and the
inferior ophthalmic, and that by constant anastomoses at the inner
angle of the orbit the blood from these veins can always find outlet by
the facial; so that increased intracranial pressure cannot afiect the
ocular circulation in the manner supposed. In the same year it was
shown by Schwalbe that the space between the two sheaths of the optic
nerve is continuous with the arachnoid space, and Schmidt, who re-
peated Schwalbe's experiments, found that by injecting the arachnoid
cavity he could distend the space between the nerve sheaths quite up to
the lamina cribrosa. Hence, he correctly inferred that increased intra-
cranial pressure would force the arachnoid fluid between the nerve-
sheaths, and produce swelling and compression at the lamina cribrosa,
so as to impede both the circulation of blood and the conduction of
nervous impressions, and to produce the changes known as stauungs-
papilla. Leber took the next step, for, in the autopsy of a patient who
23
354 EEPORT ON OPHTHALMIC MEDICINE AND SURGERy.
had been tlie subject of stauungspapilla, he found considerable thicken-
ing and an oedematous condition of the inner sheath, and of the lax cel-
lular tissue separating it from the outer. This tissue was ''much
hypertrophied, and in most places increased almost to be an interme-
diate layer." The case now recorded seems powerfully to support
Schmidt's view, since in no other way could the sudden occurrence of
so great a degree of stauungspapilla be explained. The intracranial
pressure must have been increased by the presence of the projectile, and
the arachnoid j3.uid forced between the nerve-sheaths and against the
lamina in such a way that the circulation and the nerve conduction
were both alike arrested.
It may be urged against this view that, as the ophthalmoscopic ex-
amination was not made until the eighth day, there is no evidence as
to the time at which the changes in the disc occurred. But Dr. Cohn
contends that it would be far-fetched to assume a descending neuritis,
in view of the instantaneous blindness, and refers again to the slow
pulse as an evidence of pressure. It may also be objected he says, that
a stauungspapilla is not a sufficient explanation of total blindness,
since many cases have been observed in which this condition has co-
existed with almost normal vision. He points out, however, that there
would be a vast difference between the sudden traumatic compression
and even the same degree, if more gradually produced. He refers also
to another possible objection, namely, that on Schmidt's hypothesis
every case of compression of the brain would be attended with stauungs-
papilla, which he admits is not the case. He suggests th'e possibility
that something may depend upon the part of the brain from which the
increased pressure proceeds, and points out the need for careful oph-
thalmoscopic examination in all perforating wounds of the brain. At
present he is aware of only one recorded case at all similar to the fore-
going,* and this was examined very superficially.
2. The second case of brain injury befell Jaschke, set. 23, who re-
ceived a shot in the head before Paris,'on the 20th of September. He
fell, remained unconscious for half an hour, and on recovery found his
left arm and leg paralysed, and an acute pain in the left side of the
head. He was removed to the Gonesse Lazareth, and knew then
where he was. He was wearing his helmet when wounded, and the ball
passed through the right flap of the helmet and split against the skull.
Half passed out through the back part of the right half of the helmet,
the other half lodged in the brain, whence it was removed, three months
later, by Prof. Konig, at Berlin. Dr. Cohn saw the case for the first
time on tlie nth of April. There was then a cicatrix over the right
parietal bone, not sensitive on pressure, measuring 1^" in length and ^"
in breadth and depth. The patient had complained from the day of the
injury of a dazzling before the right eye, there being no dazzling of the
left, and both being of normal aspect. After reading for half an hour
the dazzling of the right eye became excessive, and was attended by
lacrymation. If he abstained from reading he had no inconvenience,
it being only produced by exercise of the accommodation. The left
* Demme, * Spezielle Chirurgie, der Schusswunden.' Abth. 2, p. 7.
SUBGERY. 355
arm and leg were still completely paralysed, the patient using a crutch.
The pupils were of equal size, and acted equally and well to light.
Before the removal of the portion of bullet from the brain he felt
always a dull pressure in the right eye, but this disappeared a few
weeks after the removal. The vision was perfect. Dr. Hecke, the
assistant-surgeon in charge, stated that the patient would often com-
plain suddenly of feeling hot, and that his pupils would on these occa-
sions become widely dilated, soon returning to their ordinary condition.
In the right eye A = ^ but only with great effort and after half a
minute. No. i|- Snellen was read fluently from 6'^ to i8". No. 3
from 6" to 30". Left eye, No. 3 fluently from 3" to 40" ; No. i|- from
3-J" to 18". In either eye S = i. No defect of field. Fundus quite
normal ; pupils of equal diameter. The case presents, therefore, the
very rare condition of a monocular paresis of accommodation from
gunshot wound of the brain.
MffJit cases of rupture of the eyeball. Enucleation in three cases. Anato-
mical conditions of the enucleated eyeballs. Sympathetic ophthalmia.
Bemarks on the indications for y and on the performance of enucleation. —
I. C. Slurzos, set. 23, wounded on the iSth of August, before Metz.
The ball entered i" in front of the tragus of the left ear, passed through
the left zygoma, the outer margin of the orbit, the outer part of the
sclerotic, the cornea, and made its exit through the upper lid. Dr. Cohu
first saw the case four days later at Eorbach. The left upper lid was
tense and hard, with a lacerated wound at the middle of its margin,
and on its inner surface a ragged wound of conjunctiva and cartilage.
The conjunctiva of the globe much swollen and chemosed. The cornea
presented a ragged opening which occupied four fifths of its surface,
and from which a fissure passed in an outward direction for 3'" into the
sclerotic. The cavity was filled by a dark mass in which no trace of
lens or iris could be seen, and vision was entirely lost. The wounded
eye was acutely painful, and was at once removed, and placed in
diluted chromic acid for examination. The choroid was found detached
from the sclerotic by a large clot that nearly filled the remains of the
eyeball, and there was evidence of commencing suppuration. The lens,
iris, vitreous body, and retina were wanting, probably carried away by
the ball. On the 2^th of Sept. Dr. Cohn saw the patient again and
found him convalescent. The right eye read Snellen No. 2 from 1^',
and No. 3 fluently to o^(J\ There was no pain on continued exercise of
accommodation.
2. Borner, J., set. 21, struck on the i6th of August, by a shot that
entered the right eye and passed out through the neck. Seen by Dr.
Cohn on the 20th. There was a small loss of substance of the margin
of the tarsal cartilages, with cilia of both upper and lower lids, and the
upper and inner quadrant of the cornea was separated from the rest by
a gaping wound, through which a blood-tinged, watery fluid escaped.
The sclerotic at the inner corneal margin is ruptured and separated
from the neighbouring lower and outer portion by a wound 2'" wide.
The ocular conjunctiva chemosed, the eye very painful, the cornea
turbid, vision totally lost. The whole left cheek was much swollen, hot,
and painful, and there was marked facial paralysis. The ear was normal
356 HEPOUT ON OPHTHALMIC MeDICINE AKB SURGERY.
but 2'' behind the lobe, at the margin of the hairy scalp, there was an in-
conspicuous small opening, with surrounding tenderness, discharging a
little yellow serum. The vision of the left eye had been imperfect from
youth, and its lids were then spasmodically affected. Enucleation was
advised, but was necessarily deferred in consequence of other calls upon
the surgeons. It was performed on the 24th, by which time impending
panophthalmitis had made further progress, the facial paralysis being
unchanged. The edges of the lid wounds were at the same time pared,
and brought together by sutures. Recovery took place favorably, and 1
on Sept. 20th the left eye read Snellen i^ fluently over a range of from
2" to 4'- Without a lens| S = /q, after neutralizing the myopia by
— 1, S = \^. No distress of accommodation after prolonged reading.
The eyeball was examined by Dr. Waldeyer, but it was so much
destroyed by the injury that nothing beyond diffuse purulent infiltra-
tion of the choroid was recognisable.
3, Legouey, 83t. 22, struck by splinters of shell before Metz, on
Aug. 1 7th. After remaining seven hours on the field he obtained cold
compresses from a Trench surgeon at the church of a neighbouring
village, and after two days was sent he knew not where. On the 24th
of August he came to Dr. Cohn, by whom, according to his own account,
he was for the first time carefully examined. Immediately after the
injury there was, he said, a considerable fluid discharge from the right
ear, whether of blood he did not know. There were numerous burns
and abrasions of the skin over the right eyebrow, cheek, and side of the
nose. The brows were powder-blackened, and at the outer extremity
of the right eyebrow there was a lacerated wound i" long, discharging
a quantity of greenish pus. The right lids were closed, the upper lid
was moderately swollen and somewhat hard. On raising it the con-
junctiva was seen to be red and much swollen, and a scorched brownish
mass occupied the place of the cornea. Loss of vision complete. There
was purulent discharge from the right external auditory meatus, and a
watch could not be heard with this ear. Enucleation was performed
with some difficulty, it being impossible to detach the muscles entirely
from the torn sclerotic ; and the eyeball was so completely disorganised
that nothing but the sclerotic was distinguishable. A large number of
small fragments of shell were removed from the forehead, eyelid, and
cheek, and cold compresses were applied. Grood recovery followed, and
on Oct. 3rd the report was that the stump had good movement down-
wards and outwards, but very little in other directions. Left eye
normal, with no discomfort after continued use.
4. Sehn, H., set. 23, struck by a chassepot bullet at St. Privat, on Aug.
1 8th, and seen by Dr. Cohn on September 13th. The wound of entrance
was in the right ala of the nose, and was brought together by sutures
two hours after it was inflicted. The bullet passed through the nasal
bone, the left superior maxilla, and the left eye, to the temple, shatter-
ing the upper part of the outer margin of the orbit, and escaping 2" in _
front of the tragus of the left ear. Many splinters of bone had been 1
removed from the nose and from the temporal region. The eyeball ■
was reduced to a small stump, in which there was no trace of cornea,
and which was sensitive to touch. Conjunctiva of the globe much in-
SURGERY. 857
flamed. Movement downwards lost, movement inwards and outwards
limited, movement upwards very limited. The right eye had M = J^,
with p.p. for No. 2 at 4^", and was painful when used for very near
vision. Field normal. Dr. Cohn warned the patient of the possibility
of sympathetic ophthalmia, and advised him to submit to enucleation if
the field should become contracted, or if the pain felt in accommodation
should increase. On the 6th of October he saw the case again, and
found a better state of things. The p.p. at 2", the field normal, and all
pain and inflammation had subsided.
5. Gommenginger, I., set. 22, wounded on Aug. 6th at Spicheren, and
seen by Dr. Cohn on Aug. 13th. A bullet had entered at the junction of
the nasal bones with the frontal bone, shattering the cribriform lamella
of the ethmoid and the zygomatic process of the right superior maxilla,
tearing the right eye out of the orbit, and issuing on the lower and back
part of the cheek, in front of the right ear. The orifices of the wound
and the cavity of the orbit were covered by healthy granulations, with
abundant purulent secretion, and pus was also discharged from the nose
and mouth. Crepitus could be clearly felt about the zygoma. The
cheek was much swollen and very painful on pressure, the swelling
simulating facial paralysis. In the course of time many splinters of
bone were removed, and recovery took place. On the 23rd of Sept. the
patient was discharged, the left eye being of normal aspect and free
from discomfort.
6. Max, K., set. 27, wounded at Le Bourget on the 21st of December,
at 9 a.m., when in the act of leaping over a ditch. Telt as if his left eye
had been pierced by a needle, then lost consciousness and fell into the
ditch, where he remained two hours. At five in the evening found him-
self a prisoner in the hospital at St. Denis. Had a sensation of empti-
ness in the left orbit, and was told that his eye was gone, but does not
know whether it had been removed by the surgeons. The wound was
inflicted by a round ball from a Eemington rifle, and the ball, which he
saw, seemed torn, as if it had been itself explosive. A portion of the
patient's gold spectacle frame was imbedded in the bullet, and near this a
portion of one of the lenses, fused to an opalescent condition. The bullet
was extracted on the sixth day after the injury, from the left sterno-
mastoid, about 3" below the lobe of the ear. After suffering many pri-
vations he was given over to a Prussian outpost on the 5th of Eeb., and
Dr. Cohn saw him on the nth of May. The margins of the lids were
united towards the outer canthus, so that the fissure could not be
opened more than 3"', and about 2" of the frontal process of the malar
bone was wanting. The palpebral conjunctiva was almost of natural
aspect, the ocular somewhat swollen. Nothing could be seen of the
eyeball, the place of which was occupied by a cicatrix of two branches
meeting at an angle, and with somewhat swollen margins. In the
inner and upper part of the orbital cavity a probe detected some hard
substance, somewhat but not very sensitive, possibly remains of an eye-
ball. Eight eye M=3|^, S = i, with difficulty, and under good illumina-
tion. Snellen No. i was read fluently from 2" to 4". Pield of vision
normal. On the 15th of May, in very good daylight, he read S= i with
— 4. Dr. Cohn instructed him concerning the premonitory signs of
358 REPOET ON OPHTHALMIC MEDICINE AND SURGERY.
sympathetic ophthalmia, whicb might be excited if, as seemed possible,
some portion of the spectacle were still imbedded in the orbit. He
was supplied with an artificial eye, which was but little movable.
7. Steinmetz, F., set. 26, struck on the right eye and cheek by shell
splinters before G-ravelotte, on the i8th of August. He was for some
hours insensible, and on recovery found himself in a lazareth, where he
discovered that he had lost the sight of his right eye, which gradually
dwindled. During the first four weeks after the injury his left eye was
very sensitive to light, and he had sensations of dazzling when he at-
tempted to read. Dr. Cohn saw him in the following April, and fouud
some badly healed scars about the right eyelids, and the globe shrivelled
up to a small knob, freely movable in all directions, very soft, and not
sensitive on pressure. The left eye quite normal.
8. Eakel, A., set. 30, wounded by a chassepot bullet before Le
Mans, on the loth of January. The ball pierced the root of the nose
and the left eye, and passed out through the outer margin of the orbit.
On the loth of April Dr. Cohn found the left upper lid greatly thick-
ened, with discharge of pus from the orbital cavity. On lifting the lid
with a retractor, some hard substance was felt, but it was impossible
to say whether this was the stump of the eyeball or a fragment of bone,
since the patient was excessively sensitive to pain, and refused to take
chloroform. The right eye was of normal aspect, and the pupil acted
naturally, but the patient complained of constant dazzling when he looked
at any object. He could only read No. 14, and that imperfectly. No
convex lens helped him, but only produced increased strain. The daz-
zling had become much worse since he was wounded. An attempt to
take the field of vision produced lacrymation and blepharospasm, and
was therefore abandoned, but the field seemed to be totally defective on
the inner side. The fundus was normal, except that the choroidal
epithelium was almost wholly absent, and this atrophy seemed of old
date, as it extended far forward. His vision with this eye was defective
before the war. Dr. Cohn vainly urged him to submit to an explora-
tion of the orbital cavity and to the removal of the stump or foreign
body lodged there.
Upon the basis of these eight cases Dr. Cohn discusses the question
whether an eyeball lacerated by shot should generally be enucleated, and
if so, when ? Two grounds are to be urged in favour of the operation.
First, the dread of suppurative choroiditis (panophthalmitis) ; secondly,
the dread of sympathetic ophthalmia.
"With regard to panophthalmitis we know, from the experience of the
time when cataracts were removed by flap extraction, and when suppu-
ration of the eyeball occurred in a considerable percentage of thei
failures (although by the linear method it has been rendered excessively]
rare), with how great pain the distension of the eyeball by pus was
attended. We know, also, that the panophthalmitis lasted three or
four weeks, and in some cases the pain continued long after the evacu-
ation of the pus, radiating over the whole head, destroying sleep, at-
tended by fever, and materially reducing strength. Even in cases of
rapid panophthalmitis, after wounds of the ciliary region, followed by
shrinking of the eyeball, the cicatricial contraction has often produced
SUEGERY. 359
irritation of the ciliary nerves, attended by acute ciliary neuralgia, and
by danger of sympathetic ophthalmia. If we may regard enucleation as
a simple and not difficult operation, followed by little or no pain, and
absolutely excluding the risk of sympathetic ophthalmia, then the indi-
cations for its performance become imperative in every case of perfo-
rating shot wound attended by loss of sight, unless they are counter-
acted by some danger connected with the proceeding. Dr. Cohn be-
lieves that only four cases of death after enucleation have been recorded.
At the Heidelberg Congress of 1863, in a discussion on mortality after
cataract operations, v. Grafe observed that he had seen two cases of
death after simple enucleation of the eyeball, performed during the
acute stage of suppurative panophthalmitis with exophthalmia, and
deprecated the performance of the operation at such a time, since he
had never known it produce death under other circumstances. Upon
this, Mannhardt cited a case of death from meningitis (no autopsy)
after enucleation, and Horner another, in which the autopsy revealed a
meningitis that was wholly unconnected with the parts within the orbit.
Unfortunately, no full accounts of any of the cases were given, as they
were only mentioned in course of the debate. Those of Mannhardt and
Horner need hardly be here considered, but v. Grrafe's direct warning
seems to be highly important. It is to be regretted that there is no clue to
the histories of the cases, as v. Grafe has only published one instance of
enucleation in panophthalmitis, performed three years before the time
referred to, and in which there is no mention of a fatal issue.
Mooren* relates an interesting case from the Austrian war in which
a bullet struck near the union of the zygoma with the sphenoid bone,
and made its exit behind the root of the nose on the inner margin of the
opposite orbit. The patient was totally blind of both eyes immediately
after the injury, and on the same evening the shattered eye was
removed under chloroform in order to prevent suffering. The splin-
tering of the lacrymal and ethmoid bones produced great swelling of
the soft parts ; and, as this subsided, the vision of the other eye slowly
returned, until, after the disappearance of some serous infiltration of the
retina, No. i Jager could be read. Here, therefore, enucleation was
performed prior to the commencement of panophthalmitis, and without
danger to life. The same author has recorded 128 cases of enuclea-
tion, observing that he had never once seen any serious symptoms ; and
the operation has now become so common, for eyes blinded by tumours,
cyclitis, phthisis, irido-cyclitis, or irido- choroiditis, that fatal cases
would certainly have been made known if they had occurred. In the
three instances related by Dr. Cohn, in which early enucleation was per-
formed, there was evidence of impending panophthalmitis, and in all of
them, instead of danger following the operation, the previously existing
pain was promptly relieved.
As regards the risk of sympathetic ophthalmia, all ophthalmologists
are now agreed that wounds of the eye, especially in the neighbourhood
of the ciliary region, are attended by this danger. In fifty-two cases of
sympathetic amaurosis, Mooren found twenty-four which had followed
* * Oplitbalmiatrische Beobachtungen.'
I
860 HEPORT ON OPHTHALMIC MEDICINE AND SUHGERY.
a wound of the ciliary body. The same author thinks it doubtful
whether in all cases of panophthalmitis the disorganisation of the ciliary
nerves is sufficiently complete to give entire immunity from the danger.
"Whenever, he observes, he has seen symptoms threatening the second
eye follow a panophthalmitis, he has generally also found that the latter
had left a painful stump. Although much in the history of sympa-
thetic ophthalmia is still obscure, it is, at least, 'certain that any kind
of injury to the ciliary nerves may excite it, and, unfortunately, the
commencement of the mischief is often highly insidious. The patient
is only brought to the surgeon by subjective symptoms at a time when
the intractable disease has gone too far for vision to be preserved.
Moreover, the commencement differs much in different cases, being
indicated in some only by very slight concentric contraction of the field
of vision, or by slight fatigue on looking at near objects, in others by
rapid loss of sight, constant dazzling and dancing of objects before the
eyes, or by lacrymation with photophobia. That there is no available
remedy but enucleation, and that this often fails' when practised how-
ever early after the appearance of symptoms, is known to all surgeons,
and it may, therefore, be laid down that the enucleation of a shot
blinded eye will preserve its fellow the more certainly the sooner it is
performed, and that it should be performed prior to the occurrence of
the smallest lacrymation or contraction of the field. In the case of
common soldiers and others of the less educated classes, liable to be
distant from skilled ophthalmic surgeons at their own homes, and to be
tardy in seeking advice for their ailments, enucleation should be per-
formed as a prophylactic measure in all perforating shot wounds causing
blindness. The woollen seton recommended by v. Grafe is, at least, of
questionable trustworthiness for the end in view ; and the section of
the ciliary nerves, advised by v. Grrafe and first practised by Meyer, is
open to the objection that it is difficult to be certain of dividing all
the nerves by which mischief may be done, and that, when divided,
they may reunite and restore the danger of sympathetic affection. It
has been urged that for the reception of an artificial eye a wasted globe
18 better than enucleation. On this ground, Himly advised free division
of the eyeball in panophthalmitis, and Williams the abscission of the an-
terior half by passing a cataract knife through the equator, and complet-
ing the section by scissors. Apart from the free bleeding from the cho-
roidal vessels that would often be produced by such a course, it is evi-
dent that the movements of such a stump would be very imperfect, since
the recti muscles are inserted in front of the equator. It cannot be
denied that an artificial eye moves better when placed on the remains of
the globe than when on the conjunctiva and muscles only ; but it is also
true that the stump is often irritated by the foreign body, and that
sympathetic ophthalmia may be thus produced.
With regard to the method of enucleation Cohn observes that,
although the operation is very easy when dealing with an unopened eye
ball of ordinary tension, and with a natural conjunctiva, it becomes very
difficult when the conjunctiva is swollen and the eyeball ruptured or
very soft. In the former case the points of insertion of the muscles
are not easily found. Dr. Cohn thinks it a matter of indifference which
[
SURGERY. 361
muscle is first divided, or in what order of succession they are taken.
He objects to the method of the Vienna school, in which the muscle on
the left side is divided at some distance from its insertion into the
globe, and the portion still attached is seized by forceps and used to
move the globe in any desired direction. To do this diminishes the
mobility of the resulting stump towards the left. He also condemns
the use of Mazeux's hook forceps, which permits the escape of the
contents of the eyeball, and injures the preparation ; but rather prefers
spoon-bladed forceps, which will hold the eye without injury. He
advises section of the optic nerve close to the eyeball, having observed,
when it has been divided far back in cases of intraocular tumour, that
the conjunctiva has retracted in healing, and the application of a glass
eye has been rendered difficult.
Under the head of" Shell Splinter in the Ciliarg Body of the Bight
Bije^^ is related the case of a man, set. 26, who was wounded before
Paris on the 20th of September, by a fragment of shell about a cubic
line in diameter, which struck the right eye, and produced instanta-
neous blindness, soon followed by swelling. The patient was treated
by poultices and atropine instillation for three months, at the end of
which time the left eye began to redden, and objects before it appeared to
quiver. The right eye was then removed by Dr. Horing, and when Dr.
Cohn saw the case, on the 27th of February, the sympathetic symptoms
had wholly disappeared, although the patient believed that he could
not see with his left eye quite as clearly as before the injury. The
retina of the enucleated eye was wholly detached, the whole globe
disorganised by inflammation, and the piece of shell was embedded in
the ciliary body.
Two cases of grazed wounds of the eyeball contain little worthy of
note, except that in one of them the bullet performed an iridectomy
with great neatness. In both the injury was followed by blindness, due
to detachment of the retina and effusions into the vitreous.
Four cases of wound of the upper eyelid are recorded, in one of
which the shock seemed to have produced a rupture of the choroid
near the equatorial region. In another the shock produced myopia = ^,
with S -J^, in an eye supposed to be previously healthy and emmetropic.
Five cases of wound of the upper jaw, in which the eyelids and eyes
were implicated, give Dr. Cohn occasion to remark that he failed in ob-
taining primary union of eyelid wounds by paring their edges and
inserting sutures seven or eight days after the wounds were inflicted,
and when suppuration was proceeding. He removed all the bruised
parts, and obtained exact apposition by silk threads. He refers to the
possibility that silver wire might have succeeded better, but counsels
early operation in such cases, whenever it is necessary to preserve the
outline and position of the lids. The same cases show that there is no
occasion to puncture the anterior chamber in order to evacuate effused
blood, which will always be readily absorbed under a compressive
bandage.
A case of Contusion of the eyehall is related at great length. A i)all
struck the outer margin of the left orbit, fracturing the bone and pro-
ducing immediate total blindness. The cornea and iris retained
362 EEPORT ON OPHTHALMIC MEDICINE AND SURGERY.
their normal aspect, but the nature of a white appearance upon the
fundus could not be clearly made out. After a time sympathetic dis-
turbance of the other eye supervened, and enucleation was performed.
The white appearance was then found to be due to great inflammatory
effusion in and upon the retina and choroid. The sympathetic symptoms
disappeared after the enucleation, and vision, which had fallen to f, re-
turned to the normal standard. The range of accommodation also in-
creased after the enucleation from ^^ to ^. The clinical interest of the
case rests chiefly on the production of sympathetic troubles by an injury
which implicated only the outer side of the sclerotic, and which neither
directly, nor by the subsequent inflammation, affected the ciliary body.
A Wound of the zygoma by a rifle-ball was said by the patient
to have been followed by defective vision, and the conditions were very
analogous to those sometimes presented in civil practice by " railway
cases." The injury was inflicted on the i8th of Aug. 1870; and the
patient (twenty-one years old) was first seen by Dr. Cohn on the 6th of
the following January. He presented the scar of the wound of entrance
in the body of the right malar bone, about half an inch below the external
canthus, and that of the wound of exit an inch and a quarter further
back, over the temporal process. The patient said that for the first
three months he could scarcely see at all with the right eye. It had
received no direct injury, either internal or external, but seemed to pro-
trude a very little more than its fellow, and its tension seemed some-
what higher. Field of vision normal. The optic nerve showed no exca-
vation, and some slightly winding veins in the retina were found also
in the other eye. There was no manifest difference in colour between the
discs, but perhaps the right was a trace less red than the left. The pupils
of equal size, the right somewhat more sluggish. The vision was very
carefully tested on the the 6th of January by Dr. Cohn's assistant, and
on the 8th by Dr. Cohn himself, with the following results :
January 6.
Right eye. — Snellen 2^ at 3I/' the smallest legible.
With + 10, i^ to 31".
Ml 010
Left eye. — Snellen i^ from 5" to 9.''
With + 10, li to 4''.
M i-,, S f ^.
January 8.
Right eye. — Snellen 2^ at 3^", the smallest legible.
„ 3I from 2" to 45".
With + 10, U to 31".
Left eye.^-Snellen i^ from 5'' to io|".
With + 10, li to 4".
After atropinization of the right eye he read, on the i ith of January,
with -r 8, 2^ Snellen from 3" to 7" ; and with + 4, 2 Snellen from i \"
to 3". The test-types employed on the different occasions were not the
same, and the suspicion of malingering was excited when it was found
that the S of the uninjured left eye varied from |§ to |3 between the
SUllGERY. 863
6th and 8th of January, both being light days, with snow on the ground
and sunshine. Moreover, it seemed hardly credible that the S of the
aifeeted eye should range in the same time from J^^ ^q j^o j)p^ Cohn
observes that there were only three possible explauations, either am-
blyopia from concussion of the retina, or amblyopia of long standing,
or simulation. Such an effect from concussion is not very rare after
injuries of the bones of the face ; but, as the ophthalmoscope threw no
light upon the question, the only other evidence of it was the some-
what sluggish action of the pupil. The prism tests of A. v. Grraef e and
of Alfred Graefe are sufficient for the detection of simulated monocular
amaurosis, but they are useless against simulated amblyopia. The
only way to detect such cases is by repeated trials with different types,
and with and without glasses, in order to discover whether the state-
ments of the patient are consistent with each other. In this case Dr.
Cohn felt himself unable to arrive at a positive diagnosis, and therefore
refrained from prescribing the hypodermic use of strychnine, to which
he would have had recourse if he had placed full confidence in the
statements made to him.
Another injury to the right eyebrow by a shell splinter, inflicted on
the 30th of October, 1870, and producing great impairment of sight,
came under observation on the 20th of March. Dr. Cohn then found
a dark coloured projection, which seemed, when seen in the inverted
image with an ocular of +3, the size of a large pin's head, occupying
the region of the macula lutea. The patient with this eye could dis-
cern moving fingers, but could not count them, and letters of No. xx
appeared distorted. The left eye was emmetropic, with S = f g, and
read i^ from 4^' to 22", and 3 from 4" to 40'' fluently. He was not
treated, but was warned of the possibility of sympathetic disorder, and
he returned on the 1 7th of April with a complaint of failing vision in
the left eye. He said that a darkness appeared before it after ten
minutes' reading, and that he saw round black spots floating to and fro.
He could only read 3 Snellen with a near point at 8''. Enucleation of
the right eye was performed, and on the 1 7th of July the vision of the
left eye was again normal. The excised globe was found to present a
Bubretinal haemorrhage, which had lifted up the retina over the
fovea into an elevated fold projecting into the vitreous, but left the
microscopic elements apparently unchanged. The case is important,
as illustrating the occurrence of sympathetic irritation four months
after an inconsiderable haemorrhage, without participation of the ciliary
body in the injury, and without inflammation.
An appendix to the report contains two cases of injury to the lids,
treated successfully by plastic operations, but of no special interest.
Foreign lody in the orbit. — Dr. Borel,* of Eouen, describes a case
in which the amber mouthpiece of a pipe was imbedded in the orbit by
a blow, and was discovered and removed, after the lapse of ten days,
without injury to the eye.
New instruments. — Only a few new instruments have been produced.
Among the most important of these are the self-opening scissors of Dr.
Noyes, of New York, in which the handles terminate in flattened
* 'Annales d'Oculistique/ 1872, i, 245.
364 ilEPORT ON OPHTHALMIC MEDICINE AND SUEGERY.
springs instead of in the usual loops, and these springs are brought
into tension by the closure of the blades, so as to open them again as
soon as the hand of the operator is relaxed. Dr. Heymann* describes
a pair of so-called needle-forceps for the removal of capsule. The in-
strument is a small pair of forceps, with ordinary teeth, and one blade
is prolonged beyond the teeth as a cutting point. It is figured both in
natural and in double size in the paper. Dr. "Warlomontf speaks
favorably of a set of iridectomy knives, resembling those used by
Weber, of Darmstadt, in his cataract operation. The blades are shaped
like the heart on playing cards, and four are provided, respectively of
the width of two, three, four, and five millimetres. By selecting a
blade of the width of the desired incision, and by introducing it to the
full extent, the size of the internal corresponds exactly to that of the
external wound. Dr. E. Monoyer, of Strasbourg, J has invented a pair
of new double fixation forceps. They consist of ordinary forceps, car-
rying a terminal arc, each end of which is fitted with teeth in the ordi-
nary way, so that they seize the conjunctiva at two points at once on
opposite sides of the cornea. The two grasping extremities are 13
millimetres apart, and the arc on which they are placed is of 13 milli-
metres radius. The inventor states that they may be applied in any
direction, and that they fix the eye more completely than any instru-
ment that acts upon one point only.
(c) Medicine and Therapeutics.
On the visual sense in diseases of the choroid and retina. — Forster
read a paper at the Heidelberg Congress on this subject,§ in which he
started from the well-known fact of the want of correlation, in many
diseases of the choroid and retina, between contraction of the field and
impairment of the sense of vision. In certain affections, with a good
light, the sense is not materially impaired, while if the light be lowered, it
fails rapidly. In others, the reverse of this is the case. The author had
made these well-known facts the basis of some researches, and believed
that he had done something towards explaining them. He employed for
this purpose a photometric apparatus, consisting of a rectangular box,
twelve inches long by eight wide, and six high, having two holes, by
which a patient could look into the interior, and another, two inches
square and covered with white paper, for the admission of the light of
a candle. This opening was fitted with two wings of blackened tin,
which could be closed or opened at pleasure by means of a screw, and
a scale and index served to show the size of the aperture, which could
be varied from i to 1500 square millimetres. The objects of vision are
black lines on a white ground, from i to 2 centimetres wide by 5 high,
and the test is to determine by how small a degree of light they can be
seen. The retinal sensibility, which the author calls l, will bear an
inverse proportion to the size of the aperture of illumination. Thus,
* 'Archivf. Oplith.,'xvii, i.
t 'Annales d'Oculistique,' 1871, i, 97.
X Ibid., 1872, i, 64.
§ Ibid., 1872, i, 97.
MEDICINE AND THERAPEUTICS.
365
an eye which required for the definition of the test objects ten times
as much light as a normal eye, would have a retinal sensibility only
one tenth as great. It follows that, if h be the minimum of light
necessary for a normal eye, and Hthe minimum for a diseased eye, that
L = — A normal eye distinguishes the objects when A = 2 sq. mm. If,
then, we take 2 sq. mm. to be = i, and express n by half its actual
value, the value of l will always be a fraction having i for its nume-
rator. The annexed table gives the mean results of the examination in
a large number of diseases. In the third column are placed the degrees
of acuteness of vision, and in the fifth those of the retinal sensibility.
Square measure
of illuminating
No.
Diagnosis.
S.
L.
aperture.
J
Optic neuritis ....
■^-^
2 — 8
i-i
2
Apoplectic retinitis
^V
25
tV-^
3
Retinal apoplexy
i ^
12
1
4
Albuminuric retinitis (fatty de-
generation)
i — ai-S-
2—4
i-i
5
White atrophy of optic nerve
i-A
2—12
\-^
6
Hemiopia in cerebral apoplexy .
1
12
i
7
Amblyopia from abuse of alcohol
or tobacco
*
2
^r
8
Syphilitic choroiditis .
k-l
128 — 1500
ih r\-is
9
Disseminated choroiditis .
f-^V
112—450
-h ~ -^io
10
Pigmentary retinitis .
f-i
50—1500
^ T'S'S
II
Separation of retina .
i-i
312— 1500
xiir — r-STs
12
Yellow atrophy of optic nerve
(from syphilitic choroiditis)
t--.v
612 — 1500
s^is — rio
13
Normal eye ....
k
2
\
There are, therefore, two groups of diseases. In the first, from"
Nos. I to 7 inclusive the retinal sensibility is very little diminished. In
the second, from 8 to 12, it is very considerably diminished, so much so
that in many cases the full opening of 1500 square millimetres was yet
insufficient. The author called attention to the fact that the morbid
processes of the former group were such as to affect chiefly the conduct-
ing portions of the visual apparatus, such as the fibrous and gaugliouic
layers of the retina, the optic nerve as far as the brain, and perhaps the
brain itself, while those of the latter affected chiefly the choroid and
the perceptive layer of the retina. Glaucoma had been omitted from
the table on account of the variableness of the results. In inflamma-
tory cases, and during the premonitory stage of cases of a certain degree
of acuteness, the visual sense was much diminished. In chronic cases
the results differed greatly.
Some observations followed on the value of this examination as a
means of diagnosis, e.g. in negativing the suspicion of retinal detach-
ment in a case of turbid vitreous, in which L retained a high value ; and
in determining the cure of syphilitic affections of the choroid. The
author also used his instrument to discover whether a scotoma was
366 REPORT ON OPHTHALMIC MEDICINE AND SURGERY.
positive, i. e. depending on a choroidal lesion implicating the perceptive
layers of the retina ; or negative, depending on lesion of the conducting
tissues. The former was rendered more conspicuous by dim light, but
not the latter.
Dr. V. Hippel read a paper on a similar subject, in which he con-
demned the instrument of Dr. Forster as being too small for the accu-
rate determination of S together with L, and described one of his own
on a similar principle, but on a larger scale. His results, from the ex-
amination of fifty cases, were confirmatory of those of Forster. In the
subsequent discussion Dr. A. "Weber said that he also had used a similar
instrument with advantage. :
Circumscribed choroiditis. — Dr. A. Sichel* has written an important
memoir on circumscribed choroiditis, a disorder first described by Jiiger
under the name of " change in the region of the macula," and since then
little noticed. The author has collected several cases of the affection,
and has, so to speak, built up its clinical history. He describes it as
being characterised by the presence, in a single defined part of the
fundus of the eye, of changes analogous to those which occur in the
disseminated or areolar forms of choroiditis. On examination with the
oj)hthalmoscope there is seen sometimes a simple tumefaction or hy-
persemia of a very limited portion of the fundus, situated excentrically
on the side beyond the equator, or more centrally, or even over the
region of the macula ; and sometimes a single spot or several small
spots of whitish or yellowish-white colour, in the latter case grouped
so closely together as to form a little patch of agglomerated lesions on
a single part of the field, while the most careful examination reveals no
changes elsewhere. Instead of being whitish or yellowish-white, the
spot or spots may be of reddish-black or brown with notched edges sur-
rounded by a zone either paler or more dark ; or there may be a more
or less white patch in the centre, surrounded by a border variously
coloured. The disorder may be divided, in accordance with the symp-
toms and the ophthalmoscopic appearances, into four stages or periods,
namely: — i. The period of hypersemia and local congestion. 2. The
period of exudation and fatty proliferation. 3 . The regressive or pig-
mentary period. 4. The period of atrophy. These periods are im-
portant, because during the two first the malady is within the reach of
treatment, while during the two last its effects are produced, and are
practically irremediable.
The first subjective symptom experienced by the patient is a very
annoying myodopsia, the spot resting always in the same part of the
field of vision, and becoming more marked after long use of the eye, or
after exposure to strong illumination. Often, after having continued
for a time, the myodopsia gives place to a more or less pronounced haze
or mist, which may either occupy a single portion of the field, or may
render all objects indistinct. Two other symptoms soon appear, and
produce great annoyance. The first is a photophobia, occurring at
every change from a less to a greater degree of illumination, and often
accompanied by an appearance of rays, proceeding from any source of
light, in the direction of the impaired part of the field. The second is
* * Annales d'Oculistique/ 1872, i, 129 — 156.
MEDICINE AND THERAPEUTICS. 367
a sharp constrictive or penetrating pain in the eye, such as to render
its movements very painful ; and if the seat of mischief, as determined
by the ophthalmoscope, be sufficiently near the equator to allow the
corresponding part of the ocular tunics to be reached from without when
the eye is strongly turned in the opposite direction, it will be found
that this part is acutely sensitive to the touch, like the ciliary region in
cyclitis. Little by little the various symptoms diminish or increase,
until they terminate in a fixed scrotoma, centric or excentric, according
to the position of the lesion, and which, when centric, is often attended
by the apparent distortion of objects in the portion of the field around
the fault, in consequence of alterations in the plane of the retinal sur-
face. The difierential diagnosis from disseminated choroiditis, of which
the malady is, indeed, but a variety, rests on the absence of spots on
other portions of the field. At one period, when the retina is elevated
by hypersBmia or eifusion, it might be possible to suspect the early
stage of a choroidal tumour. But such growths are always attended by
retinal detachment, the more extensive as they are more central, and
this element in the case being wholly wanting, error would be impos-
sible.
The causes of circumscribed choroiditis are far from being as well
defined as those of the disseminated variety. In the cases seen by the
author he has never been able to discover indications of syphilis. Cer-
tain conditions, however, seem to be always associated with the disease,
namely, habitual constipation, suppression or irregularity of the menses
in women, suppression of a hsemorrhoidal flux in men. Indications of
a tendency to congestion about the head have been met with in the
majority of cases, and in some of the women there has been chlorosis.
Lastly, when the malady attacks the posterior pole, it has usually been
associated with myopia.
The course of the disease may be either rapid and, so to speak, acute,
or it may be slow and chronic. In the former case it may pass through
all its periods in the course of a few weeks, but its ordinary duration is
three months, or even more. If left to itself it would always terminate
in circumscribed atrophy of the choroid, which would injure vision by
producing a permanent scotoma. Only when arrested by treatment
does it terminate in a restoration to the healthy condition.
In respect of treatment the author first advises that any general
cause of the malady should be sought for, and should receive such atten-
tion as it may require. Besides this, he mentions four remedies which
he has been accustomed to employ with benefit. The first is depletion
by Heurteloup's leech from the temple, in a quantity proportionate to
the severity of the affection and the state of the patient. This has
proved most useful at the beginning of the disorder, and after the de-
pletion the patient should always be kept for from twenty-four to
thirty-six hours in absolute darkness, a precaution the neglect of which
invalidates the benefit of the leeching. The second means is the use of
Neapolitan ointment, by friction, to various parts of the body, the
quantity used at once varying from 50 centigrammes to 2 grammes, and
the application being made night and morning. The third is the admi-
nistration of Sirop de Gribert, which in these cases, as in the disorders
368 REPORT ON OPHTHALMIC MEDICINE AND SURGERY.
of the vitreous body, will be found of great service. The fourth is the
application to the forehead and temple, on one or both sides, accord-
ingly as one or both eyes are affected, of a series of from three to five
flying blisters, a resource that has scarcely ever failed to produce marked
benefit. The paper terminates with a detailed recital of six cases, which
support the statements and conclusions of the author.
Researches on syphilitic amaurosis and amhlyopia^ by Dr. Galezowski.*
The author arrives at the following conclusions :
1. Syphilitic retinitis and neuritis may exist without any change in
the choroid, and most frequently under the form of an apoplectic and
exudative retinitis. Such cases, however, are only exceptional.
2. Syphilitic retinitis presents no pathognomonic signs by which it
may be distinguished from other forms of retinitis.
3. But if retinitis or optic neuritis be attended by iritis or choroiditis,
with or without flocculi in the vitreous, it is then undoubtedly syphilitic.
Experience shows that there is no other affection except glaucoma that
will give rise at once to retinal haemorrhage and to iritis or choroiditis.
4. Disturbances of colour vision are constant in these two forms of
eye disease, and especially in optic neuritis.
5. The most effectual treatment of these maladies .is by iodide of
potassium and perchloride of mercury in full doses.
6. Syphilitic choroiditis is the most frequent < lesion in cases of
syphilitic amaurosis or amblyopia. The signs of this form of choroiditis
are very characteristic, or even pathognomonic of syphilis. They are :
— J. Disturbance or loss of sight occurring by attacks or crises, often
separated by long intervals. 2. A mist resembling cobweb floating con-
stantly before the eye. 3. Frequent photopsia. 4. Photophobia. 5.
Hemeralopia at an advanced stage of the disease. 6. Preservation of
central vision for a long period, with peripheral contraction of the field.
7. Obscured outline of optic disc. 8. Pigmentary retinitis at a still
more advanced stage of the disease. 9. Atrophy of the central vessels
of the disc with preservation of the rosy tint due to the cerebral or
nutritive vessels of the optic nerve.
7. Pigmentary retinitis is very often developed as a consequence of
syphilitic choroiditis.
8. The pigmentary spots arrange themselves along the course of the
retinal vessels, and also in a generally circular form, like the circles of
herpes circinnatus.
9. The acquired pigmentary retinitis of syphilis does not differ from
the congenital form, especially from that which has been attributed to
the consanguinity of parents, except in the circular form of the pig-
mentary spots.
10. Congenital pigmentary retinitis is an hereditary syphilitic affection.
11. Congenital pigmentary retinitis should be subjected during
infancy to an iodine or mercurial treatment. After a certain age it is
no longer possible to arrest the progress of the malady, which becomes
progressive, and at length destroys the sight.
12. The children of syphilitic parents should be submitted to careful
ophthalmoscopic examination from their birth ; and, retinitis once recog-
nised, it should be treated in the manner indicated above.
* *Arch. Gen. de Med.,* Jan., Fev., Mars, 1871.
iiEPOEi:
ON
MIDWIFERY AND THE DISEASES OF WOMEN
AND CHILDREN.
BY
J. J. PHILLIPS, M.D. LoND.,
ASSISTANT OBSTETRIC PnYSICIAN TO GUY'S HOSPITAL; ASSISTANT PHYSICIAN TO
THE HOSPITAL TOE SICK CHILDEEN; PHYSICIAN TO THE EOYAL
MATEENITY CHAEITY.
I. QYNiECOLOGT, EMBEACING THE PHTSIOLOGT AND PATHOLOGY OF THE
NON-PEEGNANT STATE.
Anomalies of Structure.
Db. L. Netjqebauee relates (' ArcMv fiir Gynakologie,' ii, 2, 1871)
two cases observed by him of one-sided hsematometra with double
uterus. The first patient was nineteen years old. She had commenced
to menstruate at seventeen ; the flow was profuse, and there was
excessive pain in the lower abdomen and pelvis. A swelling, larger
than a fist, appeared in the hypogastrium. After menstruating
regularly a few times there was amenorrhoea and absence of pain for
several months. Menstruation returned with great suffering. A
swelling extending nearly to the umbilicus was to be felt on the right
side of the abdomen. Having arrived at the diagnosis by the position,
shape, and relations of the tumour, and fearing spontaneous rupture,
Neugebauer opened the pelvic swelling with a bistoury by the vagina, and
dark brown, odourless, viscous blood, of the consistence of thin honey,
flowed away. There was sharp abdominal pain on the second day, but
the patient improved until the fourteenth day, when menstruation
returned, and she died in three days with symptoms of peritonitis.
The second case was that of a patient of the same age. Menstruation
scanty and painful. A swelling on the left side, nearly the size of the
uterus at the sixth month of pregnancy. The uterine cavity of the
right side freely communicated with the vagina. Dr. Chivat opened
the swelling by the vagina by pushing an ordinary uterine sound into
it. Slight fever and abdominal pain for the first three days. On the
thirty-fifth day there suddenly supervened severe pain in the left hip,
then high fever, frequent vomiting, and escape of blood-stained muco-
24
370 REPOET ON MIDWIFERY, ETC.
pus from the vagina. She died in forty-eight days after the operation.
Neugebauer refers to several published cases of the kind, in which the
age ranged from fourteen to twenty-seven. The length of time between
the onset of the pains from retention of the menstrual discharge and
the commencement of the treatment on account of the haematometra
varied from five weeks to fifteen years. Out of fifteen cases operated
upon, eight recovered and seven died.
Two cases of hsematometra in the closed canal of a bicomite uterus
are also recorded by Preund and Wheeler (* Boston Journal,' July,
1872). Steiner also writes (' "Wien. Med. Woch,,' xxi, 29, 1871) on
haematometra.
Breisky relates (' Archiv f. Grynak.,' ii, i, 1871) a case of pyometra
and pyokolpos lateralis in a girl the subject of a double uterus. She
had five brothers and two sisters, all well formed. Often, as a cliild,
she had sufi'ered from abdominal pains, supposed to be due to worms ;
at the age of sixteen she began to suff'er regularly every month for
three or four days from severe pelvic pains, but no menstrual discharge
appeared. There was obstinate constipation, great anaemia, and difii-
cult micturition. When on the point of seeking medical advice some- 1
thing burst, to her great relief, and a quantity of pale red, thickish, ■
foetid fluid escaped. The difficult micturition returned; Breisky punc-
tured a swelling in the vagina, and an abundant quantity of pus
was discharged. The cavity of the abscess was carefully washed out.
Subsequent dilatation enabled the condition of parts to be ascertained,
and Breisky divided the vaginal septum and part of the uterine
septum. The patient made a good recovery, and the right half of the
uterus (the seat of the abscess) afterwards underwent such contraction
that its cavity appeared shorter than that of the left. As ascertained
by the sound the right measured 4 cm. and the left 6 cm.
Two cases of absence of the vagina are recorded by Branco. In the
first case, set. 25, the vulva was normal ; no trace of a vagina existed,
but it was determined to attempt the formation of one. The tissue
which had to be dissected was a little more resisting than ordinary
cellular tissue. The uterus was reached and punctured on account of
the menstrual retention. After a severe attack of peritonitis the
patient recovered. A second puncture was necessary in fifteen months,
and when the patient was last seen the vagina was much contracted.
In the second case, set. 20, the treatment was more successful, the
vagina being kept dilated. Branco controverts the opinion of Scanzoni
that complete absence of the vagina is not met with except in conjunc-
tion with absence or a rudimentary state of the uterus, and nearly
always with deformity of the vulva. He shows that the develop-
ment of the genital organs takes place in three zones, indepen-
dent the one of the other ; the external parts in the external layer of
the blastoderm, the internal organs in the blastema interposed between
the two layers of the blastoderm, but the vagina is formed in the fold
of division which arises in the primitive cloaca. He disapproves of
operative interference except for menstrual retention ; and the opera-
tion should not be performed at a menstrual period. (' Journ. de
Bruxeiles,' Nov. 1871.)
ANOMALIES OF STRUCTURE; ^71
A woman, aet. 26, who had miscarried four times, was found, after
death, to have the ovary, Fallopian tube, and ligaments of the left side
entirely absent. This side of the uterus was perfectly free, and the
muscular structure was smoothly covered by peritoneum throughout.
Ling (* Lancet,' Sep. 1872). A patient, ajfc. 18, who had never men-
struated, died in St. George's Hospital, and the uterus was found to be
absent, though the ovaries were well developed. The only representa-
tive of a uterus was a small nodule of fibrous tissue found in the folds
of peritoneum between the rectum and the bladder (' Lancet,' Aug.
1872).
Cases of absence of the uterus and the vagina form the subjects of
interesting remarks on malformations of the female genitalia by Eichet
and by Gallard (L'Union Med.,' 1872).
Dr. Aikman describes a case of double uterus and vagina. A septum,
rather thicker than the vaginal wall, extended from about three
quarters of an inch above the hymen to midway between the uterine
orifices. The uterus, which had a tumour attached to its fundus, was
four inches long. It was divided into two cavities. The left cavity
was perfect as far as the internal os, it then tapered to end in the
left Fallopian tube. The right cavity had the usual shape of the right
half of the uterine cavity, and communicated freely with the right
Fallopian tube. (' Glasgow Journal,' May, 1872.)
A case of congenital absence of the uterus and vagina is recorded by
Dr. Smith ('Brit. Med. Journ.,' Nov. 1872). The vulva was well
formed, the mammae were large and flabby.
Absence of vagina and uterus. Warner ('Boston Journal/ Jan,
1872).
Double uterus and vagina in a young woman who died of epilepsy.
There was only one kidney. Eoberts (*Brit. Med. Journ.,' June,
1872).
Double uterus with concurrent pregnancy. Ross (' Lancet/ July,
1871).
Schatz records seven cases of incomplete union of the female genital
canal in adults ('Arch. f. Gynak.,' ii, 2, 1871).
Schatz also relates a remarkable case of deformity of the urino-
geuital system in an infant. There was a double uterus, a double
vagina, a double bladder, and a double vesico-vaginal fistula. The
mother of the child was a healthy woman, and had previously had one
child, a boy, in every way well formed. In this, her second labour,
there was only very little liquor amnii, and the cord contained only one
artery. ('Arch. f. Gynak.,' iii, 2, 1872.)
Dr. Squarey contributes ('Obst. Trans.,' 1872) three cases of absence
of the uterus, the patients being sisters.
M. Lorain mentions the case of a woman who, being examined after
a premature confinement, presented four breasts. Two of these occu-
pied the normal region ; the two others were situated near the axillae,
and were the size of a small orange. There was milk in the four
breasts. ('Lancet,' June, 187 1.)
2,1 'Z EEPOUt ON MIDWIFERY, ETd.
Menstruation.
Early appearance of 7nenstr nation. — Mr. Ashton states (' Lancet/
March, 187 1) that he has a patient, set. 7, who had a slight red dis-
charge from the vagina two weeks after birth. This recurred some-
times once a month, at other times after an interval of two or three
months, till the child was four years old. Since then the discharge has
been " regular," and sufficient in quantity to soil one diaper. The
child's mother first menstruated when nine years old, and the mother's
aunt at the age of seven.
riugel records (' Centr. f. Med. Wiss.,' Feb. 1872) a case in which J
menstruation commenced at eighteen months, and continued witli fair ^
regularity until death at the age of five and a half years. The child
was five feet high.
Disorders of Menstruation^
Dr. Eockwell reports (* Amer. Journal of Obstetrics,' May, 1872)
eight cases of amenorrhoea — one of the cases was of four years' duration
and another of two years and a half— in all of which menstruation
reappeared after the use of faradization or galvanism. General
faradization is indicated in those conditions of debility where a general
and powerful tonic influence is called for. Faradization localised
externally is but slightly efficacious. The electro-muscular contrac-
tility of the abdominal muscles is so great that a current of but little
tension can be used, and neither by reflex nor direct action can the
great sympathetic in this way be decidedly influenced. Faradization
localised internally, however, is a very eff'ective method of treatment,
and by it the uterus can be more thoroughly and powerfully influenced
than in any other way. Sometimes central galvanization or peripheral
galvanization, either external or internal, is more effectual.
Dr. "Wade, in a clinical lecture (*Brit. Med. Journ.,' July, 1872),
concludes that (i) chlorosis occurring in young women who have men-
struated at all is commonly the result of thelossof blood by the menstrual
discharge ; (2) when amenorrhoea occurs in these cases it is a consequence,
and not a cause, of the anaemia ; and (3) both primary and subsequent
menstruations produce on the system the same effects that would be
produced by any other haemorrhage of equal amount. Gaillard Thomas
('Diseases of Women,' 1872) believes that chlorosis is a neurosis of
the ganglionic system of nerves. Disordering the control which this
system exerts over the functions of organic life, it produces, as symp-
toms of its existence, impoverishment of the blood, constipation,
dyspepsia, palpitation, and menstrual derangements and irregularities.
Many observers have thought, from its ordinary period of invasion
being the time of puberty, when the dormant functions of the ovaries
are aroused, that it is dependent on some derangement in ovulation and
menstruation ; but it is more probable that torpidity of the uterus and
ovaries is, like the peculiar blood state which is so characteristic of the
disorder, merely a symptom of functional disease in the sympathetic
system of nerves. Several French pathologists have of late years
advanced the view that chlorosis differs from anaemia mainly in this —
DECIDUA MENSTRUALIS. 373
that the latter is merely a blood state, while the former is a disease of
the nervous system, which may or may not produce the latter. Eaci-
borsky also regards chlorosis as due to disorder affecting the ganglionic
nervous system.
Virchow has lately written on the relation between chlorosis and
vascular abnormalities (' Ueber die Chlorose,' &c., Berlin, 1872).
A case of " supplementary" hjemorrhage from the breasts in a girl
who had not menstruated is recorded by Meynet. The patient was
seventeen years of age on admission to Hotel Dieu, and stated that for
eight months she had each month suffered from a rather free discharge
of blood, lasting two or three days, from a crack in the nipple, some-
times on one side, sometimes on the other. The haemorrhage was
preceded by pain and swelling of the breasts. Although she had never
menstruated, she suffered, at the time of the monthly discharge
from the breasts, from abdominal pain and a sensation of fulness.
The patient was under observation for three months, and the above-
mentioned facts were observed each month. In two months after she
left the hospital, where she had been treated by tonics, menstruation
appeared naturally, and nothing abnormal was subsequently noticed in
the breasts ('Lyon Med.,' March, 1872).
A case of so-called vicarious menstruation by haemorrhage from the
nose is related by Obermeier. The epistaxis ceased during pregnancy
(' Virchow's Archiv,' 1872).
Dysmenorrhcea.
Becidua Menstrualis. — A case of the inflammatory form of dys-
menorrhoea. Dr. A. Solowieff, of Kasan, relates (* Archiv f Gynak.,'
ii, I, 187 1 ) a case of the above. The patient was twenty-one years of
age, and had been ill three years". Menstruation began at eleven, was
always irregular, and accompanied with great pams. Married at
sixteen and a half Pregnant in four months. Labour at full time.
Left off suckling at eight months. The first menstruation after wean-
ing was painless, but the following period did not appear at the proper
time, and the patient suffered from a sensation of weight in the lower
part of the abdomen and especially in standing up and in walking.
The menses appeared in a fortnight, attended with strong pains, and on
the third day a mass, the exact shape of the uterine cavity, was passed.
These pains did not disappear, but increased in severity at each
menstrual period. The vagina was red and so sensitive that it could
not even be touched. A similar mass appeared at each period.
Menstruation was always delayed a week or two. Patient bedridden.
Great irritability ; neuralgia in different parts of the body ; hyper-
aesthesia of the skin, especially of the abdomen ; disorders of digestion ;
intestinal pains. The sensitiveness of the vagina diminished, so that
the introduction of a very small speculum was, with great trouble,
possible. The uterus was more congested than natural, and somewhat
enlarged ; the most tender part was the vaginal roof, touching which
called forth a succession of reflex hysterical symptoms. Various kinds
of treatment were employed, but the most useful was the injection of
374 REPORT ON MIDWIFERY; ETC.
perchloride of iron. This was used at first every second day, and
afterwards daily. It diminished the local pain, but frequent injection
caused sleeplessness and palpitation. For eight months the injections
were continued, generally every fourth or fifth day. The membrane
ceased to be expelled, and menstruation became regular. After de-
scribing the naked-eye appearance of the membrane, Solowieff" says that
a transverse section under the microscope shows three layers, which,
proceeding from without inwards, may be called the fibrinous, the
glandular, and the granulation layers. The fibrinous layer consists of
fibrin, among the fibres of which lie red, and occasionally white, blood-
corpuscles. In the glandular layer the glands are of the usual size, and
contain cylindrical epithelium with round cells, the cells being of
various sizes, and the largest containing sometimes three nuclei. The
granulation tissue consists of round and lengthy protoplasma-cells, with
a large nucleus. The cells lie in a delicate, somewhat fibrous, inter-
mediate substance. The vessels form loops on the inner surface.
The innermost surface is irregularly covered with mucus. No epithe-
lium is to be seen. These three layers, however, pass so gradually the
one into the other that a sharp line of demarcation cannot be drawn,
and a division can only be made according to the predominance of one
or other element.
Membranous dysmenorrhoea is also elaborately described by Michaud
and Lagrave ('Arch. Gener. de Med.,' i, 1872). I
Dr. Barnes writes on tJie essential cause of dysmenorrTioeay as illus- '
trated by cases of menstrual retention. He seeks, by comparison of
diff'erent cases of dysmenorrhoea, to discover a common essential
cause. Having adverted to the evidence accumulated in proof that
cases of neuralgic and constitutional dysmenorrhoea are being gradually
transposed under closer clinical analogies to the class of obstructive
dysmenorrhoea, the author states the proposition that the essen-
tial condition in a large proportion of cases is really retention of
menstrual fluid. He illustrates this by several cases of congenital and
acquired stenosis and atresia of the genital canal. Dysmenorrhoea is
incomplete retention. (* Obstet. Trans.,' 1872.)
Dr. Priestley read a paper before the Medical and Chirurgical Society
(Nov. 1 871) on intermenstrual dysmenorrhoea. In all the cases
detailed severe pain was experienced by the patients midway in the
menstrual interval. It generally came about fourteen days after a
catamenial period, and after lasting a variable number of days ceased
before the supervention of the next period, or occasionally ran into the
following monthly period and was relieved by it. There could be
little doubt that the pain was due to perturbations in the function of
spontaneous ovulation habitually going on in the ovary. Probably
preparation for an approaching period began in the ovary ten or four-
teen days before the occurrence of the monthly uterine discharge, and
if the initial steps in the process of ovulation were opposed by certain
pathological conditions pain would ensue.
De Cristoforis relates three cases of flexion with dysmenorrhoea and
sterility, all of which were cured by mechanically redressing the uterus,
pregnancy supervening in each case. He says that in such cases it
UTERINE TUMOUESj ETC. 375
*
cannot be doubted that the flexion was the source of trouble, and his
experience leads him to think that flexions by themselves, independent
of their complications, ought to be considered as a pathological change
deserving special treatment. (' Graz. Med. di Torino,' 1871.)
Dr. Edis writes in favour of dilatation of the cervix uteri by-
graduated bougies in cases of anteflexion and dysmenorrhoea. He
commences with an ordinary No. 8 bougie and passes it once a week,
gradually increasing the size, and he allows it to remain in for about
ten minutes. This method of treatment is capable of far more
universal application than the insertion of a stem into the uterus.
Three illustrative cases are added. In the first case the patient had been
married sixteen years and was sterile. She suflered great dysmenorrhoea,
but was soon relieved by the above treatment. The second case was that
of a woman, set. 38, married seven years, sterile. Not only was the dys-
menorrhoea relieved, but she became pregnant. The third case could
not tolerate a stem, but dilatation by metal bougies had the effect of
getting rid of all inconvenience at the catamenial period. (' Brit. Med.
Journ.,' Nov. 187 1.)
Molliere relates a case where a patient, after using a cold vaginal
injection a few days after menstruation, was seized with severe
peritonitis, from which she died (' Journ. de Bruxelles,' May, 1871).
TTterine TumourSy Sfc.
Dr. Hegar describes (*Archiv f. G-ynak.,' ii, i, 1871) sarcoma of
the uterus. He submits that this morbid growth is more common than
is generally believed. It occurs in two principal forms : — (i) There
are multiple tumours, more or less distinct ; (2) there is a diffuse
infiltration. In situation and relation to the uterine wall they pre-
sent a great likeness to the intramural fibrous tumours. The seat is
almost always the body of the uterus. Yeit's case, in which the cervix
was affected, is unique. Por the most part the sarcomatous tumours
repose, with a broad basis, upon the inner surface of the fundus and body,
projecting into the enlarged cavity, as not seldom do the intramural
fibro-myomas. A kind of stalk is rare. Sometimes, as West says,
together with the intra-uterine tumours there is a second division,
which develops itself towards the abdominal cavity either in the iliac
fossa or in Douglas's pouch, reaching even to the lumbar region. The
intra-uterine tumour seldom possesses a distinct investment, but a thick,
sm.ooth, fibrous capsule may exist. Invasion of the new formation
into the cervix may take place. Either a uniform infiltration of both
walls or of one wall and lip,- with or without ulceration of the os uteri,
or tumours connected with those of the body spring from the inner
surface of the neck, or, lastly, larger tumours proceeding from one lip
fill, like monstrous hypertrophies, the vagina. In a second order of
cases the sarcoma presents itself as a diff'use infiltration of the mucous
membrane, submucous membrane, and even of the proper muscular
wall. There is on the inner surface of the uterus a large ulcerated
surface, with fungous granulations, necrotic debris of the original
376 REPORT ON MIDWIFERY, ETC.
tissues and of the new formation hanging to it. Other parts shov^
better preserved, but also rough wart-like elevations, knobs or polypouj
excrescences. The diffuse infiltration may penetrate all the tissue
strata, so that the new growth presents the aspect of an enormous
uterus, retaining its ordinary shape. The two kinds, distinct and
diffuse, are at times blended. It is remarkable that apparently sound
parenchyma is at times disseminated through the diseased tissue, recog-
nised as foci by the microscope. The first origin of the degeneration
is commonly sought in the mucous membrane, proceeding from whence
the submucous and muscular tissue is invaded. The colour of the
tumour is generally greyish-white, even white, but sometimes reddish-
grey. The consistency differs. The tumour is soft, so that it breaks
down under the fingers or the polypus forceps, like brain substance or
wet mortar. It may, however, be denser, like a soft or even a hard
myoma. The round-cell sarcoma and the medullary forms are most
frequently found. The cells are either of medium size or small. The
basis substance is homogeneous, finely striped, not seldom delicately
netted, as in gliosarcoma. The spindle-cell sarcomas appear to be
more rare. Combinations of round and spindle cells are more common.
When a large proportion of fibrous connective tissue enters into the
constitution of the tumour it acquires a firmer consistency. The pro-
portion of fibrous connective tissue may be so great that we are
compelled to admit a transition form, a fibre- and myo-sarcoma. In
some cases the fibrous tissue is so preponderant that only very careful
investigation can detect the significant diflferent tissue. Such mixed
tumours may have existed from the beginning, but a sarcomatous
proliferation may spread through a groundwork of fibro-myoma.
Virchow speaks of proliferation process of myxomatous character into
the rich and extensive interstitial tissue of many myxomas. Numerous
vessels penetrate the structure of many sarcomas. The concurrence of
carcinomatous and sarcomatous tumours is less common than the
transition forms and mixed forms of myofibromas and sarcomas.
Secondary deposits of the sarcoma in distant organs are seldom men-
tioned, as in the lungs, the parietal pericardium ; they only appear
after long duration of the disease. Deposits in neighbouring
organs are somewhat more frequent, as extension of the degeneration
to the vagina, to the rectum, with consecutive stricture and ileus.
Deposits in the lumbar and retro-peritoneal glands occur. The etiology
is obscure. It has been met with in puberty and in the climacteric
period, in virgins and in women who have borne children. The
previous health has been described as excellent. But in a small
number of cases distress pointing to antecedent disease of the sexual
organs has been complained of, as dysmenorrhoea, irregular, frequent,
protracted menstruation, discharges, rather watery than sanguineous,
leucorrhoea, abortions, sterility, and sometimes hysterical and nervous
habits. One of the earliest signs of the existence of the tumour is
monorrhagia. This is very often attended by irregular or persistent
hemorrhages. Offensive mucous discharge was in one case the first symp-
tom, being followed by bleeding. Peculiar haBmorrhages and an offensive
puriform or fiesh-water like discharge are rarely absent. These dis-
UTERINE TUMOURS, ETC. 377
charges may resemble those of carcinoma of the cervix, but the odour
is generally less penetrating. At a later stage the discharges contain
numerous small and larger shreds of the tumour. Sometimes a poly-
poid projecting portion is cast off, or falls into purulent degeneration,
giving rise to an intolerable stench. To these discharges are sometimes
added as early symptoms a sensation of pressure, of bearing-down pain
in the sacrum, in the pelvis, pressure on the rectum, dysuria. But
Hegar does not agree with Gusserow in admitting that pain is constant
and early. Mostly the pains possess a labour-like character and point
to real contractions. Besides these principal symptoms there are
numerous so-called consensual symptoms, such as attend the most
different diseases of the sexual organs, especially disorders of digestion,
cardialgia, &c., nervous symptoms, nutrition suffers ; from dysuria
hydronephrosis may follow. The constant issue is death, which either
ensues from exhaustion through the protracted discharges, through
pyaemia, or the consecutive diseases. Objective symptoms in the living
vary according to the anatomical relations of the new growth. Through
the abdominal walls we may feel tumours of varying size, knobby, over-
lapping, or distinct, between which the body of the uterus may be
made out or lost in the imbedded tumours. If, in the case of an intra-
uterine tumour, rapid degeneration does not ensue, the cervix gradually
dilates, its wall softens, its lips disappear, the os uteri opens, and the
tumour is driven through, perhaps into the vagina, simulating a fibrous
polypus, when it becomes gangrenous, suppurative, and is cast off" in
larger or smaller pieces. The sound generally indicates an enlarged
cavity of the body of the uterus, and strikes upon rough, irregular
places. The mobility of the uterus is often retained for a long time. At
a late stage peritonitis, proceeding from the extension of the disease to
the neighbouring organs, may fix the organ. The diagnosis is gene-
rally clear, but the microscope alone makes it certain. It is easy to
get small portions of the tumour. Simple hyperplastic growths are
distinguished by their fibrous connective tissue muscular substance,
vessels, follicles, glands. The duration of the disease is variable —
from five months to six years. But it lasts longer than carcinoma of
the cervix. The treatment is simple. If the cervix is not dilated, it
must be dilated, so that the finger may reach the basis of the tumour
and permit its removal by scissors or polypus forceps. G-enerally hooks
tear out and will not hold. After the operation, Hegar has introduced
potassa fusa ; a copious discharge followed, bringing away shreds of the
tumour. Hegar concludes by relating eight cases. [From ' Brit, and
Eoreign Med.-Chir. Eeview,' July, 1871.]
Winckel also describes two cases of sarcoma of the uterus and the
microscopical appearances of the growths (' Arch. f. Gyn.,' iii, 2, 1872).
See also Babl-Elickhard (' Beit, zu Gynak.,' Berlin, p. 76, 1872).
Dr. Noeggerath removed from the posterior surface of the uterus by
a curette a small growth the size of a pea, in which were felt hard
points, sandy to the touch. The growth was an adenoid tumour, and
an example of the growths called by Virchow psammomata. (' Amer.
Journ. of Obst.,' Feb. 1872.)
An inverted uterus with an intramural fibroid was removed by ecrasc-
378 EEPOllT ON MIDWIFERYj ETC.
ment by Dr. T. Hay. Before the operation it was evident that an in-
verted uterus existed, but its large size could not be accounted for. The
stump of the inverted uterus occupied almost as high a position within
the abdomen as the organ does in its natural position. The patient was
thirty-two years old, the mother of one child, six years of age. The
entire mass removed weighed one pound. The fibroid was found im-
bedded in the parietes of the uterus, and from pressure and distension the
tissues covering it were very much attenuated, and round the base so thin
and firmly adherent as to be separable only with great difiB.culty.
(' Amer. Eeporter,' Dec. 1871.)
Dr. Yalette relates ('Lyon Med.,' April, 1871) a case of inversion
of the uterus, in which the uterus was extirpated by the caustic liga-
ture. The patient was forty-two years of age, the mother of seven
children, the youngest child being four years of age. Two years
previously she began to sufier from severe metrorrhagia, and eight
months before admission she was seized with severe pain like that of
labour, which ceased immediately on the appearance of a firm tumour
at the vulva. There was much anxiety of countenance, constant pain
confiuing her to her bed for seven months, and allowing her no rest at
night, great anaemia, and for two months incontinence of urine. The
vaginal inlet was obstructed by a large tumour, composed of two parts.
The lower portion was as large as a fist, firm, not tender, of a pale rose
colour. The second portion, situated above the preceding, from which
it was separated by a pedicle, three centimetres in diameter, was smooth,
and redder than the lower portion. The first was a fibrous polyp, the
second the inverted body of the uterus. Valette determined to extir-
pate the whole of the tumour, which was done by the instrument he
describes. There was no haemorrhage, and recovery was uninterrupted.
The pulse after the operation never exceeded 88, nor the temperature
38*5° C. He points out the disadvantages of (i) simple excision with
a cutting instrument, (2) ecrasement, and (3) ligature; and con-
siders the caustic ligature, many years ago advocated by Coutaret, as
by far the safest procedure.
Gaillard Thomas writes on the enucleation of sessile uterine Jihroids,
The methods of dealing with these growths he enumerates under three
heads — (i) the setting up within their tissue a process of sloughing;
(2) the impairment of their nutrition by direct and deep incisions, and
(3) their removal by enucleation. The first method presents great
dangers from septicaemia ; the second is attended with the danger of
haemorrhage, and is withal very uncertain as to results ; so that the
third, although by no means free from danger, presents itself as a valu-
able resource in a most intractable aff'ection, for the reason that it is
the most effectual and least hazardous of the procedures now at our
disposal. The day may come when electrolysis will take the place of
enucleation. Enucleation should not be resorted to unless the state of
the patient absolutely requires it on account of prolonged and dan-
gerous haemorrhages. Full and complete opening of the os internum
should be effected by tents, and the attachments of the tumour should
be ascertained as accurately as possible. Thomas finds a pliable whale-
bone rod very useful for the latter purpose. The uterus must then be
1
UTERINE TUMOURSj ETC. 879
depressed to tlie vulva by the hand of an assistant placed over the
hypogastrium, a tenaculum fixed in the cervix, and the vagina cautiously
dilated so as to admit the entire hand. An incision should afterwards
be made into the most depending part of the tumour, and its capsule
stripped off it as much as possible. The removal of the tumour will
often prove an easy task, and even cases apparently most difficult will
yield to a persevering, bold, and cautious effort. Reports of five com-
pleted cases are given without a single death. Thomas has, however,
had two fatal cases from peritonitis during the preparatory dilatation.
He does not wish to be understood as comparing the advantages of
enucleation with those of excision or ecrasement. Enucleation is to a
great extent a dernier ressort, to be employed only when the less dan-
gerous methods are entirely impracticable from the fact that the sessile
nature of the attachment does not allow of its being grasped by a wire
or chain. (' Amer. Journ. of Obst,,' May, 1872.)
Dr. Meadows writes on the treatment of fibrous tumours of the
uterus, and recommends more frequent and decided resort to operative
interference, especially in the interstitial and submucous varieties.
These tumours are to be regarded as essentially foreign bodies, and
nature's method of dealing with them, when fair play is allowed her, is
to expel them. In order to do this a dilated os uteri and uterine con-
traction are essential, and when these are wanting it is the duty of the
physician to remedy the deficiency by free division of the circular fibres
of the cervix uteri in several directions, and by promoting contraction of
the uterus by every means in his power. These two measures will be
greatly aided by subsequent detachment of the tumour, making it
more and more like a foreign body. An illustrative case is added. The
neck of the uterus was freely divided, and the patient advised to return
in three months. The os uteri then admitted the finger, and the tumour
could be felt presenting. The next stage was then attempted, viz. the
separation of the tumour from its attachment as far as the finger could
reach. This was repeated, the descent of the growth was facilitated
by the administration of ergot, and it was ultimately removed, the
patient being discharged cured. The author states that he has never
attempted, and does not think that he ever will attempt, the process of
gouging, enucleation, or destruction by the actual cautery. (' Brit.
Med. Journ.,' Dec. 1871.)
A case of death from septicaemia after the removal of a uterine fibroid
is recorded by Dr. Emmet. The growth had been cut into masses by
scissors and broken up. (' Amer. Journ. of Obst.,' Eeb. 1872.)
Spencer "Wells reports a successful case of removal of a uterine
fibroid by abdominal section. (' Med. Times Gaz.,' July, 1871.)
Dr. Kidd, in a paper on uterine fibroids (' Dublin Journal,'
Aug. 1872), states that in some cases he has dilated the uterus and
applied nitric acid. This is often beneficial ; the tumour is checked
in its growth, and the haemorrhage very much lessened. Dr. Kidd has
seen very serious results from the perchloride of iron introduced into
the uterus for these tumours. In the last case in which he tried it
the woman got a low form of metritis and died. He points out that in
cases of intra-uterine polypi the tumour often bulges out the wall of
380 REPOUT ON MIDWIFERYj ETC.
the uterus opposite to where it is attached. A steel wire is sometimefs
much more efficient for their removal than a soft iron wire. Tlie steel
wire can be compressed to get it through the os uteri, and it then
expands by its own elasticity, and is easily slipped over the tumour.
An excellent description of the various kinds of uterine polypi is given
by Duncan ('Edin. Med. Journ.,' July, 1871).
Gueniot, in a treatise on the absorption of fibroids of the uterus,
states that the disappearance of such tumours by absorption, although
still denied, ought now to be accepted as an ascertained truth. They
sometimes disappear even rapidly, a few months sufficing for the dis-
appearance of very large uterine myomas. According to the ascer-
tained facts the absorption takes place during the period of sexual
activity, but the puerperal state only exceptionally seems to exercise
an evident influence over it. Uterine myomas may also disappear
without operation by two other processes, viz. spontaneous expul-
sion and gangrenous destruction or suppuration; but their dis-
appearance by absorption is the only method exempt from danger and
always followed by recovery. Fatty degeneration, judging from
analogy, appears necessary as a preliminary to their absorption, and
Gueniot thinks that such substances as favour this change should
be employed, such as arsenic, phosphorus, and lead. (' Arch. Gener. de
Med.,' April, 1872.)
A fibroid of the uterus, weighing nine ounces, is reported by Dr.
Hardie, in the practice of Dr. Duncan, to have become spontaneously
separated. It lay in the vagina in a putrified state, and set up chronic
septicaemia, from which the patient quickly recovered after the removal
of the tumour. (' Med. Times and Gaz.,' July, 1872.)
Dr. Brunton (' Obstet. Trans.,' xiii) believes that in a case of fibroid
enlargement of the uterus ergot of rye promoted the disappearance of
the growth by maintaining uterine contraction, promoting its absorption
by mechanical pressure. Hildebrandt ('Berl. Klin. Woch.,' 1872)
expresses a similar opinion of the action of ergotin injected subcu-
taneously, the nutrition of the fibroid being interfered with by the
increased compression. The medical treatment of fibroid tumours of
the uterus beyond surgical interference is the subject of remarks by
various observers (' Brit. Med. Journ.,' April, 187 1).
Dr. McClintock described to the Dublin Obstetrical Society in
Pebruary, 1872, a method of removing uterine polypi by means of a
loop of twisted, silken, fishing line attached to a Gooch's double
cannula. The ligature having been carefully adjusted, the instrument
is slipped up the tumour and the ligature drawn tight. The cannulae
being held in position, the ligature is drawn firmly to and fro, and the
neck of the tumour is soon cut through. He believes that hemp-saw
is adequate to cut through the structure of any vaginal or uterine
tumour requiring extirpation, and that it is more easily and with more
certainty applied round the neck of such a tumour than a wire
ligature is.
Mr. Bryant details a case of complete extirpation of the uterus and
ovaries for fibro-cystic disease. The broad ligaments were securely
separated, aiid the uterus at its neck was ligatured in halves. A
1
UTERINE TUMOURS, ETC. 381
strong clamp was put on, which sloughed off on the fourteenth day.
The tumour weighed eight and a half pounds. Eecovery was uninter-
rupted. (' Obstet. Trans.,' 1872.)
Dr. "W. F. Atlee relates a case of fibrocystic disease of the uterus,
believed to be ovarian, which was subjected to operation. The mass
weighed five pounds. The patient recovered. The uterine cavity was
not lengthened. (' Amer. Journ. of Med. Sci.,' July, 1871.)
Dr. Lloyd Roberts records the successful removal of a fibrocystic
tumour of the uterus, supposed before operation to be an ovarian
tumour. No increase in length of uterus. Tumour weighed twenty-
three pounds. (' Obstet. Trans.,* 187 1.)
Gayet quotes a case of cystic myoma of the uterus mistaken for an
ovarian tumour, in which, before the operation, the tumour was tapped
and several quarts of a transparent yellowish fluid were withdrawn.
('Lyon Med.,' March, 1872).
Mr. Spencer "Wells, in some remarks on the differential diagnosis of
uterine from ovarian tumours ('Med.-Chir. Trans.,' liv) states that
there are more than a hundred cases on record where the abdomen has
been opened with the object of removing an ovarian tumour, but the
operator discovered that the tumour was not ovarian, but uterine.
Visible enlargement of the abdomen is more often general in cases of
ovarian tumours, and partial in uterine tumours, being confined to the
lower part of the abdomen until a very large size has been attained.
The depression of the umbilicus is diminished, or the umbilicus may
become prominent in large ovarian cysts. This is rarely seen in
uterine tumours unless fluid is also present in the peritoneal cavity.
Enlargement of the superficial veins of the abdominal wall is more
common in uterine than in ovarian tumours of moderate size. Nearly
all uterine tumours, though visibly moving above, seem to be fixed
below in the hypogastric region. Very great proportionate increase of
the space from the pubes to the umbilicus is more common in uterine
than in ovarian tumours. As a rule, the fluid portion preponderates
in an ovarian tumour, the solid in a uterine tumour. The mobility of
ovarian tumours is generally greater from below upwards than that of
uterine tumours. Vascular murmurs are common in uterine, very
rare in ovarian, tumours. The diagnosis is much aided by examining
by the vagina and the rectum.
For remarks on the differential diagnosis of fibrocystic disease of the
uterus and ovarian tumours see also Lee (' New York Journal,' Nov.
1871), Beatty ('Brit. Med. Journ.,' Nov. 1871), and discussion at
Obstetrical Society (' Obst. Trans.,' March, 1872).
Dr. Snow Beck furnishes a careful microscopical account of the
structure of the uterus ('Obstet. Trans.,' 187 1). It is made up of
fusiform fibre-cells, which form striae, bands, or layers, having in the
unimpregnated organ a small amount of amorphous transparent tissue
surrounding each fibre-cell, and of oval or round corpuscles and
minute molecules or granules imbedded in a considerable amount of
transparent amorphous tissue, and constituting what he terms the soft
tissue of the uterus. The internal surface is composed entirely of soft
tissue, and this has the utricular glands imbedded in it. The soft
382 REPORT ON MIDWIFERY, ETC.
tissue also penetrates into the walls of the uterus, and is met with in
decreasing amount towards the outer surface. It will thus be seen
that Dr. Beck does not admit the existence of a defined mucous mem-
brane on the inner surface.
Uterine Cancer.
Spiegelberg writes ('Arch. f. Gynak.,' iii, 2, 1872) on the diagnosis
of the first stage of cancer of the neck of the womb. He says that the
hardness and unyielding character of malignant deposit, as compared
with the firm and rough consistence of benign induration, is well
known, but he relies on two other signs which may be briefly de-
scribed as follows: — In malignant degeneration the overlying mucous
membrane is always immovable, firmly connected with the underlying
tissue, which is not the case in simple hyperplastic induration ; and
while the latter, under the pressure of a sponge-tent in the cervix,
dilates regularly and becomes looser, softer, and thinner, the cancerous
infiltration continues unaltered, firm, and hard, and does not become
stretched. Spiegelberg is not in favour of operative interference when
the disease is far advanced.
Dr. Madge, after a careful examination, reported that a specimen
exhibited by Dr. Protheroe Smith before the Obstetrical Society was
one of epithelial cancer of the lining membrane of the body of the
uterus, which destroyed portions of the uterine substance without
affecting the cervix. The bulging masses noticed on the inner surface
were made up of a variety of elements, minutes granules, oil-globules,
epithelial cells, and other cells of an irregular and nondescript character,
with a little earthy matter, all contained in a stroma of connective
tissue. ('Obstet. Trans.,' 1872.)
Dr. Henry Bennett records a case, very obscure as regards the dia-
gnosis during life, of malignant disease of the body of the uterus. The
patient was fifty years of age, had ceased to menstruate for two years,
and a uterine tumour was casually discovered by the hand on the hypo-
gastric region. The uterus was enlarged to about the size of four
months' pregnancy, perfectly free from adhesions, movable in every direc-
tion ; there was no vaginal discharge. The sound passed four inches.
In forty-eight hours after this she was seized with peritonitis and died
A large encephaloid cancerous tumour was found in the uterine cavity,
('Brit. Med. Journ.,' Sept. 1872.)
Arpem, in * L'Impartiale ' of Florence, publishes a case which, if
the diagnosis be correct, shows the marked influence of gastric juice
on uterine cancer. The patient was fifty-eight years old, with malig-
nant disease of the rectum and of the neck of the uterus. After
stopping the haemorrhage by the perchloride of iron, seven drachms of
artificial gastric juice was divided into three parts and used locally every
day for three weeks. Ultimately the ulcers were completely healed
by it.
Dr. Eouth writes ('Brit. Med. Journ.,' Aug. 1872) in favour of
gastric j uice for uterine cancer. The effects which he has observed to be
produced by the juice on cancerous sores have been solution of sloughs,
i
DISPLACEMENTS OF THE UTElltS. 38^
solution of the granular projections of the growths themselves, and
absorption and disappearance of glandular enlargements beyond the
seat of growth. Its action is rapid. Eouth refers to some successful
cases by Lusana and Pagello in Italy.
Professor Simpson writes in favour of the removal of portions of the
diseased tissues in cases of cancer of the uterus. Even in cases in
which the whole disease cannot be removed the ablation of only a
portion of the diseased tissue diminishes the haemorrhage and the dis-
charge, relieves the pain, and thus prolongs life. Where the disease is
sessile, and not capable of removal by the ecraseur, it must be dug or
scraped out by means of the finger-nail, a Recamier's curette, or
Simon's scoop. He thinks a saturated solution of the chlorate of
potash a good application to the remaining stump. (' Brit. Med. Journ.,'
Oct. 1872.) Hemarks by various authors on the treatment of uterine
cancer by scraping away the diseased tissue and by gastric juice are
contained in the same journal for Aug. 24th, 1872.
Dr. Barnes quotes (* Brit. Med. Journ,,' July, 1871) a case of cancer
of the female genitalia in which sudden death occurred. Nothing
like embolism or thrombosis was found after death. The glands and
subperitoneal tissue in the lumbar region were involved in dense
masses of cancerous tissue ; the aorta and the vena cava ran like tunnels
through the solid cancerous mass, which extended from the pelvis to
the diaphragm, and the aorta had, in many places, its coats bent
inwards, forming nodular projections into its cavity. The aorta was
thus no longer an elastic tube expanding under the heart's systole and
then contracting, but a rigid tunnel utterly wanting in resiliency. Such
an aorta is mechanically unfitted to do its work, and under moderately
increased exertion or emotion, causiug unusual action in the heart,
this rigid tube would throw back upon the heart a portion of the
column of blood which the aorta ought to receive and propel. This
retrograde dynamic disturbance would overwhelm the feeble heart, and
thus death would follow.
Tuberculosis of the female genitalia is illustrated by a case reported
by Lehnerdt, and another case by Wernick, thirty-three days after
labour, in v^hich the disease was confined to the Fallopian tubes.
('Beitr. zur Greb. u. G-ynak.,' Berlin, 1872.)
Displacements of the Uterus.
In a paper read before the Obstetrical Society, Nov. 187 1, Dr.
Konrad discusses the etiology of prolapse of the female genitalia. He
believes, with Spiegelberg, that prolapse of the vagina is the most im-
portant feature in any prolapse of the female genitals. The anterior
wall descends most commonly, and in the large majority of cases pro-
lapse of the uterus is a sequel of this. He describes Spiegelberg's
operation for the radical cure, which combines Diefienbach's method
with a modification of Simon's colpokleisis. The cervix uteri, if greatly
hypertrophied, is first removed by the galvanic wire.
Dr. Duncan ('Edin. Med. Jour.,' Jan. 1872) believes that the causes
leading to procidentia are purely mechanical. In all chronic cases
384 ilEtOllT ON MIDWIFEHY, ETC.
they have been long acting, gradually elongating the attachments, and
stretching and elongating the organs themselves, or parts of them.
The pelvic viscera descend either from the retaining forces being
diminished or the expelling forces being predominant. That which ia
most easily displaced will descend first, and the rest will follow in the
exact order and in the exact duration of the facility with which they
may be depressed.
Dr. Duncan, in a paper on the functions of the perinseum in proci-
dentia uteri ('Edin. Med. Journ.,' Feb. 187 1), believes that the peri-
nseum has nothing to do with the maintainance of the uterus in its natural
position, and that laceration of it has no causative influence in the pro-
duction of procidentia. There can be no doubt, however, that lacera-
tion of the perinaeum favours or accelerates the occurrence of proci-
dentia. It abbreviates the latter part of the path which the uterus
travels in its descent. It abets the causes which produce prolapsus by
removing difficulties which otherwise would have to be overcome. These
difficulties lie not only in the length and resistance of the perinseum, but
also in the smallness and tightness of the vaginal orifice. Eestoration
of the perinseum does not remove any cause of prolapsus or procidentia.
It is restored in order that it may resist the progress of the descending
uterus. This opposing power of the perinseum may be increased by the
pressure of the pad of a T bandage.
Dr. Squarey writes (' Obst. Trans.,' 1872), on the causation of ac-
quired flexions of the uterus. His object is to explain why in two
cases, the same causes and conditions apparently existing, an anteflexion
is found in the one case, a retroflexion in the other. He points out that
in whatever plane of the pelvis the uterus is situated, its axis is
invariably at right angles to that plane, and he believes that the direc-
tion the fundus uteri takes in a flexion depends on the situation of the
uterus in the pelvis at the time that the cause producing it comes into
action. When an anteflexion is produced, the uterus is high up, the
axis being forward, and any force striking it from above would impinge
on the posterior and upper surface of the fundus, and so force it for-
ward, producing anteflexion. "When retroflexion is produced the uterus
has from some cause sunk more or less deeply into the pelvis, and has
its axis directed more or less backward, so that any force striking it
from above would impinge on the anterior and upper surface of the
fundus.
Dr. Rasch writes (* Obst. Trans.,' 1871) on a novel method of using
the uterine sound for redressing a flexed uterus. The sound intro-
duced into the retroflexed uterus should first be used as a lever to lift
up the organ ; then, instead of twisting the handle round, the part in
the uterus and its ideal prolongation are made the centre of motion,
round which the handle and stem sweep in a large circle. The move-
ment is well illustrated by grasping the curved part of the sound in
one's hand and swinging the handle round as it will go. By the
above method the irritation which results from making a large semi-
circle of motion in the uterine cavity is avoided.
The mechanical treatment of displacements of the unimpregnated
uterus is fully described by Pepper (' Amer. Journ. of Obstet.,' 1871)
blsEASiis oi^ the vagina. 385
i)r. Barnes furnishes ('Brit. Med. Journ.,' Sept. 1871) an accurate
description of the anatomical conditions connected with hypertrophic
elongation of the cervix uteri. The whole pelvis and its contents in
such a case were removed after death, and a vertical section was made
in the median line. The entire length of the uterus was about seven
inches. The fundus and body were somewhat lower in the pelvis than
natural; the body had undergone apparently very little elongation.
The two lips of the os uteri were much hypertrophied and somewhat
everted ; they formed a mass covered by the everted vagina outside the
vulva. The base of the bladder was carried down along with the down-
growing interior wall of the cervix uteri, forming a sacculated pouch
below the level of the urethra, and, therefore, below the symphysis
pubis. The urethra was also distorted into a curve, of which the con-
vexity looked upwards, the bladder end of it being carried downwards
along with the base. The peritoneum, descending behind the abdo-
minal wall, was reflected upwards over the bladder (the cavity of which
was enormously enlarged) at a point about two inches above the sym-
physis pubis. It descended behind the bladder quite down to a point
on a level with the sacculated pouch of the bladder, that is, below the
level of the lower margin of the symphysis pubis. Eising over the
fundus uteri, the membrane descended behind, forming a Douglas's
pouch quite below the vulva. Dr. Barnes points out that it would not
have been possible to remove more than a portion of the os without
opening the retro-uterine pouch. The specimen also explained the
difficulty commonly encountered in keeping the protruded parts inside
the pelvis by pessaries. No folds of intestine descended between the
pelvic viscera in the anterior or the posterior peritoneal pouch.
Barnes also writes ('St. Thomas's Hosp. Eep.,' 1871) on "the
hypertrophic polypus of the os uteri, and its relation to hypertrophy of
the cervix uteri." Cervical hypertrophy is known frequently to pursue
a very uniform course, affecting the whole structure of the cervix
alike ; but sometimes one lip, and sometimes even a part of one lip, is
more especially affected. A small lobe continues to grow under the
same stimulus that determines the general hypertrophy. It grows a
little more quickly, then its base, being compressed by the firm
structure of the os on either side of it, is squeezed and elongated until
it assumes the characteristic polypoid shape. The structure of these
hypertrophic polypi entirely accords with this theory of their forma-
tion. They are generally small, but sometimes as large as a cherry ;
commonly single, but it is not infrequent to find two or three, and some
show a tendency to lobulation.
Diseases of the Vagina.
Winckel gives ('Arch. f. Q-yniik.,' ii, 3, 1871) an analysis of fifty
cases of vaginal cysts, including four under his own care. The cysts
may be divided into three kinds : — (i) mucous cysts, originating either
in open or closed follicles ; (2) interstitial, submucous, or placed in
the fibro-muscular layer; and (3) sub-serous, situated above, in the
peri-vagiual connective tissue underneath the peritoneum, below,
<v5
386 REPORT ON MIDWIFERY^ ETC.
between the vagina and the rectum. The chief causes of the follicular
cysts are catarrh, inflammation of the vagina, and the physiological
hypersemia which it undergoes during pregnancy ; while the deeper
cysts, both interstitial and subserous, generally result from compression
and bruising of the vaginal wall, and the effusion of blood into its
tissue, the result of a preceding labour. The cysts are generally slow
in their growth ; in some recorded cases they attained to the size of a
hen's egg in seven or eight years. The medium-sized and small ones
generally cause but little inconvenience. "Winckel treated and cured
his cases by simple incision. The other methods of treatment recom-
mended are the excision of a portion of the cyst wall and the subse-
quent application of caustic, puncture and injection of iodine, removal
by the ecraseur, and the use of a seton.
Vaginal stenosis is illustrated by Ebell, who relates a case of great
contraction in the upper third after cholera, and by Martin, who
records two cases. (' Beitr. zur Geb. u. Grynak.,' Berlin, 1872.)
Q-ueneau de Mussy writes on hypersesthesia of the vulva and vagi-
nismus. He disapproves entirely of Sims' method, and believes that
medical means combined, if necessary, with dilatation render deep inci-
sions altogether unnecessary. He has obtained good results from
vaginal suppositories of bromide of potash and belladonna, and subcu-
taneous injection of morphia and atropia. "When the vaginismus is
accompanied by itching he gives also some arseniate of soda. (' Lyon
Medical,' 1871.)
Stoltz writes (' Gaz. Med. de Strasbourg.,' 16, 187 1) on hyperaes-
thesia and spasmodic contraction of the vaginal sphincter, with or
without fissure. Vaginismus is also treated of by Scharlau. (' Beitr.
zu. Geb. und Gyniik.,' p. 64, 1872.) On vaginal neurosis. Ferber
('Berl. Klin. Woch.,' viii, i^, 1871).
Dr. Byrne related to the Dublin Obstetrical Society a case of tumour
of the vagina. The patient was thirty-six years of age, the mother of
four children. The tumour was firm, about the size of a hen's egg,
pale in colour, quite movable. It was attached to the posterior wall of
the vagina, and appeared to be folded up in a large loose fold of the
mucous membrane. A Y-shaped incision through the mucous mem-
brane having been made, the tumour was carefully dissected out of the
cellular tissue in which it lay. The tumour was lost, and so its micro-
scopical characters were not ascertained. ('Dublin Quart. Journ.,'
May, 1871.)
Dr. Barnes removed a fibroma, the size of a large orange, from the
anterior wall of the vagina. Its attachment began just at the meatus
urinarius, extending along the anterior vaginal wall, but leaving a space
of an inch quite clear below the os uteri. (' Obst. Trans.,' 1872.)
Mr. Lawson Tait figures ('Med. Times and Gaz.,' March, 187 1) two
needles, suitable for use in operations for vaginal fistulse. One needle
is the ordinary tubular one of Simpson, which, in making a stitch, Mr.
Tait always introduces first by the left hand. He then makes slight
traction on the wire so as to lift its loop up from the point of the
needle, and introducing the other needle through the other flap opposite
the first, the wire is easily caught in its notch and the stitch completed.
t)ISEASES OP THE OVAUIES. 387
^he absolute certainty which the two needles give of the points of
insertion for each stitch being exactly opposite is a great recommenda-
.tion for their use.
Chrschtschonovitch writes on the termination of nerves in the vagina.
The mucous membrane contains numerous branched cells, resembling
connective tissue corpuscles, arranged just beneath the laminated pave-
ment epithelium with almost the same regularity as in the cornea,
while others are scattered irregularly through the membrane. The
nerves penetrating through the muscular layer to the mucous
membrane consist of large bundles of medullated fibres, which here
and there contain groups of ganglion cells. Erom these, smaller
trunks are given off, still medullated, which enter the proper mucosa
or rete Malpighii ; as these pass towards the surface the medullary
sheath is gradually lost, and the fibres either bend back or join with
a fibril from a neighbouring trunk, forming a very superficial plexus, or
apply themselves to the wall of one of the small vessels, ascending to
supply the papillsB of the membrane. Some few of them, destitute of
medullary sheath, may be seen ascending between the epithelial cells ;
but the author agrees with Hensen and Klein in stating that the
nerves do not join with the branched connective corpuscles. The
smooth muscular fibre fasciculi of the membrane are surrounded by a
very rich plexus of non-medullated nerve-fibres, from which individual
fibres are given off that exhibit here and there granule-like enlarge-
ments, and penetrate between the several muscle cells. He thinks it
probable that these last are encircled by the ultimate fibrils. Follow-
ing the branches given off* to the epithelium from the sub-epithelial
non-medullated plexus, he finds that they break up in the deeper layers
into a plexus of fibres encircling the epithelial cells, amongst which
are large branched corpuscles. ('Lancet,' Nov. 187 1.)
Diseases of the Ovaries.
■^ Professor Waldeyer describes (Archiv £. Gyniik., ii, 3, 187 1) a
diff'use fibroid of the ovary of peculiar structure. The tumour
measured 15 cm. in length, 11 in breadth, and 10 in thickness, and
weighed 910 grammes ; and had the shape of a greatly enlarged ovary.
There was on the surface one cyst nearly the size of an apple, and two
small, transparent cysts, the size of peas. The consistence of the mass
was unusually hard, so that there was a difficulty in making a section
of it. It had a close resemblance to closely meshed spongy bone, or
an osteoid tumour. "Waldeyer then describes its microscopical cha-
racters, and states that it wanted only the characteristic grouping of
the cells at the epithelial like margins of the trabeculsa, and the firm,
throughout homogeneous state of the trabecular substance itself, to
render the resemblance between it and an osteoid tumour complete,
both macroscopically and microscopically. The cystic cavities showed
on their inner surface a short cylindrical epithelium.
Scaglia writes on the diff'erent forms of ovaritis (' Gaz. des Hop.,'
Feb., 1 871), and concludes that etiologically there exist several species,
such as the variolous, blenorrhagic, rheumatic, traumatic, menstrual,
puerperal j clinically there are the very acute, the acute, and th©
388 REPOET ON MIDWIFERY, ETC.
chronic. From a clinical point of view we cannot recognise the
division into follicular, parenchymatous, and peritoneal. Slavjansky
contributes an article on the same subject. (' Arch.'f. Gynak,,' iii, 2,
1872.) See also Matthews Duncan. ('Edin. Med. Journ.,' Sept. 187 1.)
Dr. Edis relates a case of abscess of the ovary in a girl set. 12. The
right ovary was found to be distended to the size of an orange, its
walls were much thickened and covered internally by flaky purulent
lymph ; the posterior surface had given way, allowing the matter to
escape into the peritoneal cavity. There was also general chronic
peritonitis. (' Obst. Trans.' 1871).
Professor G-aillard Thomas records (*Amer. Journ. of Obstetrics,'
1 871) five cases oi malignant disease of the ovaries. He concludes that
the circumstances which most prominently point to the existence of the
disease are: — (i) The rapid development of a solid tumour in an ovary,
with marked depreciation of the strength, vital forces, spirits, and general
condition of the patient. (2) The occurrence of oedema pedum and
spanaemia at an early period, and consequently dependent upon a
general blood state, and not the consequence of pressure by the tumour.
(3) Lancinating and burning pains through the tumour. (4) Cachectic
appearance. (5) The occurrence of ascites without evidences of
hepatic, renal, or cardiac disease, or of chronic peritonitis ; the fluid
accumulating in such large amounts as to force aside the supernatant
intestines and produce dulness in place of resonance on percussion in
dorsal decubitus.
Dr. Brown records a case of solid cancer of the ovary. The tumour
weighed nineteen pounds. On section it was found to be tough and
fibrous in structure, and to have in its interior a few small cavities
containing a purulent-looking fluid. The microscopical appearances
closely resembled those found in many scirrhous cancers of the breast.
('Amer. Journ. of Obst.,' May, 1872.)
Dr. Parry writes an interesting article on sudden enlargements of,
and haemorrhage into, ovarian cysts. (* Amer. Journ. of Obst.,' Nov.
1871.)
Palm relates twenty-five cases of ovarian cysts in which from ex-
cessive distension of the cyst wall, or from some traumatic cause,
rupture of the cyst occurred. Seven of the cases were cured, five after
the first, two after repeated rupture. Eighteen died; three from
collapse, six from acute peritonitis, three from chronic peritonitis, and
six from dropsy and marasmus. (' Wiirtt. Medic. Corresp.,' 37, 1871.)
Dr. J. J. Phillips points out ('Obst. Trans.,' 1872) one source of
danger in treating suppurating ovarian cysts by drainage. The con-
traction of the main cyst makes such traction upon any adhesions
there may be around a secondary cyst that rupture of the latter mayi
take place. A case is given in illustration, and as the contents of the]
ruptured cyst were purulent fatal peritonitis occurred.
Ovariotomy,
Mr. Spencer Wells has lately (' Med.-Chir. Soc.,' Nov. 1872) com-
pleted the analysis of 500 cases of ovariotomy performed by him. In
OVAEIOTOMY. , 389
2^ cases both ovaries were removed at one operation, and there were
four cases where ovariotomy was performed twice on the same patient.
The subsequent history of patients who recovered after removal of one
ovary proved that they might menstruate regularly, and might bear
children of both sexes, or twins ; and that after removal of both ovaries
they did not become excessively fat, nor lose their feminine appear-
ance or sexual instinct. Of 373 women who recovered, 0^6 who were
unmarried at the time of the operation had married since; of these 15
had had one child, 6 two children, 3 three, 3 four children, and 2 had
had twins. Of 259 who were married when the operation was per-
formed, many being beyond the age of child-bearing, 23 had had one or
more children since. Seventeen had died of causes more or less
directly connected, and 19 of causes not at all connected, with ovarian
disease or the operation, at various periods from a few weeks to eight
years after ovariotomy. Mr. Wells stated that unilocular cysts often
disappeared after a simple tapping. They were frequently not ovarian
at all, but connected with the parovarium or the broad ligament. His
views as to early operation had become modified from those which he
at first held. He had found that the results of operations on small
tumours in healthy women were not so favorable as in cases where
the cysts were large, and the patients had become accustomed to
disease. He did not think it right to remove small ovarian tumours,
unless they caused great pain and inconvenience to the patient. (' Brit.
Med. Journ.,' Dec. 1872.)
Keith communicates ('Lancet,' Nov. 1872) a third series of fifty
cases of ovariotomy. Of the last hundred cases operated on by Keith
there have been eighty -four recoveries. There were only eight deaths
in the fifty cases now recorded ; two died from obstructed intestine,
one from acute septicaemia, and five from peritonitis. Keith now takes
perhaps more care than ever during the operation to tie every bleeding
point. Lister's animal ligatures being used. Pure, dry, sulphuric
ether is always used by him as an anaesthetic.
A tabular statement has been published of the cases of ovariotomy
performed by the late Dr. Skoldberg of Stockholm. Out of thirty com-
pleted cases twenty-six recovered. An exploratory incision was made
in four cases, and one of these died. An operation for the removal of
a solid cancerous ovarian tumour was fatal.
Mr. Christopher Heath related to the Clinical Society (Nov. 1871)
a case of ovariotomy in which very extensive adhesions to the sur-
rounding structures were found. On enlarging the abdominal incision
with scissors in the ordinary way, an empty coil of small intestine,
which was closely adherent to the wall, was divided in three quarters of
its circumference. Mr. Heath attached the bowel to the skin with
silk sutures, forming an artificial anus. The patient made a perfectly
good recovery, the use of a belt and an air pad satisfactorily retained
all fsecal matter, and she had regular stools.
Dr. Beebe relates five cases of ovariotomy in which he treated the
pedicle by simple torsion of its vessels. There was no subsequent
haemorrhage, and each case recovered. (' Amer. Jour, of Med. Sci.,*
April, 1871),
390 REPOET ON MIDWIPEHY, ETC.
Dr. Atlee records seven cases of ovariotomy, and describes a new
clamp for the operation. By means of this clamp the pedicle is com-
pressed in the linear direction of the wound, and at the same time it
limits within certain points the expansion or spreading of the pedicle
when the blades are screwed together. (Ibid.)
A new ovariotomy clamp is described by Dr. Dawson (' Amer. Jour.
Obst.,' 1 871), and a pump for facilitating the operation by Dr.
Lente.
Dr. Tracy reports six cases of ovariotomy, five of which were suc-
cessful ('Austral. Med. Journ.,' Aug. 187 1); and a successful case
performed during an attack of peritonitis. ('Med. Chir. Soe.,' 1872.)
Dr. B. S. Schultze relates ('Arch. f. Gynak.,' ii, 3, 187 1) four
cases, two of which recovered. One of these patients had two
children subsequently ; the other menstruated through the abdominal
wall, and the discharge from the site of the incision often lasted some
hours longer than that from the vagina. Martin also contributes seven
cases. ('Berl. Klin. Woch.,' March, 1872.)
Dr. G. H. B. Macleod writes ('Lancet,' Jan. 187 1) on an improved
method of dividing the pedicle in ovariotomy, and describes an instru-
ment of his own construction which he employs to grasp the pedicle
firmly near its uterine end. The cyst is then cut away by dividing
with a knife the extreme distal end of the pedicle, and the stump is
caught by special forceps at a short distance from the part grasped by
the instrument above mentioned. By slowly turning the forceps
while the first instrument is kept at rest, the stump is twisted off
close to the edge of the instrument by which it is held, and may then
be returned with safety into the abdominal cavity. Dr. Macleod
relates a successful case in which this plan was adopted ; the patient
was quite recovered about the time the clamp is found to separate in
most cases. He says that it is a question for further observation how
far the simple grasp of the first instrument, if continued for a short
time, might suffice to close the vessels of the pedicle without the
torsion. Mr. Jessop relates ('Lancet,' Sept. 1871) two cases in which
the pedicle was successfully twisted by the above method.
Dr. Hayes recommends a method for securing the vessels of the pedicle,
which he calls "the subperitoneal." The proceeding resembles the
subcutaneous ligature of nsevus. The pedicle is first compressed by a
clamp, and a needle armed with stout catgut ligature is passed
beneath a good thickness of the serous surface of the pedicle, but
superficial to the principal vessels. The needle being withdrawn at
the side opposite the point of entrance is again passed into the aper-
ture of exit, and pushed between the vessels and peritoneal covering on
the side of the vessels opposite its first passage, until it can be with-
drawn through the opening made by its first entrance. The ends of
the ligature are to be strongly tied, and cut off" short. ('Dublin
Quart. Journ.,' Nov. 1871.)
Panas relates a successful case of ovariotomy in which a subperito-
neal fibroid of the uterus was removed at the same time. (' Gaz. des
Hop.,' July 1 87 1.)
Mr. Lawson Tait has introduced a new form of trochar for use in
PEEI-UTERINE CONDITIONS. 391
ovariotomy. It is claimed that this instrument has the following
advantages over those at present in use : — that the penetrating edge
cuts, and does not tear, making a wound which the tube completely
fills, and it is easily retracted. The cutting point may be used as a
knife to slit open smaller cysts contained in the major one, and of
which the contents may be so viscid as to be unable to pass along any
trochar. The catches adapted to the trochar are such as to obviate any
possibility of its slipping. (' Med. Times G-az.,' Dec. 1872.)
Dr. Groddard relates (' Obst. Trans.,' 1871) a case of ovariotomy
performed by Mr. "Wells at the third month of pregnancy. Recovery.
Labour at term. Living child. Mr. Wells has performed ovariotomy
in four cases during pregnancy, each time with a successful result.
Barker performed ovariotomy successfully in the case of a girl set.
six years and eight months. The tumour was tapped and easily ex-
tracted. Besides the fluid contents it contained the elements usually
found in a dermoid cyst. (* Philad. Med. Times,' 1871.)
Mr. Spencer Wells relates (*Med. Times Gaz.,' Jan. 1872) three
cases of suppurating ovarian cysts with a high temperature, which were
successfully operated upon, the temperature falling quickly after the
removal of the offending cyst.
Peri-uterine conditions, Sfc.
Dr. Meadows writes on pelvic hsematocele, especially on its
diagnosis and treatment. He relates two cases in which he punctured
the tumour; and believes from his own experience and from an
analysis of Bernutz' cases that puncturing should be more frequently
practised, that this is generally best done by the rectum, but that as a
rule it should not be undertaken during the first month after the
effusion has taken place. An interesting discussion followed the
reading of this paper. (* Obst. Trans.,' 1871.)
Dr. Snow Beck, writing on the source of the hemorrhage in pelvic
hasmatoma, believes it to be highly improbable that the blood ever
regurgitates from the uterus through the Fallopian tube, as the con-
sequence of some disorder of the menstrual function. There is no
post-mortem evidence that this occurs except where there is permanent
obstruction to the outward flow of the catamenia and consequent
dilatation of the uterus. (' Obst. Trans.,' 1872.)
Delpech records (' Gaz. des Hop.,' Sep. 1871) a case of phlegmon
of the broad ligament, proceeding to suppuration, and causing death
by bursting into the peritoneal cavity. The patient was forty years
old, never married, and the cause of the phlegmon appeared obscure.
The pain first came on suddenly, eight days after the cessation of
menstruation.
Dr. Hart narrates (' Amer. Jour, of Obstetrics,' 187 1) an interesting
case of hydrocele of the roimd ligament, which at first was mistaken
for a strangulated hernia. The tumour was larger than a hen's eg^,
flattened, situated above Poupart's ligament, in the direction of the
inguinal canal. When exposed, an exploring needle was introduced,
392 REPORT ON MIDWIFERY, ETC.
and three ounces of a clear limpid fluid escaped. The sac was then
freely laid open, but no intestine or omentum was found. Two similar
cases came under the notice of Dr. Nelson, and in these there existed
the same translucency, slow growth, non-reducibility, and freedom
from pain.
In a paper on uterine inflammation after the change of life (* Brit.
Med. Journ.,' Sept. 1872) Dr. Tilt states that the occasional recur-
rence after the menopause of inflammation of the sexual mucous mem-
brane may be safely predicted to those who have long suffered from
inflammation of the entire womb, when they presume too much on their
partly recovered strength. Also that we may safely predict inflammation
of the sexual mucous membrane to those who overtax their strength
after the menopause, whenever the uterine tissues are teased by the
presence of a small interstitial fibroid or a polypus, when the cervix is
hypertrophied, and also when the women are cachectic and have
always one or more of their mucous membranes in a diseased condition.
In a discussion on uterine injections for chronic metritis at the
Societe de Medecine of Paris M. Charrier recommended iodine ; the
perchloride of iron, he said, gave rise to excessive pain. Gallard spoke
highly of a weak solution of the perchloride. He first injects the
uterus with water so as to ascertain its capacity, and afterwards injects
a similar quantity of the solution of the perchloride. (' Gaz. des Hop./
'Feb. 1871).
Professor Spiegelberg contributes ('Arch. f. Gynak.,' iii, 2, 1872)
three cases illustrating the value of puncture in the diagnosis of collec-
tions of fluid in the abdominal cavity. Having referred to a previous
case reported by him where the omission of tapping led to the error of
mistaking a hydatid cyst of the kidney for an ovarian tumour, and to
an operation and the death of the patient, he quotes: — Case i. — A
woman, set. 30, two years previously, after so-called abdominal in-
flammation, noticed a swelling in the left hypogastrium, which
increased slowly and steadily, but which gave rise to little annoy-
ance, except to fixed pain in the left side. On admission a cyst
occupying the centre part of the lower and middle abdomen ;
doubtful origin ; puncture, evacuation of pus ; attempted incision ; and
rupture of cyst after detachment of neighbouring adhesions ; escape of
echinococcus membrane ; retroperitoneal left-sided hydatid cyst ; partial
excision, the rest attached to the abdominal wound ; recovery by wasting
of the sac after long continued suppuration. Case 2. — ^t. 40, sent
in for ovariotomy. Puncture of one of the cystic spaces revealed it
not to be an ovarian tumour, for the small quantity of dark fluid with-
drawn, besides containing many red and white blood-cells, underwent
spontaneous coagulation and showed no epithelial elements. The serous
character was thus apparent. Death by marasmus and oedema of the
lungs. Tumour found to be a large retroperitoneal and mesenteric
sarcoma descending into the pelvis, and resembling an ovarian cyst on
account of numerous sacculated ascitic spaces and secondary adhesions
to the fundus uteri. Case 3. — ^t. 28, with an abdominal tumour, its
character doubtful. By tapping a glutinous fluid was withdrawn, which
contained besides crystals of cholesterin, numerous cells, a little dehris^
PHYSIOLOGY AND PATHOLOGY OP THE OVUM. 393
cells with clear contents, and much remarkably distinct nuclear cylin-
drical epithelium. This pointed to its ovarian character. Ovariotomy,
incomplete on account of numerous adhesions. Death by decom-
position of cyst. Spiegelberg concludes that although diagnostic
puncture does not always give positive information as to the origin oi
the fluid, yet that when it does the result is conclusive as compared
with the doubtful physical examination,
ir. PBEGNANCT.
jPJiysiology and FatTiology of the Ovtcm.
Dr. Livius Eiirst writes ('Arch. f. G-ynak.,' ii, 3) on the amnion in
its relation to foetal malformations. While he admits that compression
by the umbilical cord may, in some cases, be the cause of arrest of
development of certain portions of the foetus, he believes that amnial
"filamentous adnexa" — under which name he includes thready, stringy
and membranous formations — are the most common causes of mechani-
cal interruption to the development of the foetus. He then discusses
the formation of these adnexa ; by some they are regarded as plastic
adhesions, by others as the result of foetal inflammation with plastic
exudation, but Tiirst agrees with the theory which considers them due
to arrested formation of the amnion. The inner layer of the amnion,
at first in close contact with the fcetus, is gradually separated from it
by the liquor amnii ; but abnormal adhesion may take place between
the epithelial layer of the amnion and the epidermis of the foetus, and
this, by the expansion of the amnion, leads to thready and stringy
formations, which may wholly or partly interrupt the development of
the extremities. The most frequent cause of this adhesion is the small
quantity of liquor amnii, or its late secretion.
In the discussion on a specimen exhibited at the Obstetrical Society
of a child whose forearm had undergone amputation in utero. Dr. Barnes
said that it was not often strangulation by the umbilical cord that
caused these amputations, but by a string of false membranes. He
regarded the budding from the stump which is so often found, with the
signs of a cicatrix, as proof of amputation in the early stage of develop-
ment. C Obst. Trans.,' 1871.)
Dr. Braxton Hicks writes on the anatomy of the human 'placenta, and
controverts the Hunterian doctrine. He shows how the injection which
Hunter used would almost certainly produce an irruption of blood
amongst the villi. The fact of blood being found among the villi after
natural expulsion is no evidence in favour of or against a sinus system,
because there are then nearly always lacerations and denudations of the
decidua serotina. The author argues that if no blood be found among
the villi, the placenta being examined in situ, this is conclusive evidence
against the existence of the sinus system. Dissections proving the
absence of blood under these circumstances are added. (' Obst. Trans./
187?.)
394 EEPORT ON MIDWIFERY; ETC.
Joulin contributes some observations on the laminar membrane o£
the human placenta, the state of the chorion, and the placental circula-
tion at term, and concludes that at the end of pregnancy the chorion
has disappeared as a continuous membrane from the foetal surface of
the placenta, and that the greyish resisting tissue which covers the
placenta is not the chorion, but a membrane of new formation, which
he calls the laminar membrane. He illustrates the evolution of this
membrane by reference to the condition of the placenta at various
stages of its development. ('Bulletin de I'Academie de Med. de
Paris,' March, 1872.)
An interesting case of recurrent discharge of fluid from the uterus
during pregnancy is recorded by Dr. Dyce Brown ('Brit. Med. Journ.,'
May, 1872). The first gush of clear fluid, just tinged with blood, took
place at the fourth month, and was repeated almost weekly until the
sixth month, when labour came on. The amniotic sac was then felt
tense, and required to be ruptured, after which a large quantity of fluid
escaped. A similar discharge has occurred in the two subsequent
pregnancies of the same patient. Fabbri writes (' Presse Med./ xxiii,
29, 187 1) on the hydrorrhoea of pregnancy.
Dr. Matthews Duncan writes on long delay of labour after discharge of
liquor amnii. He gives an illustrative case, and refers to the researches
of "Winkler, proving that the amnion has the power of secretion and
absorption in a high degree. Firm compression of the foetus may take
place without active uterine contraction, and it is firm compression by
active uterine contraction that is incompatible with the continuance of
pregnancy. (' Obst. Trans.,' 1872.) Similar cases are also recorded
by various writers in the * British Med. Journ.,' and by Doughty
('Amer. Journ. of Obst.,' May, 1872).
In the ' G-az. Med. de Paris,' Oct. 1871, is an account of some pecu-
liar cysts' of the placenta described by M. Jacquet. He believes that
they were developed at the expense of the sheath of the placental
vessels, and he calls them perivascular cysts. Jacquet admits four kinds
of placental cysts — (i) gelatinous cysts originating in the laminated
tissue between the chorion and the amnion ; (2) perivascular cysts ;
(3) sanguineous cysts, from the placental sinuses ; and (4) the ordinary
cysts of the villi (hydatiniform degeneration).
On calcification of the placenta. — Dr. E. Frankel gives Q Arch. f.
Gynak.,' ii, 3, 1871) three cases in which a careful examination of the
placenta was made ; and he concludes that calcification of the placenta
most frequently follows the course of the capillaries and small vessels
of the villi, though it may be more diflTuse and intermediate, and then
its origin, according to Langhans, is from the epithelial layer of the
villous trunks. Most commonly capillary incrustation proceeds from
the vessel wall, spreads through at all points, and forms, as it were, a
coating for the cavity of the vessel, without as yet rendering the vessel
impervious. It usually, though not always, begins at the extremities
of the villi, and may also show itself at separate points in the trunks.
Diff'use, not too extensive, calcification is without influence on the sup-
port of the foetus, while, indeed, a less extensive capillary petrification,
especially in the earlier months of pregnancy, interferes with the foetal
PHYSIOLOGY AND PATHOLOGY OP THE OVUM. 395
blood and gaseous intercliange, and thus may lead primarily to the
death of the foetus. Calcification of a mature placenta with a living
child is only an indication of completed intrauterine growth ; and
from a similar point of view is to be regarded as secondary cal-
cification, noticed when the foetus is from other causes dead and
macerated.
Ahlfeld, of Leipzig, writes on the determination of the size and the age
of the child lef ore lalour. The attempt is made by Ahlfeld to deter-
mine the size of the foetus for two reasons ; firstly, in order to ascertain
the period of gestation, and, secondly, to make out before labour if any
disproportion exist between the foetus and the genital passages. To
arrive at the first point attention is paid to the woman's statements,
the height of the uterus, the development of the abdomen, the condi-
tion of the inferior segment of the vaginal portion of the cervix uteri,
and the state of the external genitals. To ascertain the second point
particular attention is paid to the size of the head, the hardness of
the bones which form it, and the condition of the sutures and
fontanelles. The uterine contents determine the form of the uterus, so
that in the middle of pregnancy, when the foetus forms the principal
part of the ovum, the form of the uterine walls is moulded to the posi-
tion and attitude of the foetus. There thus results an ovoid, the two
poles of which are constituted by the head and the breech, and the
separation of these two gives the length of the foetal axis, and this is
always about half the entire length of the child. Having placed the
woman on her back, with the thighs flexed, if the long axis of the uterus
be from above downward, the position of the fundus uteri is marked on
the abdomen, and then one arm of Baudelocque's pelvimeter is guided
by the finger along the vagina to the occiput of the child ; the length
from head to breech is thus ascertained, and by doubling this we have
the entire length of the child. If the long axis of the uterus be trans-
verse, the position of the head and the breech is marked, and the dis-
tance between them measured. The author has collected in eight
tables the results of measurements made in 2^0 cases, and at the same
time the estimation of the weight of the foetus. In the fortieth week
the greatest length is estimated at ^5 centimetres, the shortest at 48 ;
in the thirty-ninth week, ^6 and 46 centimetres ; in the thirty-eighth,
60 and 44 ; in the thirty- seventh, ^4*4 and 40. The second table
proves the truth of the statement already made, that the entire length
of the child is about double that of the foetal axis. The third table
gives the results of measurements made in the intervals of uterine
contractions ; the fourth, of those made during uterine action. The
fifth gives an account of the measurements in transverse and oblique
positions, and the sixth the relation which exists between the length of
the newborn child and the two transverse diameters of the head. The
seventh table gives the height of the uterus in each week of pregnancy,
and the last table the relation between the height of the uterus and
the length of the intra-uterine foetal axis, and the length of the newborn
child. The increase in the size of the uterus is about half a centimetre
a week, at least, in the last third of pregnancy. The height of the
uterus continually increases to the end of pregnancy, although it is
396 EEPORT ON MIDWIFERYj ETC.
generally said that tlie uterus descends in the last month. (* Schmidt's
Jahrbiicher,' B. clii, H. i.)
Dr. Hutton states ('New York Med. Journ.,' July, 1872) that he
has been able to predict the sex of the child in utero in seven cases, with-
out a failure, by auscultation. "When the foetal pulsations number 144
per minute the child is a female ; 1 24 per minute, a male. A variation
of six beats per minute, from 124 upward and from 144 downward,
will not endanger the diagnosis, provided auscultation be practised in
the ninth month of pregnancy. Of fifty-seven cases examined by
Steinbach he was correct in forty-five, and Trankenhausen was correct
in all the fifty cases which he examined with a view to determine the
sex of the child.
Dr. Brunton relates a case (' Obstet. Trans.,* 187 1) in which the
entire ovum was expelled at the seventh month, and although at least
fifteen minutes elapsed before the membranes were opened, yet the child
was rescued alive. Dr. Heywood Smith did not see why the child
should not have been alive. It was not in the condition of a child born
with the stimulus of the external air producing inspiratory eff'ort, and
BO incurring the danger of drowning, but in this case, with the ex-
ception of slight loss of heat, the child was in a natural condition, its
circulation continued as if it had been still in utero, with the substitu-
tion merely of aeration by the atmosphere, acting directly upon the
uterine aspect of the placenta, for the maternal blood. Dr. Grigg said
the practical lesson from the case was to take care, should the placenta
be expelled before the birth of the child, to expose its uterine surface
to the air.
Conception under unusual circumstances. — Dr. E. Olshausen re-
lates ('Arch. f. Gynak.,' ii, 2, 187 1) two cases in which conception
occurred while each of the patients was wearing an intra-uterine
stem. The first case was that of a woman who, since her last con-
finement, had suffered from menorrhagia and anteflexion of the
uterus, for which an intra-uterine stem pessary was introduced on the
28th of June. She menstruated for the last time on the 6th of Decem-
ber, and was delivered of a strong boy on the 25th of September. The
instrument was removed on the 15th of January, conception having pro-
bably occurred about the 19th of December. The second patient had
suffered from perimetritis after her last labour, and had anteflexion of
the uterus, for which she wore an intra-uterine stem. Menstruation was
regular and profuse ; the last period was on the 8th of September. The
pessary was removed on the i8th of October, and she was confined of
a girl, weighing 4 kilog., on the 24th of June. The ovum and the
instrument were probably twenty days together in the uterus in this
case. The pessaries were made of hard caoutchouc, with a globular
head.
Diseases of Pregnancy.
Dr. E. Kaltenbach writes an elaborate article on albuminuria and
diseases of the urinary organs in the child-bearing period (' Arch. f.
Gynak.,' iii, i, 1871). He relates cases as proofs of each proposition
which he lays down, and sums up his researches in the following con-
DISEASES OF PREGNANCV. 397
elusions. During pregnancy albuminuria may supervene (i) in conse-
quence of vesical catarrh, which occasionally results from pressure on
the urethra and the neck of the bladder ; (2) from general catarrh of
the urinary passages, with pyelitis ; (3) in consequence of congestion of
the renal vessels ; and (4) from parenchymatous diseases of the kidneys.
In the puerperal state albuminuria may result (i) from vesical catarrh,
brought on by the mechanical irritation of a catheter, or by the exten-
sion of the inflammatory process from the genital organs to the bladder,
or by severe labour ; (2) from general catarrh of the urinary passages,
with pyelitis, arising from a simple extension of a primary catarrh of
the bladder, or from contiguity to inflamed parts, while sometimes
pyelitis may supervene as an independent idiopathic affection ; (3) from
congestion of the renal vessels as in uncompensated insuiSciency of
the valves of the heart ; and (4) from textural disease of the kidneys,
which may appear as a primary parenchymatous nephritis, or be
secondary to the extension of inflammation from the bladder, or result
from pressure on the ureter, or be the metastatic inflammation of py-
aemia. Physiological albuminuria does not exist either during pregnancy
or in the puerperal state.
Dr. Hermann Lebert, of Breslau, relates three cases, intended as a
contribution to our knowledge of the causation of heart disease and
disease of the vessels in connection with child-bearing :
Case 1. — Acute articular rheumatism at the fourth month of preg-
nancy, symptoms of mitral endocarditis, repeated rigors, indications of
embolism in the left lower and the right upper extremity, abortion, death
from oedema of the lungs. Endocarditis with ulcerative destruction of
the bicuspid valve, embolic obstruction of the subclavian artery, of the
termination of the aorta, and of the first part of each iliac artery. The
uterus was full of blood-clot, but no pathological change existed in its
walls. Case 2. — Severe puerperal fever, great dyspnoea, with abundant
rhonchi and a bellows murmur in the vicinity of the tricuspid valve.
On opening the body there was found purulent inflammation of the
tricuspid, a large embolism in the right portion of the pulmonary
artery, with purulent inflammation of the same. The inner surface
of the uterus showed a well-marked uniform injection of its vessels,
with everywhere a rather thick epithelial layer. The organ was twice
the size it should be at the fifth week after labour, but its structure
appeared normal. There was inflammation of the right spermatic vein.
Case 3. — Abortion at the sixth month, periovaritis, pleurisy, swelling
of right knee and left elbow ; death on the twenty-fourth day. Em-
bolism in the pulmonary artery, double pleurisy, gangrene of the lower
lobe of right lung, thrombus of vena cava inferior, obstruction of the
left renal vein, periovaritis, periuterine purulent phlebitis, and endo-
metritis. ('Arch. f. Gynak.,' iii, i, 1871.)
Dr. A. Gusserow relates ('Arch. f. Gynak.,' ii, 2, 1871) five very
interesting cases of a high degree of anaemia in pregnant women. The
character of the symptoms and the cause of the disease were strikingly
alike in all . The age of the patients varied from twenty-four to thirty-
six ; they had previously enjoyed good health, and four of them had
been before pregnant. Slowly, in the course of pregnancy, and with-
398 ilEPOET ON MIDWIFEEY, ETC.
out any apparent cause, there supervened such severe anaemia and
hydrsemia, that towards the eighth month the foetus was expelled, and
each patient died soon after. In none of the organs could be found
any marked change except the appearances of extreme anasmia and
hydrsemia and their consequences. The brain and its membranes
were very anaemic. The slight fatty degeneration observed (though
not in all the cases) in the substance of the heart and in the abdominal
viscera was, he believes, simply the result of the blood-change, and not
the primary cause. The alterations which are known to occur in the
blood during pregnancy seem, in these cases, to have been carried so far
as to become a pathological condition. Gusserow recommends, in
similar cases, that abortion should be induced, or at least, as early as
possible, premature labour. Transfusion may be necessary.
Matton, of Bouzonville, writes (' Journ. de Bruxelles,' May and June,
1872) on pneumonia during pregnancy and on puerperal fever. In the
first place the author considers the modifications which pregnancy in-
duces in the blood. These consist in an increase of the fibrine and the
water, and a diminution of the corpuscles and the albumen ; thus preg-
nancy predisposes to inflammations. If the amount of fibrine exceed
certain limits, we have, succeeding to the inflammatory, the purulent
diathesis, and if it is the watery part which is increased beyond
measure, we have in addition a serous cachexia. According to Andral
during the first six months of pregnancy the amount of fibrine is
diminished, and is met with in increased quantity only after the
sixth month. Matton then quotes thirty-eight cases of pneumonia
during pregnancy, and states that nineteen cases out of twenty re-
covered when the pregnancy was not interrupted in its course, but only
nine out of eighteen got well when labour supervened. Por him puer-
peral fever is the combined result of an essential fever of internal origin,
due to the condition of the blood and other ill-understood causes, and a
local phlegmasia.
Spiegelberg writes on the complication of pregnancy with chronic
heart disease. (' Archiv. f. G-ynak./ ii, 2, 1871.)
Complications and Accidents of Pregnancy,
Dr. Madge reports ('Brit. Med. Journ.,' Dec. 1871) a case of
paralysis during pregnancy. At an early period in the pregnancy the
patient complained of severe pain in the hands and feet, which soon
became excessively sensitive and painful. In a few weeks this hyper-
aesthesia was succeeded by anaesthesia, and there was also loss of
motion. Small doses of ergot of rye were taken for several weeks
without any perceptible benefit ; this was ordered on account of its
contractile effects on the smaller vessels, thus lessening congestion,
which it is believed existed in this case in the grey matter of the chord.
Faradisation was then used, and sensation returned in two months,
but motion not until later. A dead foetus, of about four months, of
a dark muddy colour, and surrounded by muddy liquor amnii was
ultimately expelled. The patient made a good recovery.
Dr. Playfair points out (' Obst. Trans.,' xiii) that some cases of
COMPLICATIONS AND ACCIDENTS OF PREGNANCY. 899
irritable bladder in the latter months of pregnancy are due to an
oblique or transverse position of the foetus in utero. He relates three
cases in which this troublesome symptom' disappeared after rectifica-
tion of the child's position by external manipulation. Dr. Hicks sug-
gests that this results from the disturbance to the form of the bladder
by the altered form of the uterus.
In the ' G-az. Med. de Paris/ Feb. 1871, Dr. Zagiel relates a case of
pregnancy complicated with cystic disease of the left ovary. Labour ter-
minated successfully for both mother and child. Dr. R. P. Harris records
(' Amer. Journ. of Obst.,' 1871) a case of ovarian dropsy of fifty years
duration. The patient was three times pregnant during its existence,
and each labour had a successful issue to both mother and child. Two
cases of ovarian tumour coexistent with pregnancy are also to be seen
recorded in the ' Amer. Journ. of Med. Sci.,' July, 1871, p. 291 and
p. 295. A case of ovarian cystic disease with pregnancy coexisting is
also mentioned by Depaul (' Lancet,' July, 187 1, p. 165). The cyst was
tapped, and no refilling took place after the patient's confinement.
He thinks it a question worthy of notice whether the pressure of the
developing uterus had a great share in eff'ecting a cure in the case.
The' Archives Grenerales,' January to March, 1871, contain articles by
Dumaivon on pregnancy, labour, and child-bed, complicated with
ovarian cysts.
A girl, set. 16, was admitted into St. Bartholomew's Hospital with
retention of urine at the fourth month of pregnancy. She was seized
with sudden abdominal pain and died. A post-mortem examination
revealed the fundus of the bladder, the caecum, the lower part of the
small intestine, the fundus of the uterus, the sigmoid flexure, and the
extremity of the omentum to be all matted together by very old
adhesions. A little recent lymph was spread over the rest of the
peritoneum. On breaking down the old adhesions a sort of cavity was
discovered behind the bladder and above the uterus, which contained a
brown turbid liquid. This cavity communicated with the bladder by
a sloughy hole in the posterior wall of the latter. The bladder pre-
sented large sloughy patches that implicated all its coats. (' Lancet,'
May, 1871.)
Funk relates a case of reposition by the fingers of an incarcerated re-
troverted uterus in two successive pregnancies. The first "was successful,
the pregnancy proceeding to the full term ; in the second, death of the
mother succeeded to abortion, gangrene of the bladder and peritonitis.
('Oesterr. Ztschr. f. prakt. Heilk.,' xvii, 26, 1871.)
Dr. Eoss relates (' Lancet,' July, 1871) a case of double uterus with
concurrent pregnancy. Twins, advanced to between the fifth and
sixth months of utero-gestation, were born in July. Menstruation
occurred regularly after this, and in four months another child was
born at the full term. A careful examination of the uterus afterwards
revealed that a vertical septum extended from the fundus to the cervix
uteri, completely dividing it into two separate cavities.
A peculiar case of complete prolapse of the gravid uterus at the
fourth month in a patient, set. 20, who had voluntarily half starved her-
self, and allayed the cravings of hunger by incessantly smoking, and who
400 ilEPORT ON MIDWIFERY, ETC.
then placed a heavy weight on her abdomen, is related by Biggs.
('Western Lancet,' Aug. 1872.)
A case of exfoliation of the female Madder is recorded by Dr. "Wardell.
The patient was twenty-eight years old, and about three months preg-
nant ; retention of urine for five days ; abortion. On the twelfth
day she complained of great pain over the pubes. A membranous mass
was seen to protrude through the meatus urinarius, and this was fully
expelled in half an hour. On examination it seemed as if the whole of
the mucous coat of the bladder had been thrown off. The patient made
a good recovery. Similar cases are reported by Dr. J. J. Phillips,
who points out that retroversion of the gravid uterus by leading «
to retention of urine is one cause of the accident ; by Mr. Spencer 1
"Wells, whose two cases occurred after severe cystitis following par-
turition ; and by Mr. W. Whithead, who states that muscular fibre
and serous tissue are often attached to and incorporated with the
mucous lining expelled. (*Brit. Med. Journ.,' June 10, 24, July i, and
Oct. 14, 1871.)
Dr. Graily Hewitt contributes (' Obst. Trans.,* 1871) a paper on
tTie vomiting of pregnancy, and believes that it results from flexion of the
uterus, either forward or backward ; the tissues of the uterus, including
the nerve ramifications pervading it, being compressed at the seat of
flexion and thus leading to the sickness. A somewhat similar view is
also advocated by Hubert in the 'Lyon Med.,' Oct. 1871.
Mr. Metcalfe Johnson recommends the simple hydrated phosphate of
lime, in doses of from three to ten grains, in the sickness of pregnancy.
(' Med. Times and Gaz.,' July, 1871.)
Gimbert writes in favour of the bromide of potassium administered
in large doses by rectal injection for severe vomiting during pregnancy.
He relates a case in which various remedies were tried in vain, but
after three days the above method proved very successful. ('Bulletin
de Therap.,' 1872.)
A case of excessive vomiting at the sixth month of pregnancy is
recorded by Dr. Campbell (' Boston Journal,' 1872). After various
ineffectual kinds of treatment, the membranes were ruptured, and
relief was speedily obtained ; but labour did not come on for twelve
days after puncturing the membranes.
Pypingskold relates two cases of uncontrollable vomiting during
early pregnancy ; one was kept alive by nutrient enemata, the other
died without being delivered. (' Lo Sperimentale,' Jan. 187 1.)
Mr. Ling records (' Lancet,' Sept. 1872) a case in which a patient,
four months pregnant, was seized with agonising abdominal pains, fol-
lowed by intense syncope and death in twelve hours. The abdominal
cavity was filled with blood. A large hole existed at the fundus uteri,
four inches in diameter ; the edges of the wound were jagged, but the
substance of the uterus was firm. The placenta was found with its
attached surface presenting upwards in precisely the position it would
take if adhering normally to the fundus, and the foetus surrounded by
the unruptured membranes was contained in the uterus. The uterine
tissue presented in some parts only spoilt-looking granular remains of
the muscular structure with extravasated blood, suggesting an injury
bXJRATlON OF PREGNANCY. 401
and subsequent local metritis, or an inflammatory condition producing
softening of the tissue and subsequent rupture, with extravasation of
blood into the muscular tissue.
See also a case of rupture of the gravid uterus at the seventh
month. (' Amer. Journ. of Obstetrics,' Aug. 187 1.)
The Diagnosis of Pregnancy.
Dr. Braxton Hicks points out that the pregnant uterus possesses
ther power and habit of spontaneously contracting and relaxing from
the third month up to fall term. This contraction most commonly
occurs every five or ten minutes, though it may not recur for half an
hour. It is independent of reflex stimuli. It is useful in providing
for the frequent movement of the blood in the uterine sinus and deci-
dual processes, and facilitates the movement of the fluid in the inter-
villal space, and it also adapts the position of the foetus to the form of
the uterus. It is of great value in the diagnosis of pregnancy.
(' Obstet. Trans.,' 1871.)
Dr. Wallace advocates ('Edin. Med. Journ.,' Nov. 1872) the exact
diagnosis of the placental position by vaginal stethoscopy. In three
cases of flooding before delivery he has lately had the opportunity of
testing the value of this diagnostic method ; and in Case i he prognosti-
cated marginal or partial placental presentation, in Case 2 centre for
centre, and in Case 3 no placental presentation whatever. Each of these
diagnoses were verified by the subsequent progress of the labours. He
recommends a long and curved stethoscope. The patient is put into the
usual obstetric position, the nates being well over the edge of the bed ;
the stethoscope, well lubricated with oil, is passed into the vagina, and
placed first against the os uteri under the guidance of the finger. The
ear can then be brought into contact with the stethoscope without any
difficulty, and by carefully moving it in all directions from the os uteri as
a centre, the whole of the superior part of the excavation, corresponding
to the lower zone of the uterus, is explored in succession. The bellows
murmur, heard by vaginal stethoscopy in central implantation of the
placenta over the os uteri, has a loudness and distinctness of character
rather startling to the ear accustomed to abdominal auscultation.
When the presentation is central the murmur is heard over every part
of the pelvic strait. If partial or marginal, the indication of the site is
equally well marked, and in such instances combined vaginal and abdo-
minal stethoscopic examination will map out with clear precision the
site of the placenta when it has an anterior or lateral position. The
absence of the characteristic signs by the abdomen, and the posterior
situation of the vaginal bruit, with its absence in the anterior and
lateral directions in the superior part of the excavation, will determine
its partial presentation inferiorly, and posterior situation superiorly.
Duration of Pregnancy.
Dr. Matthews Duncan ('Edin. Med. Journ.,' March, 1871) states
that prediction of the day of lying-in is an important practical matter,
from whose arrangement all theory should be excluded. It is a valu-
26
402 REPORT ON MIDWIFERY, ETC.
atle calculation of a quite empirical kind. He refers to Ahlfeld's
elaborate memoir on the duration of pregnancy (' Monats. fur Geburt.,'
1869), in which the duration is estimated at 271 days. Duncan
recommends the following method : — Pind the day on which menstrua-
tion ceased, take that day nine months forwards as 275 days, unless
February is included, in which case it is taken as 273, to this add
three days in the former case, or five if February is in the count, to
make up the 278 days. Out of 1^3 cases the day of confinement was
exactly predicted in ten cases in this manner. In eighty cases labour
took place sooner, and in sixty- three cases later than was predicted.
The average error was about seven and a half days, a circumstance
which indicates that the prediction should not state the week, but the
fortnight of delivery.
Abortion and Premature Lalour.
Dr. J. J. Phillips contributes a paper on retroflexion of the uterus
as a frequent cause of abortion. He states as the result of his observa-
tions that, after making due allowance for various constitutional causes,
a most important factor in the production of abortion in many cases is
a retroflected uterus. The increased susceptibility of the retroflected
pregnant uterus to concussion from sudden movements, the mechanical
irritation to which it is subjected, the straining in micturition and
defaDcation in such cases, and the irritation which the abnormal position
sets up, appear to be very efficient exciters of uterine action, while
the interference with the uterine circulation tends to the efi'usion of
blood and death of the ovum. He relates cases where, after repeated
abortions, the full term of pregnancy was reached by wearing a Hodge's
pessary. (' Obst. Trans.,' 1872.)
Dr. Donaldson relates (' G-lasgow Journ.,' 1872) an interesting case
in which by means of premature labour induced at the eighth month,
the life of the child was saved, though three former pregnancies had
ended in the birth of stillborn children. The death of the children
resulted, it was believed, from disease of the placenta, which contained
throughout masses of cheese-like deposit.
Martini recommends chloride of gold and of sodium in the treatment
of nervous disorders dependent on uterine disease. He believes the
chloride is also useful in preventing the tendency to abortion. (' Rev.
Clin, de Boulogne,' Jan. 187 1.)
Mr. Bassett confirms the experience of Dr. Kennedy that in abor-
tion the administration of ergot is generally inadvisable. "When the
haemorrhage is slight, and the case threatening only, ergot may do
good, as also where the ovum is detached and merely wants expelling.
But no more regularity of action can be secured for it in miscarriage
than in labour. Owing to its uncertainty and irregularity, and its well-
known power of producing contraction of the circular rather than the
longitudinal fibres of the uterus, it is inadvisable to administer it in
many cases of abortion. ('Brit. Med. Journ.,' Oct. 1872.)
Dr. Noeggerath relates a case of abortion in which the secundines
were expelled without the foetus ; the latter came away four weeks, at
least, afterwards. (' Amer. Journ. of Obst.,' 1871, p. 551.)
ABORTIOi^ AND PUEMATURE LABOUR. 403
Dr. Carl Eokitansky writes in favour of the artificial induction
of labour by rupturing the membranes. ('Wien. Med. Presse,'
1871.)
Dr. Wiltshire contributes (' Obst. Trans.,' 1871) two cases of fatal
tetanus after abortion. In both cases there had been great mental de-
pression, which he believes had some influence in producing the disease.
The first case was that of a lady who, while her husband was abroad,
became pregnant illegitimately. It was suspected that abortion had
been criminally induced by instruments at an early period of gestation.
Symptoms of tetanus supervened in a few days, and rapid death. The
only post-mortem uterine lesion was a bruising and slight laceration of
the cervix uteri. A portion of placenta was adherent to the fundus.
The second case was deserted by her husband, and the effect of this
sudden mental distress was to induce abortion, which was followed by
tetanus and death in a week.
In a contribution to the study of fihrinoiM uterine polypi Dr. E.
Praukel relates two cases. He quotes Kiwisch in favour of the view
that such cases may be independent of a previous conception, and
Scanzoni as believing that they follow only some antecedent dilatation
of the uterine cavity, either from labour at the full time, or abortion, or
from some change in the uterine walls. Erankel's first case was that
of a woman set. 31. She aborted in June. In December there was a
severe flooding, and she was admitted in a collapsed state. The ques-
tion of transfusion was discussed, but the operation was not performed,
as the patient was suffering, not simply from anaemia, but also from
Bright's disease. The polyp was not removed in her then desperate
condition. Notwithstanding various remedies, convulsions, coma, and
death supervened. There were numerous capillary cerebral apoplexies,
oedema of lungs, hypertrophy of heart, wasting of kidneys. The fibri-
nous polyp was found on the posterior wall of the uterus. The whole
had the appearance of a villous hsemorrhagic neoplasma. The mucous
membrane was thickened around, and there was also a small mucous
polypus. A perpendicular section through the fibrinous polyp and the
adjacent wall showed in the latter normal, but rather large, smooth,
muscular fibres. Among them lay numerous lymphatic cells, red blood-
corpuscles, finely granular and fibrous masses. Nearer the surface the
characters of a fibrinous coagulum became clearly marked with only
scattered muscular fibres. The second case was that of a patient, also
set. 31, who had been confined three weeks previously at the full time.
The placenta had been cast spontaneously. She kept her bed for nine
days, and then followed her usual domestic work. Dragging pains in
pelvis ; metrorrhagia ; uterus slightly anteflected, its fundus extending
above the pubes. A pear-shaped body, the size of a walnut, having a
crumbled feel, with an uneven surface, presented at the os uteri. Its
origin was from the hinder wall of the uterus. A cotyledon of the
placenta had remained, which had served as the basis of the hsematoma.
After its removal and the injection of a solution of the sesquichloride
of iron the bleeding ceased, and in a fortnight the uterus was of normal
shape, size, and consistence. (' Archiv fiir Gynak.,* ii, i, 1871.)
ilcctra-uterine pre^nanc^. ^'ieriond gives a case of extra-uterine
404 ilEPORT ON MlbWll'EHY, ETC.
gestation, o£ the abdominal form, in which the foetus died at the
seventh month without rupture of the containing cyst. Chronic
peritonitis supervened, pulmonary vomicae, colliquative diarrhoea, and
hectic. Death resulted from exhaustion at the eighteenth month from
the commencement of the pregnancy. ('Lyon Med.,' Jan. 187 1.)
A case of extra-uterine foetation and superfoetation. (Argles,
'Lancet,' Sept. 1871.)
An interesting case of extra-uterine foetation is reported by Mr. John-
son. After an illness of twelve months the general health improved,
and continued good for forty-four years. At the end of this time
foetal bones were passed per rectum. (' Med. Times Gaz.,' June,
1872.)
Peck reports a case of extra-uterine foetation in which the child, a
foetus of four months, was delivered by the rectum. Soon after the
mother's bowels were relieved a foetus passed per anum. The cord was
found hanging from the bowel, and portions of the placenta subse-
quently passed away. Peck considers the case to be one in which the
placenta was attached to the fimbriated extremity of the Fallopian
tube, and the child during its growth by the side of the rectum gradu-
ally led to thinning of the tissues, and these ultimately gave way after
the effort of defaecation. (' Journ. de Bruxelles,' Peb. 1871.) The
post-mortem appearances in a case of extra-uterine pregnancy are
described by Dr. M. Duncan. (' Med. Times and Gaz.,' July,
1872.)
Adams relates a case of extra-uterine foetation, in which gastrotomy
was performed after the full term of gestation. The pain from which
the patient had previously suffered ceased at the end of the ninth
month. There succeeded a profuse purulent discharge from the rectum,
and portions of the foetal skeleton passed by the same channel. There
was also a fistulous opening near the umbilicus, from which pus and
faeces escaped. After making an incision through the abdominal wall
there was much difficulty in liberating the child, which was surrounded
by false membranes. There were three fistulous openings between the
rectum and the cavity in which the foetus was contained. The patient
recovered. (' Gaz. Med. de Paris,' xxxii, 1871.)
Edgar records ('St. Louis Journ.,' viii, 4, 1871) a case of interstitial
pregnancy.
Two interesting discussions have taken place at the Obstetrical Society
on the treatment of extra-uterine foetation (' Obst. Trans.,' xiii, xiv).
Dr. Meadows, in Nov. 1872, related a case in which a living child was
removed by abdominal section, but an attempt was made to remove the
placenta and the foetal cyst, and this was attended with such severe
haemorrhage that the mother died in a few hours. Dr. Meadows con-
tended that in all cases where the diagnosis of a living and viable child
could be made out gastrotomy ought to be performed, but that the pla-
centa and the containing cyst should be left intact. The placenta
should be left to undergo the slow but sure process of absorption, it
being argued that, as by the removal of the foetus there is no longer any
physiological necessity for the placenta, its removal by atrophy might
fairly be reckoned upon. Dr. Murray thought there was too much risk
THE MECHANISM OP LABOUR. 405
incurred in completely closing the abdominal opening, as recommended
by Dr. Meadows, and leaving the placenta behind without any chance
of escajDO. Dr. Barnes and Dr. Hicks agreed that the placenta should
not be removed, the former remarking that its non-removal was the
established practice, and the latter that in three cases reported by him
the foetus alone had been removed.
A case of double conception, bearing on the question of super-foeta-
tion, occurred in the practice of Dr. Chenery. The patient was forty
years of age, and was found to have lost large quantities of blood, among
which was a foetus with its transparent membranes entire, and alto-
gether of about the size of a common open-faced watch. The os uteri
was dilated and another and a much larger foetus was lying with its head
pushing its unbroken investments through the cervix ; its birth was
expected, but it remained in utero till the full term of gestation. The
one ovum was expelled at the eighth week with all the appearances of
life up to the time, while the other (from calculations at its birth)
was at that period at about the twentieth week. (' Boston Med.
and Surg. Journal,' April, 1871.)
Two cases of precocious pregnancy. The first case was that of a
girl, thirteen and a half years old. She suifered from puerperal con-
vulsions, but ultimately recovered. The child was living and weighed
6 lbs. 8 oz. ('Med. Eecord,' Jan. 1872.) The second was that of
a girl who had never menstruated, and who was eleven years eight
months and a half old at the time of conception. (' Brit. Med. Journ.,*
Oct. 1871). Dr. Toung also records (' Edin. Med. Journ.,' July,
187 1) a case of early pregnancy. The mother, at the time of labour,
was fourteen years and ten months old.
III. LABOUE.
The Mechanism of Lalour.
In some observations on the innervation of the uterus (' Archiv f.
Gynak.,' ii, i, 187 1), Dr. Eeimann, of Kiew, publishes the result of
experiments performed for the purpose of determining whether uterine
contractions are dependent on the central nervous system. He expe-
rimented on bitches and cats, and subjected the uterus, partly or wholly
separated from the body, to various kinds of irritation. He found that
the uterus, separated from the cerebro-spinal axis, and even removed
from the body, responded to the irritation, by peristaltic and rhythmical
movements of the whole ©rgan, even when only a portion of it had been
subjected to the irritation. The kind of irritant — electricity, heat, cold,
mechanical irritation — made no difference. He also found that the
uterus separated from the body, but maintained at its normal tempe-
rature spontaneously contracted and relaxed for about an hour after
the death of the animal ; mechanical irritation increased the movements
observed, narcotics diminished them. Similar rhythmical movements
were, under like circumstances, observed in the Eallopian tubes. Dr.
Eeimann concludes that the contractions of the uterus are under the
nfluence of certain organs (ganglionic), not yet anatomically demon-
406 EEPORT ON MIDWIFERY, ETC.
strated, but which are situated in the uterus itself ; and that, like the
contractions of the heart, they are independent of the cerebro- spinal
system, though physiological and pathological facts prove that the latter
has certain influence over them.
Oser and Schlesinger record the results of numerous experiments to
determine the cause of uterine movements. They experimented chiefly
on pregnant rabbits, in which the uterus was generally at rest when
they began their observation, and they found that whenever the blood
which circulated either through the brain or through the uterus itself
became extremely venous, tetanic contraction of the uterus took place.
The irritation of the brain which produced uterine contractions was
conducted down the spinal cord to the uterus, and when the cord was
divided irritation of the brain from venous congestion produced no
effect. Stagnation of blood in the uterus, produced by compression of
the aorta, caused uterine movements of the same tetanic character. If
spontaneous movements of the uterus were present, they soon ceased
after compression of the aorta was begun ; and when arterial blood was
again allowed to circulate through the organ a strong contraction o£ the
entire uterus, quickly followed by rest, took place. (' Centralb. f. Med.
Wissensch.,' 1871, and 'Brit. Med. Journ.,' June, 1872.)
Dr. Matthews Duncan writes ('Dublin Quart. Journ.,' May, 1871)
on tlie efficient powers of parturition. The first, and he believes the
best, results in the investigation of this subject have been obtained by
careful deduction from experiments on the tensile strength of the
amniotic membrane. He next observes that if, in an unobstructed and
powerful labour, the accoucheur, by the directly opposing pressure of
his hand on the foetal head, arrests its progress for one or several pains,
he has in the pressure by his hand, a force which, added to the small
amount required to effect parturition, exceeds all the combined powers
of labour in this case. Duncan, well accustomed to such work, finds
by actual trial with an accurate dynamometer, fifty pounds to be
about the highest power he can use situated at the bedside in attend-
ance on a case of labour. He believes that very few of the most power-
ful labours exert a force of ^o lbs., and that the great majority of
labours are accomplished by repeated impulses, whose highest power
probably never exceeds 2^ lbs. He refers to the researches of Dr.
Haughton (see ' Eetrospect,' 1869-70), who follows a different method
of investigation from the above, and measures the bulk and the extent
of the involuntary and voluntary muscles employed in the function.
Duncan comments on Haughton's conclusions. He does not say that
Haughton is wrong in supposing that the uterus can exert a force of
54 lbs., but he believes that only a very few difficult labours require for
their whole work a force exceeding 50 lbs. No perinaeum would
long resist a force of ^o lbs. repeatedly applied. He then furnishes
arguments in favour of the power of the uterus in parturition as
compared with the powers of the voluntary muscles, which he be-
lieves render Haughton's conclusion quite incredible that, while the
power of the uterus is 54 lbs., that of the voluntary muscles can be
523 lbs. Haughton believes that on an emergency somewhat more
than a quarter of a ton pressure can be brought to bear upon a
THE MECHANISM OF LABOXJE. 407
refractory child that refuses to come into the world in the usual
manner, Duncan points out that such a pressure represents a strain
to which the maternal machinery could not be subjected without
instantaneous and utter destruction. The possession and use of a
considerable portion of such a power would render the forceps and
the cephalotribe weak and useless instruments; the mother could
bray the child as in a mortar. Such a power would, if appropriately
applied, not only expel the child, but also lift up the mother, the
accoucheur, and the monthly nurse — all at once. If this force were
applied just as the chief resistance to delivery was overcome, the child
would be shot out of the vagina at the rate of thirty-six feet per
second.
See also on the mechanism of labour, Schatz, * Arch. f. Gynak.,' iii, i,
1871.
In a paper on relaxation of the pelvic articulations during pregnancy
(' Amer. Journ of Obst.,' Nov. 187 1), Professor King, after answering
some of the objections which have been raised, states that physiological
enlargement of the pelvic canal, in addition to that which takes place
during pregnancy from thickening of the interosseous cartilages, is
further increased during parturition by the muscular efforts of the
female forcing the wedge-shaped sacrum downwards and] backwards
between the two iliac bones. He adds that the practical inference from
this is that "square on the back" is the proper position for delivery;
that the feet or knees should find a firm support on a surface disposed
evenly transverse to the axis of the body, and that tvro sheets, one for
each hand, should be so arranged that the woman may pull on them,
not diagonally, but in a line parallel to the axis of her body, so that the
spine may exert its downward force evenly upon the base of the sacral
wedge.
On the mechanism of the expulsion of the placenta. — Dr. Duncan
('Edin. Med. Journ.,' April, 1871) states that the belief that the
placenta generally descends into the vagina inverted, so that its foetal
surface is turned outwards, is erroneous. The part which presents at
the OS uteri, and subsequently at the os vagin83, is not the foetal
surface, but the edge of the placenta, or a point very near the edge, and
that the mass is folded up longitudinally during its expulsion. If the
placenta descends inverted it is generally the result of pulling at the
cord. Much less space is required for the passage of the placenta by
the natural mechanism, and if the placenta is expelled inverted, as
Baudelocque, Schultze, and others describe, the forcing of the placenta
into a cuplike space cannot be effected without a hollow space being
offered for the reception of blood, or, indeed, without a certain force
being exerted to produce the foldiug and a vacuum, which force will
also tend to draw blood into the hollow from the open uterine sinuses.
The third stage of labour should be left to nature, or, if interference is
required, the natural mechanism of the birth of the placenta should be
as closely imitated as circumstances admit.
Professor Hodge, in an elaborate paper on the synclitism of the
equatorial plane of the foetal head in pelvic deliveries, criticises the
reasons adduced by Sir James Simpson and Dr. Barnes in favour of
408 REPORT ON MIDWIFERY, ETC.
podalic version in preference to the use of the forceps, and he con-
cludes that the operation of podalic version should always be regarded,
not as one of choice, but as one of necessity. It is fraught with
danger to the infant and to the mother in all complicated cases ; it
demands great skill and experience for its execution ; numerous, and
often unexpected, difficulties are apt to be interposed, and yet the
time allotted is exceedingly short. The whole process of descent must
be accomplished in a few minutes, or the child, for whose benefit these
risks are incurred, will perish. Professor Hodge maintains that in
head-last labours simple tractile force should not be the sole recourse of
the practitioner, but that flexion of the head should be insured and
maintained. (' Amer. Journ. of Med. Sci.,' July, 1871,)
Dr. Matthews Duncan contributes an elaborate paper on the curves of
the developed genital passage. HhQ first curve which he mentions is that
said to be at the brim of the pelvis, with its convexity downwards and
backwards. He discusses the views of Schatz and Schultze on this
point, and concludes that this curve does not exist. If it does exist
we must admit that the advance of the child's head is impeded, not
only by friction and imperfect dilatation, but that a new difficulty is
introduced to its transit, namely, the difference between driving a body
through a curved and a straight passage. If this curve be admitted,
the axis of the genital passage, regarded in the antero-posterior vertical
plane, has the shape of a Eoman S ; but the author thinks that we are
nearer the truth in adopting the view that in this plane the genital
passage has only one curve, having the concavity of its axis looking
forwards. The second curve is also at the brim, and is indicated by the
deflection of the uterus from the mesial line to the right or to the left.
The author gives the results of some experiments made to calculate the
amount of deflection, and he states that the angle of deviation of the
axis of the uterus from the axis of the brim has important physiolo-
gical and practical bearings, though, as yet, but little worked out. The
most interesting application of it is to assist in accounting for the pro-
duction of face cases. The third curve is the most extensive and best
known. It is the great curve in the antero-posterior vertical plane,
which begins above the middle of the third bone of the sacrum and
extends through the outlet of the ligamentous pelvis to the outlet from
the soft parts. In connection with this curve the synclitic and allied
movements of the foetal head during its progress are to be studied.
The author shows that Schultze's recommendation to facilitate the
advance of the foetal head after it has reached the floor of the pelvis by
extension of the spine (this extension he believes increasing the poste-
rior obliquity of the axis of the uterus, and therefore of the force of
labour as exerted on this part) is founded upon what he (Dr. Duncan)
regards as a misapprehension of the conditions of this curvature.
(' Med. Times and Gaz.,' March 2, 1872.)
Prof. Trenholme writes on irregular contractions of the uterus, and
states that in such cases he has found adhesions existing between the
decidua and the uterine surface at term. He attributes the irregular
contraction to laceration of the muscular fibres at the point of adhe-
sion, the parts lacerated acting as direct excitants of the spasm of
ON THE MANAGEMENT OF THE PERINiEUM. 409
the walla of the uterus. The treatment recommended is to pass the
finger and separate the united surfaces, but when they are beyond
reach it is best to rupture the membranes. Hour-glass and other irre-
gular contractions after delivery are attributed to the same cause.
('Amer. Journ. Obst.,' May, 1872.)
M. Mattel, writing on false cramps during pregnancy and labour, says
that they are to be explained by the pressure which the foetus exerts
on the course of the nerve which borders on the painful part, though
the pressure be made far from the seat of pain. But these pains may
also exist without pressure on the nerves, and may be a reflex pheno-
menon of uterine trouble. (' Graz. des Hop.,' Nov. 1872.)
Tachard writes on the use of electricity in midwifery. He believes
that uterine contractions cannot be induced by it unless they have
already commenced, and that uterine inertia coming on during the ex-
pulsive stage of labour is not to be treated by electricity, but that in
the stage of dilatation, when applied to the lumbar region it increases
the contractions, both in duration and intensity. The cervix dilates
more readily, the expulsion of the placenta immediately follows the
child, and neither the mother nor the child suffers from the treat-
ment.
Dr. Chantreuil speaks favorably of uterine expression as a means of
delivery. He bases his observations on ^40 cases in which the practice
was followed. (' Graz. Med. de Paris,' July, 187 1.)
On the management of the 'perinceii^m during labour. — Dr. Groodell gives
an elaborate historical account of the practice, and of the various
methods employed. He concludes that when it seems necessary to aid
nature the best method is to insert one or two fingers of the left hand
into the rectum, the woman lying on her left side, with her knees well
drawn up and separated by a pillow, and to hook up and pull forward
the sphincter ani towards the Ipubes. The thumb of the same hand
is to be placed upon the foetal head, scrupulously avoiding all contact
with the fourchette. The right hand is to assist the thumb in making
the head hug the pubes, or in retarding its advance, and is to press
back the head from the perinaeum and thus to repress reflex uterine
action. By this method the perinaeum is brought forward without direct
pressure, and its dilatation is diffused over its entire surface. The aid
rendered is not liable to sudden interruption by any movements of the
mother, and the circulation of the blood is left free. Dr. Goodell
believes that the rapid springing back of the fourchette over the pro-
jecting nose, or the subsequent rapid expulsion of the shoulder often
produces lacerations. These are also well controlled by the above
method, in the former instance, by merely pulling forward the sphincter
ani, in the latter by adding the support of the right hand to the emerging
shoulders. (' Amer. Jour. Med. Sci.,' Jan. 1871.)
Dr. Swayne states ('Brit. Med. Journ.,* July, 1872) that his expe-
rience proves the inefficiency of support for the prevention of perineal
lacerations. There is seldom any great danger of rupture until
the head is protruded so far that the accoucheur can grasp the
exposed portion with his thumb and fingers. "When this can be done
the best plan is to press the head forwards as much as possible under
410 IIEPOIIT ON MIDWIFEEY, ETC.
the pubic arch, so as to prevent the vis a tergo from acting so directly
downwards upon the perinseum. "When rupture takes place the rent
usually commences at the fourchette and extends backwards, but
sometimes it begins near the centre of the perinseum and extends
forwards. He believes that the most frequent cause of laceration is an
unusual breadth of the perinseum.
Dr. Aveling has collected the history of forty -four cases oi post-
mortem parturition, and deduces the following conclusions. Expulsion
of the contents of the uterus may take place after death without the
aid of art. This may occur in cases in which no symptom of natural
parturition existed before death. Spontaneous evolution of the foetus,
and prolapsus, inversion, and rupture of the uterus may occur post-
mortem. These phenomena are explained either by the contracting
power which persists in the uterus after the death of the rest of the
body, or (and this is the more frequent cause) by the pressure exerted
upon the uterus by gases of decomposition pent up in the abdomen.
A child may continue to live in the uterus for many hours after the
death of its mother. (' Obst. Trans.,' 1872.)
Deformities oftJie Pelvis ^ and Dystocia hy tJie Mother.
Prof. O. Spiegelberg gives ('Archiv f. G-ynak.,' ii, i, 1871) an
elaborate report of two cases of obliquely distorted pelvis. The first
case was that of a woman who had sustained a fracture of the right
tibia in its lower half when three years old. The pelvis was contracted
on the right side, and there was synostosis of the right sacro-iliac joint,
and considerable shortening of the right lower limb. Premature labour
was artificially induced in the thirty-fifth week of pregnancy. The
second case is described as one of inflammation of the right sacro-iliac
joint and secondary atrophy of the surrounding bones without synos-
tosis. Delivery by perforation and cephalotripsy. Discussing the
etiology, he states the two chief causes to be the inordinate pressure on
one half of the pelvis and the one-sided atrophy of the bones entering
into the sacro-iliac joint. Either of these factors may be the primary
one.
Dr. Harris describes ('Amer. Journ. of Obst.,' Nov. 1871) the
usual forms of pelvic deformities, and illustrates his paper by several
typical examples.
Petit relates a case of oblique-ovate pelvis, in which the labour was
quite natural. The child was of medium size. The brim of the pelvis,
contracted on the left, was 1 2^ centimetres (about 5 inches) in its
greatest oblique diameter, from the right ilio-pectineal eminence to the
left sacro-iliac synchondrosis, and 9 centimetres (a little over 3^^ inches)
in the short oblique diameter, from the left ilio-pectineal eminence to
the left sacro-iliac synchondrosis. The distance from the sacro-
vertebral angle to the left ilio-pectineal eminence was 6 centimetres,
and to the right nine and a half. ('Bull. Med. du Nord,' Eeb.
1872.)
Ernst Braun writes (* Arch. f. Gynak.,' iii, i) on a case of funnel-
shaped pelvis.
DYSTOCIA BY THE CHILD. 411
The causes, nature, and treatment of rigidity of the os uteri. Dr.
Isham ('Amer. Journ. of Obstetr.,' July, 187 1).
Dr. J. J. Phillips (' Lancet,' March, 1871) relates in detail three
cases of successful version with living children after failure of the
forceps. In each case the conjugate diameter of the pelvis was nar-
rowed. In the first it measured very little over three inches ; in the
second, three inches and a half, but the fcetal head was very large and
firm ; and in the third the jutting of the sacral promontory had pro-
duced a marked depression on the left parietal and frontal bones of the
foetal head.
Eor remarks on turning in pelvic contraction see Honing. (' Berl.
Klin. Woch.,' viii, 34, 1871.)
An interesting case, showing the behaviour of uterine fibroids during
pregnancy, labour, and the puerperal state, is recorded by Dr. Madge
(*Obst. Trans.,' 1872), and a case of inertia of the uterus during labour
from the existence of two fibroid masses at the fundus by Depaul
('Gaz.Med.de Paris,' Aug. 1871). Magdelaine also writes on the
complication of pregnancy and labour with subperitoneal fibroids of
the uterus ('Arch. Gener,,' xvii, 214). In a case of fibrous tumour,
nearly filling the pelvis and complicated with pregnancy. Dr. Habit
induced premature labour, and, with the patient under chloroform, lifted
up the growth out of the pelvis. Successful result to mother and
child (' Wien. Med. Zeitsch,,' 1871). Cases of fibroids of the uterus,
not interfering with the action of the organ at the time of labour are
related by Dr. Goodell ('Amer. Journ. of Obst.,' 1872) and by Mr.
Harries (' Guy's Hosp. Gaz.,' Nov. 1872).
Chantreuil writes on cancer of the uterus in reference to conception,
pregnancy, and labour. Out of sixty cases, twenty-five died during
labour or in the puerperal state, thirty-five were restored to health for
a time. In the twenty-five fatal cases rupture of the uterus during
labour occurred six times, nine cases died from peritonitis, seven died
after serious operations, and thrice the cause of death was not ascer-
tained. Twenty-eight out of the sixty children were born alive.
During the earlier months of pregnancy the body of the uterus is
developed independently of the cervix, which is the usual seat of cancer,
and thus gestation is but little interfered with until the latter part of
pregnancy, when premature labours are frequent. Occasionally can-
cerous infiltration of the cervix prevents its dilatation, and becomes
also, a cause of unusual prolongation of pregnancy beyond the normal
period. Pregnancy hastens the progress of uterine cancer. The line
of treatment which he advocates is either the induction of abortion,
the performance of the Csesarean section at term, or the incision of the
neck of the uterus and application of the forceps. The last method he
describes as almost always fatal to the mother and ofiering less chances
of life to the child. (' Du Cancer de rUterus, &c.,' Paris, 1872.)
Dystocia hy the Child.
Dr. Reimann, of Kiew, relates ('Archiv f. Gynak.,* ii, i, 1871)
a case of difficult labour resulting from the simultaneous presence of
412 REPORT ON MIDWIFERY, ETC.
twin foetal heads in the pelvis. The patient was seized during labour
with convulsions, and the attendant applied forceps to the presenting
head and delivered it easily. The shoulders did not follow, and on
examination a second head was found in the pelvis. When Dr. Keimann
arrived he applied forceps to the second head, the body of the first
child then followed, and afterwards that of the second. He thinks
that the delivery by forceps did not cause the difficulty, as this is the
only case of the kind he has found recorded in which the first head
was delivered artificially. Probably a capacious pelvis has some
influence in the production of the accident.
The delivery of a dicephalous monster is described by "Wettengel.
(' Amer. Journ. Obst.,' Nov. 1871.)
Dr. Porter relates a case of successful reduction of prolapsed funis
by the postural method. The position he recommends is on the knees,
with the cJiest and face resting on the bed. (' Amer. Journ. of Med.
Sci.,' Jan. 187 1.)
Cases of quadruplets are recorded by Leopold ('Arch. f. Gyniik.,' ii,
2, 187 1), by Lowndes ('Brit. Med. Journ.,' Feb. 1872), and by Cuppa-
ridge ('Dubl. Journ.,' March, 1872).
Ohstetric Operations.
CcBsarean section. — This operation was performed by Mr. Gibbons on
a woman, set. 22, and who was three feet ten inches in height. Uterus
contracted rapidly; no sutures were applied to the uterine wound.
Uncontrollable vomiting commenced soon after, and continued till death,
forty hours after the operation. No peritonitis, no extravasation.
Antero-posterior diameter at brim an inch and three quarters. Trans-
verse diameter 4* i inches. (' Obst. Trans.,' 1871.)
In a case reported by Dr. Inglis ('Edin. Med. Journ.,' 1871) the
abdominal incision was made on one side of the median line, so as to
avoid incising the expanded central tendon between the recti, which is
too mobile to be afterwards kept in apposition ; and the uterine incision
was commenced an inch and a half to the left of the mesial line, and was
carried first downwards and then to the side, the curve of the incision
corresponding with the direction of the outer circle of fibres surrounding
the left cornu. The object of this was to avoid cutting across more
muscular tissue than was necessary. He doubts the advisability of
inserting sutures into the uterine wall.
Dr. Harris records ('Amer. Journ. of Obst.,' 187 1-2) sixty cases of
the Csesarean section in America. Of these, thirty-two were successful
as regards the mother, and twenty-seven of the children were saved.
One hundred and six cases are quoted from Great Britain and Ireland,
eighty-eight of which were fatel to the mother, while sixty of the
children were saved.
Dr. Andrei compares ('Western Lancet,' 1872) the result to mother
and child in a large number of cases, the summary of which he
has collected, of premature labour, symphyseotomy, and Caesarean
section.
M. D'Olier performed the Csesarean section on account of a sacral
OBSTETRIC operations!. 4,13
tumour obstructing delivery, with a successful result to the mother
There was a great tendency after extracting the child to eversion of the
inner surface of the uterus, but no uterine sutures were employed,
(^Abeille Med.,' No. 4, 1871). See also a successful case for pelvic
deformity, Foster, ('Lancet,' June, 1872).
Dr. Yarrow reports ('Lancet,' Oct., 1872) a case of Caesarean
section. The pelvis was of the rickety type, the antero-posterior dia-
meter being one inch and a half. After extracting the child alive the
edges of the external wound were brought together by interrupted
sutures, but no sutures were inserted through the uterine walls. The
patient lived six days. The uterine wound measured one inch and a
half; it was open, and there was a small quantity of dark coloured blood
in the pelvis. The intestines and their peritoneal covering were
healthy, but the peritoneum investing the posterior part of the pelvis
was inflamed.
A successful case of Csesarean section is recorded by Causae (' Lyon
Med.,' July, 1872). The mother was thirty-two years old, rachitic, and
the sacro-pubic diameter measured 0*067 millimetres. The child also was
extracted alive and survived.
Dr. Hoscheck performed the Csesarean section upon a patient who
died from phthisis, near the full term of her pregnancy. The operation
took place about ten minutes after death, and although the child was
apparently dead when extracted, insufflation from mouth to mouth
restored it. (* Archiv f. G-ynak./ ii, i, 187 1.)
Molinier also relates (' Gaz. des Hop.,' Ixxxi, 1871) a case of post-
mortem Caesarean section, in which the child was saved.
On decapitation as a mode of delivery ifi cases of shoulder presentation^
in which version cannot he safely effected. — Dr. Gr. H. Kidd (' Dublin
Quart. Journ.,' May, 187 1) writes on this subject. He describes three
conditions in which version cannot be performed without exposing the
mother to danger. These three conditions are resj)ectively met with ;
I . In those cases where the shoulder is so far advanced into the pelvis,
and the action of the uterus is, at the same time, so strong that it is
impossible to raise or move the child. 2. In cases where the difiiculty
arises from the firm contraction of the uterus, the liquor amnii is
evacuated before dilatation of the os uteri has taken place, and the
uterus becomes moulded to the child's body. It is, in these cases, quite
possible to introduce the hand, seize a foot and bring it down into the
vagina ; but the child does not turn, the head remains fixed in the iliac
fossa, and the uterus may be torn in the efforts to complete the delivery.
3. In cases of transverse presentation with extreme narrowing of the
pelvis. Dr. Kidd describes the various instruments which have been
used for decapitation, and especially a plan adopted by Prof Heyerdahl,
and practised in a modified form by Pajot and Tarnier. The instrument
consists of a handle and a hollow stem, with a strong wire in its centre ;
and after it has been passed round the neck the internal wire is pushed
upwards, and a loop of string can now be passed round a knob placed
at the end of the wire. A cord is thus left round the neck, by means of
which a chain or wire rope is drawn round, and with this the neck is
sawn through. Dr. Kidd suggests that the operation may be much
414 ilEPORT ON MIDWIFERY, ETC.
simplified, as the cord miglit be very easily carried round the child's
neck by means of an elastic catheter mounted on ^a firm stylet or on a
uterine sound. The catheter should be a good deal curved, and after it
has been passed round the neck the cord may be attached to it and
drawn back with it. The ends of the cord are now drawn through a
speculum, the catheter having been first removed, and the neck is
divided. The operation might be further improved by using an ecraseur
for dividing the neck, by which the accidental interruption of the opera-
tion by breaking of the cord would be avoided, as well as the risk of
injuring the soft parts of the mother by its friction. Dr. Kidd thinks
that it would be best to stop as soon as the spinal column is divided,
and to leave the head attached to the body by a portion of the soft
tissues of the neck. It is obvious that the division of the spinal
column would do away with the difficulty of turning, and the tissues
attached to the head would facilitate extraction.
Drs. Affleck and Macdonald relate ('Edin. Med. Journ.,' July, 1871) a
case of shoulder presentation in which turning was impossible, and de-
capitation was impracticable, owing to the position of the foetus with
the head very high up and the narrowness of the inlet of the pehis ;
they, therefore, resorted to spondylotomy. The thorax having been
opened by long vaginal scissors, two fingers were introduced, so as to
push aside the contents of the chest and feel for the vertebral column.
The spine was then clipped through without any great difficulty. Trac-
tion was then resumed oq the foot, which had originally been brought
down, and this time with complete success. An old practitioner, in
the same journal (Oct. 1872), prefers to spondylotomy or decapitation
the removal of the presenting arm, and also of the other arm. He says
that the increase of space afforded by the removal of the two little fat
arms is very great, and the shoulders being removed from the chest
greatly increases the facility of turning. He has practised this method
on several occasions.
Mr. F. "W. Wright recommends ('Brit. Med. Journ.,' Oct. 1871) a
method of bisecting the foetus in utero in arm presentation, in which
version is impracticable. The presenting member is to be seized with
the right hand, and, while considerable traction is employed, the left hand
is to be introduced into the vagina and kept firmly upon the child's neck.
A blunt hook with a curve sufficiently large to embrace the neck, and
having a perforation at the extremity of the curve, is armed with a piece
of tape and made to embrace the neck. A leash of about a dozen very
thin wires, about a yard long, twisted together at the ends, should be
tied to the end of the tape. By pulling at the tape the wires will be
drawn over the child's neck, and with a saw-like motion of the wires
the head may be cut off" in five seconds.
Dr. Tucker, of Bermuda, describes a method of delivery in cases of
arm presentation, after the usual mode of turning has failed. He
places the patient as for lithotomy, perforates the body of the child,
and empties the abdomen and thorax sufficiently to enable him to
reach the bodies of the foetal spine. He then crushes these with a
strong forceps. Bending of the child's body then takes place, and
it descends sufficiently low to enable a handkerchief to be passed
OBSTETEIC OPERATIONS. 4l5
round it, when, making traction, the pelvis and lower extremities soon
descend, followed by the trunk. (' Lancet,' Feb. 1871.)
Depaul relates two cases of shoulder presentation in which he
decapitated, and insists on the operation in severe cases of the kind
where turning is impracticable. (' Jour, de Bruxelles,' July, 1871.)
Dr. Cappie suggests ('Edin. Med. Journ.,' 1871) that in using
the forceps the task of introducing, guarding, and directing the blades
should be trusted entirely to the fingers of the right hand, and
that in the first stage of introduction the left, crossed over the right
wrist, should have little more to do than to support the shank or
handle of the instrument. By thus acting the ordinary obstetric posi-
tion does not require to be disturbed, and the forceps can in this way
be applied in many instances where it would otherwise be impossible.
Barclay introduces a new form of midwifery forceps. It combines
Tigler's male and female blades with the length, strength, and curve of
Simpson's. ('Lancet,' Jan. 1872.)
Easbender publishes four cases of version performed by the method
of Braxton Hicks. He points out that one great advantage of the bi-
manual method is that it facilitates cephalic version ; in podalic version
there is always the risk of certain accidents, such as compression of the
cord, the crossing of the arm behind the neck, constriction of the neck
of the uterus around the child's neck, which, hj prolonging extraction,
more or less compromise the child's life. Easbender performed
cephalic version in three of the four cases, each of these was a case of
shoulder presentation, and podalic version in the fourth, a case of pla-
centa prsevia. ('Beitrage zur G-eburt. und G-ynak.,' Berlin, 1871,
i, 8.)
Professor Halbertsma recommends that an external examination of
the uterus should be substituted during labour for the internal exami-
nations which are so frequently made. It has been proved that internal
examination may generate infection. By external examination alone
we can, in most cases, ascertain the position of the child, whether it has
sunk deep into the pelvis, and by auscultation whether there is danger
for the child. We shall in this way not be able so well to ascertain
whether the delivery is proceeding, yet the nature of the pains and the
flow of liquor amnii are some indications. The first and second cranial
positions can often be diagnosed by external investigation alone.
When there is danger of infection from the accoucheur the external ex-
amination should be the rule, the internal one the exception. (* Med.
Times and Gaz.,' June 10, 187 1.)
Drs. Braxton Hicks and J. J. Phillips, in a paper published in the
* Obst. Trans.' for 1871, call attention to the imperfect and unscientific
manner in which the usual tables of mortality after obstetric operations
have been compiled, and to the delusive conclusions to which they con-
sequently lead. A brief abstract of a very large number of cases traced
to their original source is added, and the conclusion at which the
authors arrive is that, in a very large majority of the fatal cases, death
resulted either from the condition which rendered the operation neces-
sary, or from the too long delay of instrumental assistance.
l)r. Matthews Duncan writes ('Brit. Med. Journ.,' Nov. 1872) on
L
416 REPORT ON MIDWIFERY^ ETC.
the appliances used for meclianical dilatation of the cervix uteri. He
compares the bougie, the tangle-tent, the sponge-tent, and the india-
rubber bag, in reference to the amount of force exercised, the amount
of expansion produced, and the amount of time required for producing
the expansion. In using great force to pass a common uterine probe
the instrument is bent, and by experiment the force required to bend
it is found to be about four pounds exerted at its point, the.handle being
fixed. With the same force used the tension overcome will be the
greater in proportion as the wedge is sharper or has a smaller angle.
Assuming the surface pressed upon in the cervix to be one tenth of an
inch in breadth, then the dilating force exerted will be about nine lbs., if
the wedge have an angle of 90 degrees, or 90 lbs. on the square inch, and
about eighteen lbs. if the wedge have an angle of 45 degrees, or 180 lbs.
on the square inch. The tangle-tent was found experimentally to have
an expanding force of 500 lbs. on the square inch, the sponge-tent a
force of only from 20 to 30 lbs., and the india-rubber bag a force from
15 to 25 lbs. on the square inch. The amount of dilatation produced
by the ordinary series of surgical bougies successfully used is about a
quarter of an inch. A tangle-tent whose stem is about one fifth of an inch
in diameter expands to one half an inch if not subjected to pressure,
but in proportion as the resistance to be overcome increases so does
the amount of actual expansion decrease. A small sponge-tent more
than trebles its diameter when not under any constraint ; its expansion,
however, under slight compression is very small indeed. The expan-
sion produced by the india-rubber bag is practically unlimited, because
any bag can be easily withdrawn, and another of larger size immedi-
ately substituted for it. No time is lost in bringing the full power of
the bougie into action. The tangle-tent expands very slowly ; before
its small dimensions have doubled twelve hours will have elapsed. The
sponge-tent rapidly expands when unconstrained ; and no time is lost
in bringing into action the full power of the india-rubber bag, and its
power continues till its full expansion.
Accidents during Labour.
Rupture. — Fourrier records a case of rupture of the uterus with
escape of the foetus and placenta into the abdominal cavity, in which
he performed gastrotomy on the fifth day. The patient was 29 years
of age, the mother of two children. Six weeks before her expected
labour she fell in going down stairs ; this, however, gave rise at the
time and for a few days afterwards to only slight abdominal pains.
Labour came on at term, and soon after the rupture of the membranes
she felt sudden and severe pain, and there was cessation of labour-
pains. On careful examination four days afterwards, the abdomen pre-
sented two tumours ; the one on the right was made up of the foetus,
while that on the left was about the size of the uterus soon after
labour. An incision was made on the right, the foetus with its mem-
branes and the placenta were extracted, and, although the patient after-
wards presented some indications of purulent infection, she ultimately
recovered. Eourrier calls attention to the absence of any severe hse-
ACCIDENTS DURING LABOUR. 4l?
morrhage, only a slight sanguineous discharge appeared externally eight
hours after the rupture. The presence of the foetus in the abdominal
cavity did not give rise to general peritonitis. He believes that the fall
was an important element in the production of the rupture ; it pro-
bably produced a contusion of the uterus which led to thinning of the
uterine walls. ('Bull, de Therap.,' Aug. 1872.)
Prof. Dohrn writes (' Arch. f. Gynak./ iii, i) on a case of ruptured
uterus in the first stage of labour. Eickety pelvis, no degeneration of
uterine tissue. Cessation of foetal heart sounds early in labour.
Eupture of the uterus is also illustrated by Clements (' Brit. Med.
Journ.,' Oct. 187 1), Whinery (*Philad. Eep.,' March, 1872), and
Mordhorst ('Deutsche Klin./ Nos. 17, 18, 1872).
Mr. Jamieson relates (* Edin. Med. Journ.,' Sept. 1872) a case of
vaginal rupture, unattended at the time of its occurrence by any
serious symptoms. The child was born by aid of the forceps, dead.
At the post-mortem examination the pelvis was found to be in every
respect normal, but there was an acute curvature of the spine in the
lower dorsal region ; the spine was so shortened that the last ribs were
on a lower level than the crest of the ilium. The anteversion of the
uterus was very great, and it therefore acted at a great mechanical
disadvantage, but, continuing to contract violently, tore itself from its
vaginal attachments.
Four cases of loretero-uterine fistula are recorded in the ' Bosfcon
Journal,' Jan. 1872. Each case succeeded to a difficult labour, and
was characterised by an almost uninterrupted flow of urine from the
OS uteri, with complete continence of urine in the bladder.
Dr. Argles relates the case of a primipara, in which the foetal head
passed through the posterior wall of the vagina, and the face presented
through an artificial opening in the perin8eum,just anterior to the anus,
and without injuring the bowel. Dr. Argles passed a director down
the natural passage, between it and the child's head, and slit it up for
an inch and a half. The wound entirely healed, and the patient was
able to walk down stairs in three weeks. (' Lancet,' April, 1871.)
Inversion. — Dr. White contributes two additional cases of inversion
of the uterus, completing a series of nine cases, all of which have been
reduced by manipulation by a single effort. One case was of fifteen
years duration. In recent cases the fundus can be pressed into the
body and neck, or " dimpled " as it is termed, by pressure upon the most
depending part. In chronic cases Dr. "White uses the left hand over
the pubes, the fingers pressing on the anterior wall of the uterus and
assisting in pulling open the uterine cavity. The right hand encloses
in the vagina the entire uterus, and pressure is made against the fundus
by a wooden or hard-rubber enlarged extremity of the repositor, the
distal extremity of the stem being made into a screw so as to fasten
into a coil of steel spring wire, requiring eight or ten pounds pressure
by the breast of the operator, against which it is placed, to bring it
down. (' Amer. Journ. Med. Sci.,' April, 1872.)
Four cases of inversion of the uterus are recorded by Dr. Braxton
Hicks. Kestoration was eff'ected in each case, in one case a week after
labour. He wonders why any doubt has been expressed that removal of
27
\
418 HEPORT ON MIDWIFERY, ETC.
the placenta before attempting to restore the uterus is the best practice.
('Brit. Med. Journ.,' May, 1872). In some remarks on two chronic
cases (ibid., Aug. 1872) Dr. Hicks recommends the introduction of air
bags into the vagina, which should remain for two days. The first bag
is a ring-shaped one, pressing on the upper vagina equally all round,
and steadies the uterus under the pressure of the second bag, which is
a globular one, pressing on the inverted fundus, as the fundus passes
through the ring of the first bag. At the end of two days chloroform
should be given and reduction effected with the hand ; or pressure
should be continued on the fundus by a vulcanite stethoscope, having a
pear-shaped elastic bag drawn over the thoracic end and tied round the
stem tightly. Into the opening at the aural end of the stethoscope a
stopcock can be screwed, and attached to an india-rubber apparatus, by
which means the bag at the other end can be distended. When re-
storation is eff'ected the end of the stethoscope will have entered the
cavity of the uterus. It is well to give a dose of opium every eight or
twelve hours to lessen the irritability of the uterus.
A case of inversion of the uterus with no perceptible shock and very
little haemorrhage. Dr. Bell ('Lancet,' Sept. 1871).
Dr. Woodward relates (' Amer. Journ. of Med. Sci.,' 1871) a case of
spontaneous inversion of the uterus in a primipara. The placenta was
shed naturally, but severe post-partum haemorrhage supervened; the
hand was introduced, and when the patient was left, the uterus was normal
in position. Next morning, contrary to advice, she was allowed to get
up and sit on the commode ; severe haemorrhage came on, and the uterus
was found inverted. This was restored, but the patient died with
symptoms of thrombosis.
Dr. [Taylor contributes an elaborate article on the mechanism of
spontaneous active uterine inversion. (' New York Journ.,' May,
1872.)
A case of inversion came under the care of Dr. Hall Davis ten
months after labour. Ordinary eff'orts at reduction failed, and, the pa-
tient being too weak for 'sustained pressure during consecutive days,
the uterus was removed by the single wire ecraseur. Discharged on
the thirty-third day. (' Obstet. Trans.,' 1872.)
A case of emphysema during labour is related by Dr. Whitney (' Bos-
ton Journ.,' Nov. 30, 1871). The patient was a robust young woman,
in her first labour, which was very severe and protracted. The irrup-
tion of air took place in the night, and was momentarily attended with
some difficulty of breathing ; it was so extensive as to nearly or quite
close the eyes, reaching to all parts above the waist, where it was
arrested in its downward progress by the tightness of the clothes. The
attendant assured his patient and her friends that it would sponta-
neously disappear in a few days, and this prediction was fully verified.
Whitney refers to Cazeaux's work, which contains a chapter on pul-
monary and subcutaneous emphysema, and in which cases such as the
above are stated to be more rare than those in which the air spreads to
the face and neck only, and may occasion oppression and threaten suf-
focation. A case proving fatal in forty-six hours after delivery has
been recorded by Depaul, where the air diff'used itself through the in-
HAEMORRHAGE — TRANSFUSION. 419
tervesicular, interlobular, and sub-pleural cellular tissue, invading both
lungs without going beyond them. The autopsy revealed emphysema
of the cellular tissue of both lungs.
Dr. Mackenzie also reports ('Amer. Journ. of Obst.,' 1871) a case
of emphysema occurring during labour. He considers that the emphy-
sematous condition was caused by the rupture of one or more vesicles
in the lungs from the spasmodic action of the diaphragm. The patient
was well on the eighth day.
Mr. Jalland relates a case of vaginal thrombus. It burst spontane-
ously after the expulsion of the placenta. The patient became pulseless,
but the haemorrhage was controlled by pressure. (' Obst. Trans.,' 1872.)
Fibrous tumour removed after labour. — Dr. Yeld relates the case of a
multipara, set. 37, in which, when the hand was introduced to remove
the placenta, a large mass was found firmly adherent to the walls of the
uterus. This was believed at first to be the placenta, and was removed
by traction and breaking down of surrounding adhesions. The mass
weighed four pounds and a half, and measured nine inches in circum-
ference. The patient died in two hours. (' Brit. Med. Journ.,' June,
1871.)
Hcemorrhage — Transfusion. — Dr. Braxton Hicks calls attention to a
form of concealed haemorrhage before the expulsion of the placenta, not
usually described. Owing to adhesion of the membranes to the lower
part of the uterus, while they, together with a portion of the placenta,
are detached above, blood collects and inverts the free_ portion into the
vagina, forming a bag full of blood. ('Brit. Med. Journ.,' Feb, 1872.)
Three severe cases of concealed accidental uterine haemorrhage are
recorded by Mr. Parsons. ('Brit. Med. Journ.,' June, 1872.) Dr.
Goodell also writes on this subject. (' Amer. Journ. Obstet.,' 1871.)
A successful case of transfusion, by M. De Belina. The patient, £et.
26, had previously had many severe floodings after abortions. She was
now four and a half months pregnant, and the haemorrhage was so pro-
fuse that she was found in a state of profound syncope, and presented
all the appearances of approaching death. The blood was obtained
from her sister ; it was defibrinated, filtered, and then injected. The
improvement was sudden and well marked, and the patient soon ex-
pressed herself relieved, and said she had felt an agreeable sensation of
warmth extending from the arm to the chest. (' G-az. Med. de Paris,'
Feb. 1871.)
Dr. Aveling describes and figures ('Lancet,' Aug. 1872) his instru-
ment for immediate transfusion, and relates a successful case in which
it was used after post-partum haemorrhage. A fold of skin over a vein
at the bend of the elbow is raised, transfixed, and divided. The flat-
tened vein should be seized with a forceps and raised, while an incision
is made, and the bevel-pointed silver tube of the instrument inserted
into it. The tube should be filled with water, and kept full by placing
the thumb over its larger opening. The arm of the blood-donor should
then be prepared, and the round-pointed tube inserted into it. The hand
of an assistant liolds the eff'erent tube and the lips of the small wound
together, and another assistant holds the aff'erent tube secure. The
india-rubber portion of the apparatus, which consists of a central bulj^
420 REPORT ON MIDWIFERY; ETC.
with a tube proceeding from it on each side, terminated by a stopcock,
is filled with water and connected with the silver tubes. The cocks are
then turned straight, and the operation commenced by compressing the
India rubber on the efferent side and squeezing the bulb. This forces
two drachms of water into the afferent vein. The afferent tube is then
compressed and the bulb allowed to expand slowly, when blood will be
drawn into it by the efferent vein. By repeating this process any
quantity of blood can, at any rate, be transmitted.
Dr. Eichardson stated at a meeting of the London Medical Society
(' Lancet,' Feb. 187 1) that the details of the operation of transfusion
had reference to the needle, the knife, and the passage of fluid into the
veins. The needle he recommended is curved, probe pointed, and with
an opening in the under side at the top, curved so that when intro-
duced into the vein, if the end is held down, the apex applies itself to
the upper wall of the vein, whilst the under side of the needle is free
and allows the blood to escape. As to the knife, it should be one to
enter the vein at once, having a small blade with a cutting edge along
the entire of one side, and only for about one eighth of an inch on the
other. As to the passage of fluid, all syringes are bad. The mere ele-
vation of the vessel containing the blood above the patient is sufficient.
He uses a vessel constricted at the base and then widened out gradu-
ally to the top. At the constricted part a wet valve is formed by a
floating ball when the vessel contains fluid, and this fluid gets low in the
vessel. At the lowest part of the vessel is an arm attached to a tube,
and this tube is connected with the needle, the fluid from the vessel _
finding its way along the tube to the needle. I
Dr. Higginson contributes a report of thirteen cases of transfusion. ■
The average quantity of blood injected was nine ounces, the largest
quantity was twenty ounces, and the smallest four ounces. No sub-
stance was mixed with the blood, and it was not subjected to any mani-
pulation. Ten of the cases occurred in obstetric practice, and four of
these recovered. (' Liverpool Med. Surg. Eep.,' 187 1.) A successful
case of transfusion is recorded by Dr. Eingland. ('Dub. Joum.,' Jan.
1872.)
Dupierris publishes twenty-four cases of post-partum haemorrhage
treated by the injection of a solution of iodine into the uterus, all with
a successful issue and no accident. ('Bulletin de Therap.,' 1871.)
Dr. Booth also writes on injection of iodine in post-partum haemor-
rhage. (' Virginia Eecord,' Dec. 1871.)
Therapeutics. — MonteYerdirecovda ('Graz. Med. de Paris,' No. 8,1872)
the results of various experiments made to determine the action of
quinine on the uterus. He invariably used the sulphate, and found that
this substance exercised a general tonic influence on the various organs,
but especially on the uterus. About half an hour after its administra-
tion it produced slight contractions of the uterus independent of pain,
and these contractions became gradually of longer duration and stronger,
with distinct intervals of rest, in every respect similar to the ordinary
pains of parturition. These effects lasted two hours. The dose em-
ployed was about twenty centigrammes. Quinine appears to him
preferable to ergot of rye, since it has no injurious effect on the
THE PUERPERAL STATE. 421
mother or the child, its action is certain, the contractions it induces are
regular and natural, and it is free from danger at whatever period
of pregnancy it is administered. See also Delioux de Savignac, ' Bull.
Gen. de Therap.,' vol. 8i.
Dr. Denham concludes that ergot of rye does not act as a poison on
the foetus. Physiological experiments on animals are in favour of the
view that ergot is, at all events, not a powerful or violent poison. He
believes that when ergot is administered between the sixth and ninth
months the life neither of mother nor child is affected, and that labour
is not induced by it until the full period of utero-gestation is com-
pleted. ('Dub. Obst. Soc.,' 1872.)
Dr. Thompson believes that ergot should be administered with great
care in persons of feeble cardiac power. (' Brit. Med. Journ.,' Aug.
1872.)
IV. — The Puerperal State.
Professor Martin adheres to the view previously put forward by him
as to the nature of puerperal fever, that it is due to a diphtheritic pro-
cess set up in the female genitalia, this diphtheritis spreading by an
infiltration of the pelvic cellular tissue, occasionally by extension along
the mucous membrane direct to the peritoneum, or more frequently
through the lymphatics. In reference to the influence of retained decom-
posed portions of placenta in setting up puerperal fever he points out
that fragments are frequently retained in utero without setting up any
decomposition or putrid absorption, so that in the former cases some
other incident must be sought to explain the occurrence. He thinks a
preceding inflammation of the genitalia, as seen in several cases of
gonorrhoea before labour, has some influence in producing the diphthe-
ritic condition after labour; although, as a rule, the poison gains
access in other, and very different ways. Martin points out that
diphtheritic affection of the genitals does not exclusively attack lying-
in women, although they are particularly subject to it. Dubois
observed that at the time when puerperal fever was epidemic, the
young midwives of the Maternite were occasionally, during menstrua-
tion, attacked with a febrile affection analogous to that affecting the
women whom they attended. In reference to the treatment, the
prophylactic measures are the most important, but digitalis, quinine, and
baths are indicated for the fever, while disinfectant vaginal and uterine
injections are insisted upon. (' AUeg. Mediz. Zentr.,' Aug. 9 and 1 2,
1871.)
The pathology of puerperal fever is discussed by Omboni. (' G-azz.
Lomb.,' 25, 26, 1871.)
Dr. Waldeyer, of Breslau, writes (' Arch. f. Gynak.,' iii, 2) on the
occurrence of Bacteria in the diphtheritic form of puerperal fever.
After referring to the labours of Mayrhofer, Haussmann, Coze, and
Feltz, in the same direction, he states that he has examined the diph-
theritic deposit on the inner surface of the uterus, the puriform masses
in the lymphatic vessels o£ the uterus and of the broad ligaments, the
peritoneal exudation (both the fluid exudation and the yellowish -white
purulent fibrinous flakes), and in one case the thick exudation in tho
422 REPORT ON MIDWIFERY, ETC.
pleural cavities and pericardium. In all these he has found bacteria
in a remarkably large quantity. In the diphtheritic patches they lie
between the pus-cells and those of the partly mortified tissue elements.
The puriform contents of the lymph channels consist of pus-corpuscles
and (in large proportion) of bacteria, and these latter are also to be
found in the peritoneal flakes, mixed with pus-corpuscles, young cells,
and fibrine masses. In the last case, on which Waldeyer bases his
observations, the post-mortem examination was made six hours after
death, the body was yet warm, and nowhere were there any indications
of decomposition to be observed in the organs. The occurrence in all
the cases of bacteria within the pus-corpuscles is very noteworthy.
Waldeyer believes that the changes originate on the inner surface of
the genital canal, and creep upwards along the lymphatics to the peri-
toneum. An exudative purulent inflammation of the abdominal parietes
occurs, which quickly extends to the diaphragm; and then we find
inflammation of the diaphragm, and still further pleuritis and peri-
carditis.
Contribution to the Study of Puerperal Septiccemia. — The following is
the summary of the conclusions arrived at by M. d'Espine in his long
and elaborate articles on this important subject, recently published in
the * Archives Generales de Medecine.' i. Puerperal septicaemia con-
sists of a series of symptoms, the gravity of which is in direct relation
to the quantity of septic matter absorbed by breaches of surface in the
utero- vaginal canal. 2. These symptoms are not peculiar to the puer-
peral state, and ought to be classed with those produced by septicaemia
in the wounded and in animals. 3. The source of puerperal septicaemia
is always the uterus or vagina ; and all causes which prevent the heal-
ing of the bared interior of the uterus, or which favour the production
of septic matter in its neighbourhood, have an important action in its
production. 4. The most common channel of absorption is through
the lymphatics, and its passage through them can generally, but not
always, be traced by lymphangitis. 5. Peritonitis is the result of the
conveyance of septic matter through the lymphatics of the uterus, and
it may be compared to the local inflammations which develop round
infected wounds. 6. The eff'ect of septic absorption is to develop con-
gestions and inflammations in internal organs, chiefly in the lungs,
kidneys, and intestines ; subserous ecchymoses and interstitial apo-
plexy ; internal and external inflammations, which localise themselves
in the neighbourhood of the serous membranes ; during life, these
actions are recognised by fever, diarrhoea, pulmonary congestion, epis-
taxis, and often by fugitive cutaneous eruptions. 7. Milk fever has no
existence ; febrile action in the first week after delivery almost always
depends on absorption of lochia through slight abrasions or lacerations
of the utero-vaginal canal. It may continue for some weeks should
the uterus not be firmly contracted, or should the lochia be foetid. In
the latter case ulcerations, through which absorption takes place, may
almost always be found either on the cervix or in the vagina. 8. These
slighter afiections are often, but not always, accompanied by angioleu-
citis and slight perimetritis. When the septic poison continues long
we mn.j have consumption and death {phtUsie septique). 9. Puerperal
THE PUERPEEAL STATE. 423
py<jBonia is a complication of septicsBmia, and is almost always accom-
panied by the presence of pus in the veins of the uterus. It is a com-
paratively rare occurrence, and probably depends on septic embola being
impacted in the veins. Metastatic visceral abscesses are secondary to
it, while almost all the inflammations of the cellular tissue and of the
articulations depend on lymphatic infection, and are not embolic in their
origin. (' Medical Eecord,' No. I.)
Depaul relates a case of puerperal peritonitis with great tympanites,
in which he punctured the colon with great relief to the patient ; and,
although before the operation she appeared to be dying, she rallied
afterwards and was getting well. (' Bull, de la Soc. de Chir.,' May,
1871.)
In the 'G-az. Med. de Paris' (Oct. 1871) is contained the report
of a case of haemorrhagic smallpox after labour, which terminated
favorably.
Dr. ~E. A. Kehrer ('Archiv fiir Gynak,,' ii, i, 187 1) contributes
an elaborate paper on the morphology of the milk casein, the chief
points of which appear to be contained in the following conclu-
sions:— I. The gland-cells of the mammsB are continually, during the
milk preparation, in a state of active division, and break up on the
other hand after a preliminary fatty metamorphosis into fat globules
and protoplasma particles. 2. The fat globules of the milk are not
enclosed in coverings of albumen or casein. 3. The cell-particles (inter-
globular substance) spring up in the milk serum, and form with it a
thin scum. 4. This scum is the emulsion of the fat globules. 5. In
fresh milk the formed cell-particles are invisible, by coagulation they
show themselves as granules, nuclei, and granule -nuclei- containing
flakes. 6, They collect together out of a light basis-substance and
granular coagulating casein. 7. The casein is neither soluble in water,
nor in the salts of the milk, but is held in it as an ingredient of formed
particles.
M. Decaisne, in an important paper communicated to the Academy
of Sciences on the influence of starvation on woman'' s milh, concludes
that Id sufficient food always gives rise, within varying proportions,
to a diminution in the amount of butter, casein, sugar, and salts,
whilst it augments generally that of the albumen. In three fourths of
the cases observed the proportion of the albumen was in an inverse
ratio to that of the casein under an insufficient diet. The modifica-
tions in the composition of the milk, due to a reparative diet, always
manifest themselves in a striking manner. by the end of four or five
days. ('Med. Times and Gaz.,' Nov. 187 1.)
Dr. J. G-. Wilson records two cases in which the external application
of belladonna to the breasts after labour gave rise in four days to a
bright scarlet eruption, which appeared first on the face and chest, and
then extended all over the body. Other symptoms were present indi-
cating that the patients were under the influence of belladonna. The
complete absence of desquamation of the skin, the persistent dilatation
of the pupils for some days, and the rapid recovery of the patients
show that these were not cases of puerperal scarlatina* (* Glasg, Me4.
Journ./ 1^']%)
434 EEPORT ON MIDWIFERY, ETC.
Fuerperal Convulsions. — Halbertsma writes (' Med. Centr.,' ix, 27,
187 1) on the etiology of eclampsia. Veratrum viride in large doses is
recommended as a substitute for bloodletting in puerperal convulsions
(' Amer. Journ. of Obstetr,' 1871). Cases of puerperal eclampsia
treated by venesection are recorded by Swayne (' Brit. Med. Journ.,'
Eeb. 187 1); and by Jones (ibid., April, 1871). A case of puerperal
convulsions successfully treated by chloroform, Eoss (' Lancet,' Aug.
1 871). Puerperal convulsions treated by hydrate of chloral, Furley
('Edin. Med. Journ.,' Nov. 1871); Geikie (' Canada Lancet,' March,
1 871); Starley ('Americ. Practit.,' 187 1); Ferris (* Brit. Med. Journ.,'
April, 1872). Two cases successfully treated by chloroform are recorded
in detail by Dr. E. E-. Townsend. In one of the cases there was smart
uterine haemorrhage after delivery, but the bleeding had no effect what-
even in controlling the convulsive attacks ('Dublin Quart. Journ.,'
Eeb. 187 1). Dr. Whidborne advises the use of suppositories of
chloral hydrate, when that drug cannot be taken by the mouth.
('Lancet,' June, 187 1.)
A case of sudden death seventeen days after delivery is recorded
(*Obst. Trans.,' 187 1) by Dr. Playfair. A slight pleuritic attack
succeeded labour, and death probably resulted from embolism. The
inflammatory complication had apparently produced an increased
hyperinosis of the blood above that already existing ; and hence in-
flammatory afl'ections in the puerperal state should be regarded with a
greater suspicion and anxiety than at other times.
A case of sudden death seventeen days after delivery was related by
Dr. Ringland to the Dublin Obst. Soc. The heart was found small,
soft, and flabby, with much fat deposited externally. The pulmonary
artery and its two branches were filled with a large though soft clot.
The uterine walls were so thin, as almost to resemble the urinary
bladder.
Dr. Madden contributes a series of cases of sudden death soon after
parturition. ('Amer. Journ. Obst.,' 187 1.)
Mr. Bassett relates thirteen cases of secondary Jicemorrliage coming
on between the third and the thirty-second day after delivery. Five
were due to the irregular and inefficient contraction of the womb, with
clots in its interior ; in four cases the haemorrhage arose from a retained
portion of placenta; and the remaining cases were due to retained
portion of membrane, fibrous polypus, inversion of the uterus, and
imperfect involution. ('Brit. Med. Journ.,' Aug. 1872.)
Dr. Jenks exhibited to the Philadelphia Obstetrical Society a speci-
men of placenta succenturiata, which had been retained for five days
after the delivery of the child and of the placenta proper. It was
adherent to the uterus, and had evidently been connected with the
umbilical cord by a delicate funis of its own, Its presence had given
rise to a constant haemorrhage. (' Amer. Journ. of Obst.,' 1871.)
From a careful microscopical examination of an enlarged, imperfectly
involuted uterus. Dr. Snow Beck concludes that the enlargement is
more due to the increased size and amount of the " soft tissue" of the
uterus than to the increased size of the contractile fibre-cells. Although
the blood-vessels are loaded with fluid blood there is no evidence of the
THE INFANT. , 425
existence of inflammation. This explains the frequent hsemorrhaf^es
noticed in such cases. Any local application to be of value should
be applied to the entire uterine cavity, as the chief seat of the abnor-
mal state is the body of the uterus. (' Obst. Trans.,' 1871.)
V. — The Infant.
Dr. J. Gregory (*Arch. fiir Grynak.,' ii, i, 1871), after relating
several observations on the weight of infants^ concludes that — (i) All
children decrease in weight during the first few days after birth. (2)
They begin to lose in weight during the first hours of extra-uterine life.
(3) The duration of the decrease is generally two days in healthy,
full-time children, brought up at the breast. (4) In children brought
up by hand and in the premature the duration of the decrease
is from half a day to a day, and from two to three days longer. (5)
Full-time children brought up at the breast increase in weight after
this directly and tolerably regularly, and generally attain at the end of
the seventh day to their original weight. (6) Immature children
nourished by the breast have a varying increase, and even on the eighth
day usually only make up half their sustained loss. (7) There is gene-
rally no actual increase in the first eight days in children brought up
by hand. Since the loss is continually in greater proportion, they lose
in weight, therefore, also after the beginning of the first increase. This
applies to the premature children in this category in a greater degree
than to the mature ones. (8) Nutrition is more active in boys than in
girls, whence it follows that boys begin to increase comparatively
earlier, and that more per cent, of boys than of girls in a similar period
exceed their original weight. (9) There is no relation between the
falling off of the navel string and the commencement of the increase in
weight. (10) Nourishing support to the lying-in woman has a favor-
able reaction on the child, shortening the period of loss of weight, and
rendering the increase more regular and greater.
Wernich, from observations founded on 1889 births confirms the
statements of Hecker and Duncan, and says — (i) That the weight of
the foetus increases with the age of the mother till she has attained the
age of thirty-three, and that the length of the foetus increases up to
the forty -fourth year. (2) Each new infant outweighs and is larger
than the preceding one. (3) Long intervals between the pregnancies
are more favorable than short ones. (4) Women who have menstru-
ated early are confined for the first time of a more vigorous child than
those in whom menstruation was late in appearing. (' Gaz. Med. de
Strasbourg,' Oct. 1871.)
Stillborn infants (an epistle directed to Dr. C. Ludwig, by Dr.
Schultze, Jena, 187 1). — The condition of a stillborn infant is, accord-
ing to Dr. Schultze, in all cases one of asphyxia. The stillborn sometimes
present an anaemic, and at others an apoplectic condition, but under both
conditions the still birth is one of actual asphyxia. The mass of blood,
in the one instance, is insufficient to enable it to take up and convey
an adequate amount of oxygen to the medulla oblongata, the excita-
bility of which is, in consequence, reduced, and finally extinguished.
426 . HEPORT ON MIDWIFERY^ ETC.
On the other hand, the apoplectic form of asphyxia is when the medulla
oblongata is not in a condition to respond to the normal excitors pre-
sented to it. The following is the author's general statement of the
four pathological conditions, into one or other of which stillborn chil-
dren are distributable: — (i) A so greatly diminished excitability of
the medulla oblongata that, under the normal excitants, the proper
nervous influence from it is no longer transmitted to the respiratory
apparatus, hence there necessarily results a deficient supply of oxygen
to the blood. (2) A deficient oxygenation of the blood, and its neces-
sary concomitant, an abnormal accumulation of carbon in the blood.
(3)' Constant lessening in the force of the circulation from the slowness
of the heart's contractions, and the immediate and secondary conse-
quences, causing what may, in some sense, be considered as a com-
pensatory movement, besides overfilling the heart with blood, directing
the flow of the latter towards the thorax. (4) The clogging up, to a
greater or less extent, of the trachea with liquor amnii, meconium,
slime, and blood. To arouse the suspended vitality of the stillborn who
fall within thejirst proposition presents three indications : — To increase
the excitation of the medulla, so that the respiratory nerves shall react ;
to endeavour, by acting upon the peripheral nerves, to excite the action
of the respiratory muscles ; or to endeavour to reinstate the normal ex-
citability of the medulla. In the cases embraced in the second proposi-
tion, there is a deficiency of oxygen. Now, after birth this deficiency
can be supplied only through the lungs, and hence, in the absence of
natural respiration, an attempt must be made to imitate it artificially.
In reference to the cases of stillbirth embraced by the third proposi-
tion, it may be understood that when the infant is born deeply asphyxi-
ated, with very slight action of the heart, while the blood in the capil-
laries of the lungs is almost stagnant, how little of the circulating mass
can, by artificial inflation of the lungs, be brought into contact with
oxygen. Hence the increased action of the heart caused by such means
is only of temporary continuance. Artificial respiration can only be
productive of permanent results when, at the same time, there occurs,
as well through the vessels of the lungs as throughout the entire rami-
fication of the aorta, a life-supporting circulation of blood. The artifi-
cially excited action of the respiratory organs may, however, become
ultimately the cause of the reinstatement of the excitability of the ner-
vous centres, and thus be the means of recalling the normal activity of
the respiratory muscles. Eesuscitation, in the cases embraced by the
fourth proposition, is to be effected by the removal of the impediment,
by a sucking effort of the operator's mouth applied directly to the
mouth of the infant, or through an elastic catheter passed into the
larynx, or by a syringe and elastic tube. (' Amer. Journ. of Med. Sci.,'
1871.)
On the colour of the eyes of the newly lorn. — Dr. "Wiltshire (' Lancet,*
Feb. II, 187 1) believes that the eyes in newly born chilren are always
of a blue colour. It is a slaty, mercurial ointment, or leaden-
blue, generally different from the blue colour which obtains in
after life. A change is usually observable in the second month. If
the eyes are to become " dark," a brownish hue overspreads the leadeu
THE INFANT. 427
hue, and in time effaces it. Eyes that ultimately become brightly blue
gradually clear up, as it were, like the sky after a thunderstorm, and a
clear-tinted bluejris is the result. Dr. Wiltshire is inclined to think
that all newly born animals have blue eyes. It is stated that a similar
observation was made by Eucte, in 1846 ('Wagner's Handworterbuch
der Physiologic,' iii, part 2, 325), and even by Aristotle ('De Gener.,'
Gueniot writes on the treatment of fractures of the thigh in newly
born infants. In the majority of cases the fracture is situated at the upper
half of the bone, and nearly always occurs during an assisted labour,
the foetus presenting by the breech, the operator makes too forcible or
ill-directed traction on the fold of the groin. In one case he saw it
produced by the application of the forceps to the presenting breech.
He describes a gutta-percha apparatus which he has found useful in
the treatment. ('Bull. Gen. de Therap.,' i, 1872.)
Gueniot writes on the treatment of urinary umbilical fistulsB, due to
the persistence of the urachus. (' Bull, de Therap.,' ii, 1872.)
Dr. Littleton ('Brit. Med. Journ.,' Sept. 1872) quotes the statement
that between three and four hundred children are annually suffocated
by overlaying, and advocates the use of the arcuccio, universally used
in Italy. The apparatus bears some resemblance to the cradle adopted
to shelter an injured limb, and with it children can be safely laid
entirely under the bed clothes in winter without danger of suffocation.
On the etiology of foetal 'peritonitis. — Dr. B. Olshausen gives the dis-
section of a foetus the subject of peritonitis. The vulva and the vagina
were imperfect ; the meatus, urinarius was not to be detected. Absence
of the anus and of the lower portion of the rectum. Moderate disten-
sion of the bladder, more considerable of the uterus, and enormous of
the lower part of the intestine, with urine. Considerable dilatation of
the ureter on each side and hydronephrosis. Connection between the
uterus and the bladder through a narrow short canal, and through
another, still shorter, between it and the rectum. General peritonitis
of old date. The greatest amount of exudation in the neighbourhood of
the ovaries and the outer portions of the Eallopian tubes. As regards
the malformations, the connection of the uterus with the colon and with
the bladder may be considered the rarest, and, as regards the results in
this case, the most important one. Not only did the urine collect in
the ureters and the kidneys, but also the uterus was filled and distended
into a thin bladder, and there was distension of the colon. But the
most important point is that the urine passed into the Eallopian tubes,
dilated their inner portion, and led to effusion in the pelvis and to
general peritonitis, with gluing together of the intestines. (' Archiv
f.Gynak.,'ii, 4,1871.)
Dr. Jacobi ('Amer. Journ, Obstet.,' 1871) relates a case oi foetal
asymmetry. When shown to the Obstetrical Society o£ New York the
child was three months old. The two halves of the tongue were not
equal in size, the left being thinner than the right, and when the tongue
was protruded it deviated to the left. The entire left side of the head,
face, body, and extremities, were smaller than the right. Dr. Jacobi
believed this condition to be of pre-place?it»l origin, The circulatiou
428 REPORT ON MIDWIFERY, ETC.
I
produced in the development of the allantois is large between the sixth
and seventh week, so we must look anterior to this time for the cause.
He thought it probably due to an obstruction to the free circulation of
blood in the veins of the left side of the vascular zone.
Mr. Macgillivray relates a case of congenital hypertrophy o£ the left
hand and arm, for which he ligatured the brachial artery with a suc-
cessful issue. ('Austral. Med. Journ.,' Jan. 1872.)
Dr. Bailey, in an article on trismus nascentium, in the 'Amer.
Journ. Obstet.,' 1871, quotes the opinions of several authorities on the
subject, and says that in his experience, since 1853, he has not observed
a single case of lockjaw when due regard was paid to the management
and dressing of the umbilicus. Tumefaction and redness, without sup-
puration should always excite apprehension. Unsuitable dressing,
both before and after the separation of the cord, are common exciting
causes. In the early stage of the disease soothing applications to the
umbilicus are of great service. Dr. Bailey does not think that negro
infants are more liable to it than white children.
Dr. "Widerhofer, of Vienna, speaks highly of the value of chloral hy-
drate in the treatment of tetanus neonatorum. He has had six cases
(out of ten or twelve) of recoverv under treatment by chloral. (' Lancet,' 1
March 18, 1871.) " |
Rickets. — Dr. Blache, of Paris, writes ('Practitioner,' Sept. 1872) on
rachitis and mineral inanition. He quotes the conclusions of Dusart :
— (i) That in all living beings, whether vegetable or animal, the pre-
sence of phosphate of lime is necessary for the transformation into
cells of the azotized matters supplied by food, and that to preserve
their vitality the tissues must be constantly traversed by a kind of
current of phosphate of lime ; (2) that the vital, activity peculiar to
each species is always in proportion to the quantity of phosphate of
lime contained in it; and (3) that when the food is deficient in phos-
phate of lime the tissues draw from the osseous skeleton that which is
necessary for nutrition. He then inquires by virtue of what action do
albuminized substances assume, in presence of calcareous phosphate,
the form of cells, and of tissues of every nature without its being demon-
strated that the salt of lime forms any constituent part of them.
Knowing the property possessed by salts of lime of precipitating albu-
men in an insoluble state, may it not be admitted that there takes place
in the organism an analogous phenomenon, but with this modification,
that in the living medium this precipitate assumes the figured form and
becomes organised in tissues ? If children too young or persons debili-
tated from various causes are subjected to a course of alimentation ex-
clusively composed of the flesh of young animals, the liquid albumen
will be easily absorbed, whilst the solid parts containing the salts of
lime will resist the action of the debilitated stomach, and will be ejected.
It is not organizable elements which are wanting, but an organizing
agent, and mineral inanition ensues indirectly as surely as by adminis-
tering aliments deficient in salts of lime, such, for instance, as wheat
alone. Blache believes that the good effected by cod-liver oil in rickets
is due entirely to the exciting action produced through the whole ex-
tent of the digestive tube by the volatile oily acids to which it owes its
THE INl^ANt. 429
well-known odour. The regular contractions of the digestive tube, and
especially the glandular secretions, reappear, and this double influence
promotes the digestion of the solid parts of food, which had till then
resisted. The same result is obtained by presenting directly to the
absorption of the stomach phosphate of lime, on the condition that it
be soluble and require no labour for its digestion. The phosphate
taken into the weakened stomach of persons afllicted with rachitis will
undergo no modification. He recommends Dusart's lactophosphate of
lime, which is prepared by imitating the action of the gastric juice on
phosphates, and which contains the salt completely digested, and con-
sequently capable of being absorbed without requiring any previous
labour of the stomach.
Dr. Widerhofer, in some remarks on the differential diagnosis of
sligM cases of rickets and of chronic hydrocephalus, says the points to
be attended to are chiefly these. In rickets the form of the head is
more or less angular, but there is no special disproportion between the
head and the face. The anterior fontanelle may be large, but the
sagittal suture is generally closed at eight or nine months. The orbits
are normal and there is no prominence of the cornea. Further, some
alterations in other parts of the sketeton, e.g. beading of the ribs, or
some enlargement of the epiphyses of the radius and ulna, will probably
be present. In chronic hydrocephalus the skull is inclined to a globular
shape ; the sagittal suture is open, as well as the fontanelle ; the head
is large, out of proportion to the face, and there is divergence outward
of the temporal bones at their upper part, instead of their usual vertical
position. From the pressure of the intra-cranial effusion the upper
wall of the orbit tends to become more and more upright, so as to push
forwards the eyes and expose the cornea. Further, in rickets, the
tendency is to partial convulsions, especially spasm of the glottis ; in
hydrocephalus to general convulsions. Lastly, the former is most
frequently accompanied by diarrhoea; the latter by constipation.
('Lancet,' March i8, 1871.)
Dr. Eitchie writes on the diagnosis of rickets (' Med. Times and
Gaz.,' Jan. 187 1), and points out, as the result of numerous observa-
tions, that there is a varying fall in the evening temperature in rickets,
whereas in tuberculosis there is not only no evening fall, but there is a
positive evening rise.
Dr. Sonsino, in a paper on the physiological dyspepsia for starchy
food in infancy, confirms the opinions of Bidder and Schmidt, Guillot,
and Schiff; and concludes that in the generality of mammalia, saliva
acquires its digestive power over starchy matter only at a degree of
development which, in the larger number of the same animals, is not
reached at the time of birth. He then details some experiments made with
an infusion of the pancreas of young animals, and states that pancreatic
juice in dogs, cats, and rabbits in the first week of life is devoid of any
digestive action on starch ; and he infers that the same inability of the
pancreas to digest starch exists in the early life of man. Experiments
made with the enteric juice were not so conclusive. He thinks that
an infusion of fresh pancreas might be useful to aid the digestion of
starch in infancy ; but that good reasons exist for not feeding infants
430 UEPORT ON MIDWIFERY, ETC.
with starchy matters, however they may be rendered digestible. The
nutriment furnished by starch does not afford materials for the re-
integration of the principal tissues, but it concurs almost exclusively as
fuel to the process of hematosis, whereas the growing infantile organism
needs a greater quantity of those nutriments which directly afford
materials to the development of the tissues. (' Practitioner,' Sept.
1872.)
Dr. Dobell believes that many cases of infantile wasting occur
because the food, deficient in fat, not only fails to nourish the child,
but fails to develop the function of the pancreas for the digestion of
fat at a later period of life. The craving of the child, due to the
deficiency of assimilated fat, is met by starchy food which it has not
the power to digest, and which, if digested, cannot supply the place of
fat. Of all the satisfactory remedial effects of pancreatic emulsion
none equal those produced by it in these cases of wasting in children.
(' Practioner,' Oct. 1872.)
Gold Food for Infants. — Surgeon King writes in the * Philadelphia
Medical Times ' on this subject : — " Our best authorities direct that
the cow's milk should be given to the child at the same temperature
as that of the mother's milk, from 90° to 95° Fahrenheit, and when
great accuracy is required a thermometer employed. On reflection, it
is obvious that these instructions can never be carried out so that the
little one will take all its food at the same temperature, for during a
meal the bottle becomes cold, and there may frequently be considerable
difference of temperature between the first and the last milk imbibed
by the infant. It is unnecessary to state that very little will upset
the feeble powers of the digestive organs in the early days of infantile
life, and this difference in the temperature of the food, I am disposed
to believe, is one of the causes of gastric and intestinal disorder which
we so often have to deal with among infants brought up by hand.
Instead of giving warm milk, I have adopted the plan of giving cold
milk entirely — ordering the babe's bottle to be kept standing in iced
water in the summer and in a cold place in winter. This method I
have found, from practical experience, to answer remarkably well. If
there is any tendency to diarrhoea I recommend the milk to be heated
to 212° Fahr., and afterwards allowed to get quite cold before being
used. In private practice I am of opinion that bottle-fed infants
generally have their food given them too warm. They soon like it
better than warm food, and during the teething period cold milk seems
especially agreeable to the inflamed gums of the little sufferers."
(*Brit. Med. Journ.,' Aug. 1872.)
Vaccination. — Mr. Hutchinson contributes an important report on
two series of cases in which syphilis was communicated in the practice
of vaccination. The first series consisted of twelve persons, mostly
young adults, who were vaccinated from a healthy looking child. The
progress of the vaccination was satisfactory in all; but indurated
chancres appeared on the arms of ten of the vaccinated in the eighth
week. The primary sores rapidly disappeared after mercurial treat-
ment, but constitutional symptoms appeared in four of the patients
five months after the vaccination, and the vaccinifer showed condy-
THE INFANT. 43l
lomata at the age of six months. Four out of the five vesicles on the
child's arm were used, and more than one, possibly all of them, bled
somewhat. Mr. Hutchinson deduces the following conclusions from
the cases. The blood of a child suffering from inherited syphilis
can, if inoculated, transmit the disease with great certainty. The
result of such inoculation of blood will be an indurated chancre. If
multiple inoculations be practised, multiple chancres may be pro-
duced. A period of incubation between the inoculation and the first
occurrence of induration about the prick will occur, during which the
part may appear perfectly healthy. The period of incubation prior to
the first specific induration will usually be about five weeks. It is
quite possible for vaccine lymph and blood to be transferred at the
same time, and for each to produce its specific results, the effects of the
syphilitic inoculation occurring subsequently to those of vaccination.
It is quite possible to vaccinate successfully from a syphilitic infant in
the stage of utmost potency as regards its blood, without communi-
cating syphilis. In the second series of cases there were unquestionable
symptoms of constitutional syphilis in nine children who had been
vaccinated from the same child. There were suspicious symptoms in
six others, but a certain number of those vaccinated entirely escaped.
The vaccinifer was a fine healthy-looking child, but with slight local
symptoms indicative of inherited syphilis. (' Medico.-Chir. Trans.,' liv.)
For discussion on syphilitic inoculation by vaccination see proceed-
ings of the Societe de Medecine de Lyon. (' Lyon Med.,' vii, 5 10 — 564.)
Mr. Amos Beardesley writes on vaccination — the advantages of JBryce^s
test. There is no local appearance which can be relied upon as a guarantee
of a constitutional security against smallpox ; and in neglecting the con-
stitutional test we are aggravating the distrust in vaccination, degrad-
ing the productive power of vaccine lymph, and curtailing one of the
greatest blessings ever given by man to man. ('Practitioner,' June,
1871.)
Dr. Farquharson concludes from extensive experience in revaccina-
tion, that while it is a perfectly safe operation under ordinary circum-
stances, care should be taken in its performance on weakly subjects.
In these the resulting constitutional disturbance may cause much dis-
comfort, and some efforts should first be made to improve the tone of
the general health. ('Lancet,' July, 187 1.)
Mr. Stephen Mackenzie relates ('Lancet.' Feb. 1871) several cases
vaccinated with lymph dilated with glycerine, in the proportion of forty
drops of the latter to the contents of two capillary tubes of vaccine.
He thinks that lymph diluted to this extent is as potent as undiluted
lymph. A similar view is also expressed by Dr. E. Miiller, of Berlin
('Berlin Woch.,' April 17, 1871.), and by "Weiss (' Centr. f. Med.
■Wiss.,'48, 1871).
Guilland quotes the following case : — A primipara, confined on the
18th of January, was attacked with the eruption of smallpox on
the evening of the 20th, forty-eight hours after labour. She died
on the fourth day of the hsemorrhagic form of the disease. The infant
had been sent away to a nurse the day after it was born. On the 27th
Guillaud went to vaccinate the child, having been unable to procure
432 UEPOUT ON MIDWIFERY^ ETC.
vaccine sooner, but the pustules had appeared the same morning, and
the patient died on the 3 ist. Another child suckled by the same nurse
was successfully vaccinated on the 27th; but was seized on the ninth
day with a very mild form of varioloid and did well. The nurse pre-
sented on the loth of February five pustules around the nipple of the
right breast. These commenced on the 4th of February. There had
been, and there was no other part attacked, not even the opposite
breast, which, as it was the seat of an abscess, had not been frequently
used. Gruilland regards this case as an instance of true inoculation
from the nursling to the nurse. Being protected by early vaccination,
she was susceptible only of a local effect. ('Lyon Med.,' April, 1871.)
A foetus expelled in the sixth month of pregnancy, while the mother
was suffering from smallpox, had distinct pustules all over its surface.
(Simpson, 'Edin. Med. Journ.,' May, 1872.) See a case of iucubation
of smallpox in utero. (Townsend, 'Med. Times and Graz.,' June,
1872.) See also the case of a foetus born with a pustular eruption,
the mother at the time suffering from smallpox. (' Lyon Med.,' Oct.
1871.)
Pollak writes on JicBmorrhage from tlie kidneys in infants (' Wien.
Med. Presse,' xviii, 1871). It is liable to follow severe attacks of
diarrhoea in infants under two months old. In addition to the appear-
ances of the urine there is pain ])roduced by pressure in the lumbar
regions, and there is also great restlessness. Pollak thinks, from post-
mortem examination, that the parenchyma of the kidney is not the seat
of disease. The young patient's strength should be kept up by good
milk and by tonics. Eecovery is rare.
The Jaundice of Newly -lorn Children. — Dr. Kehrer believes that first-
born children are rather more frequently attacked than others. Early
purging of the meconium does not hinder the development of jaundice.
We must, then, abandon the idea that the jaundice is caused by resorp-
tion of the meconium, which is rich in bile in newly-born children. In
jaundice in newly-born children we find the liver throughout, or in
parts, yellow coloured, from the bile contained in the liver-cells.
Ererichs thought icterus neonatorum due to diminished tonicity of the
capillaries of the parenchyma of the liver, which takes place when the
flow from the umbilical vein is stopped, and permits of increase of bile
in the blood. Hardenhain admits that after compression of the aorta
the pressure of the secretion in the ductus choledochus falls off.
Virchow thinks that infantile jaundice results from catarrh and stop-
page of the bile-duct. The disease commenced usually on the second
or third day, and seldom on the first or fourth day of life. The
prognosis is generally good. (See * Amer. Journ. of Obstetrics,' Nov.
1872.)
Gueniot relates (* Q-az. des Hop.,' April, 1872) a case of congenital
invagination of the rectum. Dr. Dawson related to the New York
Obstetrical Society the case of a child six weeks old, who was the sub-
ject of an invagination of the colon, caecum, and a portion of the duo-
denum into the rectum, and which were bound together by exudation
where the peritoneal surfaces were opposed. The diagnosis had not
been made during life. ('Amer. Journ. of Obstetr.,' Nov. 1872.)
k
REPOEl:
ON
MEDICAL JURISPRUDENCE,
BY
THOMAS STEVENSON, M.D. Lond., E.E.C.P.,
LECTIJEEE ON CHEMISTRY AT GIJY'S HOSPITAL ; MEDICAL OFFICER OF HEALTH FOR
ST. PANGEAS, MIDDLESEX, AND OFFICIAL ANALYST ; LATE EXAMINER IN
FORENSIC MEDICINE IN THE UNIYERSITY OF LONDON.
Poisons.
General. — Prof. Goltz,^ of Halle, has experimented on the absorption
and removal of poisons after suspension of the circulation, and has
arrived at the following results: — i. In frogs, the hearts of which had
been previously ligatured, strychnine nitrate injected into the stomach
induced tetanic spasms within fifteen minutes, and the same results
ensued when the poison was injected beneath the skin. 2. The poison
reaches the spinal cord spite of the ligature applied to the heart, for
frogs were fed with the spinal cord of another frog which had been
poisoned by the injection of the poison over the muscles of the calf
subsequent to the ligature of the animal's heart, and yet tetanus super-
vened after the lapse of eight hours. 3. The passage of the alkaloid
from the region of the calf to the spinal cord is independent of the
activity of the striped muscular fibres of the poisoned limb. When the
heart was ligatured, the roots of the ischiadic nerve of one side divided
in the pelvis, and then the stychnine salt injected into the calf on the
same side, tetanus supervened. 4. The blood is the vehicle by which
the toxic substance is disseminated, for when frogs were destroyed by
strychnine subsequent to ligature of the heart the blood of these
poisoned animals was capable of inducing tetanic spasms in other frogs.
5- If a frog's heart be ligatured, and the animal be now poisoned by
the introduction of the strychnine salt into the leg, the poison passes
into the opposite limb, for if another frog be fed with the muscles
from the first poisoned frog the second frog experiences tetanic spasms.
! 6. The experiment last detailed fails if a dead frog be employed for the
\ strychnine injection in the first instance. — The author is of opinion
; that the general principles enunciated above are applicable to poisons
generally, and states that even after complete interruption of the cir-
i culation a poison may pass from one part to another of the living body
I by a process diff'erent from the osmosis which takes place in the dead
* 'Arch. f. Gesam. Physiol.,' 187 1, p. 147.
28
434 EEPORT ON MEDICAL JURISPRUDENCE.
tissues, and he promises further experiments on the force which
renders this translation possible.
Elimination of poisons. — Dr. Anstie ^ combats vigorously the pre-
valent views vyith respect to the supposed elimination of poisons,
animal, vegetable, and mineral. He appears to be of opinion that there
is no tendency in the unaided animal organism to get rid of poisons,
and that remedies administered with the object of assisting elimination
are, as a rule, powerless.
Antagonism of Poisons.
The literature of this topic is unusually interesting.
Antagonism letween physostigmine and atropine. A very elaborate
research on this subject, full of valuable results, has been completed by
Dr. Eraser.2 The author first reviews previous experiments on physio-
logical antagonism, viz. between atropine and hydrocyanic acid (Preyer),
between atropine and muscarine (Schmiedeberg and Koppe), between
physostigmine and strychnine, and between physotigmine and chloral
(Bennett), and comes to the conclusion that, although in many cases
the a priori reasons in favour of the existence of a lethal or of a more
or less general antagonism are extremely plausible, the experimental
data by means of which it has been attempted to establish the reality
of the antagonism are, probably without exception, imperfect, and
therefore insufficient to do so. His own experiments were made with
a view to determine the existence of a physiological antagonism between
physostigmine and atropine, and the limits of the same. Physostigmine
was administered either in the form of an alcoholic extract or of the
sulphate of the active principle (curarine) ; preparations chiefly made
by himself, but in some cases with those manufactured by Messrs. T.
and H. Smith, of Edinburgh. The atropine was administered in the
form of sulphate. The subjects of experiment were chiefly rabbits
weighing about three pounds, in a state of perfect health, and during
digestion. In some cases dogs were used. The plan of the experiments
was as follows. In the first place the minimum fatal doses for rabbits
of the extract of physostigmine and of the sulphate of physostigmine
respectively were determined by a number of preliminary experi-
ments, so that, on the weight of the animal being ascertained, it was
an easy matter to be certain of the dose of the particular prepara-
tion that could kill them. Then in those experiments in which
recovery followed the administration of a dose of atropine given
in combination with a dose of physostigmine equal to, or in excess
of, the minimum fatal, the animal used was killed many days after-
wards, and, when the efiect of the two substances had completely I
disappeared, by a dose of physostigmine less than or only equal to that ■
from which it had previously recovered. Therefore, when the adminis- ^
tration of atropine prevented an otherwise fatal dose of physostigmine
from causing death, a perfect demonstration was obtained of the power
of atropine to produce some physiological action or actions that coun-
teracted some otherwise lethal action or actions of physostigmine.
* *Tlie Practitioner,' viii, pp. i6i, 289, 356.
f 'Trans. Eoy. Soc. Ediu.,' 1872, xxvi, pp. 529—713.
POISONS. 435
The administration of the substances was effected by subcutaneous
injection. The following is a brief summary of the first series of
experiments :
1. The minimum lethal dose for rabbits of the extract of physos-
tigmine is i"2 grain, and that of sulphate of physostigmine 0*12 grain,
for every three pounds' weight of an animal.
2. The influence that is exerted by atropine upon the lethal action of
extract of physostigmine and sulphate of physostigmine was examined
in rabbits, and a description is given of the experiments performed for
the purpose. As an instance we quote the following: — A rabbit
weighing 2 lbs. 15^ ozs. received 0*3 grain of sulphate of atropine, and
in five minutes afterwards 1*2 grain of extract of physostigmine. Re-
covery took place.
Ten days afterwards the same rabbit, now weighing 3 lbs., received
1*2 grain of extract of physostigmine. Death occurred in twenty-two
minutes. Many other similar experiments are related with a like
result.
3. Several experiments are also described in which the influence
exerted by atropine upon the lethal action of extract of physostigmine
and sulphate of physostigmine were examined in dogs also. As an
example the following will suffice : — A dog weighing 1 1 lbs. received
0*15 grain of sulphate of atropine, and five minutes afterwards 0*9
grain of sulphate of physostigmine. Eecovery took place.
Ten days afterwards the same dog, now weighing 11 lbs. 4 oz.,
received 0*3 grain of sulphate of physostigmine. Death occurred in
seventeen minutes.
These experiments clearly demonstrate that' atropine is able to
counteract the lethal action of physostigmine in rabbits and dogs, but
whether it will do so in other animals can as yet only be surmised.
4. The influence exerted on the lethal action of physostigmine by
atropine injected directly into the veins, in which case it acts with
greater effect ; the physostigmine, being injected subcutaneously, was
the subject of another set of experiments, as an example of which we
give the following : — A rabbit weighing 4 lbs. received 2 grains of
extract of physostigmine, and five minutes afterwards 0*03 grain of
sulphate of atropine by injection into a facial vein. Eecovery took
place.
Seven days afterwards the same rabbit, now weighing 4 lbs. 3 oz.,
received 17 grain of extract of physostigmine. Death occurred in
twenty-three minutes.
The next part of the research was made with a view to determine
whether the counteracting influence of atropine upon the lethal action
of physostigmine is successful only within a definite range of doses,
and whether this range can be determined experimentally. For this
purpose three sets of experiments were made. The chief objects of
the first two of these were to ascertain the maximum dose of phy-
sostigmine that can be successfully antagonised by atropine, and the
range of doses of atropine that can successfully antagonise lethal
doses of physostigmine. The chief objects of the third series was
to ascertain within what limits of time between the administration
436 REPORT ON MEDICAL JURISPRUDENCE.
of the two substances successful antagonism occurs. The following
are the results obtained :
I. Experiments with the minimum lethal dose of physostigmine. —
While o'oo^ grain of sulphate of atropine is a dose insufficient to prevent
death, 0*009 gi'^in is one sufficiently large to do so ; and any dose of
sulphate of atropine ranging within the wide limits extending from
o'oop grain to 5*5 grains is able to prevent the fatal effect of this dose
of physostigmine ; but if the dose of sulphate of atropine amounts to
j;*3 grains the region of successful antagonism is left and death occurs.
Experiments with one and a half times the minimum lethal dose of
physostigmine. — In these it appears that while o'oi^ grain of sulphate
of atropine is a dose too small to prevent the occurrence of death after
a dose of physostigmine one and a half times as large as the minimum
lethal, o'o2 grain is a dose sufficiently large to do so ; that doses of
sulphate of atropine ranging from 0*02 grain to 4'i grains are able
successfully to counteract this dose of physostigmine, and tliat death
occurs when the dose of sulphate of atropine is so large as 4*3 grains.
Experiments ivith twice the minimum lethal dose of physostigmine. — The
range is from o"o2 gr. up to 3*2 grains sulphate of atropine. Beyond
and below this range death occurs.
Experiments with two and a half times the mininum lethal dose of
physostigmine. — The range here is from 0*025 ^^ ^'^ grains of sulphate
of atropine. Beyond and below this death occurs.
With three times the minimum, lethal dose of physostigmine. — In this
case the range of successful antagonism lies between o*o6 and 1*2 grain
of sulphate of atropine. Beyond and below these limits death occurs.
With three and a half times the minimum lethal dose of physostigmine.
— Here the range is a very limited one, extending from o*i to 0*2 grain
of sulphate of atropine.
With four times the minimum lethal dose of physostigmine. — In this
case no successful antagonism can be exerted by atropine, as death
invariably ensues.
The results of these experiments are all represented diagramatically.
In another series of experiments the interesting fact is brought out
that death may be likewise produced by the combined non-lethal doses of
the two substances. When sulphate of atropine is administered five
minutes before half the minimum lethal dose of phyostigmine, death
occurs if the dose of the former substance be 9*8 grains or more. This
result is a very remarkable one when it is considered that a very
decided counteraction is exerted by much smaller doses of atropine
against the poisonous action of doses of physostigmine greatly in excess
of the minimum lethal, and that the minimum lethal dose of sulphate
of atropine is about 2 1 grains.
II. Determination of the limits of antagonism when atropine is
administered five minutes after physostigmine.
Experiments with the minimum lethal dose of sulphate of physostig-
mine {o' 12 gr. per 3 lbs. weight). — The range of antagonism lies between
0*02 and 2*5 grains of sulphate of atropine.
POISONS. 437
With one and a half time the minimum lethal dose. — The range lies
between o'o^ and 2*1 grains of atropine.
With twice the minimiom lethal dose the range is from o'l to i*a
grain of atropine.
With three times the minimum lethal dose the range is still more
limited, recovery taking place only in one place in which o*i6 grain
atropine was administered.
Doses three times more than the minimum lethal dose of physostig-
mine cannot be successfully antagonised by atropine.
Another set of experiments shows that the smallest quantity of
atropine that, in conjunction with half the minimum lethal dose of
physostigmine administered five minutes beforehand, is sufficient to
cause death, is about ten grains per three pounds' weight of rabbit.
III. Determination of the influence of the interval of time letween the
administration of the two substances upon the dose of atropine
required to counteract a given dose of physostigmine.
The plan of this third series of experiments was that the dose of
physostigmine was constant (one and a half time the minimum lethal
dose, viz. o'i2 sulphate of physostigmine per 3 lbs. weight of animal),
while the dose of atropine and the interval of time between the ad-
ministration of the two substances varied. The experiments are — {a)
those in which the two substances were simultaneously administered ;
(5) those in which atropine was administered after physostigmine ; (c)
those in which atropine was administered before physostigmine.
{a) In these the range of successful antagonism lies between 0*05
and ^'0^ grains of atropine.
(h) The results of administering atropine five minutes after physos-
tigmine have already been given. Ten ^ninutes afterwards : the range
in this case is from 0*3 to 2*5 grains^ of atropine. Fourteen minutes
afterwards : only one experiment was made, in which 0*3 grain sulphate
of atropine was successful. Fifteen minutes afterwards : death is pre-
vented by doses of atropine ranging from 0-3 to i grain. Beyond this
interval atropine does not antagonise physostigmine.
(c) Five minutes before : the range of successful antagonism is from
0*05 to 37 grains of atropine.
Another set of experiments with varying doses of atropine, adminis-
tered at diff'erent intervals before the minimum lethal dose of physos-
tigmine, shows that o'o^ grain exerts successful antagonism with, an
interval of twenty minutes or less, but not if the interval be prolonged
beyond this.
Doses of half a grain of atropine antagonise one and a half time the
minimum lethal dose of physostigmine, if administered thirty minutes
before this, but not if the interval be longer. Doses of one grain and
! a half antagonise physostigmine within an interval of sixty-five minutes.
j Three grains of atropine administered an hour and thirty-five minutes
; before the same dose of physostigmine successfully antagonise it, but
I not if the interval is prolonged to one hundred minutes or more. Three
1 grains, however, is near the maximum limit of the range in the case of
I simultaneous administration, and, accordingly, not far from the limit iu
438 EEPORT ON MEDICAL JURISPRUDENCE.
the case where atropine is administered five minutes before physostig-
mine.
Another set of experiments shows this remarkable result, that if four
and a half grains of atropine are given ten minutes before the physos-
tigmine, death occurs, but recovery takes place if the atropine is admi-
nistered fifteen or twenty minutes before. When five grains of sulphate
of atropine are administered before the same dose of physostigmine
death occurs if the interval of time be one of fifteen or twenty minutes,
but recovery generally occurs if the interval be one included within the
wide limits extending from twenty -five to one hundred and seventy-five
minutes ; while death, again, occurs if the interval be one so great as
three hours.
A very interesting chain of events is therefore presented, for it is
seen that certain actions, produced with sufficient intensity to cause
death when the two substances are simultaneously administered, lose
the power of doing so when the atropine is administered at an interval
of twenty-five minutes before the physostigmine ; while the now unob-
scured counteraction of the lethal eflect of this dose of physostigmine
which makes the loss perceptible, persists till the interval is increased
to three hours.
The whole of this remarkable investigation is tabulated and illus-
trated by diagrams. The one substance is shown in the most conclu-
sive manner to exert a remarkable and decided physiological antagonism
to the other, and that the fatal effect of three and a half times the mini-
mum lethal dose of physostigmine may be prevented by atropine. " The
existence of such an antagonism encourages the hope that the power of
directly counteracting disease is far from unattainable, and it supplies
a strong incentive to efforts designed to determine the conditions of
disease and the actions of remedies with an exactitude sufficient to
show how the remedial action may be applied as a counteracting influ-
ence to the diseased condition."
Antagonism of various poisons. — Prof. Eeese,* of Pennsylvania, has
investigated the following supposed antagonistic poisons : — Morphine
and atropine, morphine and hydrocyanic acid, morphine and strych-
nine, morphine and aconitine, morphine and arsenic, strychnine and
tobacco, strychnine and aconitine, strychnine and tincture of chloride
of iron, strychnine and tincture of iodine, strychnine and Calabar bean,
and atropine and Calabar bean.
The antagonism between hydrocyanic acid and morphine was found
to be very slight, if, indeed, it exists at all. The positive antagonism
of atropine and morphine could not be satisfactorily demonstrated ; on
the contrary, the converse would seem rather to be proved by one ex-
periment, the morphine intensifying at least one portion of the atropine
impression — its paralytic effect. Strychnine and hydrocyanic acid can
in no sense, he thinks, be considered antagonistic ; nor can strychnine
and tobacco be regarded as true antagonistic poisons, although, so far
as relates to the human subject, we have the testimony of some autho-
rities that tobacco does really appear to antagonise the toxic influence
of strychnine. In one experiment tincture of chloride of iron seemed
* * Amer. Journ. Med. Sc.,' Ixi, pp. 133, ^'ji.
POISONS. 439
slightly to modify tlie effects of strychnine, without, however, prevent-
ing a fatal result ; but another experiment showed that the supposed .
autidote has no proper antidotal power over the alkaloid. There was
no good evidence obtained of an antagonism between strychnine and
tincture of iodine. When strychnine and aconitine were given in com-
bination the symptoms that followed were purely those of strychnine
poisoning.
Antagonism between atropine and morphine. — Eirmy* relates a case in
which he injected subcutaneously, for neuralgia, a solution containing
one twenty- fifth of a grain sulphate of atropine, combined with a
quarter of a grain of acetate of morphia. In ten minutes after, symp-
toms o£ acute atropine poisoning resulted, viz. dilated pupils, dryness of
the throat, rapid pulse, frequent respiration, delirium, and unconscious-
ness, causing great alarm. Twenty minutes after the commencement
of the symptoms of intoxication one third of a grain of morphine was
injected, with the result, in five minutes, of entirely changing the cha-
racter of the symptoms and inducing tranquil sleep, lasting the whole
night. Next day the patient was quite well.
Dr. A. Littlef asserts that the antagonism between belladonna and
opium is incontestably established, and brings forward a series of cases,
old and new, collected chiefly by American physicians in support of
this view. In one case of an infant poisoned by opium, tincture of
belladonna was successfully administered in doses of fifteen drops twice
repeated. In another case, of an adult who had taken twelve to fifteen
grains of sulphate of morphine (the patient had been in the habit of
taking morphia in small doses), extract of belladonna was given with
apparently excellent results, five grains of the extract having been
given in divided doses. Administered after opium, belladonna fails to
exercise its full influence on the pupil. It is indubitable that bella-
donna neutralizes or counteracts some of the effects produced by mor-
phine, but it is more doubtful whether the lethal action of opium is
prevented by the administration of belladonna.
Stri/chnine as an antidote to chloral. — M. OreJ finds that — i. Not only
does injection directly into the veins of i-6oth grain of strychnine
(a fatal dose for a rabbit of 4^ lbs.) fail to prevent the animal suc-
cumbing to a drachm of chloral, but the presence of the alkaloid is
not manifested by any spontaneous characteristic phenomenon. 2.
The injection into a vein of i-24th grain of strychnine occasions spon-
taneous and well-marked convulsions. 3. In proportion as the dose of
strychnine is augmented (i-i8th grain), death supervenes with greater
rapidity, and the poisonous property of the alkaloid becomes more
marked. 4. If the dose be increased beyond i-9th grain, the action
of the chloral is then completely masked, and the animal dies from
strychnine-intoxication. The antidote thus becomes a toxic agent. 5.
Whenever it is attempted to combat the effects produced by a fatal
dose of chloral by means of strychnine, introduced either subcutaneously
or into a vein, the animal always succumbs ; most frequently in conse-
* 'Dublin Journ. Med. Sc./ July, 1872, p. 38. '
t * Philad. Med. and Surg. Kept.,' xxiv, p. 334.
j * Gaz. Med. de Paris/ 1872, p. 401,
440 REPORT ON MEDICAL JURISPRUDENCE.
quence of the action of the former, sometimes, however, of the latter
agent. 6. Hence strychnine is not an antidote for chloral.
Physostigmine and strychnine. — Ashmead* describes a case of suc-
cessful treatment of strychnine poisoning by means of extract of
physostigmine. A drachm of the pharmacopceial solution of strychnine
had been swallowed. Recovery took place after the administration of
a little more than two grains of the extract of physostigmine.
Dr. J. St. Clair Grayf proposes nitrite of amyl as an antidote for
strychnine.
Aconite and digitalis. — DobieJ reports a very interesting case- in which
recovery took place from a poisonous dose of tincture of aconite treated
by the subcutaneous injection of tincture of digitalis. The patient, when
seen, was pulseless and apparently at the point of death. Twenty
minims of the tincture of digitalis were first injected subcutaneously.
Galvanism was also applied to the cardiac region. At the end of twenty
minutes the patient was able to swallow, when he received along with
brandy and ammonia a teaspoonful of the tincture. Improvement
followed, and the mixture was repeated twice within an hour. After this
the patient was out of danger. He subsequently got quite well, and
confessed he had swallowed an ounce of Fleming's tincture of aconite.
The case is looked upon by the author as proving that digitalis is a
cardiac stimulant, and not a cardiac depressant, as some suppose.
I^hosphorus poisoning. — Dr. Lichtenstein§ reports a case in favour of
the views of Personne, Andans, Kohler, and others, that oil of turpen-
tine is an antidote for poisoning by phosphorus. Dr. Schultzenl| states,
that in an experience of thirty or forty cases nearly one half termi-
nated favorably, notwithstanding that no oil of turpentine was given.
Dr. A. Welter"^ has an elaborate monograph on phosphorus poisoning
generally, but the chief point in his paper is that of treatment. He
approves of the treatment by oil of turpentine, but states that the
rectified oil is unreliable. He recommends the French oil of turpen-
tine. "We may remark that five kinds of the oil are met with in com-
merce— French, English, G-erman, Venetian, and Templin oil, which
diff'er considerably in composition and optical rotatory power. The
following is Tetter's course of treatment. In acute cases he first gives
sulphate of copper in emetic doses every ten or fifteen minutes till
vomiting is produced. No harm is done, but rather the reverse, if
several doses have to be given before emesis supervenes, for the copper
neutralizes the phosphorus. After thorough vomiting the 01. Tereb.
Gallicum is given in 40-mimm doses every fifteen minutes, mucilage
being the medium employed for the exhibition of the remedy. Next day
magnesia is given.
G-. H. Boessingh** makes some observations on the treatment of
* 'Edin. Med. Journ.,' 1872, p. 235.
t 'Glasgow Med. Journ./ Feb., 1871, p. 188.
X 'Brit. Med. Journ./ Dec., 1872, p. 682.
§ ' Berl. Klin. Wchnsclir.,' 1870, No. 2,?>'
II 'Centralbl. f. d. Med. Wissensch.,' Oct. 8, 1870.
^ • Virchow's Arch./ liii, p. 168, 1871.
** * Schmidt's Jahrh,,' clvi, p, 19.
POISONS. 441
acute phosphorus poisoning with copper and oil of turpentine. His
experiments were made on rabbits. The conclusions he has arrived at
are as follows : — (i) The statements of Bamberger, that oil of turpentine
as an antidote to phosphorus is inert, are erroneous ; (2) all the ani-
mals which were treated with turpentine, after having been poisoned
with phosphorus, lived longer than those which received copper ;
(3) the dose of phosphorus which could be borne when turpentine was
given was much greater than that where copper was employed as an
antidote ; (4) the temperature never rises so high when turpentine is
administered as when copper is used ; (^) owing to the great rise in
temperature animals poisoned with phosphorus lose weight more rapidly
when treated with copper than when treated with turpentine. In
addition to these facts, the animals which were treated with copper were
much stronger physically than those treated with turpentine. As an
example of the influence of turpentine, he gives the following experi-
ment. To one rabbit 25 minims of phosphoretted oil along with
80 minims of olive oil were given, to another the same dose of phos-
phorus along with 80 minims of French oil of turpentine. The first
died, the latter remained quite well. He regards turpentine as the
best antidote to phosphorus.
Tissue changes in phosphorus poisoning. — Yoit* and Bauer'investigate
phosphorus poisoning in relation to the fatty degeneration of the tissues
and organs which it causes. By giving phosphorus to dogs deprived of
food for several days they found that the ordinary symptoms of
phosphorus poisoning and fatty degeneration of all the organs were
produced. The fat could not have come from the food, as the animals
were in a state of starvation, nor from the other parts of the body, as
there the fat had all disappeared for the same reason. It must therefore
have been produced by the decomposition of the albuminous tissues.
They show by experiment with Yoit's respiration apparatus that in
phosphorus poisoning the fatty degeneration is due both to diminished
oxidation of fat and to its increased production from the transformation
of albumen. They find with Schultzen and Riess that the urea is
increased, but they found no abnormal products in the urine, except in
fatal cases a little sarcolactic acid. They did not find leucin or tyrosin
in the urine, but found these abundantly in the liver, heart, and blood of
dogs poisoned with phosphorus. The nitrogenous products of the
decomposition of albumen are therefore converted into urea in all cases
in the dog, and in slighter cases of phosphorus poisoning in man. In
severe cases in man the decomposition is imperfect, and the higher
products of decomposition are excreted. They think that the greater
rapidity of degeneration in acute yellow atrophy of the liver is the chief
difference between this disease and phosphorus poisoning.
Corrosive Poisoning.
Sulphuric acid. — Cases of fatal poisoning by this substance are
related by Malmsten and Schauenburg.f
* * Journ. Chemical Soc./ N, S., ix [xxiv], p. 946 ; * N. Rep. Pharnj.,* xx, p. 340.
t ' Schmidt's Jahrb.,' civ, p. 7,
442 HEPOET ON MEDICAL JURISPRUDENCE.
Nitric acid. — Stevenson* relates a case of suicidal poisoning with
about three ounces of nitric acid. Death resulted in seventeen
hours. In this case there was perforation of the stomach and ulcera-
tion of the colon. The perforation apparently occurred after death or
just before it. The ulceration of the colon may have pre-existed.
Other cases are reported by Malmsten,t and by Dougall.J
Hydrochloric acid. — Fatal cases of poisoning by hydrochloric acid
are detailed by Drs. Gr. Johnson,§ Paul,|| and Nager.^
Ammonia. — Stevenson** relates a case of poisoning by a teaspoonful
of the strong liquor ammoniaB, sp. gr. "88. Death supervened quite
suddenly, without asphyxia.
Castanft describes the symptoms resulting from the inhalation of
ammonia vapours.
Caustic potash. — NagerJJ describes a case of poisoning by caustic
potash which proved fatal in twenty-two hours under symptoms of
lobular pneumonia.
Nitrate of silver. — T. Scattergood§§ gives details of a case of poisoning
by nitrate of silver. A student, while applying a stick of lunar caustic
to the throat of a fifteen-months child, accidentally let the piece drop out
of his fingers, and it was swallowed by the child. The piece was three
quarters of an inch in length. Vomiting of the contents of the stomach
immediately followed. Large quantities of common salt were given,
vomiting occurring repeatedly. Diarrhoea set in and convulsions, under
which the child died, six hours after the commencement of the symp-
toms. The chief post-mortem appearances were corrosion of the great
curvature of the stomach and superficial corrosion of the duodenum and
commencement of the jejunum. No nitrate of silver was found in the
contents of the stomach, as it had all been decomposed by the antidote.
Chronic lead poisoning. — Heubel|||| has made chronic lead poisoning
the subject of an experimental research, with special reference to the
theories of Henle and others, that lead exerts a specific action on the
pale and striated muscular fibres. Analysis of the viscera of four dogs
which died under symptoms of eclampsia saturnina showed that in
chronic lead poisoning the bones contain the largest quantity of
lead, next the liver and the kidneys. The central nervous organs
contained less, but a greater quantity than the muscles, intestines, and
blood, &c. He therefore denies a specific affinity of the muscles for
lead. That the symptoms of lead poisoning are due to spasm of the
blood-vessels, as stated by Henle and Hitzig, he considers disproved
by the state of the pulse during an attack. That it acts directly on
* 'Guy's Hosp. Rep.,* 3rd ser,, xvii, p. 223.
f * Schmidt's Jahrb.,' civ, p. 7.
X • Glasgow Med. Journ./ 1872, May.
§ 'Brit. Med. Journ.,' 1872, p. 221.
II ' Bull. Gen. de Therap./ Oct. 20, 1872, p. 364.
\ 'Arch. d. Heilk.,' 1872, p. 213.
** 'Guy's Hosp. Rep.,' 3rd ser., xvii, p. 225.
ft 'Montpellier Med.,' Nov. 1871, p. 577.
%% 'Arch. d. Heilk.,' 1872, p. 213.
§§ ' Brit. Med. Journ.,' 1871, p. 527.
Ill) ' Virchow uud Hirsch's Jahresber.' for 1871, i, p, 316,
POISONS. 443
the pale and striated muscular fibre is very unlikely, considering that
it causes cramp in one set, and paralysis of the other. He thinks the
colicky pains cannot be due to pressure of the contracted muscular
fibres on the ends of the sensory nerves. The obstinate constipation
he attributes to abnormal irritation of the splanchnic nerve, which
inhibits peristaltic action. If the peristalsis were really increased in
colic it ought to lead to diarrhoea rather than constipation. To the
irritation of the splanchnic he likewise attributes by reflex action the
slowing of the pulse and diminution of the urine observed during the
attacks. The rapid atrophy of the muscles in lead poisoning he attri-
butes to general interference with nutrition which lead causes in a
marked degree, and partly to the paralysis itself, which he attributes to
direct action of the poison on the intra- muscular ends of the nerves,
and not on their central ends. The nerve tissues have a special affinity
for lead. To its action on these, both in their central and peripheral
parts, he attributes the symptoms of chronic saturnine poisoning, and
the repeated attacks he regards as caused by the occasional absorption
of the lead into the blood from the organs in which the poison is de-
posited. That lead does not exert a desiccating effect on the tissues, as
supposed by Talk and Hitzig, he disproves by experimental analysis.
The symptoms of encephalopathia saturnina, both acute and chronic, he
attributes to direct deposition of lead on the brain. Eclampsia satur-
nina he refers, with Traube and Eosenstein, to capillary anaemia of the
brain. He does not think, however, with Eosenstein, that this anaemia
is due to direct action on the vessels, but to oedema of the brain, which
is generally found, exerting compression on the vessels, and in cases
where oedema is not marked to the diminished diuresis giving rise to a
uraemic condition from accumulation of the urinary constituents in the
blood. The diminished diuresis does not seem to act by causing an
accumulation of lead in the system, as only traces of lead are excreted
through the urine.
Sul'phate of copper. — Maschka* relates a case of suicidal poisoning
with sulphate of copper. Death ensued in three days. Among other
symptoms jaundice occurred, a symptom which has likewise been ob-
served occasionally by others. Maschka attributes it to fatty degenera-
tion of the liver, as in arsenic and phosphorus poisoning.
Sulphate of zinc. — Well-recorded cases of poisoning by white vitriol
are, perhaps, rare. Tardieu and Eoussin f record a very instructive
case, which terminated fatally. The remarks which accompany the
paper are well worthy of perusal, though they are too long for useful
abstraction.
Carhonic oxide. — Zuntz J investigates the question whether the car-
bonic oxide compound with haemoglobin is a fixed compound or not. In
opposition to commonly received opinions as to the toxic action of this gas,
Bonders has recently stated that carbonic oxide may be expelled from
blood saturated with this gas by means of indifierent gases, such as
oxygen, hydrogen, or carbonic acid. JSTaurocki and Pokrowsky deny
* * Wien. Med. Wochensch.,' 1871, No. 26.
f 'Ann. d'Hyg.,' xxxvii, p. 329.
X ' Pfliiger's Archiv. f . Physiologie/ v, 584.
444 REPORT ON MEDICAL JURISPRUDENCE.
the possibility of separating it from blood by means of the vacuum.
Zuntz, however, has succeeded, by Pfliiger's gas pump, in extracting
the carbonic oxide. The chief point in the research is that the gas is
only given off fitfully and by repeated exhaustions of the receiver. His
experiments account for the statements that carbonic oxide cannot be
so removed from blood, as the process was supposed to be finished after
the first exhaustion. These results must modify commonly received
opinions regarding carbonic oxide poisoning. There is no need to sup-
pose that the carbonic oxide cannot be expelled as such, but requires
oxidation into carbonic acid. So long as the heart beats there is reason
to hope that, by means of energetic artificial respiration, the blood may
be again restored to its normal condition.
Podolinski* confirms the statements of Bonders and Zuntz, and shows,
in addition, that not only may carbonic oxide be expelled from blood by
indifferent gases, but that nitric oxide comes under the same category.
Nitric oxide may be expelled from its haemoglobin compound by means
of indifferent gases, such as hydrogen. The oxygen, carbonic-oxide, and
nitric-oxide haemoglobin compounds are thus in agreement with each
other. Oxygen is most easily expelled, next carbonic oxide, and lastly
nitric oxide. Each gas can be more easily expelled by the one imme-
diately following than by an indifferent gas, and each, again, can like-
wise be more easily expelled by the one immediately preceding than by
any other indifferent gas.
E. and E. S. Turnerf contribute a very interesting account of the
symptoms and post-mortem appearances in several cases of carbonic
oxide poisoning, resulting from the combustion of coal and peat in
closed chambers.
Oxy sulphide ofcarlon. — Dr. S. Eadziejewski,J working in Liebreich's
laboratory, has investigated the physiological action of this gas, dis-
covered in 1867 by Than. Oxysulphide of carbon appears to be widely
distributed in nature," giving to many sulphuretted waters their pecu-
liar sweet taste and aromatic odour. It is also a probable constituent of
the gases evolved in volcanic districts, and is, perhaps, given off during
the putrefaction of organic substances containing sulphur. Its compo-
sition is represented by the formula COS ; it is, in fact, intermediate
between carbonic acid and bisulphide of carbon. It is absorbed by
water, and slowly decomposed by this into carbonic acid and bisulphide
of carbon. The gas produces in animals toxic effects, which resemble
those observed by Eosenthal and Kaufmann in intoxication by sulphu-
retted hydrogen. Eadziejewski supposes that oxysulphide of carbon
absorbed into the blood splits up, in conjunction with water, into car-
bonic acid and sulphuretted hydrogen, a decomposition which takes
place, as we have already stated, outside of the body. To this view
there are, however, some objections. The oxysulphide is less soluble
in dilute alkaline solutions (and hence in the blood) than in water, and
even in this latter the decomposition of the gas is very tardy, whilst
the oxysulphide is more rapid in its toxic actions than sulphuretted hy-
* ' Pflluger's Arcliiv f . Physiologie,' vi, p. 553.
t 'Edin. Med. Journ./ March, 187 1, p. 106.
i * Virchow's Arch./ liij, p. 370.
»
toisoNs. 445
drogen. Notwithstanding that oxysulphide of carbon is a chemical
curiosity, it is so widely distributed in nature that its poisonous action
is a point of much interest.
Nitrous oxide. — Purcell* reports a case of death from the inhalation
of nitrous oxide. A woman, 20 years of age, apparently healthy, died
suddenly after four teeth had been extracted, while under the influence
of nitrous oxide. The cause of death was supposed to be asphyxia.
Little congestion of the lungs was found, however, and shock seemed
to be the real cause of the fatal result.
Carlolic acid. — The toxicology of this substance, now so extensively
used in medicine, has of late received much attention,t and fatal cases
have frequently resulted from its administration either by accident or
for the purpose of self-destruction. Its use as a remedial agent has
also been put to more rigid and extended tests.
Salkowski found carbolic acid to be useless as a remedy in smallpox.
In gangrene of the lungs it was more successful when given in the form
of pills. If given in the liquid form, the solution must be highly dilute,
for a one per cent, solution causes thickening of the stomach. The
remedy was found to be useful in gastric affections. The use of the
pure diluted acid never causes pain, nausea, or vomiting. This ob-
server has also carefully inquired into the physiological effects of car-
bolic acid, and his results are of great interest. When injected into
the blood carbolic acid produces both local and general paralysis, and
the muscles penetrated by the substance shrink and their fibres
lose their electric excitability. When injected the heart's beats decline in
frequency to nearly one half. Convulsive movements are also set up,
simulating those produced by strychnine, and these may be excited in
the upper extremities after the prolonged therapeutical employment of
carbolic acid as a remedy. The following is the cause of the symptoms
observed in rabbits : — A few minutes after the administration of the
acid fibrillary quiverings of the muscles may be noted, then more dis-
tinctively convulsive movements. The animal continues to run about ac-
tively, but the tremors increase in severity. Eespiration becomes slow
and the animal becomes restless. The limbs gradually lose their power,
and eventually the rabbit falls on its side. In endeavouring to rise,
clonic spasms, salivation, and dilatation of the pupil are excited. Sen-
sibility is diminished, and with lethal doses of the phenol gradually
diminishing tonic and clonic spasms are excited. The urine is seldom
tinged with blood, nor is it albuminous. The detailed course of symp-
toms appears to be dependent on an action of the poison upon the central
nervous system, and must not be confounded with the local paralysis at
first produced by injection of phenol.
Carbolic acid is quickly absorbed into the circulation, and rapidly
excreted, so that there is no fear of its exciting a cumulative effect. A
part of it is oxidized in the circulation into oxalic acid. The dark
colour of the urine so frequently observed after the use of carbolic
acid ensues as well after the internal use as after the external applica-
* 'Pliil. and Med. Surg. Rep,/ 1872, p. 343.
t 'Arch. f. Physiol./ v, pp. 335 and 470; 'Deut. Klin./ 1870, p. 341, et seq., 187 1,
p. 25, et seq.; 'Schmidt's Jahrb.,' civ, p. 272,
446 REPOET ON MEDICAL JUEISPRUBENCE.
tion of the substance, and is attributed to oxidation of phenol in the
kidneys, but from the intensity of colour of the urinary secretion no
conclusion can be drawn as to the saturation of the organism with the
remedy, which Salskowski thinks to be combined in the urine with an
alkali. The above-described symptoms of phenol intoxication are better
tests of the saturation of the body with carbolic acid than is the colour
of the urine.
Bromine water forms no test of the presence of carbolic acid in the
urine, for it fails to detect that substance in the normal urine.
Hoppe-Seyler found the symptoms of phenol intoxication ensuing on
the application of a concentrated aqueous solution of the agent to the
abdomen of animals to agree pretty closely with those cited by Sal-
skowski. Hoppe-Seyler was enabled to detect phenol in the blood,
liver, kidneys, and brain, after death from its administration, and, above
all, in the brain in much larger quantities than in the other viscera. It
would hence appear that phenol accumulates in the central organs of
the nervous system after the manner of anaesthetics. (As carbolic acid
is not an acid, it is very desirable that its scientific name, phenol, should
be substituted for the term carbolic acid. — Ed.)
Several fatal cases of poisoning by carbolic acid are reported, both
suicidal and accidental. Jeffreys and Hainworth* give details of a case
of suicide in a man, aged ^5 years, who swallowed from half an ounce to
an ounce of commercial carbolic acid. Death resulted in fifty minutes.
A. Ogstonf relates a case of a man, 45 years of age, who died thirteen
and a half hours after swallowing by mistake for spirits an ounce to
two ounces of phenol. After death the smell of carbolic acid was
distinctly perceptible in the ventricles of the brain, the bladder, blood,
and organs generally. Zimm:^ gives a similar case, where from one to
one and a half ounce of the commercial acid was taken in mistake for
cognac. Death resulted in sixty hours after swallowing the poison.
'White§ observed dangerous effects, not proving fatal, resulting from
the application of carbolic acid in necrosis of the tibia.
Hydrocyanic acid. — Preyer|| has published perhaps the most elabo-
rate and complete monograph on the actions of the above poison ever
issued, and has arrived at conclusions the importance of which can
scarcely be exaggerated. A most valuable index of the bibliography of
the subject is added.
Preyer divides the symptoms exhibited during the course of a fatal
case of poisoning by prussic acid into three stages — a preliminary
stage, before the animal falls ; a convulsive stage, ending in collapse ;
and a paralytic or comatose stage. During the first or preliminary
stage the breathing is rendered laborious and the frequency of the
respirations diminished, whilst during the second or convulsive stage
the respirations are diminished to an extraordinary extent. In the
last, the paralytic or comatose stage, either the respirations undergo a
* 'Med. Times and Gaz.,^ 1871, i, p. 423.
t 'Brit. Med. Journ./ 1 871, p. 116.
X 'Virchow und Hirsch's Jahresber. f./ 1871, i, p. 337,
§ 'New York Med. Gaz./ p. 274.
II ' Die Blausaure ' (pamphlet).
toisoNS. 447
steady and rapid diminution in frequency until respiration entirely
ceases, or they undergo a temporary exaltation in frequency as com-
pared with the previous stage, but then diminish, and ultimately cease.
If during the stage of collapse the number of respirations exceeds the
normal amount, this is an unfailing sign of speedy recovery. The
convulsions of hydrocyanic acid intoxication are, as regards their cause
and course, identical with those produced by strangulation, only they
are more intense. Vomiting and the peculiar cry were found to be
very inconstant symptoms of poisoning by hydrocyanic acid. If the
poison be received into the blood in quantity considerably greater than
that required to produce death, the animal dies either from direct
paralysis of the heart or from that in conjunction with paralysis of the
lungs. In warm-blooded animals the first stage of complete intoxica-
tion lasts from one second to fifteen minutes, commonly half a minute ;
the second stage from a few seconds to a few minutes, usually half to
one minute ; the third stage from a few seconds to several hours,
commonly half to one minute. In cold-blooded mammalia the stages
are much more prolonged.
Preyer finds the solution of the phenomena of prussic acid intoxica-
tion in the action of the poison on the vagus nerve, and his study of the
action of the acid on that nerve has led him to the discovery of an
antidote for the poison. In vrarm-blooded animals prussic acid induces
inspiratory tetanus, with stoppage of the heart, and this through the
vagus. It also, by its action on that nerve, diminishes the frequency of
the cardiac pulsations. "When the vagus is divided before the poison
is injected subcutaneously no changes in the heart's activity are
observed ; and when rabbits had both vagi divided and ordinary lethal
doses of the poison were subsequently injected, recovery took place. It
appears that the rationale of hydrocyanic intoxication is as follows : —
Irritation of the peripheral terminations of the vagus in the lungs ;
excitation of the origin of the vagus; then paralysis of that nerve;
inspiratory tetanus; stoppage of the heart; then renewed cardiac
pulsations after the stoppage of respiration ; lastly, stoppage of the
heart. Mammalia with divided vagi die after breathing the vapours of
the acid, or its injection, from direct action of the poison upon the
heart (cardiac paralysis) . Seeing that hydrocyanic acid influences the
activity of the brain (in men), and causes dizziness, headache, distur-
bances of the co-ordinating faculty, &c., the therapeutical employment
of the acid is to be deprecated.
Preyer found that prussic acid intoxication is fatal from the super-
vention of asphyxia, and that the blood cannot be distinguished from
that in asphyxia from other causes, except that it contains the poison
itself. Moreover, the thermal changes of the animal are identical
in the two classes of cases. If, however, the dose of the poison be suffi-
ciently great to kill by paralysis of the heart, the blood is bright red
and contains oxygen. In confirmation of the author's views as to the
physiological action of hydrocyanic acid, he finds that when the vagus
IS divided in rabbits, and the poison injected beneath the skin, the re-
spirations are at first quickened and afterwards retarded, whilst if the
poison be breathed after division of the vagi the converse is observed,
448 REPORT ON MEMCAL JUEISPRUDENCE.
the respirations being at first retarded in frequency and then rendered
more rapid.
Preyer finds that when respiration has ceased the only available
means of resuscitation is artificial respiration. It is, of course, presup-
posed that the heart has not also ceased to beat. Atropine is the only
real dynamic antidote to hydrocyanic acid, and it appears to be a per-
fect one, its physiological actions being in direct opposition to those of
the acid. It is necessary, to ensure success, that the alkaloid should
be administered by subcutaneous injection very shortly after the inges-
tion of the poison, on account of the rapidity with which this acts and
the comparative slowness with which atropine is absorbed from the
stomach. Eabbits to which atropine was administered before the use
of prussic acid, exhibited a surprising immunity to the action of this
most powerful toxic agent.
Dr. Amory,* of Boston, Massachusetts, publishes experiments illus-
trating some of the physiological and pathological actions of hydrocyanic
acid. The following is a summary of his conclusions: — (i) Artificial
respiration does not prevent the intoxication of prussic acid, nor does
it materially assist in the elimination of the poison, consequently
means directed to the institution of artificial respiration in cases of poi-
soning by the acid are unnecessary for the protection of life. (2)
Artificial respiration will prevent the occurrence of convulsions or of
the muscular spasms which follow the absorption of the poison in a
dose of sufficient quantity to endanger life. (3) Muscular irritability
and nervous conductibility are not impaired by the intoxication caused
by hydrocyanic acid in cases where artificial respiration has been main-
tained until after the cessation of cardiac pulsations. (4) The static
congestion of the pulmonary tissue is either a post-mortem symptom
or is due to the asphyxia which has been considered by some experi-
menters as one of the causes of death in cases of poisoning by prussic
acid. (5) Death by this agent is due to some other cause besides
asphyxia, and it may be suggested that the fundamental cause is a
state of blood poisoning due to some alteration of either the physical
or the chemical condition of the blood ; which of the two it is not the
purpose of the author to discuss. (6) The apoplexy in the ence-
phalon and spinal cord, noticed by Tardieu as an anatomical lesion due
to the intoxication produced by this agent, is probably referable to the
asphyxia, secondarily induced, and not to the direct action of the poison.
The same condition has been observed in animals dying from asphyxia
produced by other causes, as, for instance, by nitrous oxide and by
chloroform. When asphyxia is not present in a case of poisoning from
prussic acid no very marked apoplexy or congestion is noticed post-
mortem.
Dr. Mialhe f endeavours to prove that prussic acid is unable to com-
bine with the alkalies of the blood, and that the poison thus prevents
the catalytic action of the corpuscles from being aff'ected, an action
which Schonbein has already demonstrated as taking place in normal
red blood-corpuscles, and thus oxidation in the blood does not take place.
* 'The Practitioner,' viii, p. 197.
t ' L'Union Medicale,' No. 65, 1872.
ATROPINE. 449
Hydrocyanic acid would thus appear to act upon the blood in the same
manner a3 it acts upon fermenting solutions, which immediately on the
addition of the acid cease to ferment.
NifrO'henzol. — Bahrdt* describes several cases of poisoning with
nitro-benzol, one of which proved fatal. Three young persons, about
the age of 20, prepared a liqueur by filling an ordinary wine-bottle with
one part of water, two parts of alcohol, and, as was said, twenty drops
of nitro-benzol. One of the boys drank largely of the mixture about
8 o'clock in the morning. Death occurred about ^ p.m. The 8ym2:)toms
and post-mortem appearances are minutely described. The general
summary is given in the following propositions: (i) even with a fatal
dose of nitro-benzol there is a latent period of from one to two hours ;
(2) this latent period is independent of the kind of preparation, or of
the quantity swallowed ; (3) even during the latent period a peculiar
greyish-blue discoloration of the skin is observed; (4) rapid pulse,
intermittent respiration, unconsciousness coming on gradually or sud-
denly, and dilatation of the pupils, are constant signs of poisoning with
nitro-benzol ; vomiting and convulsions are usually observed, but may
be absent. A transitory recovery may occur even in fatal cases;
(5) nitro-benzol jooisoning differs from prussic acid poisoning by its
longer latent period, the greyish-blue colour of the skin, and the dark-
brown colour of the blood ; (6) as treatment, Bahrdt recommends in
the first instance the use of the stomach-pump, the inhalation of
ammonia vapour, and copious transfusion (2 — 3 ounces) ; (7) after
death there is a distinct smell of bitter almonds ; the blood is dark
brown and fluid, and the endemic rigidity is well pronounced and of
long duration.
Chloral hydrate. — Several cases of poisoning by chloral have been
[reported in the medical journals at home and abroad. As most
of the cases are in English journals and easily accessible, we merely give
the references.
See on this subject the papers by B. "W. Eichardson,t Hunt and
"WatkinSjiJ: ]S"orris,§ Fuller,|| Shaw,^ and Burr.** Maschkaff reports a
case in which, after the administration of a drachm of chloral hydrate
by a dentist for the purposes of anaesthesia during the extraction of teeth,
death resulted within a few minutes after the operation.
Atropine. — Prof. H. C. "Wood, jun.,;{;J of Pennsylvania, has confirmed
the observations of Messrs. Wharton Jones and Lemattre, that bella-
donna and atropine have little or no influence on the pupils of pigeons ;
tand has established the fact, that belladonna, stramonium, and hyos-
jcyamus resemble morphine in their want of action on these birds. It
ippears to be almost impossible to immediately kill them with the
I * ' Arcli. f. Heilk.,' 1871, p. 320.
t *Med. Times and Gaz.,' 187 1, i, p. 169.
J 'Brit. Med. Journ.,' 1871, i, p. 193.
§ 'Lancet,' 187 1, i, p. 226.
II Ibid., 18 71, i, p. 403.
if 'Phil. Med. and Surg. Ecp.,' July, 1871.
** Ibid., Dec., 1 87 1.
ft ' Wien. Med. Wochensch.,' 1871, No, 48.
Jt 'Amer. Journ. Med. Sc.,' Ixi, p. 128.
29
I
450 HEPOUT ON MEDICAL JURISPRUDENCE.
extracts given by the mouth. Three grains of pure sulphate of atropine
were given to a pigeon, and retained, and yet the dose did not appear to
interfere materially with the wellbeing of the bird. It is very possible,
however, to kill the birds with the poison by enormous doses hypo-
dermically injected. These experiments show what care must be
exercised in drawing conclusions in toxicological research from physio-
logical investigations. Dogs will bear almost heroic doses o£ atropine,
and the horse will tolerate with impunity an enormous dose of strych-
nine.* Hence conclusions as to the antidotal or non-antidotal effects
of two poisons on the human subject cannot be drawn with certainty
from experiments on the lower animals.
Tobacco. — Drs. Vohl and Eulenbergf have published an elaborate ex-
perimental essay on the toxicological relations of tobacco, with especial
reference to the chemical constituents of tobacco smoke. After an
account of the introduction of tobacco into Europe, a summary is given
of its chemical history, and the statement is made that the narcotic
action of tobacco has been attributed to nicotine in error. The authors
adduce analyses and experiments of their own in support of this view.
Stress is laid upon the fact that some forms of tobacco which produce
powerful physiological effects contain but little nicotine. In snuff this
alkaloid varied from '0392 to "062 per cent., whilst strong chewing to-
bacco contained a mere trace of nicotine, and some kinds contained none
at all ; hence nicotine intoxication is out of the question in the use of
these sorts of the weed. They were thus induced to analyse the smoke
of strong tobacco containing so much as 4 per cent, of nicotine, the
tobacco being burnt both in pipes and as cigars. The gases given off
were found to consist of oxygen, nitrogen, marsh gas, carbonic oxide,
carbonic acid, and sulphuretted hydrogen. The smoke was drawn first
through a solution of potash, and the acids thus absorbed examined ;
then through dilute siUphuric acid, and the bases thus collected were
examined. The potash solution was found to contain a neutral carbo-
hydride (CjgHjp) and several other carbo-liydrides, hydrocyanic acid,
the fatty acids from formic to caprylic acid inclusive, phenol acid, suc-
cinic acid, and kreasote, but no benzine.
In the acid solution were found annnonia and ethylamine, besides
the following homologous bases : — Pyridine, QHgN ; picoline, CgH7N ;
lutidine, C;!!^^; collidine, CgHuNg; parvoline, CgHiglS"; coridine,
C10H15N ; rubidine, C11H17N' ; and, perhaps, viridine, Cj.^iligN. Not a
trace of nicotine could be detected.
The authors ascribe to the pyridine bases, and not to nicotine, not
only the nausea and other unpleasant symptoms experienced by per-
sons beginning to smoke, but also the more chronic affections to which
inveterate smokers are liable. Parvoline greatly resembles nicotine in
odour and in physiological action, and might readily be mistaken for
this alkaloid, but they differ essentially in their respective boiling points. '
The well-known fact that a much stronger tobacco can be smoked with
impunity in cigars than in a pipe is explained thus. The smoke of a
pipe contains much more volatile bases than that of a cigar, and con-
* 'Amer. Journ. Med. Sci./ Ixi, p. 377.
t • Vrtljhrsscrft. f. Gericht. Med.,' N. F. xiv, p. 249.
TOBACCO. 461
tains especially a much larger proportion of pyridine, which is the most
volatile base of its series, and is very stupefying.
The physiological actions of the various alkaloids of the pyridine and
picoline series were not tested separately, but a mixture of the bases
was used for experiment. Two mixtures were employed, one consisting
chiefly of the fiirst three alkaloids of the series, pyridine, picoline, and
lutidine ; the other chiefly containing the higher members of the series,
collidine to viridine inclusive. The experiments upon animals with
these liquids do not appear to have been very elaborate ; it was, how-
ever, ascertained that they both acted very like nicotine, inducing con-
traction of the pupils, laboured breathing, general convulsions, and, if
in sufficient doses, death. On section the bronchial tubes and lungs
were found to be congested. Singularly enough, the eflfects were more
quickly produced when the liquids were taken internally than when
injected beneath the skin. They did not act so rapidly in any case as
nicotine.
Vohl and Eulenberg adduce the case of a man whom they know to be
able to swallow the juice from a tobacco-pipe without apparent cfi"ect.
They do not think, nevertheless, that his case militates against the rule
that pyridine bases powerfully aflfect the animal organism.
Since plants which are known to contain no narcotic are occasionally
used by smokers as substitutes for tobacco, and it is known, moreover,
that the pyridine bases are among the products of the destructive dis-
tillation of most nitrogenized vegetable and animal substances, the
authors deemed it of importance to investigate the action of the pyri-
dine bases from various sources, and those produced from stramonium,
willow wood, dandelion, and Boghead coal, were employed. The ac-
tions of these bases were very similar to those resulting from the use o£
the alkaloids obtained from tobacco, but the efiects were weaker, and
except after the use of the alkaloids produced from willow wood, there
was no contraction of the pupil. The vapour of picoline was found to
be highly poisonous.
As regards opium, Vohl and Eulenberg are of opinion that its
action when smoked is not due to the alkaloids which the drug naturally
contains, but to the bases produced by its destructive distillation,
which difier somewhat from those produced by the distillation of
tobacco.
Heubel,* who has made an experimental inquiry into the active prin-
ciples of tobacco smoke, with special reference to the researches of
Vohl and Eulenberg on this subject, thus sums up his conclu-
jSions: — (i) Tobacco smoke undoubtedly contains nicotine. This is
proved both by chemical analysis and physiological experiment. (2)
I By the slow combustion of tobacco, as in ordinary smoking, a compara-
tively large amount of the alkaloid becomes volatilised in the smoke.
; (3) The nicotine in the tobacco smoke occurs chiefly as a nicotine salt.
I (4) The reason why nicotine, though volatile and easily decomposed, is
; not all destroyed during the process of smoking, appears to be, in a
I measure, due to the fact that the alkaloid in the leaves, as well as in the
smoke, is not free, but is in the form of stable salts (malate and
* • Centralblatt f. d. Med. Wissenscli.,' No, 41, 1872,
452 EEPOBT ON MEDICAL JURISPRUDENCE.
citrate). (5) The physiological action of tobacco smoke is, to a great
extent, due to the nicotine it contains.
Opium. — Dr. Schaefer,* of Dusseldorf, publishes a case of opium
poisoning of considerable interest, — that of a child, which died after
taking about three quarters of a grain of opium in two doses. The
post-mortem appearances were unusually well marked. On sawing
through the calvarium there was a flow of black, fluid blood ; the blood-
vessels of the dura mater, but more especially those of the arachnoid,
both on the cerebral convolutions, the cerebellum, and the medulla
oblongata, were filled with blood ; and there was likewise found in both
ventricles, not only a considerable quantity of effused serum, but also
several drachms of a similar fluid were met with at the base of the
brain. Death from apoplexy was most markedly indicated. Besides
the more ordinary appearances met with on section after opium
poisoning, Schaefer describes in this case a spongy condition of the
lungs, which were gorged with black, fluid blood, blood in all the
cavities of the heart ; hyperaBmia of the liver and spleen, and a full
urinary bladder. The appearances presented by the post-mortem
ecchymoses were very striking ; instead of being purple they were rose-
red and of great extent.
The presence of opium was ascertained by analysis in the oesophagus,
stomach, and its contents, and in a portion of the small intestine,
although the whole quantity of morphia taken could not have exceeded
one tenth of a grain. The opium was administered, one half five hours,
and the remainder three hours, before death.
JPicrotoxin. — Herr Povergof has investigated the action of picro-
toxin on the reflex inhibitory centres of the brain of frogs, and arrived
at the conclusion that picrotoxin and strychine act in a similar manner
on these centres.
Vanilla ice. — Maurer* gives an account of the symptoms of poison-
ing in nine persons after partaking of vanilla ice. The chief symptoms
were gastralgia, severe vomiting, entralgia, diarrhoea, and in some cases
a greater or less degree of collapse and cold extremities. None of the
cases proved fatal. Maurer attributes the symptoms to the vanilla, and
not as has been suggested to any admixture of lactate of zinc which has
been supposed to result from the action of the lactic acid of the cream
on the zinc vessels in which the ice is generally manufactured.
Mushrooms. — C. Euckert§ has re-examined the Agaricus onuscarius,
extracting from the plant by a process first followed by Schmiedeberg
an alkaloid — muscarine. Euckert obtained '07 to '08 per cent, of the
sulphate from a thick extract of the fungus. Muscarine forms a colour-
less, syrupy substance, tasteless, and odourless. It yields the usual
reactions of an alkaloid, and is not coloured either by sulphuric acid
alone, or by this in conjunction with oxidising agents.
The physiological effects of muscarine are stated to be antagonistic
to those of atropine.
* * Vrtljhrsschrft. f. Gericht. Med.,' N. F. xvi, p. 255
t *Deut. Ztschr. f. d. Staatsarznyk/ xxix, p. i.
j ' Deutsch. Arcliiv f . Klin. Med.,* ix, p. 303.
§ 'New Rep. Pharm.,* xxi, p. 193.
MUSSELS. 453
Husemann* publishes a paper on the poisonous action of fungi,
embracing all that is known on the subject, but embodying no new
remarks.
Snahe poisons. — ^The medical profession is greatly indebted to Dr.
Fayrerf for his magnificent work on Indian snakes. It embraces the
whole range of the subject, beginning with coloured lithographs and
anatomical descriptions of various snakes, followed by an experimental
inquiry into the reputed cures for their bites. The poison of the cobra
is the most deadly of all. Dr. Payrer says that it is most deadly
in warm weather ; that it seems to act through the circulation,
and kills by some occult influence — whatever that may mean — on the
nervous system. He distinctly lays it down that the poison is capable of
being absorbed through the mucous membranes, though, of course, much
less rapidly than from an open wound or through the serous membraues.
As the poison kills when introduced into the stomach there is a certain
amount of risk attending the act of sucking a wound inflamed by a
poisonous snake. The venom of the cobra kills every living creature,
except the cobra itself, and, perhaps, some other deadly snakes.
Dr. Fayrer has tried, perhaps, every known reputed remedy for the
treatment of poisonous snake bites, and always unsuccessfully. The
lightning-like rapidity with which the venom diffuses into the blood
holds out little hopes of any remedy being applied with success.
Even immediate ligature and amputation, as appeared from experiments
upon animals, is of little avail. Among the remedies used we may
enumerate, ligatures, amputations, AristolocMa indica, carbolic acid,
liquor ammonisB injected into the blood, liquor potasssD, Condy's fluid,
eau de luce, brandy, and other stimulants, the Cape antidote,
norbish, quinine, ipecacuanha, various secret nostrums, as the Tanjore
pill, &c. There appears, then, to be no known antidote to the poison
of the deadly Indian snakes, and it is probable that the only successful
treatment (successful only in rare cases) is amputation or excision,
the application of ligatures, the actual cautery or burning by strong acids,
and the use of stimulants internally.
Dr. Payrer is of opinion that the most successful means for staying
the lamentable loss of life now going on in India from the bites of
these venomous reptiles is the off"ering of sufficient pecuniary rewards
to the natives for the destruction of venomous snakes. In 1869, out
of a population of 120,972,263, — 11,416 persons died from the effects
of snake bites, an annual rate of mortality of 0*94 per 1000 persons
living.
Snalce poison. — Mr. Vincent EichardsJ asserts that the poison of
venomous snakes may be absorbed by mucous and serous surfaces, and
even by the skin. This opinion is supported by the authority of
Dr. Payrer, who observes, that the poison is deadly when applied to a
mucous or serous membrane, to the stomach, or the conjunctiva.
Poisonous mussels. — M. de Beunie§ attributes the occasional poi-
* ' Schmidt's Jahrbucher/ cxHx, p. 89, and cl, p. 89.
t 'The Thanotophidia of India.' By J. Fayrer, M.D. London, 1872.
X *Med. Ann. of Med. Sc.,' xxix, 162.
§ ' Jour». de Pharm, et Chem,/ 1871, p. 398,
454 REPORT ON MEDICAL JURISPRUDENCE.
sonous qualities o£ the edible mussel {Mytilus edulis) to their feeding on
the spawn of star fishes. Star fishes spawn in the months of April, May,
July, and August, and it is chiefly in these months that mussels exhibit
poisonous properties. He states that the spawn of the star-fish possesses
a very irritant action, and that the slightest contact with it causes violent
itching, and may even occasion inflammation resulting in gangrene.
The following notes relate to the detection of poisons.
Phosphorus. — M. Poulet* gives a very simple method of detecting
this poison when being excreted in the urine, in which it appears as
hypophosphorous acid. The urine is calcined after the addition of
nitric acid ; when, as the liquid approaches the state of dryness, the
mixture suddenly catches fire and burns with a peculiar kind of
deflagration. This test must, however, be liable to many fallacies ;
deflagration alone in the presence of nitric acid cannot be regarded as
conclusive evidence of the presence of a lower oxide of phosphorus.
Dalmonf describes a new reaction for phosphorus. A stream of
hydrogen is passed through the organic substance supposed to contain
phosphorus ; and the issuing gas is ignited, and a narrow glass tube
inverted over the flame when detonations, accompanied by a peculiar
luminous appearance, will be observed. With care, and by a peculiar
artifice, a beautiful green ring of flame may be obtained. If the inte-
rior of the tube be previously moistened -with distilled water, and after
the above experiment with a solution of nitrate of silver, a brown preci-
pitate, speedily becoming black, will be observed. No platinum tip for
burning the gas is required.
NeubauerJ also describes an improved and simple method of
obtaining Mitscherlich's phosphorus reaction. The matter to be
tested is distilled in an ordinary flask provided with a cork, through
which passes a glass tube bent twice at right angles, the terminal and
vertical limb of which has three glass bulbs blown upon it. Before dis-
tillation, the substance to be tested is treated with a few drops of
diluted sulphuric acid and a fragment of green vitriol, in order to retain
sulphur, which hinders the reaction. A fiery stream is seen descending
through the bulbs if phosphorus in the free state be present. The end
of the tube may be made to dip into alcohol, which retains a consider-
able quantity of phosphorus, and if a few drops of the alcoholic solution
of phosphorus be dropped into water, and shaken in the dark in a bottle,
the whole appears luminous. Moreover, the alcoholic solution reduces
a solution of nitrate of silver, giving a black precipitate, and a similar
reaction occurs with sulphate of copper as a reagent, but the liquid
does not blacken lead salts as sulphuretted hydrogen does.
Hydrocyanic acid. — Almen § points out an error in the ordinary
method of applying the sulphocyanogen test for the detection of hydro-
cyanic acid. When the suspected solution, or rather a portion distilled
ofl' from it, is treated with ammonium sulphide and evaporated on a
* *Qaz. Med. de Paris,' 1872, p. 400.
t 'Ztschr. f. Anal. Chem.,' 1871, p. 132.
t Ibid., p. 254.
§ * Neu. Jahrb. d. Phaiin.,* xxxi, p, 226.
PICROTOXIN. 455
water- or sand-bath, if a trace of cyanide only be present this may be
lost through the volatility of ammoniirai sulphocyanate. This may,
however, be prevented by adding a few drops of a solution of caustic soda
to the mixture before it has reached dryness. Sodium sulphocyanate is
formed, which is not volatile at the temperature employed. Almen's
paper contains other valuable hints on the testing for prussic acid.
Preyer* finds the most delicate reagent for the detection of hydro-
cyanic acid in the blood to be Schonbein's test with guiacum and
cupric oxide. The following method is recommended for the detection
of the poison in the blood. The blood is diluted with water, and
peroxide of hydrogen added ; it then becomes brown, gives off but little
oxygen, and exhibits a continuous spectrum. Another portion of the
blood is distilled with diluted phosphoric acid, and the distillate
divided into four portions. One portion is treated with ammonium
sulphide, evaporated to dryness, and treated with ferric chloride for the
production of red ferric sulphocyanate. Another portion is treated
with liquor potassae and ferrous chloride, then with hydrochloric acid,
in order to form Prussian blue if hydrocyanic acid be present. A third
portion is tested with silver nitrate, whilst to the fourth is added tinc-
ture of guiacum and a little copper solution, when, in the event of
hydrocyanic acid being present, a blue colour is perceived.
Emetine. — Panderf states that sulphuric acid in which a little molyb-
date has been previously dissolved gives a reddish colour with emetine,
speedily changing into green, even with ^^Vo*^ grain of the alkaloid.
Even with -goVs^^ grain of emetine the reagent gives a reddish irides-
cence. Bismuth iodide, or cadmium iodide dissolved in potassium
iodide, gives a precipitate with ^oVo*^ grain of emetine in 25,000 times
its weight of water. Emetine is decomposed by fermentation.
Brucine. — Pander J has also found Dragendorff's nitric acid test to be
the most delicate for the detection of brucine. If the suspected alkaloid
be brucine, 3 Q^o^th grain of it will yield, when dissolved in sulphuric acid,
and a drop of nitric acid allowed to come in contact with it, at first
a rose, then an orange, and finally a yellow colour. The stannous
chloride test is only one fifth as delicate as the above. The presence
of strychnine does not interfere with the nitric acid test for brucine,
nor does caffeine interfere with the testing for the alkaloid. Permenta-
tion does not destroy brucine.
I^hysostigmine. — The same experimenter§ finds that bromine-water
gives a red-brown colour with xiTj*^ grain of the alkaloid. Calcium
chloride gives a red colour after a few minutes with one sixth
or one twelfth grain of the alkaloid. Fermentation decomposes
physostigmine.
Ficrotoxin. — In order to detect picrotoxin in beer, Blas|| removes
the lupuline by evaporating five quarts of the beer to a small bulk
after saturation with soda, and shakes with one tenth of its volume
* * Die Blausaure.' Pamphlet.
f • Chem. Centr.,' 1872, pp.437> 440,
t Ibid., pp. 437, 440-
§ Ibid.
II Ibid., p. 441.
456 REPORT ON MEDICAL JURISPRUDENCE.
of ether. The residue is acidified and again shaken with ether, when
the picrotoxin is dissolved out, and may be obtained by evaporating the
ethereal liquid. The mass is dried and redissolved in alcohol faintly
acidulated with acetic acid, and the filtered solution evaporated. If
no distinct crystals are obtained the residue is to be recrystallised from
alcohol. Picrotoxin as thus obtained is recognised by the fan -like or wheat-
sheaf form in which it crystallises, its very sparing solubility in water
and ether, its ready solubility in alcohol, its bitterness, and its action
on fishes. A couple of fishes of about seven ounces weight are placed
in rather less than two quarts of water. A solution of the crystals,
obtained as above, is made by dissolving them in alcohol, adding water,
and boiling ofi" most of the alcohol. This solution is then added to the
water containing the fishes. The fishes speedily die if the suspected
substance be picrotoxin. Lupuline has not this poisonous action on fishes.
Thirty grains of cocculus indicus, corresponding to one and a half grain
picrotoxin, is sufficient to kill a fish of seven to eleven pounds' weight
in ten hours. At least five quarts of beer should be operated on.
Depaire,* in a notice on the above paper, gives another process for
separating picrotoxin. The beer is shaken with common salt — 400
grains per quart — and filtered. The filtrate is exhausted twice with
ether ; the residue from the evaporation of the ethereal solution
dissolved in alcohol, half an ounce of water, and one drop of sulphuric
acid added to the solution, the liquid heated for a quarter of an hour on
the water-bath, cooled, filtered, and shaken with ether, the ethereal
solution is evaporated, the residue recrystallised from alcohol and
examined.
The Wharton-Ketchum Trial.f
This celebrated trial has excited so much interest throughout the
United States, and the nature of the evidence offered is so remarkable,
that we are induced to ofi'er a summary of the scientific testimony along
with a brief history of the case. The theory of the prosecution was
that Mrs. "Wharton was in debt to General Ketchum, and had invited
Lim to her house for the purpose of poisoning him, and that she
actually accomplished her design by means of tartar emetic. The
trial lasted fifty-two days, and the jury were locked up for seven weeks.
Collateral evidence was ofiered to show that she had also attempted to
poison a Mr. Van Ness, connected with her firm of bankers, who was
staying in her house at the same time as G-en. Ketchum.
Greneral Ketchum, the deceased, was an old army officer, an intimate
friend of the accused. He was in apparently good health and of active
habits. On June 24, 187 1, a very hot, sultry day, he had undergone
considerable bodily exercise by walking in Washington on business
matters. He neglected eating his dinner, partook plentifully of iced
water, took the train for Baltimore, and arrived at JMrs. Wharton's
house between 6 and 7 p.m. He ate very heartily at supper about 9
p.m. He retired, apparently in good health, at 11 p.m., but had to go
to the closet once or twice in the course of the night. Next morning he
* Loc. cit.
t • Anier, Journ, of M^d. S(;.,Mxiii, p, -^29,
^HARTON-KETCHUM TRIAL. 457
remarked that he had not been very well in the night, but he went out,
and partook of all his meals with the family on that day ; and although
complaining of not feeling well, he appeared more cheerful after tea,
chatting with the family and smoking until he retired at 1 1 p.m. Before
goiDg to bed he drank a glass of lemonade with a Mrs. Chubb. His
glass contained some brandy, which he himself added. On that night?^
he was again sick, and had slight purging. On the morning of the
a6th he complained of sickness and giddiness, and remained in his
room during the day, although he ate all his meals. In the afternoon,
at the solicitation of the accused, he saw Dr. Williams. At 4 p.m. that
physician found him sitting up and vomiting into a vessel which he
held. Dr. Williams ordered him to bed, and prescribed creasote and
lime-water, thinking him to be suffering from cholera morbus. No
mention is made of diarrhoea at this time. Next morning he had much
improved, and he dismissed his physician, the latter regarding his
patient as well.
Throughout this day, however, he was somewhat drowsy, as if under
the influence of some narcotic. He stated that he had taken some of
his own medicine, and a vial which had contained laudanum was found
beneath his bed. On June 27th he appears neither to have vomited
nor been purged, but on the morning of the 28th he was found on a
sofa nearly insensible. At 10 p.m. Dr. Williams found him in a semi-
comatose state, very difficult to arouse, and giving inarticulate answers.
On being touched a slight convulsive tremor passed over him from head
to foot. His head and face were much congested, of a purplish tinge.
His limbs were rigid. He gave only muttered replies to questions, and
did not complain of suffering. The respirations were normal, the skin
was not preternaturally moist, the pupils were not contracted, but were
insensible to light. The treatment consisted of ice to the head, and
40 drops of tinct. of gelseminum in water. This was to be repeated in 2
hours. Whilst the ice was upon the head, he had some convulsions of
a peculiar character, the tendency of which was to throw the body
from the back to the left side. At i p.m., after a third dose of gel-
seminum, the general became very restless, and uttered incoherent cries.
The convulsions increased in intensity, giving to the body the true
character of opisthotonos. He tore at his neck and abdomen, so as to
inflict extensive abrasions ; but it is doubtful whether these movements
were not automatic. At 1.30 Dr. Williams administered chloroform,
j and drew off the urine, suspecting ursemic poisoning, but detected no
albumen. Thirty grains of chloral hydrate were given in milk, but
the convulsions were so violent that he bit the spoon so that his first
tooth was loosened. At 3 p.m. he died in a convulsion.
The autopsy was made next day by Dr. Williams, assisted by Prof.
Miles and Chew. The brain and abdominal cavity only were examined.
Nothing was discovered to account for death, the only thing noted
beiug red punctiform congestion of the cerebral lobes, and doubtful
congestion in patches of the alimentary canal. The stomach was se-
cured and handed to Dr. Aikin for analysis. It presented nothing of
a very marked character. Dr. Aikin reported that he had satisfied him-
self of the existence in the stomiach of tartar emetic to the extent of
458 REPORT ON MEDI€AL JURISPRUDENCE.
at least twenty grains. His method of arriving at this conclusion is
curious and open to much objection ; nevertheless, it has great influ-
ence in forming the probable ground of the opinion, expressed at the
trial, of Dr. Williams and of Profs. Chew, Miles, Donaldson, Howard,
Johnstone, and Smith, that the death was not due to natural causes.
Dr. Aikin's analysis of the contents of the stomach was conducted
thus. Inferring the possible existence of strychnine or of arsenic, he
tested for the former of these by the process of Stas, which gave him,
he says, negative results. He appears, however, to have omitted apply-
ing the colour and physiological tests. He next proceeded to examine
for arsenic and antimony, using the material already employed in the
analysis for strychnine. A portion of this material was treated with
hydrochloric acid and chlorate of potassium, then, without previous
treatment with a sulphite, a stream of sulphuretted hydrogen was passed -
through the solution. A dark brownish precipitate was thus obtained.
As this precipitate did not dissolve in ammonia, he was satisfied that it
could not be arsenical. Another portion was now treated with tartaric
acid and sulphuretted hydrogeo, without preliminary destruction of
organic matter, when a reddish-brown or brownish-red precipitate was
obtained. When this was separated and dried it dissolved in hydro-
chloric acid ; this solution, when dropped into the water, gave a white
precipitate ; that white precipitate became orange red when treated
with sulphide of ammonium, and it was soluble in tartaric acid. This
completed all that was necessary to satisfy Dr. Aikin of the presence
of antimony, and he stated in evidence that he knew of nothing that
would have produced these results except antimony. He admitted that
Eeinsch's test had failed to give any result for antimony ; and he en-
tirely neglected to attempt to procure metallic antimony from the
stomach. His method of determining the quantity of tartar emetic
present was simply a piece of guesswork. The chemical testimony for the
defence demonstrated that the colour test (the orange red precipitate)
with all its subsequent reactions, save one^ might be obtained when no
antimony was present.
Bloodstains.
P. L. Sonnenschein * proposes a new reagent for the verification
of these, viz. soluble tungstates, which give, with albuminates and
gelatine, a precipitate insoluble in acids. Sodium tungstate, super-
saturated with either acetic or normal phosphoric acid, is preferred, and
forms even a more delicate reagent for the proteids than Millon's solu-
tion. A dilute and filtered solution of blood gives, with the above-
mentioned solution, a voluminous, reddish-brown, or chocolate-coloured
precipitate, which shrinks much in volume on boiling, and is then seen,
under the microscope, to consist of small vesicles. The precipitate is
soluble in ammonia and in alkaline solutions, forming a dichroic mix-
ture having the same intensity of colour as the blood itself when
treated with ammonia. On acidification the original precipitate re-
appears. The precipitate contains all the elements of blood. On in-
cineration and fusion of the ashes with a mixture of sodium carbonate
* * Vrtljhrssch. f. Gericht. Med.,* N.F., xvi, p. 263.
HAIR. 461)
and a trace of potassium nitrate, and subsequent lixiviation, an insolu-
ble residue of ferric oxide is left, free from tungsten.
Mol ybdic acid gives a similar precipitate to that produced by tungstic
acid with albuminates and blood.
The precipitate produced by tungstic acid in solutions of blood or of
blood and veins may be treated with ammonia and examined by the
spectroscope.
J. V. Geuns and J. W. Gunning f find in zinc acetate an excellent pre-
cipitant for the colouring matter of blood. The bulky, flocculent precipi-
tate which forms in solutions containing blood, on the addition of the
acetate, can be readily washed, placed on an object-glass whilst still in a
pasty condition, treated with acetic acid, and haemine crystals obtained.
Zahnf applies the evolution of oxygen which follows on the addition
of hydrogen peroxide as a means of detecting blood stains. He does
not regard it as an absolutely certain test, but thinks that it may be
applied directly without the necessity of dissolving off the colouring
matter from the articles stained. The non-evolution of oxygen is not
a proof of a stain not being due to blood, as the corpus delicti may have
been previously treated with boiling water. If the other tests for
blood are successful and the hydrogen peroxide test fail, it is a proof
that the stained articles have been subjected to the action of hot water
on the influence of a high temperature.
Sorby J contributes a valuable paper on the spectroscopy of blood, and
Preyer§ has an excellent description of the modes of testing for blood.
The Structure of Hair in its Medico-legal Aspects.
Hoffmann|| has investigated the structure of hair in man and the
lower animals for the purpose of diagnosis in medico-legal cases. He
sets himself to answer the questions : — (i) Whether man's or brute's
hair ? (2) !From what part of the body ? In regard to the first ques-
tion the difficulty, as a rule, is not great. The chief point to be attended
to is the structure of the medulla. In human hair the medulla is very
fine or altogether wanting, while in the hair of animals the medulla is
very broad and the cortical substance greatly reduced. The medulla of
human hair is granular, while that of animals is well-marked and cel-
lular, and this gives it quite a different appearance. The second question
as to what part of the body the hair is from is answered chiefly by ex-
amination of the free end of the hair, which, when it has not been dis-
turbed, forms a fine point, or, if cut, exhibits a square end, which, after
some time, gradually becomes rounded or fibrillated. The free ends of
the body-hairs undergo changes by friction and the action of the
perspiration. The appearance of the free end of the hair, taken in con-
junction with other circumstances, may enable us to determine, if not
with perfect definiteness, yet with more or less certainty, from what part
of the body the hair has come.
* 'Chern. Centralb.,' 1871, p. ^"j.
f * Virchow und Hirsch's Jahresber.,' 1871, p. 416.
X ' Monthly Micros. Journ.,' vi, p. 9.
§ Op. cit., p. 208.
II Prager, * Vierteljahrsc. f. Heilk./ 1871, iv, p. 67.
460 REPORT ON MEDICAL JURISPRUDENCE.
EccTiymoses after suffocation, — Dr. Julius Lukomsky,* of Kiev, pub-
lishes an interesting criticism on tlie eccliymoses which Tardieu has
described as characteristic of death from suffocation. In order to arrive
at a satisfactory settlement of the questions at issue. Dr. Lukomsky
made an elaborate series of experiments on the pressure of the blood in
the various vessels during the time that animals were being suffocated.
By suffocation (erstickung) is meant, in a restricted sense, all causes of
death by mechanical applications for the purpose of excluding air, ap-
plied to the mouth and nose, to the air passages and oesophagus, pres-
sure on the chest and abdomen, and suffocations by being buried in
earth, or in any pulverulent material.
During suffocation it was found that both the arterial and venous
pressures were materially increased. After this had been established be-
yond doubt, the variations in respiration were noted — ist, after simple
closing of the trachea so as to produce suffocation ; 2nd, after suffoca-
tion induced by irritation of the nerves ; 3rd, after suffocation conse-
quent on section of the nerves ; 4th, by occlusion of the trachea after
forcing air into the lungs under increased pressure ; 5th, in suffocation
by rarefaction of the air. It was thus proved, on comparing the pressure
of the blood and the variations in the mechanism of respiration during
suffocation, that — (i) during suffocation a typical change in the rhythm of
respiration takes place ; (2) a considerable increase of pressure was noted
in both arteries and veins, especially in the region of the thorax; (3)
there was a diminution of pressure in the pulmonary artery ; (4) the
greatest increase in the pressure of the blood coincided with the period
of most powerful respiratory effort, i. e. with expiration. Dogs were
the animals experimented on.
The connection between the arterial and venous pressure and Tar-
dieu's ecchymosis is next traced. In normal respiration, during in-
spiration, there is an increased flow of blood into the right heart, a
quickened action of the heart, and consequently an increased arterial
pressure; whilst during expiration the converse obtains. Bat in
suffocation the greater effort at and duration of each inspiration in-
creases the flow of blood to the right ventricle. In consequence of a
diminution of pressure in the pulmonary artery, blood flows more
quickly from the right into the left ventricle, and consequently both
the activity of this and the pressure in the arteries are heightened.
But when a rapid and energetic expiratory effort follows upon the
climax of inspiration, and this effort at expiration adds an increase of
pressure to the already heightened arterial pressure in the thorax, it is
seen that there is a direct connection between the altered relations of
the respiratory mechanism during suffocation and the development of
the peculiar form of subpleural ecchymosis which Tardieu has pointed
out as a diagnostic sign of suffocation. The memoir is enriched with
experiments bearing upon the altered rhythm of respiration and varia-
tions in arterial and venous pressure when suffocation is artificially pro-
duced by various means, as, e.g., by section of nerves; but these expe-
riments, valuable as they [are, are of more interest to the physiologist
th^n to the medical jurist.
* * Vrtljhrsschrft f . Gericht. Med.,' N. F., xv, p. 58.
BBPOET
MATERIA MEDICA AND GENERAL
THERAPEUTICS.
' BY
THOMAS STEVENSON, M.D. Lond., E.E.C.P.
Sulpliovinate of sodium. — M. Eabuteau* proposes the use of this salt
as a purgative, and states that it possesses the following advantages.
(i.) Its taste is very slight at first, and is afterwards sweet, so that it
is taken without difficulty even by children. (2.) It is the mildest in
its action of all the saline purgatives, and is especially useful in colic.
(3.) It produces no pain or tormina, and is exclusively a dialytic pur-
gative ; hence it is useful during menstruation and pregnancy. (4.) It
presents all the advantages, and none of the disadvantages, attending
the use of citrate of magnesium. In the first place, the sulphovinate is
more agreeable to take, especially when administered in seltzer water,
than the citrate ; and in the next place, it does not tend to the produc-
tion of calculi, as the citrate of magnesium is apt to do. (5.) Sulpho-
viDate of sodium acts as a purgative when given in relatively small
doses. Bather less than an ounce of the salt dissolved in seltzer water
is invariably sufficient to produce in an adult five or six stools.
i\ drachms suffice for a child, and this dose produces very appreciable
effects even in an adult. (6.) It does not produce after-constipation,
as saline purgatives are so apt to do ; this owing to the rapidity with
which the sulphovinate of sodium is eliminated after its absorption.
Peroxide ofJiydrogen. — Dr, John Day, f of Geelong, finds in pessaries
containing peroxide of hydrogen a convenient method of destroying
the oflensive odour which accompanies the discharges of patients suf-
fering from cancer of the uterus. The following is his formula:
Melt, with gentle heat, twelve drachms of cocoa-butter, and well stir
in until thoroughly incorporated eight scruples of ethereal solution of
peroxide of hydrogen. When nearly cold divide into eight pessaries.
One to be inserted into the vagina every night and morning, or of tener
if necessary. They keep well.
* *Gaz. Hebd./ June 10, 1870.
t * Austr. Med, Journ.,' 1871, p. 303.
46 a REPOUT ON MATERIA MEDICA, ETC.
Chlorides. — Eabuteau* has found that common salt, when given in
considerable quantities, greatly increases tissue change and the excretion
of urea. At the same time it increases the secretion of gastric juice
and its acidity. On this account animals which get much salt digest
their food well, but do not get fat. The red blood-corpuscles become
more numerous when salt is taken, and this, along with its other pro-
perties, will render it useful in phthisis and diabetes. Very large doses
of salt are purgative. Salt food produces constipation, because the salt
is absorbed into the blood, and lessens the exosmosis into the intestines.
Small doses of salt are, therefore, very serviceable in diarrhoea and
dysentery, when other remedies fail.
Chloride of ammonium acts as a diuretic, increases the excretion of
urea, quickens the pulse, and seems to raise the temperature. It does
not impair digestion. It is not diaphoretic. Large doses induce
vomiting, and cause temporary weakness of the lower extremities. Sal
ammoniac alone has a specific remedial action in bronchial catarrh ;
but all ammonium compounds increase expectoration.
Chloride of potassium increases the excretion of urea, but has only a
slight diuretic action. It increases the appetite, and causes slight con-
stipation. It slows the heart, and Eabuteau thinks this salt might be
used instead of digitalis.
Chloride of magnesium, injected in large doses into the veins, slows
the heart like chloride of potassium. Two and a half drachms produces
purgation, not accompanied by colicky pains, and not succeeded by
constipation. It is also pleasanter to take than the sulphate of mag-
nesium, and Eabuteau, therefore, recommends it in place of the latter
salt, in doses of 7 drachms for men, 5^ drachms for women, and half an
ounce for children. The dose should be dissolved in a considerable
quantity of water.
Ferrous chloride does not coagulate either egg- or serum-albumen,
and hinders the coagulation of blood. One grain injected directly into
the circulation stops the heart like potassium chloride. The blood
remains fluid. Ferrous chloride is chiefly excreted by the intestine.
Ferric chloride is reduced by albuminous substances, and undergoes
reduction in the body. It is quickly absorbed. Eabuteau recommends
the employment of ferrous chloride in medicine, and he finds that re-
duced iron, ferric oxide, and ferrous carbonate are converted into
ferrous chloride in the stomach.
Gold and palladium chlorides are reduced in the body, and when
given for a long time produce albuminuria and renal afi'ection. The
author considers that there is a particular kind of albuminuria pro-
duced by metals, as albumen appears in the urine in poisoning by lead,
nitrate of silver, and the salts of uranium and cadmium.
Bromides. — "VVoodf finds that, by combining bromide of potassium
with tincture of cannabis indica, the dose of bromide may be raised to
a drachm and a half three times a day without any bad efl'ect following.
The bromide in doses of one drachm frequently causes melancholy
when given alone. Dacosta thinks that if 40 to 60 grains of bromide
* ' Union Medicale/ Ixxiii, p. 150 et seq., * Comp. Rend.,' Ixxiii, 24, p. 1390.
t *Brit. Med. Journ.,' Oct. 14, 187 1, 435.
ALCOHOL. 463
are given a few hours before a dose of opium they prevent headache,
giddiness, and nausea, as well as increase the hypnotic action of the
opium. The itching of the skin is also lessened.
Bartholow* considers that the bromides of potassium, sodium, and
ammonium agree in their mode of action, and produce similar symptoms.
They all produce weakness, trembling, impaired co-ordinalion, and
paralysis. This effect he ascribes to diminution of the irritability of
the muscles themselves, and also of the motor nerves. They depress
the heart and lower the temperature. They diminish the activity of
the brain, and procure sleep. The action on the muscles and nerves is
greatest with the employment of the bromides of potassium and am-
monium ; least on the heart with the use of the sodium salt, and most
with the administration of the bromide of ammonium. On the brain
bromide of potassium acts most, and bromide of ammonium least;
whilst the potassium salt is intermediate in its activity. The toxic
action is greatest in bromide of potassium, and least in bromide of sodium.
Arsenic. — Yaudryf finds that arsenious acid, in doses of i-6oth to
i-ioth grains, quickens and strengthens the pulse, facilitates respira-
tion, improves the appetite, aids digestion, increases all secretions with
the exception of the urine, imparts muscular activity and a general
feeling of comfort, and causes an increase of weight. After it has
been given for some time the feeling of comfort disappears, but again
returns when the dose is increased by i-3oth to i-i^th grain. Doses
of i-6th to 2-5th grains cause disturbance of the intestinal canal. In
some persons even i-T2th grain will occasion diarrhoea. The author
considers the effect of arsenic on respiration to be due to stimulation
of the vagus. Animals gradually acquire a tolerance of arsenic.
Arsenate of quinine. — Prof. Griov J has given this salt successfully in
cases of neuralgia involving the brachial plexus, in doses of if — 2
grains, the treatment being continued for eight or ten days.
Mercury. — Dr. J. H. Bennett § records experiments which show that
calomel, blue pill, and corrosive sublimate, digested in the stomach, do
not irritate the orifice of the common bile duct in the duodenum, nor
does their application or any other kind of local irritation cause in-
creased secretion or flow of bile into the duodenum. The gall-bladder
is not contractile, and therefore does not contract on the application
of either direct or reflex irritation. Pressure on the gall-bladder or
liver, in consequence of extensive contractions of the neighbouring
muscles, causes a copious flow of bile into the duodenum.
Byasson || finds that corrosive sublimate, when given by the mouth,
appears in the urine in two hours and in the saliva four hours after
its administration. It does not appear in the sweat. Its elimination
is completed in twenty-four hours.
Alcohol. — Parkes and Wollowiczl" have investigated the action of
alcohol when taken in the form of claret as well as in the form of
* * Amer. Journ. Med. Sc./ 187 1, p. 359.
t 'Vircliow and Hirsch^s Jahresber.,' 1 871, p. 312.
X 'Schmidt's Jahrb./ cli, p. 271.
§ ♦Brit. Med. Journ.,' 18 71, p. i.
II ' JoTirn. de I'Anat. et de Physiol.,' 1872, p. 500.
^ • Pr. Roy. Soc.,' xviii, p. 362.
464 REPORT ON MATERIA MEDICA, ETC.
brandy. The eflPects of both of these are the same in many respects.
They quicken the heart and dilate the vessels. There was no distinct
alteration in temperature in the axilla or rectum, nor any change in
the excretion of nitrogen or phosphates either in the urine or faeces.
They do not consider the dietetic effects of claret to be the same as those
of brandy and water, but the differences could not be discovered by the
method of experimentation they employed. Ten ounces of claret con-
taining about one fluid ounce of pure alcohol caused no unpleasant heat
or flushing. Twenty ounces produced both. Alcohol began to appear
in the urine. The authors consider that the use of alcohol by healthy
persons is unnecessary and may be injurious.
BouvierJ found that when fever was produced in animals by the in-
jection of putrid matters, those which were treated with alcohol resisted
the fever much longer than others. Their temperature could be reduced
several degrees by the administration of alcohol. He obtained good
results from the use of alcohol in typhus, but not in intermittent fever.
Eabowf found that wine and brandy, in doses of two or three table-
spoonfuls, increased the temperature in 23 cases, and left it unchanged
in 2. The rise was generally o'4 — 07° Fahr., but often only 0*2° Fahr.
A rise of temperature was also noticed during collapse, when the admi-
nistration of wine was attended with much benefit.
Manizu % and Fokker § found little change in the temperature of the
human body after the moderate use of alcohol, but Fokker observed a
slight fall in a dog. It somewhat diminished the excretion of urea in
the dog, and the effect of a given quantity was the same whether it were
given in repeated small doses or in one large one. Fokker regards it
as food, and indicated in all diseases where there is danger of death
from inanition. He does not consider it to act as a febrifuge.
Danet || gives several cases showing that the mortality in pneumonia
is least when patients are treated with alcohol and blisters, greater with
digitalis and blisters, and greatest with antimonials and blisters. He
has also seen benefit from the use of alcohol in congestion of the lungs,
and mentions the beneficial effects of its local application in cases of
purulent infection.
Subbotin^ finds, from experiments on rabbits, that a considerable
quantity of alcohol is eliminated by the skin and lungs in the first five
hours after its introduction into the body. Twice as much alcohol is
eliminated by the skin and lungs as by the kidneys. This result is in
direct opposition to the statement of Lallemand, Perrin, and Duroy,
that alcohol is excreted chiefly by the kidneys. Part of the alcohol
probably undergoes combustion in the body.
Chloral hydrate. — Dr. A. Monti** contributes a paper on the employ-
ment of chloral hydrate in the diseases of children. This observer
noted that in children, when the dose was proportioned to their age,
* ' Centralblatt f. d. Med. Wiss.,' p. 801.
t 'Berl. Klin. Wchnschr.,' 1871, No. 22, p. 257.
j 'Diss. Bonn.,' 1870, 'Virchow and Hirscli's Jahresber./ 1871, p. 324.
§ * Virchow and Hirsch's Jahresber.,* 187 1, p. 324.
II 'Gaz. des Hop.,' 1871, 418, 421 j 'Ztscbr. f. Biologic,' vii, p. 361.
% ' Zeitsch. f. Biologic,' vii, p. 361.
** * Jahrb. f. Kinderheilk.,' v, p. 63.
ANAESTHETICS. 465
within an hour and a half there supervened slight suffusion of the
countenance and a quasi-intoxicated state, passing into sound sleep.
The pulse, which at first was somewhat quickened, was afterwards re-
tarded, the respirations were unafiected, and the temperature of the
body sank. It was only after very large doses of the hydrate that the
numbness of the skin, followed by anaesthesia, was preceded by excite-
ment and contraction of the pupils. The sleep induced is quite normal,
and on awakening there is neither headache nor cerebral congestion,
nor any other disturbance of function. Chloral hydrate sometimes in-
duces vomiting, but never diarrhoea. The dose is i to 4 grains for a
new-born infant ; up to one year, i-J- to ^ grains ; from one to five years,
3 to 10 grains ; and for children from five to twelve years of age, from
8 to t8 grains. To infants at the breast i grain was given every fifteen
or thirty minutes, till the desired result was obtained. His conclusions
are summarised as follows: — Sleep is as readily induced by chloral
hydrate in children as in adults. In symptomatic as well as in idiopa-
thic convulsions it acts symptomatically. and is contra-indicated only
where there is inflammatory disease of the bronchi, lungs, or heart, and
the remedy must be used with caution where the child is anaemic or
atrophic. Chloral is useful in laryngismus stridulus, chorea, and hoop-
ing-cough, except in the third stage of this last, wlaen it acts prejudi-
cially by checking expectoration. It proved useless as an anaesthetic in
surgical operations and in idiopathic and traumatic tetanus.
Husemann * contributes a long and able resume of all that is known
regarding the pharmacological and toxicological relations of chloral
hydrate. A vast amount of literature has been laid under contribution
for the preparation of his monograph.
Ancesthetics. — Koblerf reviews all the recent work that has been done
with anaesthetics. His memoir is a valuable one, and is enriched with
cuts of the various forms of apparatus that have been designed for the
inhalation of anaesthetics.
Byasson and Pollet % have compared the action of trichloracetate of
sodium, chloral, and chloroform. The effect of tricloracetate of sodium is
more like that of chloroform than of chloral. Chloroform given by
inhalation is the most powerful anaesthetic, but when given subcuta-
neously it has less action than either of the other two. Chloral, when
given by the stomach, is a more powerful soporific than the others, but
has less anaesthetic power than chloroform.
The authors distinguish three degrees of action in chloral. In the
first, it acts as a slight soporific and sedative of the sensory nervous
system. This eff'ect is often accompanied by agitation like that occur-
ring during unpleasant dreams. In the second, it has a powerful sopo-
rific action, lessens sensibility considerably, and produces calm and
deep sleep. This may be kept up for a considerable time, without
danger, by giving a fresh dose when the effect of one is passing off". In
the third, it produces complete anaesthesia, entire loss of general sensi-
bility, and muscular relaxation. Death almost always occurs after
* 'Schmidt's Jahrb.,' cli, p. 81.
t Ibid., p. 193.
j * Journ. de I'Anat. et de Physiol.,' 1870, p. 570.
30
466 REPORT ON MATERIA MEDICA, ETC.
this stage has been reached. It may sometimes be averted by artificial
respiration or inhalation of oxygen.
Bromal hydrate. — Berti and Namias* have investigated the thera-
peutical properties of this proposed remedy, and arrive at the following
conclusions, i. Even in small doses, and well diluted, bromal hydrate
produces burning pain in the throat, pyrosis, vomiting, and diarrhoea.
2. In an emulsion (i to 300) its use is barely supportable. Even after
long and cautious administration it produces vomiting and purgation.
3. In relatively large doses it does not induce sleep, or abate restless-
ness. It is useless in epilepsy. 4. Subcutaneously injected it excites
local inflammation, and exercises little action in the nervous system.
^. Eubbed up with an equal quantity of fatty matter, and applied
locally, it produces erythema of the skin, but it is not so safe an appli-
cation as a sinapism. 6. Bromal hydrate ofters no advantages as a
therapeutic remedy over other safer and speedier remedies. 7. Toxic
doses induce stupor, paralysis of motion and sensation, and rapid or
sudden cessation of the respiratory movements, ending in death.
Oroton chloral. — Liebreichf finds that croton chloral produces in ani-
mals, first, anaesthesia of the head, then loss of reflex movements through-
out the body, and, finally, death by paralysis of the medulla oblongata.. In
man it produces anaesthesia of the fifth nerve, while the sensibility of
the body and the pulse and respiration remain unaffected. He con-
siders that it is split up in the blood into formic ether.
ByassonJ supposes that the action of chloral is partly due to the
formic acid, which it yields along with chloroform when decomposed in
the blood. This supposition he has confirmed by the administration of
formic ether, which also yields formic acid in the blood. When
given to animals, either by inhalation or subcutaneously, it produces
symptoms of asphyxia, diminution of temperature, partial flaccidity of
muscles, and lessens sensibility without completely destroying it. In
man it caused a tendency to sleep, and formic acid appeared in the
urine.
Bichloride of methylene has been recommended as an anaesthetic by
Gl-aine§ and Spencer "Wells, || but its administration is not without
danger, death having occurred^ during anaesthesia produced by it.
Methylamine. — Fargier-Lagrange** finds that trimethylamine, in
doses of about 9 grains daily, lessens pain in rheumatism. It slows
the respiration and pulse, and reduces the temperature.
Nitrite of amyl. — H. C. Wood, jun.,tt finds that nitrite of amy I
greatly lessens, but does not destroy, the irritability of nerves and
muscles. The power .of the central motor ganglia is also much
diminished, but sensibility is only slightly lessened. He thinks with
Brunton that the diminution in the blood-pressure which nitrate of
* • Journ. de Bruxell./ lii, p. 328; 'Schmidt's Jahrb./ cliii, p. 141.
t 'Coinp. Eend.,' 1872, p. 1202.
X Ibid., 187 1, Ixxii, p. 742.
§ 'Med. Times and Gaz.,* 187 1, p. 232.
|[ 'Lancet/ 1871, i, p. 591.
if 'Brit. Med. Journ.,* 1871, p. 457.
** 'Virchow and Hirsch's Jahresber.,' i87i,p. 341.
ft ' Amer. Journ. Med. Sc.,' July, 1871, p. 39, and October, p. 3^9.
TURPENTINE. 467
aiiiyl produces is chiefly due to dilation of the capillaries, but considers
tnat the power of the heart is also lessened by the action of the drug
on its muscular substance. When directly applied to nerves, muscles,
or the heart, it lessens their irritability, without causing any temporary
increase at first. It hinders oxidation both within and without the
body, and diminishes the temperature and excretion of carbonic acid.
When the spinal cord of animals is divided, and they are laid in a warm
place, their temperature rises much, and they rapidly decompose. Both
of these effects are prevented by nitrite of amyl. He confirms
Brunton's statements regarding its beneficial efiects in angina pectoris,
and recommends it in synocha and tetanus.
Talfourd Jones* gives cases of benefit from the use of this remedy
in spasmodic asthma, epilepsy, laryngismus stridulus, colic, and hemi-
crania. He recommends it in colic and cholera. Goodhartf noticed
a fall of temperature from its inhalation.
Lauder BruntonJ mentions that nitrite of amyl was tried in cholera
by Hayden and Cruise without efi'ect. He discusses the symptoms and
pathology of cholera, and ascribes the difficulty in breathing to con-
traction of the pulmonary vessels and obstruction to the flow of blood
through the lungs. He shows by experiment that nitrite of amyl
dilates the pulmonary as well as the systemic vessels. The fact that it
does not lessen the difficulty in breathing, although' it possesses this
power, is explained by its forming a compound with the hsBmoglobin of
the blood and preventing oxidation, as shown by Gramgee. He, there-
fore, recommends it to be given by the mouth, or subcutaneously if
used in cholera.
Benzine. — This liquid has been found§ useful in allaying the
paroxysms of hooping-cough, in doses of lo — 20 drops suspended in
syrup or mucilage ; or the vapour of benzine may be inhaled.
Tar. — Magnes-Lahens|| recommends a convenient method of adminis-
tering this substance. The tar is triturated with charcoal till the mass
no longer soils the hand, and has a granular aspect similar to gun-
powder. The powder can then be administered in various ways- — in-
haled, smoked, taken into the stomach in various menstrua, &c.
Turpentine. — Warburton Begbie^ considers that turpentine is ab-
sorbed by the skin when applied externally, and eliminated by it to
some extent when administered internally. He regards the occurrence
of a smell of violets in the urine as indicating to a certain extent a
healthy condition of the kidneys. The external application of turpen-
tine is not absolutely counter-indicated by renal disease, as the drug is
I eliminated to a great extent by the lungs and intestines. The author
recommends it as the most trustworthy remedy in purpura hsBmor-
rhagica associated with hsematuria. In asthenic typhus with subsultus,
stupor, or delirium, and in puerperal fever, he has found it efficacious.
In doses of 10 — 30 drops, thrice a day, it is of great service in sciatica,
* * Practitioner,' October, 1871, p. 213.
t Ibid., p. 12.
% 'Brit. Med. Journ./ 1872, p. 42.
§ ' Ann. de Therap.,' 1870-71, p. 74.
\ 'Bull de Therap., Ixxx, 187 1, p. 213, 313.
^ * Edin. Med. Journ./ 1871, ii, p. 39.
468 HEPORT ON MATERIA MEDIC A, ETC.
and in neuralgias, crural and brachial, succeeds when other remedies
have failed. He also recommends it in doses of 20 — 30 grains for
frontal headache resulting from mental fatigue, and in cases of gan- ■
grene of the lungs, pysemia, and diphtheria. I
Aconitine. — H. Duquesnel * has recently obtained this alkaloid in a "
crystalline condition from Aconitum napellus, by a modification of
Stas's method, and he states that hitherto the term aconitine has been
applied to several substances differing in therapeutical value with the
source from which they are derived. He regards the alkaloid, to which
he assigns the formula Q27^a<^^w ^^ ^ glucoside, and considers that
this view explains the spontaneous deterioration of various preparations
of it on keeping. The chemical properties of aconitine are fully de-
scribed, and phosphoric acid, tannin, potassio-mercuric iodide, and
iodine in potassium iodide, are stated to be the most sensitive reagents
for it.
The same observer, in conjunction with M. Grr^hant,t describes the
physiological action of the crystallised aconitine prepared by him.
From experiments on frogs, they conclude that small doses of aconitine
are analogous in physiological results to curarine, destroying the
motor power of nerves, but with large doses the heart's action was
arrested, and the nerves did not lose their motricity, because, through
cessation of the circulation, the did not come in contact with the
poison. In mammalia, the effects of the poison are more rapidly deve-
loped, and are more difficult to analyse.
Opmm. — O. Hesse J has described some new alkaloids from opium
— laudanine, codamine, meconidine, and lanthopine. These collec-
tively, when impure, form the porphyroxine described by Merck. The
physiological and therapeutical properties of these new bases have not
yet been ascertained.
Eabuteau § has investigated the action of the alkaloids of opium,
and classified them accordingly. The alkaloid having the most I
powerful action is placed first, and that having the weakest is placed
last. They stand in this order as soporifics — morphine, narceine, and
codeine. The other principles have no soporific action. As poisons —
morphine, thebaine, codeine, papaverine, narceine, and narcotine. As
analgesics (pain destroyers) — morphine, narceine, thebaine, papaverine, i
and codeine. Narcotine does not seem to diminish pain. The author
has also examined their effects in preventing secretion from the intes-
tine, as he supposes diarrhoea to depend on more fluid passing into it ;
by osmosis from the vessels. Morphine is the most powerful anexos-
motic, and next to it comes narceine. The other principles do not seem
to arrest diarrhoea. Opianine is present in opium in very small quan-
tity. Its action is like that of morphine. Meconin and meconic acid
have no action whatever.
Opium and chloroform. — Labbe and and Guyon || have confirmed the
statement of Claude Bernard and Nussbaum, that when morphine is
* * Comp. Rend./ Ixxiii, p. 207.
t Ibid., p. 209.
J 'Ann. Chem. Pharm.,' Supp., Bd. viii, p. 261.
§ * Journ. dc I'Anat. et de Physiol.,* 1872, p. 302.
II ' Journ. de Pharm. et de Chem.,' 1872, p. 398.
MONOBEOMIDE OF CAMPHOR. 469
given along with chloroform much smaller doses of chloroform are re-
quired to produce complete anaesthesia than when it is given alone, and
the risk of death occurring is thus diminished. The anaesthesia lasts a
long time, and may be prolonged still farther by small doses of chloro-
form.
Eabuteau * finds nearly all the principles of opium, with the excep-
tion of narcotine, aid the action of chloroform. Morphine is the most
powerful in this respect, but narceine is nearly equal to it. Codeine
and papaverine have only a feeble action.
Apomorpliine. — The action of this substance has been investigated by
Vincent Silbert.f The minimum dose required to produce vomiting,
when injected subcutaneously, is about one tenth of a grain. A grain
and a half given by the stomach produced only nausea in one case, but
much smaller doses may sometimes produce vomiting.
Quehl % finds that the dose required for subcutaneous injection is
i-i2oth to i-3oth of a grain; by the mouth, i| to 2f grains ; and by
the rectum, 2f to ^^ grains. No tolerance is produced by its long-
continued use, nor does it injure health. Excessive doses, 3 grains or
more, do not produce vomiting at all, but cause staggering, weakness,
and manege movements. Vomiting is also prevented by division of tho
vagi nerves.
Blaser § recommends simple syrup as the best solvent for apomor-
phine.
Muscarine. — This alkaloid has its chemical characteristic detailed by
Euckert.|| It is recommended by Deneife^f in delirium tremens. Ho
gives it in doses of 4^ to 60 grains daily, in the form of pill.
Gamplior. — Dr. 0. Heubner'''* has investigated the action of camphor
on the heart, and obtained results of much therapeutical interest. The
results were obtained by experimenting on frogs. He finds that cam-
phor renders the cardiac contractions more energetic, the pauses be-
tween the contractions of longer duration, and that the heart bestows
upon the circulation greater rapidity.
Monohromide of camphor. — Dr. Wm. A. Hammond ft has tested the
alleged efficacy of this medicament, and his experience of its use, though
thus far limited, is eminently satisfactory. The preparation used was
in beautiful crystals free from the slightest yellow tinge, hence it con-
tained no free bromine. Employed in two cases of infantile convul-
sions due to the irritation of teething, the bromide prevented the
further occurrence of paroxysms which, previously to its administra-
tion, had been very frequent. In each case a grain was given every
hour, rubbed up with a little mucilage. Three doses were sufficient in
one, and two in the other case. In a very obstinate case of hysteria,
in the form of paroxysms of weeping and laughing, alternating with
* * Journ. de I'Anat. et de Physiol.,' loc. cit.
t 'Untersuch. u. d. Wirk. d. Apormorph. Diss. Derpat.,* 1871.
t 'Diss. Halle,' 1872.
§ 'Arch. d. Heilk.,' xiii, p. 272.
II 'New Rep. Pharm.,' xxi, p. 193.
\ 'Presse Med. Beige/ 1, p. 405.
** * Arch. d. Heilk./ xi, p. 334.
ft 'New York Med, Jouru.,' xv,-p, 522,
470 REPORT <*^ MATERIA MEDICA, ETC.
epileptiform and 'choreiform convulsions, where the acts usually lasted
from five to eleven days, uninfluenced by medication or moral suasion,
the influence of the drug was distinctly perceived after two doses (four
grains every hour) were taken, but ten were necessary to entirely
break off the attack. Dr. Hammond also speaks highly of the bromide
in headache from mental excitement. In wakefulness it is inferior to
other bromides, as, e.g. bromide of calcium.
Digitalis, — Dr. Eudolph Boehm,* of Wurzburg, has investigated the
physiological actions of digitalis and digitalin. He finds that digitalin
increases the irritability of the inhibitory nerve-centres situated in the
heart, and exercises a specific action on the muscular fibres of the
heart, first of all increasing their contractility, next rendering their
contractions irregular, and finally conferring upon them a peculiar
r^idity. The essay is a long and valuable one.
Dr. A. Weil f contributes a paper on the physiological actions of this
drug. His memoir is very instructive, but as the object of the experi-
ments, made upon frogs, was to demonstrate the mechanism of the
reflex inhibitory centres (reflexhemmungs mechanismen), we do not
think it necessary to do more than make a short reference to them.
He finds — (i) That small doses of digitalin (i-6oth of a grain) dimi-
nish very considerably in decapitated "reflex frogs" (a term applied to
to frogs in which, on the previous day, the cerebral hemispheres had
been separated by cutting through the bones) the frequency of the
heart's action, the heart's beats being stopped sooner in the decapitated
animals than in those which had not been so treated. The same oc-
curred with doses of i-3oth of a grain. (2) Small as well as large
doses act as excitants of the inhibitory centres. (3) Large and small
doses induce a period at which division of the medulla oblongata no
longer restores the reflex irritability, at which period also the irritationj
of the inhibitory centres has given place to paralysis of the cord. Pre-
vious to this, the action of the digitalis is limited to the brain, so far aai
reflex excitation is concerned.
Gourvat % finds that a moderate quantity of digitalin paralyses the]
motor nerves of voluntary muscles in frogs, and that a large quantity
destroys the irritability of the muscles themselves. It seems to act aa
a stimulant to involuntary muscles. It causes contraction of the arte-]
rioles and raises the blood pressure. The cardiac pulsations become]
slower, stronger, and more regular, after a moderate dose. The slow-
ness of the pulse is due to the increased blood pressure, and is propor-
tional to this. The contraction of the arterioles produced by a moderate
dose soon passes off, but lasts longer when a large dose has been given.
After the contraction has ceased they become paralysed and dilated.
Their contraction causes diminution of the sweat and the secretions of
mucous membranes and glands, but the amount of urine is increased.
Ackermann § has investigated the action of digitalin — ist, on the
heart ; 2nd, on the arteries ; and 3rd, on the temperature. He finds
* 'Arch. f. Anat.,' v, p. 153.
t 'Arch. f. Physiol.,' 1871, p. 252.
X ' Gaz. Med.,' 1871, No. 26, et seq.; *Gaz. des H6p.,' cxxxii, p. 526.
§ ' Berl. Klin. Wchnschr.,' 1872, 27; 'Deut. Arch. f. Kliu. Med.,' xi, p. 125.
DIGITALIS. * 471
— (i) That after the iDJection of a large dose of digitalin (o*o^ gram.)
into the veins the pulse becomes very slow, then quicker, and then slow-
again. The first slowing of the pulse is caused by the digitalin acting
directly on the vagus roots, and stimulating them ; the quickening is
caused by the drug paralysing the ends of the vagus in the heart, and,
at the same time, stimulating the accelerating nerves. The second
slowing is due to paralysis of the muscular substance of the heart. (2)
Large doses of digitalin increase the pressure of blood in the arteries
by causing contraction of the arterioles. It does not cause them to con-
tract by stimulating the vasor-motor centre in the medulla oblongata,
but by acting on the ends of the vaso-motor nerves in the vessels or on
the muscular fibres in their walls. (3) It lessens the temperature of
the interior of the body and increases that of the surface. It probably
does this by quickening the circulation through the skin.
Lauder Brunton and A. B. Meyer * bring forward a new proof that
digitalin causes contraction of the arterioles. They find that the blood
pressure rises after its injection, but the pulse wave becomes smaller.
This shows that the rise is not caused by the heart. At the same time
each wave descends more gradually, showing that the blood is escaping
more slowly through the arterioles. As the blood pressure is high, the
slow flow of the blood through the arterioles can only be caused by their
contraction. The pulse is rendered slow. This is partly due to the
increased blood pressure.
* ' Journ. of Anat. and Physiol.,' 1872, p. 134.
REPORT ON PUBLIC HEALTH.
BT
THOMAS STEVENSON, M.D. Lond., F.E.C.P.,
lECTUEEE ON OHEMISTET AT GUY'S HOSPITAL; MEDICAL OFFICEE OP HEALTH
FOE ST. PANGEAS.
Cholera.
Choleea is the disease wliicli bas attracted the largest amount oi
attention from sanitarians during the last two years, and the literature
of the subject has been very abundant.
The recent diffusion of cholera in Europe. — A report of remarkable
interest on the recent diffusion of cholera in Europe* has been sent by
Mr. J. Netten Badcliffe to Mr. Simon, who has forwarded the report
to the president of the Local Government Board, with a recom-
mendation that it be brought under the official notice of foreign govern-
ments. The report commences with an account of the first appearance
and subsequent progress of the epidemic which, beginning in South
Eussiaat Kiev, in the autumn of 1869, spread during the months of
November and December into several of the districts in South, Central,
and West Eussia. In January of the following year cholera appeared
in Moscow, and in February cases were reported from Novgorod.
During the summer and autumn the disease spread actively, so that in
1870 cholera prevailed with hardly a break— if indeed with any break —
throughout the tract of country lying between Moscow and the north
coasts of the Black Sea and the Sea of Azov. To the north and west
of this tract it had appeared at St. Petersburg ; and to the south and
east it appeared along the north-east coast of the Black Sea, from the
Straits of Kertch to Poti, through the valley of the Eion across Trans-
caucasia to the Persian frontier of the empire. In 187 1 cholera was
generally diffused throughout Eussian Europe. It spread also into
Siberia, appeared in the autumn at Astrachan, prevailed in Ciscaucasia
along the course of the Kouban, and in Transcaucasia was present
at Baku on the west coast of the Caspian, and at Erivan. During the
whole progress of this remarkable diffusion of cholera, the disease did
not spread into Europe beyond the limits of the Eussian empire,
except at four points. In July it passed the Polish frontier into East
Prussia, and on the 24th of the month attacked Konigsberg. In
August it extended to Memel, Dantzic, Elbing, Stettin, Swinemlinde,
* * Parliamentary Paper.'
CHOLERA. 473
and the adjacent districts ; scattered cases were also recorded in Berlin,
and outbreaks of the disease occurred in Hamburg and Altona.
On the 3rd of September it appeared at Hernosand in Sweden, and
at the same date at Constantinople. In October, cholera was reported
to be present on the Danube at Sulina and Galatz, and in November at
Tultcha. At the commencement of August an outbreak occurred in
Asia Minor at Brusa in Anatolia, a commercial town of considerable
size, with a port at Mundania on the Sea of Marmora. At this time
cholera was prevalent at the ports of Kherson, Nicolaiev, Taganrog,
and Eostov on the Don to the north ; and at Bagdad, and several
points in Turkish Kurdistan, in the vicinity of the Persian frontier,
and in the province of Azerbijan in Persia to the east and south-east.
Previous to the outbreak, cholera had spread largely along the courses
of the Euphrates and Tigris within the pashalik of Bagdad, and had
extended into Eastern and Northern Arabia. Erom Brusa, cholera
spread to the surrounding districts ; and, subsequently to the appear-
ance of the disease at Constantinople, cases occurred in the lazaret at
Salonica and in the vicinity of that town, and in the lazaret at Varna
in European Turkey, in the island of Cerigo, at St. Jean d'Acre on the
east coast of Asia Minor, and at Samsoun and Trebizonde on the north
coast, and at Amasia in the interior of Anatolia. The cases at Salonica
and Yarna occurred among passengers who had recently arrived there
by ordinary steam transit from Constantinople. The first case at St.
Jean d'Acre was landed from a Russian steam-vessel coming also from
Constantinople. On the loth of October an ill-furnished emigrant
steamship sailed from Stettin for JSTew York, touching at Copenhagen
and Christiansund. About a week after this vessel had left Christian-
sund cholera appeared among the passengers, 610 in number. She put
into Halifax, Nova Scotia, on the 6th of November, and introduced
cholera into that city and into the village of Chezetcook, twenty-five
miles north of Halifax. In the course of September two cases of
cholera were imported by steamships from Hamburg to England, both
into the port of Hartlepool. One of these cases, which ended fatally,
was imported on the 7th of the month ; the other, which recovered, on
the 1 8th.
While these events were taking place in Europe, cholera was also
spreading rapidly from the head of the Persian Q-ulf along the courses
of the Shat-el-Arab, the Euphrates, and the Tigris, within the pashalik
of Bagdad, in which province the disease had appeared at Meshed Ali,
in December of the previous year (1870). Early in the summer of
1 87 1 a Turkish expeditionary force became affected with cholera at
Bassora, as it was about to embark for Koweyt, and carried the disease
into Eastern Arabia. About the middle of June cholora broke out at
Hayel in the Djebel Shomar, Northern Arabia, introduced there, it is
stated, by an infected caravan coming from Meshed Hussein. Erom
Hayel the disease passed, two months later, to Khaiber, three days'
journey from Medina, and in September it broke out in the latter town,
at a time when numerous pilgrims were there. In November cases are
stated to have occurred at Mecca, and in December a severe outbreak
occurred on the east coast of the Red Sea, at G-onfudah, south of
474 EEPORT ON PUBLIC HEALTH.
Jedda. The disease appeared at Gonfudali among troops recently
arrived from Constantinople, and it prevailed chiefly among the garri-
son. Cases subsequently occurred at Jedda and Yembo towards the
close of the year.
The source of the remarkable diffusion of cholera in Europe during
1869, 1870, and 187 1, is a question of considerable interest, and of im-
portant practical bearing. Dr. Pelikan, the Director of the Imperial
Medical Department of Bussia, is of opinion that the diffusion was not
a new epidemic, but that it was a recrudescence of the epidemic of 1865,
an opinion which is shared by Dr. Fauvel.* Mr. Eadcliffe is unable to
accept this theory as sufficient to explain all the phenomena of the
diffusion. He calls attention to the fact that this diffusion was pre-
ceded by the most considerable development of cholera in North Persia,
particularly in the Caspian provinces of the kingdom, that had occurred
for several years. Previous outbreaks of cholera in North Persia of
like extent had been invariably followed or accompanied by the appear-
ance of the disease in Eussia. The history of cholera in Persia since
186^ is of much interest in relation to the subject under consideration.
The persistence and recurring activity of cholera in Persia from 1866
to 1 87 1, although paralleled by previous periods of long-continued pre-
valence of the disease — for example, from 1851 to 1861 — have led some
observers on the spot to question whether the malady is not becoming
naturalised in Persia. From 1865 to 1868 the general movement of
cholera in Persia had been from west to east.
With the return of a band of pilgrims from Meshed in July, 1868,
when cholera raged with great violence, a reverse movement began,
and with it indications of greater diffusiveness of the malady. This
diffusion, in the course of 1869, spread over the greater portion of
Northern, Western, and Central Persia, and throughout Irak-Arabi, in
the pashalik of Bagdad.
Mr. Eadcliffe is of opinion that the prevalence of cholera in Persia
cannot be rightly studied without, at the same time, a study of the
prevalence of the disease in India. Now, in 1867, cholera, which had
broken out with much fierceness among the multitude of pilgrims
assembled at Hurdwar for the great annual religious Hindu fair held
there, followed in the track of the pilgrims returning northwards
into Afghanistan, and towards the close of the year it was prevalent
at Cabul. In 1869 it again became epidemic over the whole of the
Bombay Presidency and Northern India, and spread anew into Af-
ghanistan. The great trade route between Persia and India through
Afghanistan, by way of Herat to Meshed, has been the track chiefly fol-
lowed in previous invasions of Persia by cholera migrating from Northern
India ; and Meshed, from its large commerce, as the principal centre of
trade between the two countries and Afghanistan, and also from its
being the focus of a great pilgrimage from all parts of Persia, has
always played a very important part in the diffusion of cholera when
the disease has been introduced there.
Mr. Eadcliffe thinks that the outbreak of cholera at Meshed in 1868,
and the subsequent diffusion of the disease from that city was more prO"
* * Bulletin de I'Academie de Medecine/ xxxvi, 694V
CHOLERA. 475
bably aa extension of the outbreak in Northern India in 1867, ^an a
revivication of the epidemic of 1865-67. At any rate, in Russia as in
Persia, before adopting the recrudescence theory, the better understood
eifects of reimportation during the migratory period of the disease must
be more clearly excluded.
The reappearance of cholera in an active form in Russia in 1869,
when the disease was prevalent in Northern Persia, is sufficiently intel-
ligible in the light of previous diffusions ; but the locality of tlie reap-
pearance, Kiev, an inland town of South Russia, and the absence of any
extension of cholera across the Russo-Persian frontier or to the Russian
coast of the Caspian, in either 1868 or 1869, appeared at first sight to
shut out absolutely any connection by importation in the ordinary
course of traffic between the two countries.
The result of investigations into the lines of traffic between the two
countries was to elicit the important fact that since 1 864 there had been
a great displacement of traffic between Persia and Russia in Europe.
Previous to the date given the main lines of traffic were by way of Astra-
chan and by way of Trebizonde; but since 1864 the traffic has been
largely diverted from these routes to routes traversing Transcaucasia to
the coast of the Black Sea at Poti, and thence to the ports of South
Russia. This route has been greatly promoted by the Russian Grovern-
ment, and still further to develop the traffic from Persia along the Poti
route, a railway has been projected from Poti to Baku, by way of Tiflis
and Elizabethpol, and will shortly be opened.
It is a most noteworthy fact that the outbreak of cholera in South Russia
should coincide with the wide prevalence of the disease in North Persia,
and the establishment of a direct and more rapidly traversed route of
traffic between South Russia and Persia. Mr. Radcliffe justly suggests
that a more probable explanation of the outbreak in South Russia in
1869 or 1870, and of the subsequent large diffusion of the disease in
Northern Europe, is to be sought in the movement of cholera, in some
way (from imperfection of data) as yet unknown, along the route into
Russia, rather than the assumption, less consistent with our knowledge
of epidemic diffusion of the disease beyond the limits of India, of th©
recrudescence of the well-nigh extinguished epidemic of 1865.
If this suggestion be correct, the establishment of the route by way
of Poti and the ports of South Russia, as the principal line of traffic
between Persia and Russia, is a matter which seriously affects the sani-
tary welfare of Europe, particularly when considered in connection With
the development of railway communication between Central Europe
and the Russian Coast of the Black Sea. With the completion of the
Transcaucasian railway it may be anticipated that " contagions current
in Persia will become current in Europe."
Cholera on the Tipper Nile. — Of great interest in connection with the
events above narrated by Mr. Radcliffe are the facts relating to the
recent prevalence of cholera in Nubia.* Cholera broke out in the Taka
country, in Upper Nubia, in June, 1872. This country, of which the
capital town is Karsala, lies between the rivers Atoara and Barca, and
communication between it and Egypt, is chiefly maintained through the
* * Cholera on the Upper Nile," The * Times,' January 3, 1872.
476 REPORT ON PUBLIC HEALTH.
port of Souakin, by way of the Red Sea. The Taka country is a dead
flat converted in the rainy season into an impracticable slough, but at
present under process of reclamation by the Khedive for the purposes
of cotton cultivation. It was among the labourers engaged in these
works that the outbreak of cholera occurred, and, according to reports,
brought among them by camel drivers from Souakin. Cholera prevailed
among the workers from the close of June to the close of August, when
it seismingly ceased ; but in October the disease reappeared, and spread
among the native tribes of the Taka country, This second outbreak
was of great severity, and it probably did not come to an end till the
beginning of December. Prom the Taka country cholera, in August,
extended to Berber. There it broke out with violence, and prevailed
until the beginning of October, causing a great mortality. On the 3rd
and 4th of September the deaths from cholera were reported to have
been 200. In September the disease attacked the tribes occupying the
country west of Berber, and it was carried by them southwards towards
Kordofan, and northwards into Dongola. Up the Nile, cholera appears
to have passed from Berber into the Halfaya district, where the disease
was probably present in November, and down the Nile, scattered cases
were reported as low as Korosko.
The probable source of this outbreak forms one of the most interest-
ing e-pisodes in the history of the late westward diffusion of cholera.
As already related in Mr. JRadcliffe's report, cholera spreading from the
head of the Persian Gulf was carried to Mecca and Gonfudah at the
close of 1 87 1. From Gonfudah the disease was carried by the troops
to Hodeida in the following February. In Mecca the malady was sup-
posed to have disappeared at the close of January, 1872. From the ipth
to the 23rd of February a great religious festival was held in ^lecca, at
which upwards of 80,000 pilgrims were congregated in and around tlie
city during those days. On the 27th of February cholera reappeared
in Mecca, the earliest cases being observed among the Takruri pilgrims ;
that is to say, negro pilgrims from Nubia and Central Africa. These
were in a most destitute condition. The number of pilgrims from the
west coast of the Eed Sea who attended the festival at Mecca in 1872
exceeded 2^00. Before the reappearance of cholera the greater number
of the pilgrims had left Mecca. Two great caravans, the Damascus and
the Egyptian had started about the 25th of February. Hardly had
these caravans got clear of the city when cholera appeared among them,
causing great mortality. Cholera was introduced by them into Medina.
In the track of the returning pilgrims, who diverged from Medina to the
sea coast, cholera reappeared at Gambo in March, and did not cease
until April. Jedda, however, escaped. In April, also, cholera is re-
ported to have ceased in Hodeida.
The outbreak of cholera in the Taka country followed upon the series
of events here related, and the disease is surmised to have been carried
to Taka from Hodeida by way of Souakin. The particular steps of the
transmission are not known. The time of the outbreak followed close
upon the time'of the return and passage of Takruri pilgrims from Mecca
by the Souakin route ; and it is known that cholera first shewed itself
among these pilgrims when, at the close of February, it reappeared in
CHOtERA. 477
that city. To what extent Europe owes its safety from last year's out-
break of cholera in the Hedjaz to the energetic measures adopted by
the Egyptian Government, to prevent the introduction of infected
pilgrims into Egypt, and their passage through the Suez Canal to ports
in the Mediterranean, it would be difficult to say. But the preventive
measures taken were well conceived and well carried out, and they
offered the greatest chance of protection to Europe from the importation
of the pestilence.
The comparatively light diffusion of cholera in Upper Nubia appeals
to have been to some extent due to the military cordons established by
the Egytian Government.
Cholera in tJie British islands. — Considerable apprehension was
entertained in this country during the course of both 1871 and
1872 of an invasion of our shores by Asiatic cholera; and, indeed,
England was on more than one occasion invaded by the disease,
though, thanks to the precautions taken, no extension of the disease
occurred.
Having for nearly two years been in Eussia,* and since August, 1870,
more or less in St. Petersburg, cholera in the spring and early summer
of 187 1 spread somewhat considerably in the Baltic provinces of
Eussia, and at the end of July began to touch the contiguous parts of
Germany, when, soon after, Konigsberg suffered most severely. With
cholera actually epidemic at St. Petersburg, Cronstadt and Eiga, and
likely soon to become epidemic at parts still nearer to England, it was
evident that ships from the Baltic might in certain cases be a source of
danger to this country. Since quarantine in this country was not to
be thought of, the steps taken by the British Government were mainly
these: — Local authorities (and especially port authorities) were warned
of the danger in question, and were advised of the precautions which
in the present state of our knowledge are regarded as of most value
against the infection of the disease ; and every legally possible facility
was given for the local exercise of such precautions. Eacili^es were
given for the examination of ships arriving from the Baltic ; and a
central inspector visited our ports to confer with the local authorities
as to the provision of hospital accommodation, &c. Never before was
the extension of infection from the first imported cases so successfully
and completely met.
Ground water. — Pettenkoferf returns to the subject of the influ-
ence of ground water on cholera and typhoid fever in a paper on
typhoid, cholera, and ground water in Ziirich. Spite of the opposition
his views have met with, and the facts urged in refutation of the
validity of his conclusions, Pettenkof er still adheres to his now well-
known views on this subject.
Diffusion of cholera in India. — PettenkoferJ in a small work has
entered into an examination of the recent reports on cholera in India by
Macpherson, Murray, Macnamara, Cunningham, Lewis, Bryden, &c., and
* " First Report of the Local Government Board," p. Iv.
t ' Zeitsehrif t f. Biologie/ vii, p. 86.
X 'Verbreitungsart der Cholera in Indien.' Braunschweig, 1871. ' The Diffusion of
Cholera in India.' Translation in 'Indian Annals of Med. Science,' No. xxix,
pp. 176—300.
478 EEPOUT ON PUBLIC HEALTH.
states liis own conclusions in the following theses. ( i) In India there arc
one or more regions in which cholera has had its endemic site since the
most ancient times with a prevalence fluctuating according to the season
of th« year. The cause of the disease and its endemicity cannot be looked
for in the people living there, but is to be looked for in a yet un-
known relation between the specific disease-germ and the soil and
climate. (2) Cholera in India has at all times periodically difi"used
itself in the form of epidemics from the endemic districts over other
tracts of land. As the means of diffusion some people in India assume
the currents of air, specially the monsoons (the miasmatists, Bryden),
others human intercourse, specially through the excreta of cholera
patients (contagionists, Macnamara), while others allow the diffusion
in both these ways. The proposition goes on to state that neither of
these views sufficiently explains the facts, but that along with human
intercourse there must be certain local and periodical conditions, and
that diffusion by currents of air alone is certainly not in harmony
with what has been observed in India. (3) That which determines the
local thriving of the cholera germ, which may be called ^, does not
proceed from the human organism, but from the localities due to yet
unascertained processes in the soil. This principle applies not only to
the endemic circle but to all places in which epidemics of cholera arc
developed. The substratum furnished by the locality or soil, on which
the local and periodical disposition for cholera epidemics is depen-
dent, may be called y. The cholera germ x is able to travel witli
human beings, the true substratum y is associated with the locality.
(4) That part of the cholera process which goes on in the soil, and on
which the periodic rhythma of cholera prevalence is essentially depen-
dent, both in the endemic and epidemic regions, requires, in addition t-
other conditions, a certain medium amount of soil moisture. Both grea .
persistent dryness (as in deserts) and excessive continued moisture (as
in the Ganges Delta towards the end of the rains) of the soil are alike
unfavorable to cholera. On this account, it happens that in the dr}
and hot districts with scanty rain-fall, which abound in Upper India,
cholera usually prevails in association with the rains (summer or
monsoon cholera), whilst in the moist and hot regions with very abun-
dant rain-fall prevailing in Lower Bengal, cholera abounds in the
rainless spring (spring cholera of Calcutta) and is put to flight again
by the monsoon rains. Places which, like Madras, under otherwise like
conditions, stand as regards their rain-fall in the mean between Lahore
and Calcutta, show also, with tolerable regularity, spring and summer
cholera in one and the same year.
"Whenever, as the result of altered conditions of rain and temperature,
the moisture or soil- water conditions in a place deviate from the formerly
existing rule, the periodical rhythma and prevalence of cholera of that
place are likewise altered, so that such a place, for example Bombay,
instead of prevalent spring cholera, can also exceptionally have monsoon
cholera and vice versa.
One and the same amount of rain acts on differently associated soils,
and on soils which differ in their dryness or moisture in entirely different
ways. Just such diversities as are dependent on the reception of water
CHOLERA. 4^ 9
by various soils, are also rendered prevalent by the dispersion of it into
the atmosphere through evaporation. Soil and soil-water conditions may
be regarded as causes of temporary or permanent immunity. (5) In
addition to the cholera germ x which is diffused by intercourse, and the
cholera substratum y which represents the local and periodical dispo-
sition, the number of attacks is essentially dependent on the individual
predisposition, which is very considerably less among the native Indians
than among the Europeans. Among the natives, again, the inhabitants
of hill countries show a greater individual predisposition than the in-
habitants of the plains. (6) Ships at sea never generate y, or, in other
words, they are never in themselves possessed of the local or periodical
disposition, and are, therefore, to be regarded as exempt localities. In
so far as cholera occurs on board ships, it always originates on shore.
In the greater majority of cases the persons who are attacked on board
a ship were already infected when they came on board, and are unable
to transfer the disease to others who were not on shore, or who, previous
to embarcation, were in no infected place. Only ii^ a very few cases do
people sicken who have not been on shore, and these cases also take
place invariably only subsequent to some communication of the ship
with the infected land. In these cases, moreover, it must not be assumed
that the infection occurred independent of the co-operation of the soil
(y), or that they prove it to be unnecessary, but that the communication
with the land has procured a sufficient quantity of the infectious mate-
rials, which was generated there in the ordinary manner (from x and
y), and which, probably under certain circumstances, must enter into
some further alteration, or attain a certain ripeness on board the ship
before the infection can make itself known. (7) The use of various
drinking waters, possible contaminated with the excretion of cholera
patients, can in nowise explain the local and periodical appearance of
cholera in India.
For the further details of this elaborate paper we would refer readers
to the original itself, or to the admirable translation by Dr. Cunningham
from which we have quoted.
Dr. Cunningham* has himself written an excellent report on cholera.
This observer states that in the town of Madras, and in its immediate
neighbourhood, cholera is least prevalent during very dry and very wet
seasons. Palaveran, a place nearly exempt from attacks of the disease,
and St. Thomas's Mount, without any apparent differences in their
soils, show a remarkable difference in their liabilities to be attacked by
cholera. In the Neilgherries many facts seem to be in favour of the
j soundness of Pettenkofer's theory, and the general immunity of the
j Neilgherry plateau appears to be quite in accordance with the require-
ments of the subsoil theory. The facts are nevertheless susceptible of
explanation by several of the current hypotheses, though that of the
pure contagionists entirely fails ; and the immunity experienced must
be ascribed to some of the physical conditions under which the inhabi-
tants of the district live. At Salem, again, the facts are in accordance
with Pettenkofer's views, but are inexplicable on the diffusion-by- water
hypothesis alone. He concludes thus :
* ' Seventh Annual Report of the San. Com. of the Gov. of India,* p. 139.
480 REPORT ON PUBLIC HEALTH.
ist. That with the present extremely imperfect data it is quite pre-
mature to decide exclusively in favour of any one theory regarding the
localisation of cholera.
2nd. That several of the existing theories may really involve partial
truths, and that they only become incompatible with one another when
insisted on as absolute and entire explanations.
3rd. That although in the report much stress has been laid on tlie
soil theory it is not on account of any assumption of its essential
superiority to the others, but because it appears to be little understood
in this country (India), and to be regarded with a considerable amount
of prejudice in consequence. It has seemed to Dr. Cunningham, there-
fore, very desirable that the existence of any facts in its favour should
be distinctly put forward, and the more so that there seems to be
enough of these to forbid the wholesale rejection of the theory, and to
warrant the continuance of careful observations which may teach in
time the laws of the association of ground moisture with the propaga-
tion of cholera.
Dr. Zehnder's report on the cholera epidemic in Zurich in 1867* con-
tains much valuable information on the origin and diffusion of this
disease. He regards water-closets contaminated with cholera de-
jections as the most common cause of contagion, from the germs
getting into the air and thus gaining access to the alimentary canal.
He did not observe that drinking water played any important part in the
diffusion of the disease. Meteorological conditions did not seem to
exert any special influence on the spread of the epidemic. The year
was very rainy. The nature of the soil, as well its configuration, its
elevation, and geological formation, especially in reference to the sub-
soil water, were likewise without apparent influence on the spread of
the epidemic. A comparison of the levels of the ground water with the
daily number of cases of cholera, showed that at the time of the out-
break the surface was tolerably dry ; at the end of August (the time
when the disease was spreading) the rain had caused an increase in the
moisture of the soil, while in September the moisture increased as the
epidemic gained in strength. From the middle to the end of the month,
at which time the epidemic ceased, the moisture gradually diminished
till it reached the same condition of dryness as at the time when the
outbreak occurred. Hence the disease began with a dry condition of
the soil, gained energy as the moisture increased, and again became
less active as the dryness returned. Accumulations of filth outside the
houses exercised little or no influence on the diffusion of the disease,
but the accumulation of moist sewer gases in the interior of houses
exercised a most prejudicial effect and greatly contributed to the spread
of the contagion. iThe paper concludes with a description of the
methods taken and recommended for checking the diffusion of the
disease : — (i) Absolute prevention of access to water-closets in a house
once infected after disinfection of the same, and the use of utensils
which are to be carefully disinfected and emptied out of the house ;
(2) the formation of privies for the convenience of those in whose
houses or neighbourhood cases of cholera have occurred, but whose
* Virchow and Hirsch's * Jabresb.,' 1871, ii, p. 214.
CHOLERA. 48l
mode of life renders it impossible in them to avoid the infected
spots.
Erichsen* investigates Pettenkofer's subsoil water theory in re-
ference to diffusion of cholera in St. Petersburg, and comes to the
conclusion that in reference to this town it is insufficient to account
for the facts observed in regard to the outbreak and spread of the
disease.
Pfeiffer,t who is a firm believer in Pettenkofer's subsoil water
theory, writes on the influence of temperature of the soil on the origin
and spread of cholera. He believes that the temperature of the soil, in
addition to the state of humidity and state as regards putrefactive
changes, exercises a very important influence on the causation of
cholera and its allies. As to arctic regions there are no data on which
to build, and in the tropics the uniform temperature of the soil can
have little influence. In reference to temperate climates, however,
Pf eifler finds that the acme of an epidemic of cholera coincides with the
season of the greatest superficial temperature of the soil ; that the
cholera diminishes with the rapid decrease of the temperature, and that
when the soil has a temperature under 41° — 45° Fahr., the disease en-
tirely disappears. The causes of the variation in soil-temperature are of
course numerous, such as the temperature of the air, the conductivity of
the soil, the humidity, &c. The value of each of these factors the
author has studied in the epidemic at Weimar in 1870. The facts are
as yet too few to allow of very general conclusions being drawn, but
he thinks that more attention should be paid to a subject which
is likely to throw much light on the etiology of cholera and other
Causes of cholera. — Honert:}: believes that cholera depends on poison-
ing with ammonia which is set free along with so-called marsh gaa
during the decomposition of nitrogenous substances. Cholera and
malarious fever have, therefore, a similar origin. Cholera germs are an
absurdity, and the disease is truly autochthonous.
Earth § also supposes that cholera is due to the action of a specific
poison generated in the earth, and that this poison paralyses the
nervous system. Communication from one person to another is an un-
warrantable supposition. The poison is evolved into the air or becomes
dissolved in the water in the ground, and so gains access to the system.
Cholera contagion. — Popoff || has made several experiments in regard to
the infecting power of cholera excreta, and has compared the efi"ects pro-
duced by putrid infection. His experiments were made on dogs. As
material for putrid infection he used infusions of putrid meat and rotten
yeast, and for cholera he employed the vomited matters, faeces, and urine,
in a fresh condition. The materials were introduced partly into the cir-
culation direct, partly into the alimentary canal. The differences be-
tween the symptoms and post-mortem appearances in the two cases
* 'St. Petersburg Med. Zeitschr.,' i, p. 325 ; ii, pp. 437, 537.
t ' Zeitschr. f. Biologic,' vii, p. 263.
t Virchow and Hirsch's ' Jahresb.,' 187 1, ii, p. 222.
§ Ibid., p. 222.
11 'Berlin Klin. Wchnschrft.,' 1872, p. 393.
31
482 REPORT ON PUBLIC HEALTH.
are accurately and minutely detailed. Of the latter the most charac-
teristic differences are observable in the alimentary canal. In putrid
infection the signs are those of simple gastro-enteritis hsemorrhagica
(Bergmann) without special affection of the lymphatic glandular
apparatus, while in cholera these are affected in a marked degree.
He draws the following conclusions :
(i) Cholera excreta are undoubtedly contagious, as well the vomited
matters, as the dejecta and the urine. (2) Cholera excreta are
specially contagious in the fresh condition. (3) Decomposed excreta
cause a modification of the choleraic symptoms and induce a con-
dition resembling putrid infection. (4) The infection can be caused
by direct introduction of the poison into the blood, without having
passed the alimentary canal. (5) The action of the cholera poison does
not begin at once, but generally after one to three days or longer.
Organisms in cholera. — In a paper on the micrography of cholera,*
Nedsvetzki states that from his microscopical investigations of
cholera blood and cholera excreta he has been able to confirm the
statements of Klob, Thome, and others, and he likewise claims to have
made some fresh discoveries. In the dejecta, vomit, and urine of
cholera patients he finds in all, (i) an upper layer consisting of oil-
globules of various sizes ; (2) a great number of epithelial cells more
or less altered such as occur in diphtheritic products ; (3) the cells are
all filled, as well as the fluid in which they occur, with myriads of
actively moving organisms. These organisms are of various forms ;
granules single and united in a rosette form, rod-shaped organisms,
a granular mass composed of minute cellules. These he calls cholera-
bacteridia; (4) red and white blood-corpuscles filled with the same
organisms; (5) mucus; (6) occasional spores resembling those of
aspergillus and penicillium.
In the blood from the skin, theVeins, and the heart, he found a greater
or less number of fat-globules. In all cases he found the red blood-
corpuscles more darkly coloured and less transparent than usual. The
darkest blood was found in the parenchyma of the lungs. The white
blood-corpuscles were not increased in number. The chief difference
appeared to be that in many cases they had passed into a granular
mass and had lost their individual contours. The granules after a time
began to move like the previously described organisms.
The blood in the capillaries, as studied in fine sections of the skin
hardened in chromic acid, exhibited between the corpuscles finely
granular masses composed of organisms like the first of those described.
He also states that the expired air of cholera patients contain bacte-
ridia. These he regards as the carriers of cholera infection. In the
paper (' Moscaner Med. Zeitung ') in which his researches are pub-
lished at length, the author enters into other investigations into the
nature of cholera parasites, but which are not here detailed.
Enteric Fever.
Foreign journals f for the year 1871 are rich in contributions re-
* ' Centralblatt. f. d. Med. Wissench.,' 1872, p. 232.
t Vide Virchow and Hirsch's * Jahresb.,' 1872, ii, p. 226.
^ ENTERIC FEVEll. 483
specting the epidemics of enteric fever which occurred in reserve and
field lazarettes during the late Franco- German war. Many of these
discuss specially the etiology of the disease, and more than ordinary
attention has been directed to the question of its diffusion by the
agency of drinking water. Wohlrab * gives a very interesting account
of a small epidemic which occurred in the spring of 1870 in the
village of Oberwiesenthal, situated 2800 feet above the sea level. The
water supply was conveyed through wooden pipes which were found to
be in a very filthy state, and so laid that the oozings of open cesspools
could easily gain access and become mixed with the water. The
disease spread in such a way as to preclude the possibility of diff"usion
by communication from one person to another. The sudden occurrence
of the malady in five houses simultaneously pointed to a common
cause. This was traced to contamination of the water supplied to
these five dwellings, by the dejecta of the first case which occurred,
by oozings from the cesspool into which they were thrown. Subsequent
cases occurred traceable to a similar cause. The water was found to
contain a large proportion of chlorides. The large quantity of rain
which fell during the season was considered to have been the means
whereby the mixture of cesspool oozings and the water in the main
cisterns was effected.
Eeichjt who investigated an epidemic of enteric fever which pre-
vailed in Salzbach from June 1870 to January 187 1, though unable to
determine how the disease was imported into the town, traced the
diffusion of it to a running well which had become contaminated by the
overflow of a cesspool situated near it. That this was the source of
the spread of the disease appeared from the following facts : — (i) That
the disease occurred only in those houses which were supplied from
this well, while all the other houses immediately in the vicinity of the
infected ones, but which got their water supply from pump wells, re-
mained quite free from contagion. (2) The epidemic ceased and no
new cases occurred after the cleansing of the cistern and stoppage of
the flow from the welL (3) Analysis of the water proved that it con-
I tained a very large amount of organic matter, which must have come
from external sources, as the well itself was a granite spring.
; Raymond J attributes the diffusion of typhoid in Brussels in the
i spring and summer of 187 1, not so much to conveyance of the con-
j tagion by water, but rather to meteorological conditions and to the
! effluvia from sewers.
! Socin § has investigated the relation of typhoid in Basle to the state
j of the subsoil and the rainfall. His conclusions are : — (i) In all pro-
bability unusual dryness favours the development of typhoid in Basle,
while increasing moisture checks it. (2) The intensity of the epidemics
cannot be explained by the degree or rapidity of the variations in
humidity. (3) The epidemics occur usually in the second half of the
* 'Arch. d. Heilk.,' 1871, p. 134-
t ' Aerztl. Mittheil. aus. Baden,' No. 15, 187 1.
i ' Archiv. Med. Beiges,' Juin, 1871, p. 385.
§ * Typhus, Regenmenge und Grundwasser in Basel, Inaug. Diss.' Basel, 187 1,
PP* S9> 231. Virchow and Hirsch's * Jahrsb,' 1871, ii, p. 231.
484 REPORT ON PUBLIC HEALTH.
year and follow increasing humidity ; whence it remains undetermined
whether, in contradiction to the first proposition, humidity favours
the development of typhoid, or whether it is a late effect of the
previous dryness, or whether it is entirely due to temperature. (4)
The movements of the disease are the same in all parts of the city,
whether high or low, or near or at a distance from the Ehine. (5)
The epidemic does not select one part of the city more than another.
Mr. De E-enzy* has given a remarkable instance of the extinction of
enteric fever in a prison by the simple method of changing the supply
of drinking water. For many years some of the ablest of our
metropolitan physicians failed to detect the true cause of the un-
healthiness of Millbank prison, and assigned various causes for it which
later experience has proved to be unconnected with it. Enteric fever
was rife from time to time in the gaol. In the year 1 854, however,
the water supply was changed with the best possible results. Pre-
viously, the water used for drinking purposes in the prison was
pumped direct from the Thames, but was of course filtered before
use. The water used for domestic purposes is now supplied by the
artesian well in Trafalgar Square. The change was carried into effect
in the midst of the cholera epidemic which was then so severely
visiting London, and the prison was suff'ering from cholera at the
time. Six days after the change the disease suddenly ceased, and a
marked improvement took place in the health of the prisoners. Erom
the date of the introduction of the new water supply up to April 1872,
a period of nearly 19 years, there have been only three deaths from
enteric fever, viz. one in 18^5, one in i860, and one 1865.
Mr. De Eenzy thinks that the sanitary history of Millbank — which
he gives in detail — appears to warrant the following conclusions :
I. That the extinction of enteric fever, and other diseases of the
same class, is quite within the range of practicability. 2. That the
extinction of one class of zymotic diseases is not necessarily followed
by zymotic diseases of a different class. Eor example : — It is supposed
that the increased prevalence of scarlatina and measles of late years
is due to the partial displacement of smallpox by vaccination. The
case of Millbank shows that it is practicable to protect a community
against every kind of zymotic disease. Ignorance of sanitary science
is the great obstacle to the extension of this protection to the free
population. 3. That since some of the ablest physicians in London
failed for many years to detect the true cause of the unhealthiness of
Millbank Prison, and assigned causes for it which later experience
has found to be unconnected with it, the probability is that a similar
error is frequently made elsewhere, and that the -prevalence of some
zymotic disease is ascribed to locality, malaria, heat, cold, variations
of temperature, moral depression, and other intangible influences
which would be entirely removed by the general disuse of impure
water. 4. That as it required long years of observation to establish
the noxious influence of Thames water in Millbank, even when well
filtered, under conditions very favorable for detection, we should be
* 'Lancet,' 1872, i, pp. 787, 820.
ENTEKIC FEVER. 485
cautious in accepting the opinion, based on the results of chemical
analysis, that the use of that water by the population of London is free
from danger.
The ' Second Annual Eeport of the State Board of Health of Massa-
chusetts'* contains a number of queries and the replies to them, from
medical men in 163 towns in the State, in reference to the causes of
enteric fever.
The following is a statement of the questions and answers :
(i) Have you observed a difference in the prevalence of this disease
between houses supplied with water from wells about the premises and
houses supplied with water conveyed from springs or from ponds of
unquestionable purity ? — Iteplies "• " Yes," 23 ; "no difference has been
remarked," 71 ; whole supply of towns from wells, 18; indefinite, 51.
(2) Can you inform us whether, at times, when typhoid prevailed,
the water of the wells was rising or falling, and whether it was higher
or lower than the average for the year ? (To this question is appended
a note recommending observation of the height of the subsoil water in
future, if attention had not previously been directed to it.) — Eeplies :
Eising after being very low, 11 ; falling, 16; very low, 28; "have not
observed," loo.
(3) Have you observed any connection between typhoid fever and
foul soil, whether from privies, pigsties, manure heaps, or similar collec-
tions of decomposing matter lying on the ground ? — Eeplies : Yes, 79 ;
no, 45; doubtful, 39.
(4) Have you observed any connection between typhoid fever and
putrid air, whether from rotting vegetables in cellars, bad drains, un-
ventilated living or sleeping rooms, or from any other cause ? — Eeplies :
Yes, 90; no, 36; doubtful, 37.
Ten towns report that typhoid is a disease almost entirely unknown
among them, and they can assign no reason for this. In a table is given
the mortality from typhoid fever in the urban population of Massa-
chusetts during the last ten years, from which it appears that in 147
cities and towns of more than 2000 inhabitants the average annual rate
of mortality from this disease was 0*755 P^^ 1000 persons living; whilst
in 184 towns of less than 2000 inhabitants the average annual rate of
mortality was so much as 1*189 P^^ "looo persons living.
Typhoid is more prevalent in the smaller rural towns than in the
large manufacturing towns, but the mortality from all causes is higher
in the latter. Decomposing organic matter is considered in the report
as the proximate cause of enteric fever.
Typhus. — Grrun f is of opinion, from his investigations into the epi-
dem'ic of typhus in East Eussia, in 1867 and 1868, that the disease is of
autochthonous origin, and springs up where filth, poverty, and bad air
prevail, and where vegetable and animal organisms find a suitable nidus,
and develope a poison which disseminates itself further by way of con-
tagion.
VirchowJ has convinced himself that there are no sufficient grounds
* ' Dublin Quart. Journ. of Med. Sci.,' li, p. 480.
t ' Vierteljahrschr. f . Gerichtl. Med.,' xiii, p. 203.
X ' Virchow's Archiv,' 53, p. 134.
486 REPORT ON PUBLIC HEALTH.
for believing in the spontaneous genej-ation of this disease, and that it
can, as a rule, be traced to contagion.
Pastau* describes an epidemic of typhus which prevailed in Breslau
from 1868 to 1869. The disease followed close on an epidemic of re-
lapsing fever, and spread particularly in those districts in which relapsing
fever had raged. In all, there occurred 738 cases, 419 of which were
among men, and 319 in women; 78 persons survived both diseases.
Nearly the half of the cases fell between the ages of sixteen to thirty-
five years. The mortality, on the average, was i4'92 per cent., and in-
creased with age. During the prevalence of the typhus epidemic, cases
of enteric fever were less numerous. Etiologically, according to
Pastau, typhus seems to have something in common with relapsing
fever. Good results were obtained from the cold water treatment.
With this treatment the mortality was 9*23 per cent, during the first
week, and 14" 66 per cent, in the second week, against a percentage of
t6*47 when the expectant treatment was followed.
Belapsing fever. — Tennentf communicates a very interesting series
of observations on the epidemic of relapsing fever in Q-lasgow in 1870.
The origin of the epidemic was traced to infection from Edinburgh.
From this focus the contagion spread, and reached its height in the
middle of December. About 1200 in all were aff'ected, a very small
number when compared with the epidemic of 1843, on which occasion
as many as 32,000 cases occurred. The disease prevailed almost exclu-
sively in the poorer districts of the town. The disease was very infec-
tious, so that out of 352 cases, infection was clearly traced in 29 j.
Nearly all the occupants of the same house were affected about the
same time. This was evidently dependent on faulty hygienic condi-
tions, since of 80 nurses and attendants in the hospital only 16 cases of
the disease occurred. It was also observed that in proportion to the
increase in the number of cases of relapsing fever those of typhus dimi-
nished, a fact which was likewise observed in London and Edinburgh.
The paper gives a full account of the symptoms and sequela; of the
disease. The mortality was small, only 6 fatal cases occurring out of a
total of 352 cases.
Tennent did not observe the ophthalmia described by Mackenzie
among the sequelae.
Charteris,J however, had opportunity during this epidemic of study-
ing this "post-febrile ophthalmia," of which he gives a detailed
account.
The reappearance of relapsing fever in the southern district of the
metropolis at the close of 1872 was followed by its appearance in Man-
chester in the Pottery District, and led to the issue, by the medical officer
of the Local Government Board, of a memorandum on the chief practical
points to be borne in view by the sanitary and other authorities
responsible for taking precautions against the disease and its conse-
quences.
* * Centralblatt f. die Med. Wissensch.,' 1871, p. 362.
t * Glasgow Med. Journ.,' May, 187 1, p. 354.
X Ibid., p. 347.
SMALLPOX. 487
Scarlet fever. — Dr. Alfred Carpenter* propounds some new ideas re-
garding the causation of scarlet fever. He brings forward a number of
lacts relating to the diffusion of this disease in Croydon, which seems
to warrant the conclusion that scarlet fever may originate, de novo,
i'rom the decomposition of blood outside the organism under certain
imknown conditions. The fatal cases of scarlet fever occur in Croydon
chiefly in three places, which have this in common, that they are in the
neighbourhood of slaughter-houses, from which the drainage is imperfect.
He holds that, unlike typhoid, scarlet fever is independent of the sanitary
state of the district, inasmuch as it prevails to a great extent where good
drainage, &c., has driven typhoid away. Cases are given where scarlet
fever broke out, and proved very fatal, in new houses which had been
built on land previously manured with blood from slaughter-houses.
Copeman f believes that the scarlet fever miasma is diffused chiefly
by the faeces, and hence he recommends that these should be thoroughly
disinfected.
Dr. Geo. Johnson J considers that the infective period of scarlet fever
lasts over a month from the first day of the disease. The carriers of
the poison are the secretions of the throat, the nose, and the epidermic
scales. Also the fseces and the urine may carry the contagion. He
recommends as prophylactic treatment the isolation of the patient and
burning a fire night and day in the apartment. All carpets, &c., must
be removed, and the attendants must wear easily washed clothes,
and avoid intercourse with other persons as much as possible. Excreta,
urine, &c., must be carefully disinfected.
In order to avoid infection from the skin, the patient should be
bathed, once or twice a day, as long as desquamation goes on, in a warm
bath, and afterwards rubbed with camphor oil, or better, with carbolic
acid soap, during the bath.
When the patient is well, the room and everything in it must be
thoroughly cleaned out and disinfected. The doors and windows
of the room should be left open for a long time, and a fire kept con-
tinually burning in it.
Children living in a house where scarlet fever prevails must be kept
from school, in order to avoid any risk of their propagating the contagion.
Smallpox. — The year 1871 was chiefly remarkable at home through
the prevalence, first in London, and afterwards generally in England,
of a far severer epidemic of smallpox than any which had been wit-
nessed of late years, or probably since the general use of vaccination. It
appears to have killed in England, within the year, nearly 23,000 persons,
including 7876 of the population of London. § The severity of the epi-
demic became evident in two ways — first, by the extraordinary multitude
of persons whom the disease attacked, and secondly, by the extraordi-
nary intensity of the disease in the individual cases. To illustrate the
latter point, it may suffice to mention that at the London Smallpox
Hospital, where 950 cases were treated during the year, the deaths, in
* 'Lancet/ 1871, pp. no, 148.
t ' St. George's Hosp. Rep.,' vol. v. No. 3, p. 55.
X ' British Med. Journ.,' 1870, ii, p. 315.
§ ' First Report of the Local Government Board,* 1871-72, p. Hi, (blue book).
488 REPORT ON PUBLIC HEALTH.
proportion to the cases, were nearly twice as many as the average ex-
perience of the hospital for thirty-two years would have prognosti-
cated.
This great epidemic of smallpox was not confined to our own country,
and though authentic information cannot be quoted as to all the diffu-
sion of the disease in Continental Europe, facts enough are known to
justify the belief that, at least in the north-western parts of the Con-
tinent, the power of the epidemic was as great as here.
The lessons of this epidemic, in reference to the value of vaccination,
afford some very suggestive facts for comparison. In the chief towns
of Holland, where vaccination is non-compulsory, and where, as a rule,
the children are long left unvaccinated ; in Hamburg, with non-
compulsory vaccination ; in Paris, where not only vaccination is non-
compulsory, but where also, at least some years ago, there were strong
grounds for suspecting the quality of much of the current vaccination ;
— in all these places the epidemic seems to have raged with very much
more severity than even in London; and Hamburg, which, though
having but a tenth part of our London population, suffered nearly two
thirds as many deaths as London, has now, under influence of this
terrible suffering, been led for the first time to pass a law of compulsory
vaccination.
The proceedings taken by the Local Government Board for Eng-
land, with reference to the epidemic of smallpox, consisted in endea-
vours to move local authorities to resist the disease in their respective
districts by duly administering, first and above all, as specially appli-
cable to the case, the provisions of the vaccination law, and secondly,
those provisions of nuisance law which apply to all dangerous infectious
disease, and are meant to secure the isolation of the sick and the dis-
infection of infected houses and things. The extensive diffusion of the
disease in England brought into prominence the evil results of the
general want throughout the country of hospital accommodation for
cases of dangerous infectious disease.
The epidemic brought also into strong relief two popular errors with
regard to re- vaccination. First, the error of not having it performed on
each person (irrespectively of any immediate alarm of smallpox) on his
attaining the age of puberty, and secondly, the error of seeking under
panic to have it performed indiscriminately again and again. Under
the influence of these two errors, Mr. Simon states,* the first allowing
an indefinite accumulation of postponed cases, and the second giving
swarms of needless, or relatively needless, re-applicants, the demand for
re-vaccination, under alarm of this great epidemic, was such as medical
practitioners could not by any possibility at once meet without sacri-
ficing the cardinal conditions of safe vaccination.
It is stated in a reportf that the necessity of re-vaccination when the
protective power of the primary vaccination has to a great extent passed
away, cannot be too strongly urged. No greater argument to prove
the efficacy of this precaution can be adduced than the fact that, out of
* Loc. cit.
t * Report of a Committee of the Managers of the Metropolitan Asylum District,
&c., 1872.' Pamphlet.
SMALLPOX. 489
upwards of 14,800 cases received into the hospitals, only four well-
authenticated cases were treated in which re-vaccination had been pro-
perly performed, and these were light attacks. Further conclusive
evidence is afforded by the facts, that all the nurses and servants of the
hospitals, to the number at one time of upwards of 300, who were
hourly brought into the most intimate contact with the disease, who
constantly breathed its atmosphere, and than whom none can be more
exposed to its contagion, have, with but few exceptions, enjoyed com-
plete immunity from its attacks. These exceptions were cases of
nurses or servants whose re-vaccination, in the pressure of the epi-
demic, was overlooked, and who speedily took the disease ; and one case
was that of a nurse who, having had smallpox previously, was not re-vac-
cinated, and took the disease a second time.
The medical officer of the Homerton Fever Hospital* (used during the
smallpox epidemic for smallpox patients) gives tables, embodying the
experience of that institution, to disprove a very common error, viz.
that more vaccinated than unvaccinated persons are attacked by small-
pox, and states that the real truth is that vaccinated persons, and by
vaccinated persons he means only properly vaccinated persons, form but
a very small proportion of those attacked by smallpox. Looking at the
cases, divided into those occurring before and after puberty, he finds
the case stands thus with regard to patients treated in the above-men-
tioned hospital. Of 41 1 of smallpox vaccinated and unvaccinated, only
17 had been vaccinated according to the standard of the vaccine insti-
tution, and 4 according to Mr. Marson's standard, i. e. that of 41 1
smallpox patients, but 21 had been vaccinated properly. The pro-
portion of well- vaccinated persons attacked by the disease after puberty
was higher than under that age, but it was still true that well-vacci-
nated persons formed but a small proportion of the smallpox cases. Of
549 cases occurring after fifteen, 32 only had been vaccinated according
to the directions of the vaccine institution, and but 13 according to
Mr. Marson. Taking all the cases together, and assuming the two
standards referred to as equally good, it was found that of 1000 cases of
smallpox, 6^ only had been efficiently vaccinated, the other 93 j had been
inefficiently vaccinated.
Another table is given showing the importance of quality in vacci-
nation, and illustrating the influence of different kinds of vaccination in
determining the severity short of death. Not a single severe case
occurred in a vaccinated child, and only 7 well vaccinated children had
the disease, and these in a very mild form. Of 152 cases of severe
smallpox occurring after twelve years of age, 51 per cent, occurred
amongst the unvaccinated, 23 per cent, amongst the badly vaccinated,
4 per cent, amongst the fairly well vaccinated, and amongst the well
vaccinated there was but one case.
A select committee of the House of Commons sat in the session of
1870, and arrived at these among other conclusions :t — That the cow-pox
affords, if not an absolute, yet a very great protection against an attack
* 'Report of the Medical Officer of the Homerton Fever Hospital for 187 1-2.'
Pamphlet.
t Report. Vaccination Act (1867). Blue book.
490 REPORT ON PUBLIC HEALTH.
of smallpox, and an almost absolute protection against death from that
disease. That if the operation be performed with due regard to the
health of the patient vaccinated, and with proper precaution in obtain-
ing and using the vaccine lymph, there need be no apprehension that
vaccination will injure health or communicate any disease. That
smallpox unchecked by vaccination is one of the most terrible and
destructive of diseases ; as regards the danger of infection, the pro-
portion of deaths among those attacked, and the permanent injury to
the survivors, and therefore that it is the duty of the State to endea-
vour to secure the careful vaccination of the whole population. As a
consequence of the recommendations of the select committee, the
A^accination Act, 1871, was passed, the provisions of which must be
known to the readers of this * Eetrospect.' The bulky report of the
select committee contains a mass of extremely valuable matter re-
lating to vaccination and re-vaccination, including all that can be said
against the operation.
Scurvy. — Much interesting matter has been published relative to a
scorbutic epidemic which prevailed in Paris during the winter of the
siege of 1870-71.* As regards the etiology of the disease, Dr. 0.
Berger is of opinion that scurvy was brought about by the following
causes : — Depressing mental influences ; undue bodily exertion, as well
as want of exercise; overcrowding; cold; alteration in diet, more
especially the want of fresh vegetables ; want of food, and this was the
chief cause of the epidemic. An insufficient quantity of food acted,
however, as a predisposing cause only, and was incompetent to induce
the disease in the absence of special conditions, notably the withdrawal
of fresh vegetables. Even with this in other respects best of diets,
lack of fresh vegetables induced scurvy. As regards the quantity of
food it is worthy of note that the theory which asserts that the use of
salt meat produces scurvy, receives no support from the facts observed
during the siege ; a diet of fresh meat induced scurvy -where fresh
vegetables were withheld, even when every other hygienic condition
was perfect. Acid fruits were found to replace fresh vegetables.
"Wounds received whilst fighting were not proved to predispose towards
the disease. Chalvet found the cause of scurvy to be inanition, iu
conjunction with cold. It is also asserted that the great benefit de-
rived from the use of green vegetables and fruits arises from this, that
the potash salts contained in them readily split up in the organism into
acid and base, whilst the phosphate, nitrate, and chloride, being much
more stable, cannot replace the less stable potash salts.
Delpechf found that an abundant diet of fresh meat did not ward
off" the disease where fresh vegetables were withheld, and asserts that the
deprivation of a vegetable diet is the sole determining cause of scurvy.
Dwellers in marshes. — Prof. Prestel,J of Emden, recommends rain-
water for use among the dwellers iu marshes, where, as is well known,
it is often next to impossible to procure good drinking-water from wells
* * Ann. d'Hyg.,' xxxv, p. 297, and xxxvi, p. 279. * Gaz. Hebd.,' viii (xviii), 187 1,
6, 9, 14, 16, 17, 18. * Schmidt's Jahrb.,' cliii, p. 82.
t Loc. cit.
X ' Vrtljhrsschrft. f. Gericht. Med.,' N.F., xvi, p. 336.
ENTOZOA. 491
sunk in the ground. He raises a novel criterion of the fitness of rain-
water for drinking purposes. It is a familiar fact that rain-water un-
dergoes a sort of fermentation, by which it is freed from various organic
matters, which have been washed out of the atmosphere. Subsequently
various animal organisms are developed in the water. Dr. Prestel says
that, as long as entomostracse (cypris, cyclops, daphnia, &c., i. e. water-
fleas, &c.) are active in the water, it is fitted for drinking purposes.
The animals may readily be separated by a very coarse method of filtra-
tion. "Whenever such water becomes an unhealthy and non-potable
liquid the above organisms perish.
The author also asserts that in marshes the mortality is in inverse
ratio in different years and seasons to the amount of rainfall; a
diminished rainfall in one month is followed by an increased mortality
during the succeeding month, and, viee versa, an unusual rainfall during
one month is followed by a diminished mortality during the next month.
The saying, "More rain the less sickness," may be accepted as an
axiomatic truth.
Air and rain. — Dr. Angus Smith* has published an elaborate but
highly diflPuse work on the above subject, and intended as the begin-
ning of a chemical climatology. Its great merit consists in the large
number of facts embodied in it ; and Dr. Smith, from his official posi-
tion as (Q-eneral) Inspector of Alkali Works for the British Govern-
ment, has had better means than almost any man living of getting at
facts bearing upon the subject of which he treats. He shows that
small differences from the mean of io'g6 — the percentage of oxygen in
pure air — may make vast differences in its healthiness or unhealthiness ;
and also that a moderate increase in the percentage of carbonic acid,
formed at the expense of the oxygen, may have much to do with the
unhealthiness of air. It must not be forgotten that when the carbonic
acid is derived from the act of respiration, organic impurities are also
brought into play, and these the author attempts to determine quanti-
tatively by Wanklyn, Chapman, and Smith's process of oxidation by an
alkaline solution of permanganates, and estimation of the resultant
ammonia — a process which has been found to be exceedingly valuable
for the determination of the amount of nitrogenous organic impurity in
drinking waters.
Dr. Angus Smith's work is merely tentative and of a preliminary
character, so that it is rendered unsuited for ,brief abstraction. No
doubt he will extend his researches, and endeavour to draw some useful
general conclusions from them.
Alcoholism. — Several exhaustive essays upon this topic have appeared.
We can merely indicate the titles of some of these : — M. Ach. roville,t
jun., on ' Practical Means for Combating Drunkenness j' Dr. Jules
liergeronj: on ' The Eepression of Alcoholism.'
Petroleum. — M. A. Chevallier§ has investigated the dangers attending
the manipulation, stowage, and use of petroleum. The physiological
* • Air and Kain.' London, 1872.
t * Ann. d.'Hyg.,' [2] xxxvii, pp. 1, 299.
X Ibid., xxxviii, p. i.
§ Ibid., xxxviii, p. 277.
492 REPORT ON PUBLIC HEALTH.
effects produced by petroleum are a peculiar action on tlie brain and
heart. The lighter portions of the oil, known as petroleum ether or
benzoline, may be used as an anaesthetic. It is known that workmen
who are engaged in petroleum warehouses suffer severely from inhala-
tion of the vapours ; and certain precautions are necessary in order to
work safely with petroleum.
JEntozoa in relation to public health and the sewage question. — Dr.
Spencer Cobbold* is of opinion that the utilization of sewage for the
purposes of irrigation greatly contributes to the diffusion and growth of
parasites in man and the domestic animals. He mentions facts which
seem to render this not merely a hypothesis ; the common occurrence of
entozoa, the difficulty of diagnosing the diseases caused by them and the
enormous number of ova which they produce. Parasites once intro-
duced into a locality can by means of sewage irrigation become ende-
mic. In regard to the enormous reproductive powers of entozoa, he
mentions the case of a girl under treatment for bilharzia haema-
tobium, whose urine daily contained so many as 10,000 ova of this
parasite.
Disinfection. — Prof. Hoppe-Seylerf has made a valuable contribution
to our knowledge of putrefactive and fermentative processes, and he
has also investigated the influence which several reputed disinfectants
exert upon these processes. Our review will embrace this latter portion
of the subject only.
After reference to Pettenkofer's well-known views as to cholera-
germs, the author asserts that, although deodorants, as, e.g. sulphate
of iron, destroy the ill-smelling products of fermentation and putre-
faction, it must not be supposed that the infective materials of such
diseases as cholera and typhus are thereby necessarily destroyed, and
that in carrying out disinfection we must not rest contented with
merely destroying bad smells. He is of opinion that metallic salts act
as disinfectants chiefly by precipitating ferments, and along with these
the lower organisms also. He has proved that i -20th of green vitriol
suffices to prevent all development of infusorial life in a solution ; but
it is questionable whether the ferment and the organisms are re-
spectively so changed and destroyed as to be incapable of showing their
activity renewed under altered conditions. As regards carbolic acid,
Hoppe-Seyler finds that the destruction of the lower organisms is
admirably achieved by the use of a very small quantity of this agent,
but that the prevention of fermentation demands the employment of a
much larger amount of it. One per cent, of carbolic acid will effectually
put an end to organic life, but two per cent, is required to prevent
putrefactive changes.
Sulphurous acid gas appears to the author to be the most effective
agent for destroying germs in the air. Eather less than li — 3 ounces
of sulphur burnt in each 100 cubic feet of the space to be dis-
infected entirely prevents the growth of fungi. These quantities
of sulphur give one and two volumes per cent, respectively of sulphurous
acid gas.
* * Med. Times and Gazette,' 1871, i, pp. 93f 215, 236, 363.
t * Medizin.-Chem. Untersueh.,' 1871, p.561.
DisiNPECTioi^. 498
Some further useful and new information on this subject is also con-
tained in a paper by Dr. Zapolsky.*
The Chemical Society of Berlinf has issued the following instruc-
tions for disinfection. They are so valuable that we give them almost
ia full :
JExcrementitious matters and privies.— Fov commodes, solutions of
permanganate of potash or of carbolic acid are to be used, also for pus-
basins and chamber utensils, rinsing with carbolic acid solution,
leaving a little of the solution in the vessels after the operation. For
spittoons, carbolic acid powder. Eor night stools, carbolic acid powder if
they are to remain uneraptied, and solutions of permanganate of potash
if they are emptied immediately. Por closets with separate recep-
tacles, carbolic acid powder to the solid, solution of carbolic acid to the
liquid, excrement. For water-closets use carbolic acid water. For
privies communicating with cess-pits use carbolic acid powder, solu-
tions of chloride of manganese, green vitriol, or other metallic salt ;
applying the disinfectant to the surrounding soil also. For privies
communicating with dung pits, sprinkle with carbolic acid powder or
with a solution of carbolic acid in water. For sanitary pipes use
carbolic acid water. For latrines in camps and barracks use lime,
gypsum, or, at all events, earth, and change the site of the latrines
frequently. Dung-heaps are to be treated with carbolic acid powder.
IJrinals are to be treated with carbolic acid water and solution of
chloride of lime (we have found chloride of lime of little use in deodo-
rising urinals ; the chloride soon expends itself in liberating nitrogen
from urea. — Ed.). Spent charpie, lint, bandages, &c., should be col-
lected in vessels of tinned iron containing permanganate of potash or
carbolic acid, and then burnt. If the above are thrown into dust-bins,
chloride of lime is to be employed. Straw, hay, and the like, from
transports for the wounded, and soaked mattresses not again to be
used should be treated with chloride of lime, and burnt as quickly as
possible. Animal refuse from slaughter-houses and lairs are to be
buried deeply and covered with quicklime or with chloride of lime.
Enclosures. — These include sick-rooms, railway carriages, and
waggons (and things used for transports of every kind), cowstalls
('especial attention must be paid to the mangers), workrooms in
factories, schools, prison-cells, sentry- and watch- boxes, lavatories,
barracks, living-rooms, urinals, operation-rooms, dead-houses, ware-
houses filled with animal matter, slaughter-houses, and ship -decks.
The floors of these are to be scoured with carbolic acid water, and
the walls and ceilings lime- washed with carbolic acid and lime, and the
air is to be purified by the evaporation of wood-vinegar, or carbolic
acid (from the powder).
If the rooms are unused — and only then is an actual disinfec*
tion of the air feasible — the floors are to be washed with a solution
of chloride of lime or of hypochlorite (liq. sodaB chloratse, &c.) or
a solution of chloride of manganese. Place about the room or other
vessels containing chloride of lime with either hydrochloric or acetic
* * Medizin.-Chem Untersuch.,' p. 842.
t ' Deut. Ztschr, f. Staatsarznkd,' n. f. xxix, p. 164
494 REPOllT ON PUBLIC HEALTH.
acid, or strong nitric acid, or nitric acid and pieces of tin-foil.
Sulphur may be burnt (roll brimstone is best) in earthenware vessels.
After fumigation use free ventilation and sprinkle carbolic acid water
about.
Open spaces. — Courts, market-places, open abattoirs, cemeteries,
battle-fields, and deserted places of rendezvous here included.
Above all things, remove the causes of danger (putrefying refuse,
corpses, &c. &c.), burying such matters, or covering them with chloride of
lime, lime, or earth. Further, larger surfaces are, when possible, to
be watered with a solution of chloride of manganese. The sowing
of plants of rapid growth is very advisable.
TFater. — Drinking water is best rendered harmless by previous boil-
ing. Failing this, permanganate of potash may be added till the water
is just tinged by the salt.
Turbid water, or water that becomes turbid on standing, may be
clarified by the addition of a little alum or soda.
Carbon filters remain active only when they are frequently calcined
with exclusion of air.
Flowing or stagnant water. — Sinks, gutters, conduits of all kinds,
pools, &c., are to be sluiced with as much water as possible, and to be
frequently treated with the following agents : carbolic acid, quick lime,
chloride of magnesium, and tar (Suvern's mixture, see below), alum
salts, chloride of manganese, and other metallic salts.
Body- and hed-linen, articles of clothing , &c. — Linen must be sprin-
kled immediately after use with carbolic acid water, and then immersed
for some time in boiling water.
Mattresses, uniforms, and articles of clothing, are best heated in an
oven to 212° to 258° Fahr., and afterwards beaten. When this cannot
be done, the actually infected articles are to be burnt, and the rest
soaked in carbolic acid water, and then dried in a warm room.
Men and living animals that have come into personal contact with
infected matters. — "Wash the hands in a solution of permanganate of
potash. The animals are to be sprinkled all over with carbolic acid
water and especially on the soft parts.
Corpses which are to he removed to a distance are to be sprinkled with
carbolic acid water, and to be wrapped in cloths soaked in solution of
chloride of lime (i in 20.)
When possible the abdomen is to be opened— a small opening will
suffice — and solid chloride of lime inserted.
Wounds. — The treatment of these must always be left to the surgeon.
It may, however, be remarked that solutions oipure permanganate of
potash and pure carbolic acid should alone be used.
Directions for the preparation of the disinfecting materials. — Solutions
oi permanganate of potash should contain i part of the pure salt in 100
parts of water, or, if the crude salt be used, 5 — 10 parts in the same
quantity of water. It acts, in solution, as a disinfectant, but acts only
on the surface of solid masses.
Carbolic acid tvater is obtained by dissolving i part of pure crystal-
lized carbolic acid (liquefied by immersing the vessel in warm water)
in 100 parts of water. Crude carbolic acid, the strength of which
tEGISLATION. 495
is yery variable, is used in the proportion of i part acid to 50 of
water.
GarloUo acid powder m prepared by mixing 100 parts of peat, gypsum,
earth, sand, sawdust, or charcoal, with i part of carbolic acid previously
mixed with water. The crude acid is recommended, used in double the
above proportion.
If carhoUc acid salts are employed twice as much is required as of the
acid itself.
Garlolic add lime-white is made by mixing i part of carbolic acid
with 100 parts of milk of lime.
Solution of chloride of lime should be made by mixing i part of the
chloride with 100 parts of water.
bromine may be used, but with great care, on account of its highly
poisonous action. Its saturated solution in water is the best substance
to be used, and may be employed where chloride of lime and the like
are directed to be employed. The preparation of bromine water should
not be entrusted to unpractised hands.
Solutions oi green vitriol and other metallic salts are prepared by
agitating an excess of the salt with water.
Suvern'^s mixture is made from 100 parts slaked lime, 15 parts coal-
tar, and i^ parts chloride of magnesium, mixed with water.
Legislation,
The Sessions of the British Parliament of 1871 and 1872 were the
occasions of the passing of the following Statutes bearing upon the
public health : — the Local Government Board Act, 1871 ; the Factory
and Workshop Act, 1871 ; the Metropolis Water Act, 1871 ; the
Infant Life Protection Act, 1872 ; the Factories Steam Whistles Act,
1872 ; and the Adulteration of Food, Drink, and Drugs Act, 1872.
The Local Government Board Act, 1871, provided for the con-
stitution of a central board, now known as the Local Government
Board, to which were transferred all the powers and duties vested in
the old Poor Law Board, those vested in the Medical Department of
the Privy Council Office, those vested in the Secretaries of State under
Local Government Acts, and certain sanitary functions of the Board
of Trade. This Act was a necessary preliminary to the bringing in of
a new Public Health Bill.
The Factory and Workshop Act, 1 871, transferred from the local
sanitary authorities to Her Majesty's Inspectors of Factories the
supervision of the hours of labour limited and prescribed by previous
statutes for women and children, and introduced certain modifications
of the legal hours of work in certain trades and occupations.
The Metropolis Water Act, 1872, provides, under certain regulations,
for a constant water supply to the houses in London and its suburbs.
The regulations have been framed, but the Act has hitherto been a
dead letter. The interests of small property holders are too powerful
to permit local authorities to put the provisions of the statute in
force ; hence London remains with a, for the most part, intermittent
water-supply.
496 REPORT ON PUBLIC HEALTH.
The Infant Life Protection Act, 1872, contemplates the periodical
examination and licensing of all houses where baby-farming is carried
on as a practice, and is intended to insure for infants sent out to
nurse, proper food and attention; and, in the event of death an
inquest is directed to be held.
The Pactories Steam Whistles Act requires the sanction of the local
sanitary authority for the use of steam whistles and trumpets, in order
to prevent annoyance in quiet neighbourhoods.
The Act of 1872 to amend the law for the prevention of adul-
teration of food and drink and of drugs is a most important one.
By the old statute of i860 it was made penal to adulterate articles of
food and drink with substances injurious to health. By the Pharmacy
Act of 1868, the provisions of the above statute were extended to drugs ;
but the adulteration of drugs was deemed of such importance to the
community that all admixtures of drugs were declared to be adultera-
tions. These Acts were entirely inoperative, and not being obligatory,
were never put in force. The recent statute amends the definition of
adulteration, and enacts a penalty for the mixer, and the person who
orders admixture, as well as for the vendor of adulterated articles of
food, drink and drugs. It is thought that the law now stands thus,
I. All admixtures of drugs are adulterations injurious to health. 2.
Pood and drinks are adulterated when they are mixed with substances
injurious to health, and also when substances are added fraudulently
to increase weight and bulk. 3. Local authorities are empowered to
appoint analysts, who must have competent medical, chemical and
microscopical knowledge, and it is supposed that the Local Government
Board can compel recalcitrant local authorities to apppoint analysts.
The Public Health Act, 1872, is a most important measure, pro-
viding for the constitution of urban and rural sanitary districts,
authorities and officers ; bringing the whole of England under sanitary
regime, and giving the central Local Government Board a direct voice
in, and control over, the proceedings of the local sanitary authorities.
It is expected that this statute will speedily be supplemented by a
consolidation of sanitary law — a reform much needed.
INDEX,
Abdominal aneurism (Durham), 205
— tumour, cases of (Dickenson), 166
Abortion, case of (Noeggerath), 402
— caused bj' retroflexion of the uterus
(Phillips), 402
Abscess, intra-cranial, trephining for, 268
— of the brain, titles of papers on, 93
— of the lung, 122—3
Absorption, by the unbroken skin (Aus-
pitz, Neumann, Rohrig), 3 — 4
— influence of muscles on (Genersich), 3
— influence of nerve centres on, 4
— list of authors on subjects connected
with, 5
— of lymph by tendons (Genersich,
Lesser, &c.), 3 — 4
— of solids from serous cavities (Aus-
pitz, Neumann), 3
Accommodation, paralysis of, in diphthe-
ria (Hutchinson), 104
Acid, carbolic, action of, internally (Sal-
kowski), 446
— do., in cholera, 48—50
— do., poisoning by, 445
— carbonic, amount of eliminated from
the skin (Aubert), 13
— do., tension of, in blood and lungs
(WolfEbey), 15
— hydrocyanic, action of (Amory, &c.),
446—48
— do., chemistry of (Miahle), 448
— do., detection of (Almen, Preyer), 454
— nitric, cases of poisoning by, 442
— sulphuric, cases of poisoning by, 441
— sulphurous, action of, on germs, 492
Acids, cases of poisoning by various, 442
Aconite, antagonism of, to digitalis
(Dobie), 440
Aconitine, on (Duquesnel, &c.), 468
Acupressure, a new plan of using (Lucas),
198
— on (Pirrie), 197
I Adams, case of extra-uteiine foetation,
I 404
Adams (J. E.), dislocation of wrist, 248
— excision of wedge of bone at knee,
224
— fracture of head of radius, 258
Adams (J. E.), transition of testicle into
perineum, 281
Adams (Mr. W.), fracture of skull in a
child, 266
— subcutaneous division of neck of thigh-
bone, 234
Addison's disease, cases of (Laschke-
witsch. Tuck well, Payne), 76
— do., red corpuscles in (Laschkewitsch), 8
— do., titles of papers on, 76
Adenoma, lymph- (Murchison), 111
Adenopathy, bronchial, on (Gueneau de
Mussy), 110
Adipocere in a ranula (Tay), 284
^gophony, on (Stone), 107
Afileck, cases of dilatation of the stomach,
153
— case of shoulder presentation, 414
Ague {see fever, intermittent), 45
Ahlfeld, determination of the size and
age of child before labour, 395
Aikman, case of double uterus and va-
gina, 371
Air and rain, on, 491
Albuminoid compounds in muscle in
tetanus (Danilewsky), 27
Albuminuria, 167 — 71
— during pregnancy, on, 397
— in smallpox (Cartaz), 63
— in syphilis in a child, QQ
Alcock, ovariotomy in child, 301
Alcohol, action of (Parkes, &c.), 463
— do., in fever, 464
— do., on temperature, 464
— elimination of (Subbotin, Dupre, &c.),
18, 464
— use of, in pneumonia, 464
Alcoholism, on, 491
AUbutt (Clifford), cases of tetanus,
98
— effects of strain on the heart, 132
— effect of exercise on the bodily tem-
perature, 15, 40
— emaciation in typhoid, 52
— histology of brain, &c., in hydropho-
bia, 42
Almen, detection of hydrocyanic acid,
454
82
498
INDEX.
Alopecia, general, case of (Crisp), 184
— on (Pincus), 184
Amenorrhoea, 372
Ammonia, case of poisoning by (Steven-
son), 442
Ammonium, chloride of, action of, 462
Amnesia, case of (Bristowe), 87
Amnii, liquor, urea in, 17
Amnion, on the, in relation to foetal mal-
formations (Fiirst), 393
Araory, action of hydrocyanic acid, 448
Amputation after excision of the hip, case
(Jackson), 221
— at the hip-joint, 211
— at the knee-joint (Erichsen, Staples),
212—13
— death-rate after (Callender), 211
— in senile gangrene (Lister, Morgan),
213
• — of the foot, modification of (Stokes),
213
— re-, at the hip (Otis), 212
T- recurrent haemorrhage after, 211
— supra-condyloid, of thigh (Stokes), 212
— through femoral condyles (Richard-
son), 212
Amputations, ankle-joint, on (Smith), 213
— in utero, on (Barnes), 393
— results of (Benny), 213
Amyl, nitrite of, as antidote to strychnine
(Gray), 440
— do., on (Wood, Jones, Brunton),
466—7
Anajmia during pregnancy (Gusserow),
397
Anajsthetics, on, 193 — 465
Analgesia in hysteria (Rosenthal), 80
Anchylosis, excision of the elbow for,
216—8
— of knee, excision of wedge of bone in
(Morton, Adams, Watson), 223—25
— do., subcutaneous osteotomy in
(Little), 225
— of the lower jaw, operation for (Maas,
Bottini), 230
Anderson (McCall), case of hromatidrosis,
183
— cases of elephantiasis, 182
— cases of skin disease, 174
— on tinea favosa, 185
Anderson (Mr.), on epidermic grafting,
335
Andrei, on Csesarean section, 412
Andrew, case of rheumatism, 74
Aneurism, at the root of the neck, double
ligature in (Lane), 202
— axillary, traumatic (Gay), 202
— axillo-subclavian (Gay), 201—202
— close to the heart, diagnosis of (Bal-
four), 149
Aneurism, dissecting, case of (Barth), '
150
— false, cases of (Spence), 210
— femoral, cases of, 208
— f emoro-popliteal, temporary deligatiou
of femoral in (Stokes), 208
— injection of ergotin in (Dutoifc), 199
— list of papers on, 150—51
— of the abdominal aorta, distal com-
pression in (Bryant), 206
— do., compression in (Durham, Murray),
205—7
— of the arch of the aorta, ligature of
common carotid in (Heath), 201
— do., simulating innominate (Heath),
202
— of the aorta, diagnosis of, with the
laryngoscope (Johnson), 149
— of the common carotid artery, ligature
(Lane, Gamgee), 200
— of the coronary artery (Crisp), 149
— of the heart, cases of (Murchisou,
Townsend), 139
— of the innominate, apparent cure
(Morgan), 201 ;
— of the mitral valve, case of (Simon), |
141 I
— of the vertebral artery, traumatic
(Kocher), 202
— popliteal, bursting into knee-joint
(Jamieson), 209
— do., cases of, 209
— do., compression in, 209
— do., flexion in, 209
— do., ligature in, 209
— subclavian, compression and ligature
of innominate in (Bickei'steth), 201
— surgical treatment of (Holmes), 198
— traumatic, after reduction of disloca-
tion of humerus (Morgan, I^ivington),
248
— treatment of (Bryant), 199
Angina pectoris (Moinet), 146
— pharyngo-scrofulous (Isambert), 151
— ulcerative (Lubauski), 151
Angioma mucosum proliferum, 189 — 90
Animal parasites affecting man, 77 — 9
Animals, infection from poison of (list of
authors on), 42
Ankle, amputation at the (see amputa-
tion)
— dislocation at the (see dislocation), 255
Annandale, case of haemorrhage from
internal wound of oesophagus, 287
— case of injury to the head, 267
— excision of the elbow in anchylosis,
216
— excision of the hip -joint, 220
— intestinal obstruction from band of
lymph, 298
INDEX.
499
Anuandale, removal of testicle for neu-
ralgia, 281
Anstie, on elimination of poisons, 434
Anthracosis, 123
Antiseptic catgut ligature, on, 195
— gauze, on (Lister), 194
— surgery, on (Lister), 194
Antrum,distensionof,reference(Haward),
235
— tumour of, from canine tootli (McCoy),
234
Anus, imperforate, case of (Stern), 299
Aorta, aneurism of the {see aneurism)
— do. of the arch of the (Heath), 202
— do. do., ligature of the common caro-
tid (Heath), 201
— abdominal, compression of, in aneu-
rism (Durham, Murray), 205 — 7
— do., distal compression of the (Bryant),
206
Aortic disease, retinal pulsation in
(Becker), 340
— insufficiency, case of (Mussy), 130
— do., double sound in femoral artery
(Riegel), 142
— do., on (Peter), 141
Aphasia, cases of (Baginsky, Simon,
Jackson), 87
— from embolisim, case (Wrany), 134
— on (Bristowe, Hammond), 86 — 87
— power of singing in (Jackson), 88
— titles of papers on, 88 — 89
Aphasics, autopsies of two (Samt), 86
Aphemia, case of (Bristowe), 87
Apomorphine, on, 469
Apoplexy, cases of, and titles of papers
on, 84—88
— meningeal, titles of papers on, 89 — 90
Apparatus, plastic, 255
Archebiosis, on (Bastian), 2
Argles, case of passage of foetal head
through vaginal wall, 417
Armour, passage of portions of taenia
solium at the age of three days, 79
Arndt, hydrocephalus externus, 89
Arnold, cases of tumours of meninges,
188
Arnott, cancer of imperfectly descended
testis, 281
— epithelioma of the heart and lungs,
124
— on case of congenital hypertrophy of
the tongue, 284
Arpem, case of cancer of uterus, 382
Arsenic in multiple lymphoma (Billroth),
244
— on the effects of (Vaudry), 463
Arteries, acupressure of, 197
— - amount of oxygen in blood of various
(MatMeu, D'Urbain), 13
Arteries, a new plan of acupressing
(Lucas), 198
— catgut ligature for, 195
— compressionof,instrumentfor(Stokes),
— measurements of the (Beneke), 8
— muscular spasm relieved by compres-
sion of (Broca), 200
— surgery of, in gunshot wounds (Ver-
neuil), 263
— torsion of (Callender), 198
— vaso-motor nerves of (Ludwig), 23
Arterio-capillary fibrosis, on (Gull and
Sutton), 168
Artery, carotid, ligature of the (Lane), 202
— common carotid, aneurism of, ligature
(Lane, Gamgee), 200
'— do., ligature of, in aortic aneurism
(Heath), 201
— coronary, aneurism of the {see aneu-
rism), 149
— femoral, aneurism of, cases of, 208
— do., ligature of, cases of, 209
— do., temporary deligation of the
(Stokes), 208
— iliac, common, ligature of the, for
haemorrhage (Baker), 207
— do., external, ligature of the, cases,
207—8
— innominate, aneurism of, apparently
cured (Morgan), 201
— internal carotid, case of rupture of
(Verneuil), 84
— pulmonary, stenosis of, after birth
(Paul), 142
— radial, ligature of, high up (Hulke),
210
— rupture of, after dislocation of hume-
rus (Morgan, Rivington), 248
— subclavian, ligature of (Fergusson, Gay,
Lane), 201—2
— vertebral, traumatic aneurism of the
(Kocher), 202
Arthritis, chronic rheumatic (Hutchin-
son), 326
Ashhurst, extroversion of the bladder, 276
— on excision of the hip-joint, 220
Ashmead, on antagonism of strychnine
and physostigmine, 440
Ashton, early appearance of menstrua-
tion, 372
Aspirator, pneumatic, in pleurisy (Bou-
chut), 113
— do., in pleurisy, &c., titles of papers
on, 115
— do., use of, &c. (Dieulafoy, Loh-
mayer, Jessop), 231 — 32
— use of, in hernia (Labbe, Demarquay),
289
— do., (Jessop), 290
500
INDEX.
Asthma, bronchial (Leyden), 117
— do., titles of papers on, 117
Astigmatism after cataract operations
(Woinow), 347
Astragali, both, excision of (Lund), 226
Astragalus, cases of excision of, 226
Asymmetry, on a case of foBtal, 427
Ataxy, locomotor, case of (Greenhow,
Cayley), 98
Atheromatous tumours of neck, removal
of (Schede), 243
Atlee (Dr, W. F.), fibro-cystic tumour of
uterus simulating ovarian, 381
— do., removal of cystic tumour of
neck, 237
— calculus in female, 278
— cases of ovariotomy, 301, 390
— on a new clamp, 305
— peritoneal inflammatory cyst simulat-
ing ovarian tumoui', 304
Atropine, antagonism of, to morphine
(Firmy), 439
— do., to physostigmine, (Fraser),
434
— effects of, on heart (Schmiedeberg),
10
— do., on ocular tension, 338
— do., on pupils of pigeons, 449
Aubert, amount of carbonic acid elimi-
nated from the skin, 14
Auchenthaler, coincidence of measles and
scarlet fever, 60
Auscultation in diagnosis of sex of child
(Hutton), 396
Auspitz, absorption of solids by serous
membranes, &c., 3
Aveling, cases of post-mortem parturition,
410
— on transfusion, 330—419
Axilla, medullary cancer of (Durham),
244
Bacon, case of idiotcy, 88
Bacteria, development of (Bastian, San-
derson, &c.), 2
— development of, in various solutions
(Sanderson, Bastian), 36
-- in blood (Nepveu, &c.), 36—37
— in skin, in smallpox (Weigert), 63
— presence of, at high temperature
(Blake), 2
Baginsky, cases of aphasia, 87
Bahrdt, poisoning with nitro-benzol,
449
Bailey, trismus nascentium, 428
Baker (Morrant), ligature of the com-
mon iliac artery for ha)morrhage, 207
Balfour, diagnosis of aneurism near the
heart, 149
— pre-systolic murmur, 131
Ballot, deaths from acute exanthems, 59
Banks, catheterism followed by fatal
urethral fever, 271
Barclay, midwifery forceps, 415
— pre-systolic cardiac murmur, 131
— on urates and phosphates, 172
Barker, ovariotomy in a child, 301, 391
Barnes, amputation in utero, 393
— anatomy of hypertrophy of the cer-
vix uteri, 385
— case of fibroma of the vagina, 386
— case of sudden death in cancer of
genitals, 383
— hypertrophic polypus of the os uteri,
385
— on marriage of consumptives, 128
— on the essential cause of dysmenor-
rhcea, 374
Barth, on cholera, 481
— case of dissecting aneurism, 150
— on spontaneous rupture of the heart,
143
Bartholow, use of bromides, 463
Barton, imperforate hymen, 282
Barwell, case of popliteal aneurism, 209
Basedow's disease, cases of, and titles of
papers on, 77
Bassett, cases of secondary ha3morrhage
after labour, 424
— treatment of abortion, 402
Bastian, fungi in blood, 36
— mode of origin of simplest forms of
life, 2
— on muscular sense and on thinking,
85
Bauer, tissue changes in phosphorus
poisoning, 441
Baume, long retention of ball in gun-
shot injury to neck, 264
Bazin, case of intra-uterine ague, 45
Beach, case of peritonitis, 157
Beale, distribution of nerves in fishes,
24
Beardesley, on Bryce's test for vaccina-
tion, 431
Beck (Snow), on involuted uterus, 424
— rupture of the heart, 144
— source of hajmorrhage in pelvic hema-
toma, 391
— structui'e of the uterus, 381
Becker, retinal pulsation in aortic disease,
34^
Beebe, cases of ovariotomy, 389
— on division of pedicle in ovariotomy,
306
Beer, on detection of picrotoxin in (Bias,
Depaire), 455
Begbie (Warburton), on absorption of
turpentine, 467
— swelled leg of fevers, 41
INDEX.
501
Behier, case of pleuritic effusion, 113
Belina, case of transfusion, 419
Bell, case of inversion of the uterus, 418
— case of tracheotomy for croup, 106
Bell (Dr. Joseph), intestinal obstruction
without sickness, 295
— on mode of removing the mamma,
234
— osteoid cancer of ulna, 244
— on veslco-vaginal fistula, 282
Bell (Royes), excision of phalanx of
thumb, 218
Belladonna, antagonism of, to opium
(Little), 439
— eruption after application of, 423
Beneke, size of arteries, 8
Bennett (Edward), operation for ununited
fracture of tibia and fibula, 259
— removal of foreign body from the
larynx, 321
Bennett (J. Henry), absorption of poisons
by unbroken skin, 37
— action of mercury on the secretion of
bile, 463
Bennett (Henry), case of cancer of uterus,
382
' Bennett (Risdon), cancer of lung, 124
Benzine, use of, in cough, 467
Berger, cases of ephidrosis unilateralis,
183
— cases of premature gray hair, 184
— on scurvy, 490
Berkart on emphysema, 116
Bernhard, paralysis of arm after dislo-
cation, 247
Bernhardt, case of embolism, 135
Bernstein, exchange of gases in placenta,
14
Bert, influence of changes in the baro-
metric pressure on vital phenomena,
13
Berthrand, dislocation of cuneiform bones,
254
Berti, on bromal hydrate, 466
Beunie, on poisonous mussels, 453
Bickersteth, case of subclavian aneurism,
201
— removal of pterygo-maxillary tumours
of the mouth, 239
— removal of scrotal tumour, 243
Biesiadecki, corpuscles in blood in syphi-
lis, 65
Biffi, inoculation of tubercles, 38
Bile, action of mercury on the secretion
of (Bennett), 463
— colourless, on (Robin), 165
Bile- ducts, affections of the, authors on,
&c,, 164
Biliary acids, detection of, in urine
(Strassburg), 17
Biliary calculus, case of, 164
— concretion causing obstruction (Clark),
— fistula, case of, 164
Billroth, arsenic in multiple lymphoma,
244
— enchondroma of the ribs, 241
— resection of the oesophagus, 285
— on traumatic fever, 311
Binz, action of quinine on blood-cor-
puscles, 7
Birch-Hirschfeld, tumour removed from
the abdominal cavity, 189
Bird, hydatid cyst of lung, 125
Birkett, removal of exostosis from first
rib, 240
Bizzozero, on certain large corpuscles m
pus, 34
Blache, on rickets, 428
Bladder, case of double, 371
— case of ulceration of the, in pregnancy,
399
— extroversion of the (IVIaury, Ash-
hurst), 275
— female, exfoliation of the (Wardell,
(fee), 400
— inversion of the (Croft), 275
— lithotrity with atony, of the (Malie-
jowsky), 276
— removal of piece of bone from the
(Thompson), 277
— resistance of the sphincter muscle of
the, 20
— rupture of the (Stokes), 277
— stone on the, choice of operations for
(Thompson), 276
— wound of, with fracture of the pelvis
(Bell), 277
Blake, diatoms growing at high tempera-
ture, 2
Bias, on detection of picrotoxin, 455
Blaser, on apomorphine, 469
Blood, a ciliated hsematozoon in the
(Boyd-Moss), 7
— a colloid fluid with difilisible con-
stituents (Marcet), 7
— (see leucocythaemia) 69
— {see microcythffimia), 70
— alkaline, in leucajmia (Mosler), 8
— analysis of the, in scurvy (Chalvet), 8
— ashes of the, on ( Jarisch), 6
— bacteria, &c., in (Sanderson, Lostorfer,
Ferrier, Bastian, &c.), 36
— coagulation of the, on (Schmidt,
Schiffer, Boll), 7
— colouring matters of the (Struve), 5
— corpuscles, action of bile on ( Jurasz), 6
— corpuscles, authors on, 8
— corpuscles, passage of, through the
walls of the vessels (Norris), 34
502
INDEX.
Blood - corpuscles, red, in Addison's
disease, state of (Laschkewitz), 8
— corpuscles, red, size of, in septicaemia
(Manassein), 6
— corpuscles, state of, in case of bronzing
of skin (Laschkewitsch), 76
— corpuscles, white, action of quinine on
the (Geltowsky, Kerner, Binz), 7
— corpuscles, white, glycogen in, while
mobile (Hoppe-Seyler), 8
— corpuscles, white, origin of pus from,
on (Duval), 7
— corpuscles on the structure of the
white (Richardson), 6
— crystals, on the (Preyer, Brond-
geest), 5
— current in muscle (Hafiz, &c.), 278
— examination of, in scurvy (Chalvet),
75
— filaria in the (Lewis), 6
— fungi in the (Lostorfer), 7
— list of authors on, 8
— peculiar corpuscles in the, in syphilis
(Lostorfer, Strieker), 8
— pressure, action of strychnine on
(Mayer), 10
— do., influence of nerves^ on (Mies-
cher), 9
— quantity of oxygen in, in various ar-
teries (Mathieu, D'Urbain), 13
— rapidity of the current of the (Cyon,
&c.), 9
— sarcina) in the (Lostorfer, Ferrier,
Bastian), 36
— spectroscopy of (Sorby), 459
— stains, on detection of (Sonnenschein,
&c.), 458—59
— transfusion of, on, 329
— vessels, development of the earliest
(Klein), 7
Boehm, on action of digitalis, 470
Boelt, case of oedema glottidis, &c.,
101
Bogolowsky, inoculation of tubercle, 38
Boisseau, aphasia in intermittent fever, 45
Boldyrew, histology of respiratory mu-
cous membrane, 11
Boll, coagulation of the blood in a
chick, 7
Bond, on gonorrhceal rheumatism, 282
Bone"! disease in hereditary syphilis
(Wagner), 307
— gunshot injuries of (Mac Cormac),
264
— removal of piece of, from rectal fossa
(Thompson). 300
— removal of tumours from (Paget),
242
Bones, composition of, whilst improper
fpod was given (Weiske), 29
Bones, delayed union of (Callender), 256
— ossification of the marrow of (Demar-
quay), 332
Borel, amber mouthpiece of pipe in orbit,
363
Borgioni, treatment of epididymitis by
ice, 282
Botkin, on cholera, 47
Bottini, operation for anchylosis of the
lower jaw, 230
Bouchut, case of hydatids of the liver,
163
— on pleuritic effusion, 113
— ophthalmoscopic appearances in acute
afi'ections of the nervous system, 90
— treatment of diphtheria, ].06
Bouvier, action of alcohol in fever, 464
Bradley, case of syphilitic renal dropsy,
168
— syphilis with albuminuria in a child,
66
Brain, abscess of the, titles of papers on,
93
— cases of gunshot injury to the (Cohn),
352
— changes in newborn children (Jas-
trowitz), 91
— disease, ophthalmoscope in, 90 — 91
— do., trephining in (Pepper), 268
— diagnosis of syphilitic disease of the
(Rees), 65
— effects of galvanizing the (Fritscb,
Hitzig), 22
— hydatids in the, cases (Reeb), 78
— inflammation of, onidipoathic (Elam),
91
— injury to, affections of lungs from
Brown-Sequard), 269
— do., locality of, causing convulsions
(Callender), 268
— softening of the, cases of, and titles
of papers on, 91 — 93
— temperature of, with excitation of sen-
sory nerves, 22
Brakel, on peristalsis, 16
Branco, cases of absence of the vagina,
370
Brasch, treatment of diphtheria, 106
Braun, case of deformed pelvis, 410
Bread, relative value of different kinds
of (Meyer), 18
Breast, cancer of, statistics of (at Brad-
ford), 233
— mode of removing the (Bell), 234
— removal, &c., of, 233—34
— statistics of removal of tumours of
(Syme), 233
Breeding, experiments on (Galton), 3
Breisky, case of pyometra and pyokolpos
lateralis, 370
INDEX.
503
Bristovve, case of hemiplegia, &c., 87
— on impairment, &c., of speech, 86
13roa(iheut, cases of cerehral tumour, 92
— case of dropsy of the optic nerve-
sheath, 90
— case of herpes, 176
— case of renal disease, 169
— cerebral mechanism of speech and
thought, 81-
— on the mechanism of thought, 25
Broca, muscular spasm relieved by com-
pression of arteries, 200
Bromal hydrate, on, 466
Bromides, action of (Wood, Bartholow),
462
— in epilepsy (Vance, Lutz), 83
Bronchial adenopathy in the adult (Gue-
neau de Mussy), 110
— asthma (Ley den), 117
— do., titles of papers on, 117
Bronchitis, cases of, 116
— titles of papers on, 116 — 17
Bronchocele, removal of (Greene), 236
— treatment of (Mackenzie), 237
Bronchotomy, on (Hewitt), 320
Brondgeest, on crystals of blood, 5
Bronzing of skin, cases of, 76
Brouardel, on pneumonia, 120
Brown (Dyce), case of solid cancer of
the ovary, 388
— case of stenosis of the pulmonary
artery, 148
— recurrent discharge of fluid from the
uterus during pregnancy, 394
Browne, gangrene of the lung, 123
Brown-Sequard, affections of lungs from
injuries to brain, 269
— ecchymoses in the lungs from injury
to the head in guinea-pigs, 108
— on epilepsy in guinea-pigs, 82
Brucine, detection of (Pander), 455
Bruckner, on pendulum-like respiration,
107
Bruit du diable, on the origin of the
(Duchek), 132
Bruit, subclavian, cases of (Snelling),
132
Bruns, resection of superior maxillae for
removal of naso-pharyngeal tumours,
235
Brunton (Lauder), on action of digitalis,
471
— cases of combined exanthems, 60
— effects of heat on the heart, 9
— effects of temperature on the heart,
133
— ergot of rye in uterine fibroid, 380
— expulsion of ovum at seventh month,
396
— on nitrite of amy], 467
Bryant, colotomy for recto- vesical fistula*
299
— congenital fibro- cellular tumour of
buttock, 243
— distal compression in aneurism of the
abdominal aorta, 206
— extirpation of uterus, &c., for tumour,
380
— on intestinal obstruction, 294
— puncture of intestine in hernia,
289
— treatment of aneurism, 199
Bubo, epithelioma simulating, 273
Buchanan (Dr.), cases of tracheotomy,
321
— gastrotomy for intestinal obstruction,
296
— tracheotomy in croup, &c., 105
Buck, treatment of cicatrices from burn,
331
— treatment of psoriasis, 176
Bulley, a double tourniquet, 210
Bumstead, on pemphigus caused by iodide
of potassium, 176
Burchardt, test types, 343
Burman, gangrene of the lung, 123
Burn, treatment of cicatrices from (Buck),
331
Burow, marine grass for sutures, 349
Butlin, cases of chorea, 81
Buttock, congenital fibro-cellular tu-
mour of the (Bryant), 243
Buzzard, case of facial atrophy after
chorea, 81
Byasson, action of corrosive sublimate,
363
— on anaesthetics, 465
— on croton chloral, 466
Byrne, case of tumour of the vagina,
386
Cabral (Dr. Camara), cure of spina bifida,
326
Caesarean section, cases of, 306 — 412
Callender, death-rate after amputation,
211
— delayed union of bones, 256
— locality of injury to brain causing
convulsions, 268
— reduction of old dislocation of shoulder,
247
— on torsion and on dressing wounds,
198
Calculous disease, prevention of (Thomp-
son), 279
Calculus, cholestearine (Duncan), 279
— cystine, cases of (Ulzmann), 279
— vesicae, choice of operations for
(Thompson), 276
504
INDEX.
Calculus vesicffi in the female, opera-
tions for, 278—79
Calvert (Crace), on development of bac-
teria, &c., 2
Campbell, case of doubtful typhus, 56
— vomiting in pregnancy, 400
Camphor, action of, on heart (Heubner),
469
— monobromide of (Hammond), 469
Cancer, medullary, of axilla (Durham),
244
— of breast, 233—34
— of female genitals, sudden death in
(Barnes), 383
— of the heart (Payne), 139
— of imperfectly descended testis, refer-
ences (Arnott), 281
^ of liver, cases of, 163
— of lungs (Bennett, Arnott, Sparks,
Waters), 124
— of penis, cases of, 275
— of the uterus, cases of, &c., 382—83
— osteoid, of ulna (Bell), 244
Canton, case of excision of the knee, 222
— excision of the ankle, 226
— removal of both superior maxillcB,
230
Capsules, supra-renal, changes in, 76
Carbolic acid in cholera, 48 — 50
— do., internal use of (Salkovvski), 445
— do., poisoning by, 446
— spray, on (Lister), 195
Carbon, oxysulphide of, on (Radzie-
jewski), 444
Carbonic acid, amount of, eliminated
from the skin (Aubert), 13
— do., tension of, in lungs and blood
(Wolffbey), 15
— oxide, poisoning by (Zuntz, Bonders,
&c.), 443
Carcinoma (see cancer)
Cardiac murmur, coincidence of, with
period of heart's action, on (Jacobson),
129
— do., pre-systolic (Barclay, Balfour),
130
— do., on, 129—34
— do., titles of papers on, 131
Cardio-sphygmograph, on a (Garrod), 9
Carmalt, on keratitis, 33
Carotid artery, common, ligature of, in
aortic aneurism (Heath), 201
— do., case of ligature of the (Lane),
202
— do., internal, case of rupture of (Ver-
neuil), 84
Carpenter (Dr. Alfred), origin of scarlet
fever, 60, 487
Cartaz, on urine in smallpox, 63
Carter, paracentesis in pleurisy, 113
Carter (R. B.), report on ophthalmic
medicine and surgery, 337
Casein of milk, morphology of 423
Cataract, extraction of, without opening
the capsule (Pagenstecher), 345
— do., mode of (Wecker), 344
— do., on (Mazzei), 343
— operations,astigmatism af ter(Woiuow),
347
Catgut ligature, on antiseptic, 195
Catheter, a new self-retaining (Wright),
271
— improved, flexible, for retention in
bladder (Thompsan), 271
— vertebrated (Squire, Sayre), 272
Catheterism, followed by fatal urethral
fever (Banks), 271
Causse, case of Csesarean section, 413
Cayley, case of locomotor ataxy, 98
— case of paralysis agitans, 97
Ceradini, action of heart on respiration, 11
— effects of heat on the heart, 9
Cerebellum, cases of tumours of the, and
titles of papers on, 92 — 93
— hydatid cysts of the (Evans, Pullar),
93
— tubercle of the (Cordier, Jackson),
92
Cerebral disease, diagnosis of syphilitic
(Rees), 65
— do., trephining (Pepper), 268
— hemispheres, effects of galvanizing
the (Fritsch, Hitzig), 22
— mechanism of speech and thought
(Broadbent),84
— softening, cases of, 91 — 92
— do., titles of papers on, 93
— tubercle, case of (Heischraann), 92
Cerebritis, iodiopathic, on (Elam), 91
Cerebro-spinal meningitis, titles of papers
on, 44 — 45
— spinal meningitis on (Eulenberg,
Kotsonopulos, Russel), 43 — 44
Chalvet, analysis of the blood in scurvy,
8
— on scurvy, 75
Chamberlain, on acute atrophy of the
liver, 160
Charcot, on hysterical contraction of the
limbs, 79
— on irritative spinal lesions, 95
Charrier, uterine injections for chronic
metritis, 392
Cbarteris, post-febrile ophthalmia, 57,
486
— on relapsing fever, 486
Chautreuil, on cancer of uterus in con-
nection with labour, &c., 411
— on uterine expression as a means of
delivery, 409
INDEX.
505
Chauveau, contagion due to solid parti-
cles, 35
Cheadle, on cirrhosis of the liver, 162
Cheiloplastic operation, on Zeis' (Stokes),
330
Chest, fourfold gunshot injury of, re-
covery after (Lorinser), 264
Chevalier, on petroleum, 491
Chicken-pox {see varicella), 60 — 62
Chiene, obturator hernia, 290
Child, determination of age and size of,
before labour (Ahlfeld), 395
— sex of, determination of, in utero
(Button), 396
Chisolm (Dr.)> dislocation of the semi-
lunar bone, 248
Children, jaundice in new-born, 482
Chloral hydrate, antagonism of strych-
nine to (Ore), 439
— do,, in cholera, 50
— do., on the employment of, 464
— do., poisoning with, cases of, 449
Chlorides, on use of (Rabuteau), 462
Chloroform combined with morphine,
468
— on the administration of (Haward),
193
Chlorosis, on (Wade), 372
— (Virchow), 373
Cholestearine in calculus (Duncan), 279
Cholera, burning of straw, &c., in, 51
— carbolic acid in, 48 — 50
— cause of, on, 481
— chloral hydrate in, 50
— contagion, 481
— diffusion of, in India (Pettenkofer),
477
— epidemic at Zurich, report on (Zehn-
der), 480
— germs, action of disinfectants on,
492
— influence of ground water on the
spread of (Pettenkofer), 477
— on nitrite of amyl in (Brunton), 467
— on the spread of (Radcliffe), 472—77
— opium in, 50
— organisms in, 482
— propagation, symptoms, treatment,
&c., of, 47—52
— quinine in, 48 — 50
■— report on (Cunningham), 479
— titles of papers on, 51—52
Chorea, case of facial paralysis after
(Buzzard), 81
— case of, with embolism (Murchison),
134
— cases of (Jones, Gray, Tuckwell), 81
— cases of, treated by sulphate of zinc
(Butlin), 81
— titles of papers on, 81
Choroid, disease of, visual sense in
(Forster, Hippel), 364—66
— tubercles in the (Frilnkel), 91
Choroiditis, circumscribed (Sichel), 366
— syphilitic, on (Galezowski), 368
Chrschtschonovitch, on the termination
of the nerves in the vagina, 387
Chunder Roy, case of abscess of the liver,
160
Churchill, fatty tumour under the tongue,
284 ^ ^
Chyluria, filaria in blood in (Lewis), 7
Cicatrices from burn, treatment of
(Buck), 331
Ciliary muscle, paralysis of, in diphtheria
(Hutchinson), 104
Circulation, rapidity of the, &c., 8 — 10
Clapham, on sunstroke, 58
Clark (Le Gros), meclianism of resi)ira-
tion, 14
Clarke, carcinomatous mass in thorax,
111
Clarke (Fairlie), case of congenital hy-
pertrophy of the tongue, 284
— unilateral atrophy of the tongue, 335
Classen, cases of diphtheria, 104
Clavicle, dislocation of {see dislocation),
246
— necrosis of, during scarlet fever
(Kelly, Nowlan), 61
Clay, case of ovariotomy, 305
Cleft palate, formation of bone after
operation for (Whitehead), 233
— operation for, cases of (Smith, &c.),
232—33
Cleghorn, hydatids of the liver, causing
abscess, 164
Clemens, case of variola, 62
Clement, case of typhoid fever, 53
Clements, case of acute atrophy of tho
liver, 161
Climate, influence of change of, 14,
190—91
Climates for consumptives (Williams),
127
Coagulation of the blood, on the
(Schmidt, Schifi'er, Boll), 7
Coal-dust in lungs (Mayet), 123
Coats, calcareous degeneration of the
heart, 140
Cobbold, on entozoa, 492
Coccius, on testing the tension of the eye,
339
Cockle, case of aortic aneurism, 201
Cohn, gunshot wounds of eye, 349 — 63
— refraction of eyes of children, 342
Cold-water treatment of typhoid (Lis-
sauer, Scholz, Popper, &c.), 54—55
Colloid cysts in larynx, 188
— in lip, 188
506
INDEX.
Colloid cysts in thyroid, 188
Coloboma of the iris, congenital (Ponti),
339
Colotomy for stricture of rectum, cases of
(Hulke), 299
— in intestinal obstruction (Bryant),
294
— in recto-vesical fistula (Bryant), 299
Colour-blindness, diagnosis of (Woinow),
340
Colouring matters of the blood, 5
Coma, diminished frequency of pulse
before death from (Gray), 133
Compression {see aneurism), 198, &c.
— of arteries, instrument for (Stokes),
209
Condie, contagiousness of phthisis, 128
— spurious consumption, 125
Consumption {see phthisis), 125
Consumptives, climates for (Williams),
127
— should they marry ? (Williams, Barnes,
Bennett) 128
Contagion, bacteria, &c., as means of
(Sanderson, Bastian, Lostorfer, &c.),
36—37
— by organised poison (Liveing), 37
— by solid particles (Chauveau), 35
— by unbroken skin surface (Bennett),
37
— list of authors on subject of, 37]
— of typhus, direct (Virchow), 56
Convulsions after injury to brain, on
(Callender), 268
— puerperal, cases of, 424
— with loss of speech (Jackson), 87
Copeman, scarlet fever, 487
Copper in phosphorus poisoning, 441
— poisoning by, on, 443
Cord, spinal {see spinal)
Cordier, cases of diphtheria, 106
— tubercle of cerebellum, 92
Corelysis, on (Wecker), 348
Cornea, " cells" of the, nature of (Gener-
sich), 33
— healing of wounds of (Giiterbock), 34
— inflammation of the, experiments on,
(Carmalt, Strieker, &c.), 33
— regeneration of the epithelium of the
(Heiberg, Hansen, &c.), 33
Corpuscles of the blood {see blood)
Corradi, removal of pharyngeal prolapsus
by the galvanic cautery, 236
Costa (Da), on irritable heart, 146
Cramps, on, during pregnancy and labour
(Mattel), 409
Crisp, abscesses of the heart, 140
— aneurism of coronary artery, 149
— case of dilatation of the stomach, 154
— case of general alopecia, 184
Crisp, inoculation of tubercle, 38
Cristoforis, cases of flexion with dys-
menorrhoea, 374
Croft, inversion of the bladder, 275
Croton chloral, on, 466
Croup, development of exudation in
(Letzerich), 103
— nature of (Hartmann), 104
— titles of papers on, 106 — 7
— tracheotomy in, cases of, 105 — 7
Crystals of the blood, on the (Preyer,
Brondgeest), 5
Cunningham, on cholera, 479
Curran, case of scleriasis, 179
Cyon, on diabetes in dogs after section of
ganglia, 20
— rapidity of current of blood in veins, 9
Cyst of neck removed (Hardie, Atlee),
237
Cystic tumours of breast, on, reference
(Goodhart), 234
Cysticerci ocuH, cases of (Hirschberg), 79
Cystine calculus, cases of (Ulzmann),
279
Czerny, excision of the elbow for anchy-
losis, 217
Da Costa, on irritable heart, 146
— on membranous enteritis, 155
Dactylitis syphilitica (Taylor), 308
Dalmon, detection of phosphorus, 454
Dalton, on the sugar of the liver, 17
Damaschino, on infantile paralysis, 96
Danet, use of alcohol in pneumonia, 464
Danilewsky, quantity of albuminoid com-
pounds in muscle, 27
Daturine, effects of, on heart (Schmiede-
berg), 10
Davis (Dr. Hall), case of uterine inver-
sion, 418
Davies (Dr. Herjaert), on the four ori-
fices of the heart, 131
Dawson, invagination of colon, &c., 432
— new clamp for ovariotomy, 305, 390 J'
Day (Dr. John), use of peroxide of hy-
drogen pessaries, 461
Decaisne, on an epidemic of jaundice,
164
— milk of women taking insufficient
food, 20
— on the influence of starvation on the
mother's milk, 423
Decapitation as mode of delivery (Kidd),
413
Deglutition, nerves of (Waller, Prevost),
15
Delafield, pigment induration of the
lungs, 121
Delivery, decapitation as mode of (Kidd),
413
INDEX.
507
Delivery in arm presentation, 414
— position of foetal head during artificial,
407
Delpecli, case of plilegmon of tlie broad
ligament, 391
— on scurvy, 490
Demarquay, ossification of the marrow of
bones, 332
— use of aspirator, 290
Dengue, titles of papers on, 43
Denhara, action of ergot of rye on the
foetus, 421
Depaire, on detection of picrotoxin in
beer, 456
Depaul, cases of shoulder presentation,
415
— puerperal peritonitis, 423
Diabetes, cause of (Zimmer, Salinger),
72—73
— large doses of opium in (Kratschmer),
73
— production of, in dogs (Cyon, Aladoff),
20
— rheumatic pains in subject of, taking
lactic acid (Foster), 74
— titles of papers on, 73
Diaphragmatic pleurisy (Hayden), 114
Diarrhoea in infants, on (McSwiney,
Rosse), 157
Dickenson, cases of abdominal tumour,
166-67
Dieulafoy {see aspirator), 115
Digestion, report on subjects connected
with, 16—18
Digitalis, antagonism of, to aconite
(Dobie), 440
— on action of (Boehm, &c.), 470
Diphtheria, cases of (Classen), 104
— development of exudation in (Let-
zerich), 103
— experiments on (Oertel), 103
— fungous nature of (Letzerich), 102
— nature of (Hartmann), 104
— outbreak of, in Kent (Kersey),
105
— paralysis after (Kraft-Ebing), 105
— paralysis from, treated by faradisation
(Greenhow), 105
— paralysis of ciliary muscle in (Hutchin-
son), 104
— peculiar case of defect of sight in
(Classen), 104
— subcutaneous emphysema in (Giiter-
bock), 105
— tracheotomy in, successful, &c.
(various), 104 — 6
— titles of papers on, 106 — 7
— treatment of, 106
j Diphtheritic puerperal fever, 421
i Disease and dust (Tyndall), 37
Disinfectants, action of, on cholera-germs,
&c., 492—95
Disinfection, on modes of, 492 — 95
— rules for, 493
Dislocation at the knee (Erichsen), 254
— compound, of foot (Smith), 255
— of both femora (Pollard), 254
— of clavicle, supra-sternal (Smith),
246
— of both ends of clavicle (Haynes), 247
— of cuneiform bones (Bertherand), 254
— of elbow, compound, excision in
(Malins), 218
— of elbow, old, excision in, 216 — 18
— of humerus, extravasation of blood
after (Morgan, Rivington), 248
— of humerus, paralysis of arm after
(Bernhard), 247
— of shoulder, reduction of old (Callen-
der), 247
— of the bones of the pelvis (Salleron),
249
— of the femur, old, reduction of (Mc-
Kee, Norton), 253
— of the femur, unreduced(Mac Cormac),
253
— of the semilunar bone (Chisolm), 248
— of wrist (Erichsen, Adams), 248
— subastragaloid, of foot (Gosselin),
254
— unilateral, of fifth cervical vertebra
(Reyburn), 260
Dislocations, reduction of, without trac-
tion, reference (Parker), 254
Dittmar, on spinal cord, 21
Dobell, on feeding of infants, 430
Dobie, antagonism of aconite and digi-
talis, 440
Dogiel, on rapidity of arterial current and
arterial pressure, 9
Dohrn, case of ruptured uterus, 417
Donaldson, induction of premature
labour, 402
Donders, on poisoning by carbonic oxide,
443
Domitz, on structure of muscle, 27
Down (J. Langdon), case of hemiplegia,
88
Downs, case of injury to the head, 267
Dressing of wounds, on (Callender), 198
Dressings to wounds, antiseptic (Lister),
194
— do., of dry lint (Gillespie), 195
Dropsy, renal, on, 167 — 70
Duchek, bruit du diable, 132
Duchenne, pseudo-hypertrophic paralysis,
72
Duckworth, on acute atrophy of the liver,
160
— on moUuscum contagiosum, 182—83
508
INDEX.
Dufour, case of scleroderma, 179
Dulirssen, absorption of cheesy products,
127
Duncan, causes of procidentia, 383
— on the curves of the genital passages,
408
— duration of pregnancy, 401
— functions of the perinseura, 384
— long delay of labour after discharge
of liquor amnii, 394
— on mechanical dilatation of the cervix
uteri, 415
— mechanism of the expulsion of the
placenta, 407
— on the efficient powers of parturition,
406
— on uterine polypi, 380
Dunlop, cases of rotheln, 62
Dupienis, cases of post-partum hsemor-
rhage treated by injections of iodine
into uterus, 420
Duplay (Dr. Simon), on scapulo-humeral
periarthritis, 332
Dupre, elimination of alcohol, 18
Duquesnel, on aconitine, 468
Dura mater, tumours of the (Janeway,
Teakle), 93
Durante, experiments on inflammation,
33
Durham, compression in abdominal aneur-
ism, 205
— medullary cancer in axilla, 244
— on opening the larynx for removal of
growths, 322
Dust and disease (Tyndall), 37
— inhalation of, into lungs (Mayet,
Eoss, Merkel), 123
— on (Tyndall), 2
Dutoit, injection of ergotin in aneurism,
199
Duval, on corneal inflammation, 7
— on the origin of pus, 34
Dyce Brown (see Brown)
Dysentery, list of papers on, 159
Dysmenorrhcea, case of inflammatory
(Solowieff"), 373
— cases of, with flexion, &c., 374
— dilatation of cervix in treatment of
(Edis), 375
— essential cause of (Barnes), 374
— intermenstrual, on (Priestley), 374
Dyspepsia for starchy food in infancy,
429
Dyspncea, nocturnal, in disease of the
heart (Habershon), 133
Dystocia by the child, 411 — 12
— by the mother, 410 — 11
Ear, removal of foreign bodies from ex-
ternal (Gruber), 335
Ebell, vaginal stenosis, 386
Ebstein, secretion of glands of stomach,
16
Ecchymoses after suffocation, on (Lu-
komsky), 460
Echinococci (see hydatids), 163
IScraseur, a rectilinear (Nott), 244
Eczema, papers on, 186
Edes, tumours in connection with ner-
vous system, 93
Edis, abscess of the ovary, 388
— treatment of dysmenorrhcea, 374
Elam, idiopathic cerebritis, 91
Elbow, dislocation of (see the)
— excision of the
Electric excitation of muscle, 31
Electricity, use of, in midwifery, 409
Elephantiasis, papers on, 187
— Arabum, pathology and cases of,
181—82
— GriEcorum, cases of (Anderson), 182
Emaciation in typhoid (Allbutt), 52
Embolism, cases of, 134—36
— gangrene of feet from, 213
— intra-cranial, cases of, and titles of
papers on, 91 — 93
— titles of papers on, 136
— with heart disease, case of (Simon),
141
Emetine, detection of (Pander), 455
Emmert, on exophthalmic goitre, 77
Emmet, septicajmia after removal of
uterine fibroid, 379
Emphysema, changes in vessels in (Isaak-
son), 116
— during labour, cases of, 418 — 19
— instrument for treatment of (Berkart),
116
— titles of papers on, 116—17
Empyema (see also pleurisy), 113
— titles of papers on, 115
Encephalitis, diffuse, in new-born chil-
dren (Jastrowitz), 91
Enchondroma of the ribs (Billroth, Men-
zel), 241
— of phalanx of thumb, 218
Endocarditis, titles of papers on, 142
— in pig, with arthritis (Roth), 74
— ulcerative, case of (Heiberg), 140
Engelmann, on innervation of the con-
tractile gland- cells of the frog, 24
— on wrinkles in nerves, 21
Englisch, on hernia of the ovary, 291
Enteric fever (see typhoid), 52 — 55
Enteritis, membranous, on (Da Costa,
Whitehead), 155—56
Entozoa, relation of, to public health,
492
Ephidrosis unilateralis, cases of, 183
Epidermic grafting, on, 335
INDEX.
509
Epididymitis, treatment of, by ice (Bor-
gioni), 282
Epilepsy after injuries to the liead (Lan-
genbeclc), 83
— bromide of potassium in (Vance,
Lutz), 83
— from necrosis of femur (Martin), 83
— in guinea - pigs (Brown - Sequard,
Westphal), 82
— production of, in guinea-pigs (West-
phal), 23
— titles of papers on, 83
Epistaxis, treatment of (Kiichenmeister),
331.
Epithelioma of the tongue, removal of,
with galvanic wire (Gozzini, Puce ion i),
283
— simulating bubo (Geber), 273
Epithelium, development of ciliated (Let-
zerich), 103
Ergot, action of, on the foetus, 421
— use of, in abortion, on (Bassett), 402
Egotin, injection of, in aneurism (Dutoit),
199
— in treatment of varix (Vogt), 211
Erichsen, amputation at the knee-joint,
212—13
— dislocation at the knee, 254
— dislocation of wrist, 248
— herniotomy in infant, 288
— obturator hernia, 291
— wrist-drop after injury to nerve in
fracture, 256
— (Petersburg), on cholera, 481
Erismaun, refraction of eyes of children,
342
Erysipelas, bacteria in blood in (Nepveu),
37
— laryngeal obstruction with (Russell),
101
— subcutaneous antiseptic injections in
(Wilde), 318
— traumatic, on (Wilde), 318
Erythema exsudativum multiforme, on
(Lipp), 174
— marginatum, parasite in (Fox), 184
— papers on, 186
— parasitic (Kohn), 185
— solare, case of (Wilson), 175
Esmarch, ice in acute rheumatism, 74
Espine (M. d') on puerperal septicaemia,
422
Ether, death from the administration of,
193
— on the administration of (Haward), 193
Eulenburg, cases of muscular atrophy, 70
— on cerebro-spinal meningitis, 43
— toxicological effects of tobacco, 450
— on yellow fever, 46
Evans, hydatid cyst of cerebellum, 93
Evans, on thoracentesis, 113
Ewens, case of excision of the shoulder,
215
Exanthemata, the acute, 58, &c.
Excision of the ankle (Gant, Watson,
Maunder, Canton), 226
— of the ankle, and removal of the tarsal
bones (Swain), 226
— of the astragalus, cases of (Gant, Han-
cock, &c.), 226
— of the astragalus, malleoli, &c. (Wat-
son), 226
— of both astragali in case of talipes
(Lund), 226
— of the breast, 233—34
— of the breast, mode of performing
(Bell), 234
— of both elbows (Forstcr), 218
— of the elbow in anchylosis (Annan-
dale), 216
— of elbow for anchylosis after disloca-
tion of radius (Watson), 217
— of the elbow for anchylosis (Czerny),
217
— of elbow for compound dislocation
(Malins), 218
— of elbow for old dislocation (Marshall),
218
— of the elbow, on (Gant), 215
— of the elbow, primary, on (Maunder),
216
— of end of humerus for anchylosis of
elbow (Watson), 218
— of the hip, amputation after (Jackson),
221
— of the hip-joint, cases of, 220 — 21
— of the hip-joint, on (Gant), 218—20
— of the hip, specimen from (Annan-
dale), 220
— of the knee, on (Gant), 221—22
— of knee, cases of, 222—23
— of knee, sources of failure after
(Treves), 221
— of lower jaw, mode of performing
(Watson, Lizars), 228—29
— of lower jaw, through the mouth
(Maunder), 235
— of OS calcis (Gant, &c.), 226—27
— of phalanx of thumb for enchondroma
(Bell), 218
— of shoulder and elbow in same arm
(MacCormac), 213
— of the shoulder, cases (Ewens), 215
— of the shoulder, on (Gant), 215
— of the superior maxilla, 229 — 30
— of the tarso-metatarsal joints (Holmes),
227-28
— of the trochanter major (Gant), 219
— of wedge of bone at knee for anchy-
losis (Morton, Adams, Watson), 223 — 25
510
INDEX.
Excisiou of the wrist, cases of, 218
Exercise, effects of, on the bodily tem-
perature (Allbutt, &c.), 15
Exophthalmic goitre, cases of, and titles
of papers on, 77
Exostosis from first rib, removal of (Bir-
kett), 240
Extender, spiral spring (Holthouse), 255
Eye, gunshot wounds of (Cohn), 349—63
— instruments, new, 363 — 64
— syphilitic affections of the interior of
the (Galezowski), 368
Eyeball, contusion of, case of, 361
— enucleation of, in sympathetic oph-
thalmia (Colin, Mooren), 355—60
— on testing the tension of the (Coccius),
339
— on tension of the (Monnik), 338
Eyelids, suture of the (Verneuil), 349
Eyes, colour of, in the newly born, 426
Facial paralysis after chorea (Buzzard),
81
Faeces of sheep in foot-and-mouth disease
(Hallier), 79
Fagge, case of intestinal obstruction, 293
— murmurs attendant on mitral contrac-
tion, 140
— post-mortem changes in scleroderma,
178
Falck, on urea, 172
Farquharson, cases of pneumonia, 118
— on re vaccination, 431
Fasbender, cases of version, 415
Fat, storing up of, in fat- cells (Hoffmann),
32
Fatty masses in a ranula (Tay), 284
— tumour under the tongue (Churchill),
284
Fauvel, on cholera, 49
Favus, frequency of, in Scotland, 185
Fayrer, radical cure of inguinal hernia,
288
— on snake poisons, 453
Febris lymphatica (Harley), 61
Femur, dislocation of {see dislocation), 253
— neck of, subcutaneous division of
(Adams), 234
— necrosis of, producing epilepsy (Mar-
tin), 83
Ferber, case of rheumatism, 73
— on hay fever, 43
Ferguson, case of hysteria, 80
Fergusson (Sir W.), excision of superior
maxilla, 229
— ligature of the subclavian artery, 201
Ferment, acting on starch, found in
many parts (Lepine), 16
Ferrier, fungi in blood, 36
— on molluscum contagiosum, 182
Fever, action of alcohol in, 464
— dengue, titles of papers on, 43
— exanthematic {see measles, &c.), 58,
&c.
— following surgical operations, on
(Wells), 317
— hay {see hay fever), 43
— intermittent, aphasia in (Boisseau), 45
— intermittent, intra-uterine (Bazin), 45
— intermittent, relation of, to relapsing
(Senator), 57
— intermittent, titles of papers on, 45
— puerperal, on, 398, 421
— relapsing {see also relapsing),
— relapsing, case at Glasgow (Tenneut),
57
— relapshig, epidemics of, 486
— relapsing, incubation of (Murchisou),
41
— relapsing, in London, 58
— relapsing, outbreak of, at Leeds (Rob-
inson), 57
— relapsing, post-febrile ophthalmia
after (Charteris), 57
— relapsing, relation of, to intermittent
(Senator), 57
— traumatic, from gunshot wounds
(Hueter), 315
— traumatic, on (Billroth), 311
— typhoid {see typhoid), 52 — 55
— typhoid, tuberculosis after (Birch-
Hirschfeld), 39
— typhus {see typhus), 56
— urethral, fatal, after catheterism
(Banks), 271
— on " war typhus " (Virchow), 56
— yellow, on (Munro, Sullivan, Hiron,
Eulenberg, &c.), 45—47
— yellow, titles of papers on, 47
Fevers, incubation of (Murchison), 41
— list of authors on, 41
— swelled leg of (Begbie), 41
Fick, effects of heat on the heart, 9
— effects of heating and cooling the
blood passing to the nerve-centres, 22
— on the peptones, 16
Fieber, spinal hemiplegia, 84
Filai'ia in the blood in chyluria (Lewis), 7
Finney, cirrhosis of kidneys, 170
Firmy, antagonism between atropine and
morphine, 439
Fistula, recto-vesical, colotomy in (Bry-
ant), 299
— vesico-vaginal, on (Bell), 282
— uretero-uterine, cases of, 417
Fitzmaurice, on pneumonia, 118
Fleischman, case of cerebral tubercle, 92
— development of teeth in ricjcets, 76
— mortality of scarlet fever, 59
«— symptoms of rotheln, 62
INDEX.
511
Fleming, case of tubercular meningitis,
89
Flint, on the gastric and intestinal
tubules, 153
— results of muscular exercise, 31
Floegel, on structure of muscle, 26
Flugel, case of early menstruation, 372
Fa3tal asymmetry, on a case of, 427
— peritonitis, on, 427
Fcctatlon, extra-uterine, cases of, 403 — 4
— extra -uterine, treatment of, on, 404
— super-, cases of, 404 — 5
Foetus, action of ergot of rye on the, 421
— malformations of the, influence of the
amnion on, 393
— method of bisecting (Wright), 414
— smallpox in a, 432
Fokker, action of alcohol on the tempera-
ture, 464
FoUet, on anaasthetics, 465
Food during siege of Paris, on (Payen),
17
— effects of absence of lime from
(Weiske), 29
— for infants, on, 430
Foot, amputation of the,
— dislocation of bones of, 254
Form, transmutation of, in certain pro-
tozoa (Johnson), 3
Forceps, midwifery (Barclxiy), 415
Forster (Cooper), case of popliteal aneur-
ism, 209
— case of tracheotomy for croup, 106
— excision of both elbows, 218
— death after extraction of naso-pharyn-
geal polypus, 236
Forster, on cholera, 50
— visual sense in disease of the choroid
and retina, 364
Foss, case of rotheln, 62
Foster, case of Csesarean section, 306
— rheumatic pains in diabetes, 74
Fothergill, on hypertrophy of the heart,
138
Fox (E. L.), on phthisis, 126
Fox (T.), case of lichen ruber, 177
— case of pityriasis pilaris, 177
— on keloid, 180
— parasite in case of erythema, 184
— do., in the air of wards, 184
Fracture of femur, complete extension
cannot be effected after (Montgomery),
259
— do., neck of, ununited, operation for
(Lister), 259
— do., spontaneous (Durham), 259
— of the fifth cervical vetebra, survival
after, 260
— of head of radius (Adams), 258
*— of ilium by muscular violence, 258
Fracture of odontoid process, mode of
production of (Smith), 259
— of olecranon, atrophy of triceps after
(Hutchinson), 257
— of skull in child, case of (Adams), 266
— of skull, operation in, cases, 266 — 68
— of tibia and fibula, ununited, operation
for (Bennett), 259
— of tibia, continuous extension in
(Montgomery), 259
Fractures, gunshot, mortality after (Volk-
mann), 260
— do., of lower extremity, on (M'Cormac),
266
— do., of skull, 265
— do., on (Mac Cormac), 264
— incomplete (Smith), 255
— in the newly-born, on, 427
— paralysis from injury to nerve in
(Erichsen), 256
— plastic apparatusin (St. John), 255
— ununited, on (Callender), 256
— do., removal of wire alter operation
for (Mason), 256
Frankel, calcification of the placenta,
394
— on fibrinous uterine polypi, 403
— tubercle in choroid, 91
Fraser, on antagonism of physostigmine
and atropine, 434
Friction sound, auricular pericardial
(Salter), 130
Friedlnger, secretion of glands of sto-
mach, 16
Fritsch, galvanisation of cerebral centres,
22
Fuller, case of hysteria, 80
Fungi in the blood (Lostorfer), 7
— poisonous action of (Husemann), 453
Fungus in diphtheria (Letzerich), 102 — 3
— a variety of, in the skin (Vaulair), 185
Funk, reposition of cancerous uterus, 399
Funis, prolapsed, successful reduction of,
412
Fiirst, on the ammion in relation to
foetal malformations, 393
Gag, improved, for operations (Wood),
233
Galezowski, on exophthalmic goitre, 77
— on syphilitic amaurosis, &c., 368
Gallard, uterine injections in chronic
metritis, 392
Galton (Mr. F.), on pangenesis, 3
Galvanic cautery, removal of pharyngeal
polypus by the (Corradi, Gozziui), 236
— wire, removal of epithelioma of the
tongue with the (Gozzini,Puccioni),283
Gam gee, ligature of common carotid
artery for aneurism, 200
Gangrene, hospital, on (Jones), 319
5ia
INDEX.
Gangrene, hospital (Heiberg), 318
— of feet from embolism, amputation in
(Gant), 213
— of the lung, 122—23
— senile, amputation in (Lister, Mor-
gan), 213
Gant, amputation in gangrene from
embolism, 213
— excision of the ankle, 225
— on excision of the astragalus, 226
— do., of the elbow, 215
— do,, of hip-joint, 218
— do., of the knee-joint, 221
— do., of the shoulder, 215
— do., of the OS calcis, 227
Garden, orchitis after lithotomy, 274
Garrod, on a cardio-sphygmograph, 9
— on lead poisoning, 99
Gases, exchange of, in the placenta, imi-
tation of (Bernstein), 14
Gastric juice, effect of; on uterine cancer,
382
Gastrotomy for intestinal obstruction,
296—98
— in extra-uterine fcetation, 404
Gatzuck, effect of, venesection on arte-
rial current, 9
Gay (C. C. F.), ligature of subclavian in
traumatic axillary aneurism, 202
Gay (John), case of axillo-subclavian aneu-
rism, 201
— cases of excision of the hip-joint,
220
— ligature of subclavian artery, 202
Gay, on histology of prurigo, 178
— pathology of the sweat-glands in
elephantiasis, 181
Gayet, case of cystic myoma of uterus,
881
Geber, case of epithelioma simulating
bubo, 273
Geltowsky, action of quinine on blood-
corpuscles, 7
Gemma, on pellagra, 67 — 68
Genersich, absorption of lymph by ten-
dons, &c., 3
— on the cells of the cornea, 33
Genital passages, on the curves of the
(Duncan), 408
Gerhardt, cases of papilloma, 181
Germs, action of sulphurous acid on,
492
— on development of (Bastian, Sander-
son, &c.), 2
■ — on detection of blood-stains, 45
Gescheidlen, distribution of urea in the
body, 19
Geuns, on detection of blood • stains,
459
Gibbons, case of Csesarean section, 412
Giese, mode of origin of sounds of heart,
129
Giles, on gonorrhoea and peritonitis in
women, 166
Gillespie, cases of excision of the knee,
223
— dry dressings to wounds, 195
Gimbert, bromide of potassium in the
vomiting of pregnancy, 400
Gior, on arseniate of quinine, 463
Giovanni, position of the heart, 132
Gland-cells, innervation of contractile, of
frog (Engelmann), 24
Glands, authors on anatomy of, 20
— lachrymal innervation of the (Wolf erz),
25
— mesenteric, anatomy of (Popper), 4
— salivary, affections of the, list of papers
on, 152
— of the stomach, secretion of the (Eb-
stein, &c.), 16
— termination of nerves in (Pfliigcr),
24
— uterine, epithelium of (Lott), 30
Glaucoma, value of iridectomy in (Quag-
lius), 347
Glosso-pharyngeal nerve, case of paralysis
of (Taylor), 91
Glover, case of pericarditis, 137
Gluge, case of typhoid, 53
Glycogen in blood- corpuscles, while mo-
bile (Hoppe-Seyler), 8
Glycerine lymph, on, 431
Goitre, exophthalmic, cases of, and titles
of papers on, 77
Gold, chloride of, action of, 462
— chloride of, in nervous diseases (Martin),
402
Goltz, on absorption of poisons, 433
— influence of nerve centres on absorp-
tion, 4
Gombault, case of progressive muscular
atrophy, 71
Gonorrhoea and peritonitis in women
(Giles), 166
Gonorrhceal rheumatism (Bond), 282
Goodell, on the management of the pe-
ri nseum during labour, 409
Goodfellow, case of disease of the heart,
139
Goodhart, inoculation of tubercle, 38
Goodridge, case of acute atrophy of the
liver, 161
Gosselin, subastragaloid dislocation of the
foot, 254
Gott (Dr.), excision of superior maxilla^
230
Gourrat, on action of digitalis, 470
Gout, connection of, with hay fever
(Gueneau de Mussy), 43
INDEX.
513
Gozzini, removal of pharyngeal polypus
by galvanic cautery, 236
— removal of the tongue with the gal-
vanic wire, 283
Grafting, epidermic, on, 335
— skin, on, 335
Gray (St. Clair), antagonism of nitrite of
amyl and strychnine, 440
— (of Oxford), cases of chorea, 81
Gray, fall in frequency of pulse before
death from coma, 133
Gregory, on weight of infants, 425
Green, case of disturbed innervation of
the heart, 147
— case of interstitial hepatitis, 162
— interstitial pneumonia, 120
Greene, removal of bronchocele, 236
Grehant, on action of aconitine, 468
Greenhow, case of locomotor ataxy, 98
— paralysis in diphtheria, 105
Greyness of hair, premature, on (Pincus,
Berger), 184
Gross (Dr.), on ulceration of the jugular
veins, 826
Ground water, influence of, on spread of
cholera, 477
Gruber, removal of foreign bodies from
external ear, 335
Grun, on typhus, 485
Gubler, nervine symptoms of smallpox,
63
Gueniot, on absorption of uterine fibroids,
380
— on fractures of the thigh in the newly
born, 427
— hematoma in typhoid, 53
— on urinary umbilical fistula), 427
— congenital invagination of the rectum,
432
Guilland, case of inoculation of smallpox
431
Guinea-pigs, epilepsy in (Brown-Sequard,
Westphal), 82
Gull, on Bright's disease, 168
Gunning, on detection of blood-stains,
459
Gunshot, trephining for (Halstead, How-
ard), 265
Gunshot injuries of bone (Mac Cormac),
264
— injuries, mortality after, compared
with civil practice (Volkmann), 260
— injuries to the brain, cases of (Cohn),
352
— wound of chest, fourfold, recovery after
(Lorinser), 264
— wound of neck, retention of ball
(Baumes), 264
— wounds, experience in (Mac Cormac),
Gunshot wounds of eye (Cohn), 349 — 363
— wounds of lower extremity (Mac
Cormac), 266
— wounds, operations not adapted for
(Moore), 263
— wounds, surgery of arteries in (Ver-
neuil), 263
• — wounds, traumatic fever from (Hueter),
315
Gusserow, anaemia during pregnancy,
397
— on urea in liquor amnii, 17
Giiterbock, emphysema in diphtheria,
105
— healing of wounds of the cornea, 34
Habershon, cases of disease of the stomach,
154
— nocturnal dyspnoea, 133
— peritoneal adhesions giving rise to
pain, 166
Hsematidrosis, case of (Wilks), 183
Hsematocele, pelvic, on (Meadows, Beck),
391
Haematoma in case of scarlet fever (Ru-
ber), 60
— in typhoid (Gueniot), 53
Hsematometra, 369 — 70
Hsematozoon, a peculiar ciliated (Boyd
Moss), 7
Hffiraaturia, paroxysmal, on (Pavy), 170
— titles of papers, on, 170
Ha3moglobin crystals, &c. (Preyer), 5
Hemoptysis, experiments on, as cause of
phthysis (Sommerbrodt), 126
— in phthisis, proportion of (Williams),
127
Haemorrhage from kidneys in infants, 432
— meningeal, titles of papers on, 89 — 90
— recurrent, after amputation, 211
— secondary, after delivery, 424
— supplementary to menstruation, 373
— transfusion for, 419
Hafiz, properties of muscle, 27
Hainworth, case of poisoning by carbolic
acid, 446
Hair, loss of, over the whole body (Crisp),
184
— papers on diseases of, 187
— premature greyness of (Berger, Pin-
cus), 184
— structure of, in its medico-legal as-
pects, 459
Halbertsma, external examination of
uterus in labour, 415
Hallier, examination of faeces of sheep in
foot-and-mouth disease, 79
Hallopeau, on chronic myelitis, 93
Halstead, trephining for gunshot, 265
Hammarsten, absorption of lymph, 4
514
INDEX.
Hamilton, case of tumour of the lower
jaw, 229
Hammond on apliasia, 86
— on monobromide of camphor, 4G9
Hancock, excision of the astragalus, 226
— on excision of the hip-joint, 220
— excision of wrist, 218
Hanson, regeneration of epithelium of
cornea, 33
Hardie, removal of congenital cystic
tumour of neck, 287
— spontaneous separation of uterine
fibroid, 380
Harley (J.), on scarlet fever, &c., 61
Harris, cases of Csesarean section, 412
— on Cesarean section, 306
• — on forms of pelvic distortion, 410
Hart (Dr.), case of hydrocele of the round
ligament, 391
Hartmann, on croup and diphtheria, 104
Hasse, course of blood in spleen, 19
Hattute, case of elephantiasis, 181
Haughton, mechanics of muscle, 30
Haward (Mr. W.), on ether and chloro-
form, 193
Hay (T.), removal of inverted uterus with
intramural fibroid, 377
Hayden, diaphragmatic pleurisy, 114
Hayem, case of pneumonia, 119
— on scurvy, 75
Hay fever, relation of, to gout (Gueueau
de Mussy), 43 "
— quinine in (Ferner), 43
— symptoms of (Waters), 43
— titles of papers on, 43
Hayes, method of securing vessels of
pedicle in ovariotomy, 390
Haynes, dislocation of both ends of
clavicle, 247
Head, gunshot injuries to, 265
— injury to, cases of, 266—08
— injuries to the, on artificial respira-
tion in (Schiff), 14
— injury to the, emphysema and ecchy-
mosis of lungs in — experiments (Brown-
Sequard), 108
Health, public, report on (Stevenson),
472
— resorts, on, 190 — 91
Hearing, action of the tensor tympani on
(Schapringer), 25
Heart, abscesses in the (Crisp), 139
— action of camphor on the, 469
— aneurism of mitral value of (Simon),
141
— aneurism of the (Murchison, Towns-
end), 139
— calcareous degeneration of the (Coats)j
140
— cancer of the (Payne), 139
Heart, case of disease of tricuspid valve
of (VVhipham), 141
— case of disease of (Smith), 138
— circulation in, with inspiration
(Quincke, Pfeiffer), 13
— congenital malformation of the, cases
of, 147—48
7- do., list of papers on, 148 — 49
— dilatation of the, on (Thompson), 138
— disease of, case of (Goodfellow), 139
— disease, cases of, with embolism, 134
—36
— disease complicated with pregnancy
(Spiegelberg), 398
— disease of, during pregnancy, causa-
tion of (Lebert), 397
— disease of the walls of the (Quain),
137
— disease, on prevention of (Stone), 132
— disease, titles of papers on, 134, 142 —
43
— effects of heat on the action of the
(Ceradini, Brunton, Pick), 9
— effects of strain on the (AUbutt), 132
— effects of temperature on the (Brun-
ton), 133
— effects of the, on respiration (Landois,
Ceradini), 13
— fibrous tumour of the (Wagstaffe), 138
— hypertrophy, &c., of the, on (Fothcr-
giil), 138
— irritable, on (Costa), 146
— murmurs in diseases of, on, 129 — 34
— do., titles of papers on, 134
— nervous palpitation of the (Mazza),
147
— neurosis of the (Nunneley, Moinet,
&c.), 145—47
— nocturnal dyspnoea in disease of the,
133
— orifices of the, on (Davies), 131
— origin of first sound of the (Giese),
129
— palpitation of the, on (Nunneley), 145
— position of the (Giovanni), 131
— presystolic murmur in disease of, on
(Fagge), 140
— rupture of the, cases of, 143 — 45
— sounds of, audible after cessation of
respiration, 141
— sounds of, intensification of the
(Poore), 130
— sounds of the, titles of papers on,
134
— valvular disease of, prognosis in (Pea-
cock), 139
Heart's action, effects of respiration on
(Hering), 10
Heat, effects of, on action of the heart
(Ceradini, Branton, Fick), 9
INDEX*
515
Heath, case of aortic aucnrism, &c., 202
— lio^aturc of the common carotid in
aortic aneurism, 201
— case of wound of intestine during
ovariotomy, 305, 389
— tumour of lower jaw, 229
Hebra, case of herpes impetiginiformis,
176
liegar, on sarcoma of the uterus, 375
Ileiberg, endocarditis with mycosis endo-
cardii, 140
— on hospital gangrene, 318
— on use of tracheal tampon, 320
— regeneration of epithelium of cornea,
33
lleidcnhain, temperature of brain with
sensory excitement, 22
— on tone of muscles, 30
Heine, subcutaneous injection of tu-
mours, 244
Heifer, carbolic acid in diphtheria, 106
Hemiplegia, cases of (Perroud), 84
— from rupture of internal carotid (Ver-
neuil), 84
— right- sided, without defect of speech
(Down), 88
— spinal, cases of (Fieber), 84
— titles of papers on, 88 — 89
— with embolism, cases of, 134 — 36
Hemisphere of brain, functions of each
(Perroud), 84
Henocque, distribution of nerves to mus-
cular tissue, 30
Hereditariness of nervous diseases (Jas-
trowitz), 91
Heriug, action of respiration on the
heart's action, 10
Hermann, on electrisation of muscle, 31
Hernia, catgut sutures to tendinous
openings in (Lister), 289
— diaphragmatic, on (Popp, Sargent),
290
— direct inguinal, in the female (Squire),
288
— femoral, reduction of, en masse, 288
— incarcerated scrotal (Hutchinson), 289
— obturator, cases of (Chiene, Erichsen),
290—91
— of the ovary, on (Englisch), 291
■ — radical cure of inguinal (Fayrer), 288
— sciatic, case of (Marzolo), 293
— strangulated, on (Paget), 288
— strangulated, treatment of, by punc-
ture of the intestine (Bryant), 289
— strangulated umbilical, 289
— use of aspirator in (Labbe, Demar-
quay), 289
Herniotomy, cases of, in infants (Erich-
sen, Hill), 288
Herpes frontalis (Sichel), 175
Herpes impetiginiformis (Hebra), 176
— papers on, 186
— with urticaria (Broadbent), 176
— zoster, on (Wyss, Sichel, Parrot, &c.),
175—76
Herpetic fever, on (Parrot), 175
Hertel, case of bronchitis, &c., 116
— case of congenital malformation of the
heart, 147
Heschl, state of capillaries, &c., in ty-
phoid, 52
Hesse, on alkaloids from opium, 468
Heterogenesis, on (Bastian, &c.), 2
Heubel, on chronic lead poisoning, 442
Heubner, action of camphor on the
heart, 469
Hewitt (Graily), on the vomiting of
pregnancy, 400
Hewitt (Prescott), on bronchotomy, 320
Hicks (Dr. Braxton), anatomy of the
human placenta, 393
— cases of inversion of the uterus,
417
— on diagnosis of pregnancy, 401
— haemorrhage in connection with labour,
419
— on tables of mortality after obstetric
operations, 415
Higginson, cases of transfusion, 420
Hildreth, on transfusion of blood, 329
Hill (Berkeley), a new stricture dilator,
272
Hill (J. D.), excision of part of scapula,
231
— • herniotomy in infant, 288
Hip, amputation at the {see amputation)
— re-amputation at the, on (Otis), 212
Hippel, visual sense in disease of the
choroid and retina, 3G6
Hiron, on yellow fever, 46
Hirschberg, cysticerci oculi, 79
Hirsclifeld (Birch-), on inoculation of
tubercle, 39
Histology, papers on, 32
Hitzig, galvanisation of cerebral centres,
22
Hodge, on position of foetal head during
delivery, 407
Hof man, treatment of acute exanthems,
58
Hoffmann, on storing up of fat in the fat-
cells, 32
— structure of hair in its medico- legal
aspects, 459
Holden (Luther), cases of popliteal aneu-
rism, 209
— haemorrhage after use of catgut liga-
ture, 209
Holden (of America), on sea voyage ia
phthisis, 190
616
INDEX.
HoUis, case of simultaneous lead and
mercurial poisoning, 99
Holmes (Timothy), excision of the tarso-
metatarsal joints, 227 — 28
— on excision of the knee-joint, 222
— flexion of leg in popliteal aneurism, 209
— on surgical treatment of aneurism, 198
— treatment of suppurating ovarian
cysts, 302
Holthouse, removal of tracheotomy tube,
321
— spiral spring extender, 255
Honer on cholera, 481
Hoppe-Seyler, glycogen in blood, 8
— on disinfection, 492
Hoscheck, case of Csesarean section, 413
Hospital gangrene, on (Heiberg, Jones),
18—19
Howard, trephining for gunshot, 265
Huber, haematoma in scarlet fever, 60
Huchard, cause of death in smallpox, 63
Huebel, active principles of tobacco
smoke, 451
Hueter, traumatic fever from gunshot
wounds, 315
Hughes, case of rupture of the heart, 145
Hulke, cases of colotomy for stricture of
rectum, 299
— case of cleft palate, 233
— case of gastrotomy for intestinal ob-
struction, 297
— case of ligature of radial, 210
— case of stricture of urethra, 272
Humerus, dislocation of (see dislocation),
247
Humphry, on myology, 31
Husemann, on chloral hydrate, 465
— poisonous action of f migi, 453
Huss, pain in pleurisy, 112
Hutchinson (Mr. Jonathan), atrophy of
triceps after fracture of the olecranon,
257
— case of cerebral tumour, 92
— ease of incarcerated scrotal hernia, 289
— cases of vaccino-syphilis, 306
— chronic rheumatic arthritis, 326
— incontinence as a symptom of reten-
tion of urine, 273
— on orchitis from irritation of the pros-
tatic urethra, 273
— paralysis of ciliary muscle in diph-
theria, 104
— on periostitis of temporal bone, 333
— xanthelasma palpebrarum, 183
Hutton, prediction of sex of child by aus-
cultation, 396
Hydrocyanic acid, detection of (Almen,
Preyer), 454
Hydatids in the brain, cases (Reeb), 78
— in the lung, case (Zuber), 79
Hydatids of cerebellum, cases of, 93
— of the liver, cases of, 163
— of the lungs (Lebert, Zuber, Bird),
124—25
Hydrocele of the round ligament, case of
(Hart), 391
Hydrocephalus, cases of, and titles of
papers on, 89
— chronic, on, 429
Hydrochloric acid, cases of poisoning by,
442
Hydrocyanic acid, action of (Preyer), 446
— action of (Amory), 448
Hydrogen, peroxide of, use in pessaries
(Day), 461
Hydrophobia, histology of nervous centres
in (Allbutt), 42
— list of authors on, 42 — 43
— pathology of (Rudnew), 42
Hymen, imperforate (Barton), 282
Hypersesthesia, titles of papers on, 88
Hypermetropia, frequency of, 342
Hypertrophy, congenital, case of, 428
Hysteria, case of analgesia with (Rosen-
thal), 80
— contraction of limbs in (Charcot), 79
— on cases of supposed (Fuller), 80
— titles of papers on, 80
— trance in (Jamieson), 80
Ichthyosis, papers on, 186
Icterus neonatorum, 432
Icterus, on, 164
Iliac artery, common, ligature of the, for
haemorrhage (Baker), 207
— external ligature of the, cases of,
207—8
Ihlder, nerves of the tongue in birds, 25
Impetigo, papers on, 186
Incubation of fevers (Murchison), 41
Induration of lungs, brown (Delafield,
Rindfleisch), 121
Infantile paralysis, cases of, nature of,
&c. (Damaschino, Roger, Rinecker,
Rosenthal), 96—97
— paralysis, titles of papers on, 97
— spinal paralysis (Charcot), 95
Infants, hemorrhage from the kidneys
in, 432
— on feeding of, 430
— on still-born, 425
— weight of, 425
Infection from poison of animals, list of
authors on, 42
— list of authors on subject of, 37
— means of (see also contagion), 35 — 37
— use of respirator to prevent (Tyndall),
37
Inflammation, condition of the walls of
the vessels in (Durante), 33
INDEX.
617
Inflammation in the cornea, experiments
on (Heiberg, Hansen, Carmalt, &c.), 33
— list of authors on, 34
— persistent, ti*eatment of (Marshall),
334
— the state of the walls of the vessels
in (Durante), 33
Infusions, development of bacteria in
(Sanderson, Bastian), 36
Inglis, case of Csesarean section, 412
Injection in tumours, (Heine), 244
Innervation of contractile gland-cells of
frog (Engelmann), 24
Inoculability of tubercle (various), 38 — 39
Inoculation of small-pox, case of, 431
Innominate, compression and ligature of
(Bickersteth), 201
Insolatio, on (Thin, Macdonald, Clap-
ham), 58
Intermittent {see fever), 45
Intestinal obstruction, cases of, 293 — 99
— obstruction, formation of artificial
anus (Mc Carthy), 296
— obstruction from bands of lymph,
cases of, 298
— obstruction from congenital constric-
tion (Southey), 295
— obstruction from a knot (Taylor), 295
— obstruction from peritonitis, case of
(Buchanan), 296
— obstruction, list of papers on and cases
of, 158—59
— obstruction, on lumbar colotomy in
(Bryant), 294
— obstruction without sickness (Bell,
Croom), 295
Intestine, changes in, in typhoid (Heschl,
Murchison, Maclagan), 52
— puncture of, 297
— puncture of, in hernia (Bryant), 289
— syphilitic disease of small (Oser), 65
— wound of, case of, 299
— wound of, during ovariotomy (Heath),
305
Intestines, afEections of the, list of papers
on, 157
Intussusception {see invagination), 432
— list of cases of, &c., 158
Invagination, congenital, of the rectum,
432
— of the colon, &c., 432
Iodine as injection in chronic metritis,
392
— causing pemphigus (Bumstead), 176
Iridectomy, value of, in glaucoma (Qua-
glino), 347
Iris, congenital coloboma of the, 339
Iron, chloride of, action of, 462
— perchloride of, as an injection in
chronic metritis, 392
Isaakson, on emphysema, 116
Isambert, pharyngo-scrofulous angina,
151
Itch, treatment of (Monti, Weinberg),
185
Jackquet, cysts of the placenta, 394
Jackson (J. Hughlings), convulsions and
loss of speech, 87
— power of singing remaining in two
aphasic boys, 88
— tubercle of the cerebellum, 92
Jackson (T. Carr), amputation after ex-
cision of the hip, 221
— excision of the astragalus, 226
Jacobi, on case of foetal asymmetry, 427
Jacobson, on coincidence of murmurs
with period of heart's action, 129
Jalland, case of vaginal thrombus, 419
Jameson, case of abscess of the liver, 159
Jamieson, case of popliteal aneurism,
209
— case of trance, 80
— case of vaginal rupture, 417
Janeway, tumours of dura mater, 93
Jarisch, composition of the blood, 6
Jastrowitz, hereditary character of ner-
vous diseases, 91
Jaundice, authors on, &c., 164
— in new-born children, 432
Jaw, lower, anchylosis of the, operation
for (Bottini, Maas), 230
— lower, excision of, &c,, 228 — 29
— lower, myeloid tumour of (Maunder),
235
— lower, removal of, through the mouth
(Maunder), 235
— upper, excision of the 229 — 30
— upper, resection of, for removal of
naso-pharyngeal tumours (Burns), 235
Jeffreys, case of poisoning by carbolic
acid, 446
Jenks, case of placenta succenturlata,
424
Jessop, use of pneumatic respirator, 232
Joffroy, case of tetanus, 98
— changes in paralysis agitans, 97
Johnson (Mr.), extra -uterine fcetation,
404
Johnson (Dr. G.), diagnosis of aortic
aneurism with the laryngoscope, 149
— on Bright's disease, 167 — 68
— on laryngeal spasm, 102
— on scarlet fever, 487
Johnson (Metcalfe), phosphate of lime in
the vomiting of pregnancy, 400
— on transmutation of form in certain
protozoa, 3
Joint disease, necrosis in (Treves), 325
518
INDEX.
Joint, knee, loose cartilages in, removal |
of (Square), 326
Joints, amputation tlirough {see ampu-
tation)
— disease of, authors on, 326
— disease of, from continued rest,
(Menzel), 325
— excision of {see excisions), 213
Jones (Handfield), cases of acute rheu-
matism, 74
— cases of chorea, 81
— on case of pleurisy, 112
Jones (Dr.), on hospital gangrene, 319
Jones (Sydney), cases of excision of the
knee, 223
— excision of wrist, 218
Jones (Talfourd), on use of nitrite of
amyl, 467
Jordan (Furneaux), new method of re-
moving the tongue, 283
Joulin, on the laminar membrane of the
human placenta, 394
Jugular veins, ulceration of the, on
(Gross), 326
Julian, on capillary bronchitis, 116
Junker, on the use of the tracheal tampon,
319
Jurasz, action of bile on the blood-cor-
puscles, 6
Kalteubach, albuminuria during preg-
nancy, 396
Kehrer, jaundice in new-born children,
432
— morphology of milk casein, 423
Keith, cases of ovariotomy, 302
— on ovariotomy, 389
Kelly, case of congenital malformation of
the heart, 148
— case of scarlet fever, 61
Keloid, on (Kohn, Fox), 180
Kennedy, on phthisis, 126
Keratitis, experiments on (Carmalfc,
Strieker, &c.), 33
Kerner, action of quinine on blood-cor-
puscles, 7
Kersey, outbreak of diphtheria, 105
Kidd, decapitation as mode of delivery,
413
— on uterine fibroids, 379
Kidney, amount of uric acid excreted by
the (Sawicki), 30
— atrophied, uraemia from (Murchison),
169
— Bright's disease of, causes of (Roberts),
168
— Bright's disease of, diagnosis, &c., of
(Johnson), 167
— Bright's disease of, dropsy in (Wood),
167
Kidney, Bright's disease of the, titles of
papers on, 170
— Bright's disease of, with contracted
kidney (Gull and Sutton), 168
— cirrhosis of the (Finney), 170
— disease of, ending in apoplexy, 169
— extreme, granular degeneration of,
without cardiac affection (Moxon), 169
— hydatids in the (Shepherd), 171
— hypertrophy of, on (Rosenstein, Perl),
171
— syphilitic disease of (Bradley), 168
— titles of paners on affections of the,
171
Kidneys, haemorrhage from the, in
infants, 432
— on formation of urea by the (Rosen-
stein), 19
King (Dr.), removal of tumour of palate,
238
King (Prof.), relaxation of pelvic articu-
lations during pregnancy, 407
King (Surgeon), on cold food for infants,
430
Kittel on trichinosis, 78
Klein, development of earliest corpuscles
and blood-vessels, 7
— distribution of nerves in membrana
nictitans, 24
— on serous membranes, 4
Knee, amputation at the {see amputation)
— anchylosis at, excision of wedge of
bone in, 223—25
— anchylosis at the, subcutaneous osteo-
tomy in (Little), 225
— dislocation at the, 254
— excision of the {see also excision)
Knoll, pseudo-hypertrophic paralysis, 71
Kobner, reinfection of constitutional
syphilis, 306
Kocher, on traumatic aneurism of the
vertebral artery, 202
Kohler, on anassthetics, 465
Kohn, on keloid, 180
— on parasitic erythema, &c., 185
Konrad, etiology of prolapse of female
genitalia, 383
Korner, on tubercle, &c., 126
— on tuberculosis, 108
Kotsonopulos, on epidemic of cerebro-
spinal meningitis, 44
Kowalewsky, on arterial current, and
arterial pressure, 9
Kraft- Ebing, paralysis after diphtheria,
105
— suppuration in muscles, after typhoid,
53
Kratschmer, on diabetes, 73
Kronlein, on open treatment of wounds,
195
INDEX.
519
Kiiclienmeister, on treatment of epistaxis,
334
Knpressow, power of sphincter vesicso
muscle, 20
Kiissmaul, on lead poisoning, 99
Kuttner, on invagination of the intestine,
158
Labbe, on morphine and chloroform, 468
— use of aspirator, 289
Laborde, nervine symptoms of smallpox,
63
Labour, accidents during, 416
— artificial induction of (Rokitansky),
403
— determination of age and size of child
before (Ahlfeld), 395
— difficult, cases of, 410—12
— external examination of uterus in
(Halbertsma), 415
— haemorrhage in connection with
(Hicks, &c.), 419
— hfBraorrhagic, smallpox after, 423
— induction of premature (Donaldson),
402
— influence of uterine fibroids on, 411
— long delay of, after escape of liquor
amnii (Duncan), 394
— management of perinseum during
(Goodell, Swayne), 409
— mechanism of, on, 405 — 7
— ruptureof the uterus during (Fourrier),
416
— sudden death after, 424
Lachrymal fluids, innervation of the
(Wolferz), 25
Lagrange (Fargier-), on methylamine, 466
Lahens (Magnes), on use of tar, 467
Lair, on sterco-bilen, 17
Landois, action of heart on respiration, 31
Lane, double ligature in aneurism at the
root of the neck, 202
— ligature of common carotid for aneu-
rism. 200
Langenbeck, on epileptic convulsions after
injm'ies to the head, 83
Lannelongue, use of nasal mucous mem-
brane in uranoplasty, 334
Laryngeal nerves, function of (Navratil),
102
— obstruction after erysipelas (Russell),
101
— obstruction with oedema, case of (Boelt),
101
Laryngotomy for removal of foreign
bodies (various), 320 — 21
Larynx, colloid cysts in the, 188
— growths in the, on (Mackenzie), 324
— opening the, for the removal of growths
(Durham), 322
Larynx, removal of foreign bodies from,
cases of, 320—21
— spasm of, on (Johnson), 102
— titles of papers on affections of the,
102
— ti'acheotomy for disease of, cases,
371
Laschkewitsch, blood-corpuscles in Ad-
dison's disease, 8
— cases of bronzing of skin, 76
Laseue, treatment of diphtheria, 106
Latham, on typhoid fever, 53
Lavdowsky, on lym])hatics, 4
Laveran, inoculation of tubercle, 38
Lawson, case of congenital hypertrophy
of the tongue, 284
— case of reduction of femoral hernia
en masse, 288
— on cholera, 48
Lead and mercurial poisoning, case of
(Hollis), 99
— poisoning, case of (Kussmaul, Maier),
99
— poisoning, chronic, on (Heubel), 442
— poisoning, on (Garrod), 99
Leared, gangrene of the lung, 122
Lebert, on causation of heart disease during
pregnancy, 397
— hydatid cysts in lung, 124
— on pneumonia, 119
Lee, removal of tracheotomy tube, 322
Legg, on acute atrophy of the liver,
160
Leg, swelled, of fevers (Begbie), 41
Legislation, sanitary, 495
Leichtenstein, on volume of expired air,
11
Lepiue, ferment converting starch into
sugar widely diffused, 16
Lesser, on absorption of lymph, 4
Letzericli, fungous origin of diphtheria,
&c., 102—3
Leucaamia, alkaline blood in (Hosier), 8
Leuchaemia {see leucocythemia), G9
Leucocythaemia, examination of urine in
(Salkowski), 69
— post-mortem, on case of (Reincke), 69
— relation of, to pseudo-leukaemia, 69 j
— state of retina in (Reincke), 69
— titles of papers on, 70
Lewis, filaria in blood, 7
Leyden, on bronchial asthma, 117
Lichen, papers on, 186
Lichen ruber, case of (Fox), 177
Lichtenberg, extraction of polypus, 236
Lichtenstein, on phosphorus poisoning,
440
Liebig (G. v.) effects of atmospheric
pressure on respiration, 15
Liebreich, on croton chloral, 466
520
INDEX.
Life, phenomena of, influence of baro-
metric pressure on (Bert), 13
Ligature {see artery)
— antiseptic catgut, on, 195
— antiseptic, of innominate (Bicker-
steth), 201
— catgut, haemorrhage after use of
(Holden), 209
— of common carotid in aortic aneurism
(Heath), 201
— of common carotid artery for aneu-
rism (Lane, Gamgee), 200
— of the common iliac artery (Baker),
207
— of the external artery, cases of
207—8
Light, violet, influence of, on growth
(Pleasanton), 18
Lime, effects of absence of, from food
(VVeiske), 29
— phosphate of, in vomiting of preg-
nancy (Johnson), 400
Ling, absence of ovary, &c., 371
— injury to jDregnant uterus, 400
Lipp, on erythema, 174
Lissauer, treatment of typhoid, 54
Lister, on antiseptic surgery, 194
— amputation in senile gangrene, 213
— case of, amputation of the hip-joint, 211
— cases of popliteal aneurism, 209
— catgut sutures to tendinous openings
in hernia, 289
— excision of wrist, 218
— operation for ununited fracture of neck
of femur, 259
— removal of loose cartilages from knee-
joint, 326
— treatment of cicatrices, 332
Lithotomy, cases of, &c., 277
— haemorrhage after (Square, Tay), 277
— in female, 278—79
— orchitis after (Hutchinson, Garden),
273—74
— rectal (Schiiffer), 278
— removal of piece of bone from the
bladder (Thompson), 277
Lithotrity, case of, with atOny of the
bladder (Matiejowsky), 276
Little (Dr. A.), antagonism between
belladonna and opium, 439
Little (W. S.), subcutaneous osteotomy
at knee, 225
Littleton, on overlaying, 427
Liveing, cases of molluscum contagio-
8um, 183
— poison of contagious diseases, 37
Liver, abscess of the, cases of, 159 — 60
— acute atrophy of the, cases of, 160 —
61
— do., list of papers on, 161
Liver, cancer of the, cases of, 163
— cirrhosis of the, cases of, 161 — 62
— do., list of papers on, 162
— deposits in, in syphilis, on (Simon),
m
— hydatids of the, cases of, 163 — 64
— do., list of papers on, 164
— list of papers on various affections of
the, 165
— size of, in children (Steffen), 165
— sugar of, on (Dalton), 17
Lizars, excision of the lower jaw, 229
Locomotor ataxy, case of (Greenhow,
Cayley), 98
— titles of papers on, 98
Lohmayer, use of pneumatic aspirator,
232
Long, calculus in female, 278
Lorain, case of woman with four breasts,
371
Lorinser, fourfold gunshot injury to
chest, recovery, 264
Lostorfer, diagnosis of syphilis by the
microscope, 64
— fungi in blood, 36
— fungi in human blood, 7
Lott, epithelium of uterine glands, 20
Lowe, case of rupture of the heart, 145
— opening the stomach for cancer, 299
Lubanski, ulcei'ative angina, 151
Lucas, a new plan of using acupressure,
198
Liicke, on paculosis, 180
Ludwig, vaso-motor centre of medulla, 23
Lukomsky, ecchymoses after suffocation,
460
Lunatics, gangrene of lung in (Browne,
Burman), 123
Lund, excision of both astragali, 226
Luneau, cases of embolism, 135
Lung, abscess of the, cases and titles of
papers, 122—23
— gangrene of the, cases and titles of
papers, 122—23
— hydatids in the, case of (Zuber), 79
Lungs, affections of, from injuries to
brain (Brown-Sequard), 269
— brown induration of (Delafield, Rind-
fleisch), 121
— ecchymoses in, from injuries to the
head, experiments (Brown-Sequard),
108
— emphysema of the, from injury to the
head (Brown-Sequard), 108
— encephaloid disease of (Sparks), 124
— epithelioma of the (Arnott), 124
— hydatids of (Lebert, Zuber), 124 —
25
— hydatids of, in Australia (Bird), 125
— hypertrophy of, title (Thierfelder), 121
INDEX.
521
Lung, ill- effect on, from ill-developed
muscles of neck (Koruer), 108
— inhalation of dust into (Mayet, Ross,
Merkel), 123
— lymphatics of the (Sikorsky), 11
— scirrhous cancer of (Bennett, Waters),
124
Lupus, papers on, 187
Luschka, cases of colloid cysts in the
larnyx, 188
Lussana, nerves of taste, 25
Lutz, on bromide of potassium in epi-
lepsy, 83
Lymph, absorption of, by tendons (Gen-
ersich. Lesser, &c.), 3 — 4
— flow of, circumstances influencing, 4
Lymphadenoma, case of (Murchison), 111
Lymphadenomata, on (Wagner), 188
Lymph-corpuscles, glycogen in, while
mobile (Hoppe-Seyler), 8
Lymph, glycerine, on, 431
Lymphatic varix, congenital (Paterson),
211
Lymphatics, arrangement of, in serous
membranes (Klein, Sanderson), 4
— of the lungs, on the (Sikorsky), 11
Lymphoma, multiple, arsenic in (Bill-
roth), 244
Lymphomata, cases of (Maier, Roth), 188
—89
Lyons, on typhus in India, 56
Maas, cases of sporadic pellagra, 68
— operation for anchylosis of the lower
jaw, 230
MacCall, on whooping-cough, 117
McCarthy, formation of artificial anus in
intestinal obstruction, 296
McClintock, mode of removing uterine
polypi, 380
MacCorraac, excision of shoulder and
elbow in same arm, 213
— experience of gunshot wounds, 263
— on gunshot injuries of bone, 264
— gunshot wounds of lower extremity,
266
— opening the stomach for cancer, 299
— unreduced dislocation of the femur,
253
McCoy, tumour of antrum, 234
Macdonald, case of shoulder presenta-
tion, 414
— on sunstroke, 58
McDougall, haemorrhage after amputa-
tion, 211
Macgillivray, case of congenital hyper-
trophy, 438
McKee, reduction of dislocation of the
femur, 253
Mackenzie (Dr., of America), case of
emphysema during labour, 419
Mackenzie (Morell), treatment of bron-
chocele, 237
Mackenzie (Mr. Stephen), on glycerine
lymph, 431
Maclagan, intestinal lesion on typhoid,
52
Maclaren, on sea voyage in phthisis, 190
Macleod (Dr.), on division of pedicle in
ovariotomy, 305, 390
— on skin grafting, 335
McPherson, case of biliary calculus, 164
MacSwiney, case of tubercular menin-
gitis, 89
— • on infantile diarrhoea, 157
Madden, cases of sudden death after
labour, 424
Madge, paralysis during pregnancy,
398
— report on specimen of epithelioma of
xiterus, 382
Magnesium, chloride of, action of, 462
Maier, cases of lipomatous tumours, 188
— on lead poisoning, 99
Malarial poison, vegetable (Liveing), 37
Malformations of foitus, influence of
ammion on (Fiirst), 393
Malins, excision of elbow for compound
dislocation, 218
Malmsten, cases of poisoning by sulphuric
acid, 441
Mamma, on mode of removing (Bell),
234
— removal, &c., of, 233—34
Mamma?, case of four (Lorain), 371
— cases of haemorrhage from, supplemen-
tary to menstruation, 373
Manassein, size of blood-corpuscles at
different temperatures, 39
— size of blood-corpuscles in pya3mia,
&c., 6
— temperature in animals after swing-
ing, &c., 39
Manizu, action of alcohol on the tem-
perature, 464
Manometer for respiratory movements
(Waldenburg), 108
Marcet, blood a colloid fluid, 7
— chemistry of muscle, 28
Marine grass for sutures (Burow), 349
Marriage in consumptives, on (Williams,
Barnes, Bennett), 128
Marshall, excision in old dislocation of
elbow, 218
Martin, epilepsy from necrosis in thigh,
83
— on puerperal fever, 421
Martini, case of muscular atrophy, 70
— treatment of uterine disease, 402
522
INDEX.
Maschka, on poisoning by sulphate of
copper, 443
Masius, on microcytliajmia, 70
— sterco-bilin, 17
Mason (Mr. F.), cleft palate, 233
— removal of wire after operation for
ununited fracture, 256
Materia medica, report on (Stevenson),
461
Matliieu, amount of oxygen in blood in
different arteries, 13
Matiejowsky, case of stone, with atony
of the bladder, 276
Mattel, cramps during pregnancy, &c.,
409
Matthews, removal of an artificial tooth -
plate from the oesophagus, 287
— rupture of the heart, 144
Malton, pneumonia during pregnancy,
398
Maunder, excision of the ankle, 226
— excision of lower jaw through the
mouth, 235
— on primary excision of the elbow, 216
Maurer, symptoms of poisoning by vanilla
ice, 452
— on trichinosis, 78
Maury, extroversion of the bladder, 275
Maxilla, inferior, anchylosis of the, opera-
tion for (Maas, Bottiui), 230
— inferior, cases of excision of, 228 — 29
— inferior, excision of, mode of per-
forming (Watson, Lizars), 228—29
— inferior, removal of, through the
mouth (Maunder), 235
— superior, excision of the, 229
Maxilla), superior, resection of, for re-
moval of naso-pharyngeal tumours
(Bruns), 235
Mayer, action of strychnine on the blood
pressure, 10
— case of softening of the stomach, 155
Mayet, on anthracosis, 123
Mayo, on an outbreak of typhoid, &c., 54
Mazza, on nervous palpitation of the
heart, 147
Mazzei, on cataract extraction, 343
Marzolo, case of sciatic hernia, 293
Meadows, on pelvic hematocele, 391
Measles and smallpox coincident (Au-
chenthaler, Brunton), 60
— mortality of (Ballot), 59
— treatment of (Hofman), 58
Meadows, on treatment of fibroid tu-
mours of the uterus, 379
Mediastinal growth, a peculiar (Virchow),
109
— growths, titles of papers on, 112
Mediastinum, carcinomatous mass in
(Clarke), 111
Medicine, report on (Shepherd), 33
Medulla oblongata, vaso-motor centre of
the (Ludwig), 23
Melanosis of penis, (Holmes), 275
Meldon, case of injury to the head, 266
Membrana nictitans, distribution of nerves
in the (Klein), 24
Membrane, respiratory mucous, histology
of (Boldyrew), 11
Meningeal apoplexy, titles of papers on,
89—90
Meninges, psammomata of the (Arnold),
188
Meningitis, cerebro-spinal, on (Eulenberg,
Kotsonopulos, Russell), 44 — 45
— do., titles of papers on, 44 — 45
— chronic (Arndt), 89
— ophthalmoscopic appearances in (Bou-
chut, Socin, Broadbent, &c.), 90 — 91
— titles of papers on, 89
— tubercular (Fleming, MacSwiney), 89
Menstruation, defective, on, 372
— early appearance of (Ashtou, Flugel),
372
— haemorrhage supplementary to, 373
— painful, 373
Menzel, on disease of joints from con-
tinued rest, 325
— enchondroma of the ribs, 241
— impaction of foreign bodies in stric-
tured oesophagus, 286
— intra-buccal resection of the inferior
maxillary nerve, 328
Mercurial and lead poisoning, case of
(HoUis), 99
Mercury, action of bichloride of, 463
— action of, on secretion of bile (Ben-
nett), 463
— oleate of, in treatment of inflamma-
tion, 334
— subcutaneous injections of, in syphi-
lis (Sigmund), 308
Merkel, inhalation of dust, 123
— on Cheyne-Stokes's respiration, 107
— on structure of muscle, 26
Mesenteric glands, anatomy of (Popper),
4
Methylamine, on (Lagrange), 466
Methylene, bichloride of, use of, 466
Meyer, on action of digitalis, 471
— on exophthalmic goitre, 77
— value of different kinds of bread, 18
Meynet, case of scarlet fever, 61
— case of supplementary haemorrhage,
373
Mezger, subcutaneous rupture of vessels
in nsevus, 211
Mialhe, chemistry of hydrocyanic acid,
448
Micrococci in warts (Richter), 79
INDEX.
523
MicrocytlisBinia (Vaulair, Masms),"70
Microzymes, development in solutions,
&c. (Sanderson, &c.), 36—37
Miesclier, action of nerves on blood pres-
sure, 9
Mignot, lowering of temperature before
death, 40
Military surgery, mortality in, compared
with civil practice (Volkmann), 260
Milk casein, morphology of, 423
— condition of woman's, under defi-
ciency of food, 20
— on the influence of starvation on a
mother's, 423
Moinet, on angina pectoris, 146
Molinier, case of Csesarean section, 413
Molliere, case of peritonitis after use of
vaginal injection, 375
Molluscum contagiosum, on presence of
parasite in (Ferrier, &c.), 182
— contagiosum, on contagiousness of
(Ferrier, Liveing, Duckworth), 183
Monnick, on ocular tejision, 338
Monoycr, double fixation forceps, 364
Monteverdi, on the action of quinine on
the uterus, 420
Montgomery, on fracture of femur, 259
Monti, on treatment of scabies, 185
— on the use of chloral hydrate, 464
Moore (S.), experience of gunshot wounds,
263
Moore (Dr.), Scbleissner's paper on
cholera, 49
Mooren, case of injury to orbifc, 359
Morbilli {see measles), 62
Morgan (Mr., of Dublin), amputation in
senile gangrene, 213
— aneurism of the innominate, appa-
rently cured, 201
Morgan (C. de), extravasation of blood
after dislocation of humerus, 248
Morphine, antagonism of, to atropine
(Firmy), 439
— combined with chloroform, 468
Morris, reduction of femoral hernia en
masse, 288
Mortality in civil and military practice
(Volkmann), 260
Morton, case of cure of spina bifida, 326
— on excision of hip-joint for disease,
326
— excision of the os calcis and astraga-
lus, 226
— excision of wedge of bone at knee, 223
Mosler, blood in leucaemia, 8
— function of spleen, 19
Moss (Boyd), ciliated heematozoon in the
blood, 7
Mouth, affections of the, on, list of papers
on, 153
Moxhay, cases of excision of the knee,
223
Moxon, case of granular disease of kid-
neys, 169
— identity of grey and yellow tubercles,
125
— suppuration in syphilitic deposits in
the liver, 162
— on syphilitic pneumonia, 120
Mucous membrane, respiratory, histology
of (Boldyrew), 11
Miiller, case of heart disease, 141
Munro, cases of yellow fever, 45
Murchison, case of aneurism of the left
ventricle, 139
— case of biliary fistula, 164
— case of hydatids of the liver, 163
— case of paralysis agitans, 97
— case of peritonitis, 157
— case of uraemia, 169
— changes in intestine in typhoid, 52
— embolisms, with chorea, &c., 134
— incubation of fever, 41
— lymph-adenoma. 111
Murmur, presystolic, on the (Fagge),
140
— subclavian, cases of (Snelling), 132
Murmurs, cardiac, titles of papers on,
129—34
— vascular, on (Nolet), 10
Murray, rapid cure of an abdominal aneu-
rism, 207
Muscarin, effects of, on heart (Schmie-
deberg), 10
— on, 469
Muscle, anatomy of (Floegel, Meikel,
&c.), 26—27
— atrophy of, after fracture (Hutchin-
son), 257
— blood current in (Hafiz, &c.), 27 —
28
— chemistry of (Marcet, Petersen), 28 —
29_
— ciliary, paralysis of, in diphtheria
(Hutchinson), 104
— quantity of albuminous fluid in, in
tetanus (Danilewsky), 27
— resistance of, to electric current, 31
— dissections of (Humphry), 31
— distribution of nerves of (Henocque),
30
— mechanics of the (Haughton), 30
— of embryo, electrical excitement of
(Valentin), 31
— production of acids during action of
the (Nigetiet), 30
— suppuration in, after typhus, 53
— tone of the, on (Hidenhain), 30
Muscular atrophy, examination of mus-
cles in (Martini), 71
524
INDEX.
Muscular atrophy in children (Eulenberg,
KnoUy, Duchenne), 70—72
— atrophy, progressive (Vogt, Gombault,
Knoll), 70—72
— atrophy, titles of papers on, 72
— exercise, effects of (Flint), 31
— hypertrophy, pseudo- (Martin, Eulen-
burg. Knoll, Duchenne), 70 — 72
— hypertrophy, pseudo-, titles of papers
on, 72
— sense, on the (Bastian), 85
— spasm relieved by compression of
arteries (Broca), 200
Musculo-spiral nerve, paralysis of, after
fracture (Erichsen), 256
Mushrooms, chemistry of (Ruckert),452
Mussels, on poisonous (Beunie), 453
Mussy (Gueneau de), a case of aortic
insufficiency, 130
— bronchial adenopathy, 110
— on hay fever, 43
— hyperesthesia of the vulva, 386
— symmetry of diseases of the skin, 174
Mycosis endocardii, case of (Heiberg),
140
Myelitis, chronic, classification of, forms
of (Hallopeau), 93
Myoidema (Tait), 128
Myoma of uterus, 380
Myopia, frequency of, 342
Myxoma of the breast, specimens, refer-
ence, 234
Na)vi, removal of, with the ccraseur
(West), 211
Na3vu8, subcutaneous, rupture of vessels
in (Mezger), 211
Namias, on bromal hydrate, 466
Nasal polypus, death after extraction of
(Forster), 236
— polypus, extraction of, by cutting
maxillary bone (Lichtenberg), 236
Naso-pharyugeal tumours, resection of
maxillary for removal of (Burns), 235
Nassc, on flow of lymph, 4
Navratil, on laryngeal nerves, 102
Neck, atheromatous tumours of the,
removal of (Schede), 243
— cyst of, extirpated (Hardie, Atlee),
237
— effects of ill-development of muscles
of, on lungs (K5rner), 108
— gunshot injury to, long retention of
ball in (Barnes), 264
— tumours of {see bronchocele), 236, &c.
Necrosis in joint disease (Treves), 325
— of clavicle, during scarlet fever (Kelly,
Nowlan), 61
Nedsvetzski, on cholera, 482
Nephritis, on, 167—70
Nepven, fungi in blood, 36
Nerve-centres, effects of heating and
cooling blood going to the (Fick), 22
— do., influence of, on absorption (Golz),
4
— glosso-pharyngeal, case of paralysis of,
(Taylor), 91
— inferior maxillary, intra-buccal resec-
tion of (Menzel), 328
— optic {see optic), 90-91
Nerves, cases of injury to, of upper ex-
tremity, 23
— distribution of, in fishes (Pouchet,
Beale), 4
— distribution of, in membrana nictitans
(Klein), 24
— distribution of, in wing of bat (Schobl),
24
— effects of stretching on excitability
of(Schlisch), 21
— on excitability of (Willy), 21
— excitability of, in various parts of their
course (Rutherford), 21
— influence of, on circulation (Miescher),
— influencing deglutition (Waller, Pre-
vost), 15
— laryngeal, function of (Navratil), 102
— multiple tumours of the, 188
— of the lachrymal glands (Wolferz),
25
— of muscle (Heuocque), 30
— of taste, on the (Lussana), 25
— of the tongue, on the (Ihlder), 25
— on the structure of (Ranvier, Tamam-
ischeff, Engelmann), 20—21
— sensory, effects of excitation of, on
temperature of brain (Heidenhaiu),
22
— stretching of, for cure of spasm, &c.
(Nussbaum), 329
— termination of, in glands (Pfliigcr),
24 ^
— trophic, on, 23
— vaso-motor, distributed to arteries
(Ludwig), 23
Nervous centre, extrication of heat
during activity of (Schiff), 22
— diseases, hereditary character of
(Jastrowitz), 91
— do., titles of papers on, 100 — 1
— disorders from uterine disease, treat-
ment of, 402
— system, ophthalmoscope in diseases of,
90—91
— do., papers on the, 24
Neubauer, detection of phosphorus, 454
Neugebauer, case of one-sided hamato-
metra, 369
Neumann, absorption by the skin, 4
INi)EJC.
525
J^Teumann, changes In Involuntary muscles
of the sldn, 173
— on culture of achorion, 185
— development of sarcomatous growths,
187
— on sycosis, 185
Neuralgia, titles of papers on, 88
Newman, case of ovariotomy, 301
Nicholson, case of injury to the head,
267
Nicol, inoculation of tubercle, 38
Nigetiet, production of acids in muscles
during action, 30
Nitric acid, cases of poisoning by, 442
Nitro-benzol, poisoning with (Bahrdt),
449
Nitrogen, effects of diet and disease on
elimination of (Parkes), 18
Nitrous oxide, on, 194
— oxide, poisoning by (Purcell), 445
Noeggerath, case of abortion, 402
— psammoma of the uterus, 377
Nolet, on vascular murmurs, 10
Norris, on blood-corpuscles, 8
— on passage of corpuscles through the
walls of the vessels, 34
Norton, reduction of dislocation of the
femur, 253
Nose, vicarious haemorrhage from the,
373
Nott (Dr.), a rectilinear ecraseur, 244
Nowlan, case of scarlet fever, 61
Noyes, self-opening scissors, 363
Nunneley, on palpitation, &c., of the
heart, 145
Nussbaum, stretching of nerves for cure
of spasm, 329
Ocular tension (Monnik), 338
Odontoid process, mode of production of
fractures of (Smith), 259
Oertel, experiments on diphtheria, 103
ffisophagus, affections of the, list of
papers on, 152 — 53
— hjomorrhage from internal wound of,
287
— impaction of foreign bodies in stricture
of the (Menzel), 286
— removal of artificial tooth-plate from
the (Matthews), 287
— resection of the (Billroth), 285
— spasm of the (Paget), 285
Ogle (Dr. W.), on right-handedness in
animals, 30
Ogstou, case of poisoning by carbolic
acid, 446
Oleranon, atrophy of triceps after frac-
ture of (Hutchinson), 257
Olier (M. D'), case of Csesarean section,
412
Ollivier, cases of croup, 106
— on cirrhosis of the liver, 161
Oilier, on skin grafting, 335
Olshausen, conception under unusual cir-
cumstances, 396
— on foetal peritonitis, 427
Omboni, on puerperal fever, 421
Operations, statistics of, 196
— statistics of, reference (Stokes), 234
Ophthalmia, post-febrile, after relapsing
— fever (Charteris), 57, 486
— sympathetic, on (Cohn, Mooren), 355
—61
Ophthalmic medicine, report on (Carter,)
337
Ophthalmoscope in brain disease, titles
of papers on, 91
— in diseases of the nervous system,
(Bouchut, Socin, Broadbent), 90—91
Opium, alkaloids from (HesSe llabateau),
468
— antagonism of, to belladonna (Little),
439
— in cholera, 50
— in conjunction with chloroform, 468
— large doses of, in diabetes (Kratsch-
mer), 73
— poisoning by (Schaefer), 452
Optic discs in cases of gunshot injury to
the brain (Cohn), 352
— nerve sheath, dropsy of, case (Broad-
bent), 90
— do., hsemorrhage into, in diphtheria
(Classen), 104
Orbit, amber mouthpiece of pipe in
(Borel), 363
— gunshot wounds of or near (Cohn),
349—63
Orchitis after lithotomy (Garden), 274
— from irritation in urethra (Hutchin-
son), 273
— from stricture of urethra, case (Hulke),
272
Ore, strychnine antagonistic to chloral,
439
Organisms, presence of, in blood, 35
Organs, functional interchange of
(Ranke), 18
Os calcis, excision of the, 226 — 27
Oser, cause of the uterine movements,
406
— on movements of the uterus, 31
— syphilitic ulceration of intestine, 65
Ossification of the marrow of bones
(Demarquay), 332
Osteoid cancer of ulna (Bell), 244
Osteotomy, subcutaneous, in anchylosis
at knee (Little), 225
Otis (G. A.), on re-a'mputation at the hip,
212
526
INDEX.
Ovarian cysts, danger of drainage in
(Phillips), 388
— do., rupture of (Palm), 388
— do., sudden enlargements of (Parrv),
388
— do,, suppuration, operation on (Wells),
391
— do., treatment of suppurating
(Holmes), 302
— disease with pregnancy, cases of, 399
— tumour simulated by enlarged uterus,
302
— do., simulated by peritoneal inflam-
matory cyst (Atlee), 304
— do., simulated by uterine, 380 — 81
— tumours, on diagnosis of, from uterine
(WeUs, &c.), 381
Ovaries, malignant disease of the
(Thomas, &c.), 388
Ovaritis, different forms of (Scaglia), 387
Ovariotomy after tapping an ovarian
cyst (Clay), 305
— cases of (Atlee), 305
— clamps for (Atlee, Dawson), 390
— division of pedicle in, 305
— during pregnancy, 391
— improved method of dividing the ped-
icle in (Macleod), 390
— in a child, 391
— in children, cases of, 301
— new clamps for, 305
— statistics, 301
— do. of (Wells, &c.), 388—91
— sub-peritoneal, method of securing
vessels (Hayes), 390
— torsion in (Beebe), 389
— trochar, a new (Tait), 390
— with removal of fibroid of uterus
(Panas), 390
— wound of intestine during (Heath),
305, 389
Ovary, abscess of the, case of (Edis),
388
— absence of the, 371
— fibroid of the (Waldeyer), 387
— hernia of the, on (Englisch), 291
Ovum, expulsion of entire, at seventh
month (Brunton), 396
Packard, tracheotomy for parotitis, 322
Paculosis, 179—80
Page, on skin grafting, 335
Pagenstecher, extraction of cataract
without opening the capsule, 345
• — on treatment of ulcus serpens corneaj,
348
Paget (Sir J.)j removal of tumours from
bone, 242
— spasm of oesophagus, 285
— on strangulated hernia, 288
Palate, cleft, operations for, 232—33
— cleft, use of nasal mucous membrane
in closure of (Lannelongue), 334
— tumour of, removal by division of
jaw (King), 238
— tumour of, removal through the mouth
(Bickersteth), 239
Palladium, chloride of, action of, 462
Palm, cases of rupture of ovarian cysts,
388
Panas, case of ovariotomy, 390
Pancreas, cirrhosis of the (Pepper), 1G6
Pander, detection of emetine, brucine,
and physostigmine, 455
Pangenesis, on (Gralton), 3
Panophthalmitis, sympathetic (Cohu,
Mooren), 355—60
Papilloma, cases of (Gerhardt), 181
Papillon, inoculation of tubercle, 38
Paracentesis in diagnosis of abdominal
disease, on (Spiegelberg), 392
— thoracis, on (Evans), 113, 234
— do. (Behier), 113
— do., case of (Carter, Vallin, &c.), 112
—13
— thoracentesis, titles of papers on, 115
Paralysis after diphtheria, cases of, 104
—5
— agitans, pathology of (Murchison,
Cayley, JofEroy), 97
— do., titles of papers on, 98
— facial, after chorea (Buzzard), 81
— from injury in fracture (Erichsen),
256
— infantile, cases, &c. (Damaschino,
Roger, &c.), 96—97
— of arm after dislocation (Bernhard),
247
— of glosso-pharyngeal nerve, case of
(Taylor), 91
— pseudo-hypertrophic (Eulenberg,
Knoll, Duchenne), 70—72
— with typhoid (Clement), 53
Parasites (animal, affecting man), 77 — 79
— cutaneous, papers on, 187
— vegetable, 79
Parasitic skin diseases, 184 — 86
Paraskeva, inoculability of tubercle, 38
Parkes, action of alcohol, 463
— effects of diet and disease on elimina-
tion of nitrogen, 18
Parotitis, tracheotomy in (Packard), 322
Parrot, on herpetic fever, 175
Parry, enlargements of ovarian tumours,
388
Parsons, cases of concealed hamorrhage
during labour, 419
Partui-ition, cases of post-mortem (Ave-
Img), 410
**- on the efficient powers of (Duncan),406
INDEX.
527
Pascliutln, action of ptyaliu on stavcli, 16
Fassavant's operation, on (Wecker), 348
Pastan, on typlius, 486
Patei'son, congenital lymphatic varix, 211
— on cholera, 48
Paul, on phthisis, 127
— stenosis of the pulmonary artery after
birth, 142
— on thoracentesis in pleurisy, 112
Pavy, on paroxysmal hematuria, 170
Payen, on food during siege of Paris, 17
Payne, cancer of the heart, 139
— case of Addison's disease, 76
— case of Hodgkin's disease, 165
Peacock, prognosis in valvular disease of
the heart, 140
Peck, case of extra-uterine fcetation, 404
Pellagra in young children (Gemma), 68
— skin affections in (Gemma), 67
— sporadic, cases of (Maas), 68
— titles of papers on, 68—69
Pollarin, on cholera, 50
Pelvic articulations, relaxation of, during
pregnancy (King), 407
Pelvis, dislocation of the bones of the
(Salleron), 249
— distortions of the, 410
— fracture of the, wound of bladder in
(Bell), 277
Pemphigus, from iodide of potassium
(Bumstead), 176
— papers on, 186
Penis, amputation of the, 275
— fistula of the, treatment of (Wood,
&c.), 273
Pepper, cirrhosis of the pancreas, 166
— treatment of displacements of uterus,
384
— trephining in cerebral disease, 268
Peptones, on the (Pick), 16
Pericardial, auricular, friction sound, on
(Salter), 130
Pericarditis, case of (Glover), 137
— titles of papers on, 137
Pericardium, on adherent (Wilks), 136
Perineal section, case of (Hulke), 272
Perineum, functions of the, in proci-
dentia uteri (Duncan), 384
— management of, during labour (Good-
ell, Swayne), 409
— transition of testicle into (Adams), 281
Periostitis of the temporal bone, on
(Hutchinson), 333
Peristalsis, on (Brakel), 16
Peritoneal adhesions giving rise to pain
(Habershon), 166
— cavity, blood in, in new-born children
(Steiner), 165
— inflammatory cyst, resembling an
ovarian tumour (Atlee), 304
Peritoneum, list of papers on affections
of the, 167
Peritonitis after use of vaginal injec-
tion, 375
— cases of (Beach, Murchison), 157
— foetal, on, 427
— gastrotomy in case of, 296
— in connection with gonorrhoea in
women (Giles), 166
— puerperal, on, 423
Perl, on hypertrophy of kidney, 171
Perrond, case of extra-uterine pregnancy,
403
— on hemiplegia, &c., 84
Pertussis {see whooping-cough), 117 — 18
Pessaries, use of peroxide of hydrogen
for (Day), 461
Peter, on aortic insufficiency, 141
Petersen, analysss of flesh, 29
Petit, cases of deformity of pelvis, 410
Petri, on trichinosis, 77
Petroleum, dangers of, in commerce, 491
Pettenkof er, diffusion of cholera in India,
477
— influence of ground water on the
spread of, 477
Pfeiffer, effects of inspiration on the car-
diac cu'culation, 13
— on cholera, 481
Pfliiger, termination of nerves in glands,
24
Pharyngeal polypus removed by the
galvanic cautery (Corradi, Gozzini),
236
Pharynx, affections of the, on, 151
— list of papers on, 152
Phenol, on poisoning by, 446
Phillips, cases of delivery with distorted
pelvis, 411
— on abortion, 402
— on tables of mortality after obstetric
operations, 415
— treatment of suppurating ovarian
cysts, 388
Phlegmon of the broad ligament, case of
(Delpech), 391
Phosphates, chemistry of (Barclay), 172
Phosphorus, detection of (Poulet, &c.),
454
— poisoning, oil of turpentine in (vari-
ous), 440
— poisoning, tissue changes in (Voit),
441
— poisoning, treatment of acute (Roes-
singh), 440
— poisoning, various authors on, 440
Phthisis {see tuberculosis)
— contagiousness of (Condie), 128
— experiments as to haemoptysis in
(Sommerbrodt), 126
528
INDEX*
Phthisis, identity of grey and yellow
tubercles (Moxon), 125
— intermittent pyrexia in, denoting ab-
sorption (Duhrrsen), 127
— muscular irritability in, on (Tait), 128
— on climates for (Williams), 127
— on marriage in those affected with
(Williams, Barnes, Bennett), 128
— on Niemeyer's views on (Fox, Kcir-
ner, Kennedy, Skoda), 126
— on spurious (Condie), 125
— a thousand cases of (Williams), 127
— starting-point for, in a thousand cases
(Williams), 127
— titles of papers on, 128
Physiology, report on (Power), 1
Physostigmine and strychnine, on antago-
nism of (Ashmead), 440
— antagonism of, to atropine (Fraser),
434
— on detection of, 455
Picrotoxin, action of (Povergo), 452
— on detection of (Bias, Depaire), 455 —
56
Pigmentation of the skin, papers on, 187
Pilz, on temperature, 39
Pincus, on alopecia, &c., 184
Pirrie, on acupressure, 197
Pityriasis pilaris, case of (Fox), 177
Placenta, anatomy of the human (Hicks,
Joulin), 393—94
— calcification of the (Frankel), 394
— cysts of the (Jacquet), 394
— exchange of gases in, imitation of
(Bernstein), 14
— mechanism of the expulsion of the
(Duncan), 407
— succenturiata, 424
Plaster of Paris in fractures (St. John),
255
Play fair, cause of irritable bladder during
pregnancy, 398
— sudden death after labour, 424
Pleasanton, influence of violet light on
growth, 18
Pleurisy, case of (Renault), 114
— cases of thoracentesis in (Jones, Re-
denbacher, Paul), 112
— diaphragmatic (Hayden), 114
— explanation of pain (Huss), 112
— modes of operating for (Bouchut),
113
— titles of papers on, 115
Pleuritic efEusiou on operation in (Be-
hier), 113
Pneumatic aspirator {see aspirator),
113—15
Pneumonia, action of alchohol in, 464
— chronic, relation of, to phthisis (Fox,
Korner, Skoda), 126,
Pneumonia during pregnancy (Malton),
398
— etiology of (Sturges), 118
— experiments on (PopofF), 119
— interstitial (Green), 120
— do,, rapid formation of, and of false
membranes (Brouardel), 120
— lowering of vitality in (Farquharson),
118
— nature of (Revillout), 118
— often mistaken for other ailments
(Fitzmaurice), 118
— sudden death during convalescence
from (Hayem), 119
— syphilitic (Moxon), 120
— temperature, &c., in (Lebert), 119
— titles of papers on, 121
— treatment of, neutral acetate of lead
in (Strohl), 120
Pneumothorax, titles of papers on, 115
Podolinski, on poisoning by carbonic oxide,
444
Poison of animals, infection from, list of
authors on, 42
Poisoning by acids, cases of, 442
— by ammonia, case of (Stevenson), 442
— by carbolic acid, on, 446
— by carbonic oxide, on (Zuntz, Bonders,
&c.), 443
— by caustic potash, case of (Nager),
443
— by copper, on, 443
— by lead, on chronic (Heubel), 442
— by nitrate of silver, case of (Scatter-
good), 442
— by opium (Schaefer), 452
— by oxy sulphide of carbon, 444
— by phosphorus, on turpentine in, 440
— by sulphate of copper (iMaschka), 443
— by sulphate of zinc (Tardieu), 443
— by sulphuric acid, cases of, 441
— by vanilla ice, symptoms of (Maurer),
452
— with chloral hydrate, cases of, 449
— with nitro-benzol (Bahrdt), 449
Poisons, on absorption of (Goltz), 433
— animal, mode of contagion by, 35 — 37
— antagonism of, on, 434
— detection of, 454 — 56
— eflects of certain, on heart's action
(Schmiedeberg), 10
— on elimination of (A.nstie), 434
— snake, on (Fayrer, Richards), 453
— various, antagonism of, on (Reese),
438
Poisonous action of fungi (Husemann),
453
— mussels, on (Bcunie), 453
Pollak, hajmorrhage from the kidneys in
infants, 432
IKDEX.
52i)
Pollard, dislocation of both femora, 254
Pollock, case of psoriasis, 176
Polypus, nasal, death after extraction of
(Forster), 236
— do., extraction of, by sawing maxillary
bone (Lichtenberg), 236
— pharyngeal, removal of, with galvanic
cautery (Corradi, Gozzini), 236
Ponti, congenital coloboma of the iris,
339
Pooley, abscess of the tongue, 284
— fibrous tumour of the tongue, 284
Poore, intensification of sounds of heart,
130
Popoff, on cholera, 481
— experiments on pneumonia, 119
Popp, on diaphragmatic hernia, 290
Popper, mesenteric glands, 4
— treatment of typhoid, 55
Porro, case of congenital atresia of the
oesophagus, 152
Porter, case of acute atrophy of the liver,
161
— successful reduction of prolapsed funis,
412
Potash, caustic, case of poisoning by
(Nager), 442
Potassium, bromide of, in epilepsy
(Vance, Lutz), 83
— do., in vomiting of pregnancy ((xim-
bert), 400
— chloride of, action of, 462
— iodide of, causing pemphigus (Bum-
stead), 176
Pouchet, distribution of nerves in fishes,
24
Poulet, detection of phosphorus, 454
Povergo, action of picrotoxin, 452
Power, report on physiology, 1
Pregnancy, anaemia during (Gusserow),
397
— causation of heart disease during
(Lebert), 397
— chronic heart disease with (Spiegel-
berg), 398
— diagnosis of, on (Hicks, Wallace), 401
— duration of (Duncan), 401
— extra-uterine, cases of (Perrond), &c.,
403—4
— in case of double uterus, 399
— influence of uterine fibroids on, 411
— interstitial, case of (Edgar), 404
— irritable bladder during, on cause of
(Playfair), 398
— on albuminuria during (Kaltenbach),
396
— on cramps during (Mattel), 409
— on the vomiting of (Hewitt, &c.), 400
— paralysis during (Madge), 398
— pneumonia during, on (Matton), 398
Pregnancy, precocious, cases of, 405
— recurrent discharge from the uterus
during (Brown), 394
— relaxation of pelvic articulations during
(King), 407
— treatment of vomiting in, 400
— under unusual circumstances (Olshau-
sen), 396
— vesical fistula in case of, 398
— with ovarian disease, cases, 399
Prestel, on drinking water, 490
Presystolic cardiac murmur (Barclay,
Balfour), 131
Presystolic murmur, on the (Fagge),
140
Prevost, nerves of deglutition, 15
Preyer, on action of hydrocyanic acid,
446
— on the crystals of the blood, 5
— on detection of blood, 459
— detection of hydrocyanic acid, 455
Priapism, persistent, case of (Mackie),
273
Priestley, on intermenstrual dysmenor-
rhcea, 374
Progressive muscular atrophy (Charcot),
95
— do. atrophy, cases, &c. (Martini, Vogt,
Gombault, Knoll), 70—72
Prostate, enlarged, on (Quain), 274
— irritation of the, causing orchitis
(Hutchinson), 273
Protozoa, transmutation of form in cer-
tain (Johnson), 3
Prurigo, cases of (Wilson), 178
— histology of (Gay), 178
Prussic acid {see hydrocyanic acid)
Psammoma of the uterus, 377
Psammomata, on (Arnold), 188
Pseudo-leukffimia and leucocythemia
(Wood), 69
Pseudo-muscular hypertrophy, 70 — 73
Psoriasis guttata, case of (Pollock), 176
— papers on, 186
— treatment of (Buck), 176
Pterygo-maxillary tumours, removal of
(King, Bickersteth), 138—39
Ptyalin, action of, on starch (Paschutin),
16
Puccioni, removal of the tongue with the
galvanic wire, 283
Pudzinowitsch, relation of perspiration to
temperature, 40
Puerperal convulsions, cases of, 424
— fever, on (Martin, &c.), 421
— fever, on 398
— peritonitis, on, 423
— septicaemia, on, 422
Pullar, caseof hydatid cyst of cerebellum,
93
34.
mo
INDEX.
Pulmonary artery, stenosis of the, after
birth (Paul), 142
Pulsation, instrument for audibly measur-
ing (Jacobson), 129
Pulse, diminished frequency of, before
death from coma (Gray), 133
Purcell, poisoning by nitrous oxide, 445
Purpura, titles of papers on, 75
Pus, large bodies found in (Bizzozero),
34
— origin of, from white corpuscles, on
, (Duval), 7, 34
Pya3mia, autopsy of a pig sufEering from
(?) (Roth), 74
Pyajmic symptoms with stricture of
urethra, &c. (Hulke), 272
Pye Smith, case of congenital malforma-
tion of the heart, 148
Pyokolpos lateralis, case of, 370
Pyometra, case of, 370
Pypingskold, vomiting in pregnancy,
400
Quadruplets, cases of, 412
Quaglino, value of iridectomy in glau-
coma, 347
Quain (Dr.), affections of the walls of
the heart, 137
— on fatty degeneration and rupture
of the heart, 143
Quain (Mr.), on enlarged prostate, 274
Quehl, on apomorphine, 469
Quincke, effect of inspiration on current
of blood through the heart, 13
Quinine, action of, on white corpuscles
(Geltowsky, Kerner, Binz), 7
— arsenate of, on (Giov), 463
— in cholera, 48 — 50
Babagliati, statistics of cancer of breast,
233
Rabow, action of alcohol on temperature,
464
Rabuteau, on alkaloids from opium, 468
— on opium with chloroform, 469
"— on use of chlorides, 462
— do. sulpho-vinate of sodium, 461
Radcliffe, (Mr. J. Netten), on the spread
of cholera, 472—77
Radius, fracture of head of (Adams), 258
Radziejewski, on oxysulphide of carbon,
444
Ranke, on functional interchange, 18
Ransome, mechanical conditions of respi-
ratory movements, 14
Ranula, fatty masses in a (May), 284
Ranvier, structure of nerves, 20
Rasch, method of using uterine sounds,
384
Ratcliffe (Netten), on outbreak of fever, 54
Rattray, on change of climate, 14, 190
Raymond, on typhoid, 83
Re-amputation at the hip, on (Otis),
212
Rectal fossa, removal of piece of bone
from the (Thompson), 300
— lithotomy on (Schaffer), 278
Recto - vesical fistula, colotomy for
(Bryant), 299
Rectum, congenital invagination of the,
432
— stricture of, colotomy in, 299
— stricture of the, treatment of, 299
Redenbacher, case of pleurisy, 112
— cases of hydatids of brain, 78 — 79
Rees (Owen), diagnosis of syphilitic dis-
ease of brain, 65
Reese (Prof.), on antagonism of various
poisons, 438
Refraction, ocular, frequency of defects of,
342
Reich, on typhoid, 488
Reichard, on cholera, 50
Reimann, difficult labour from presence
of two foetal heads, 411
— on the innervation of the uterus, 405
Reincke, post-mortem on case of leuch-
aemia, 69
Relapsing fever (see fever)
— fever, ophthalmia after, 486
Renal capsules, supra-, changes in, 76
Renault, case of pleuritic efiusion, 114
Rendle, popliteal aneurism on both sides,
cured by compression, 210
Renzy, on cholera, 50
— on typhoid, 484
Resection {see excision), 213
Respiration, action of the heart on
(Landois, Ceradiui), 13
— artificial, on, in injuries to the head
(Schiff"), 14
— authors on, 15
— effects of division of spinal cord on
(Schiff), 13
— effects of, on circulation (Quincke, &c.),
13
— effects of, on heart's action (Hering),
10
— influence of atmospheric pressure on
(Liebig), 15
— pendiQum-like, on (Briichner, Meikel)^
107
— titles of papers on, subjects con*
nected with, 109
— volume of expired air in, experiments
on (Leichenstein), 11
Respirations, manometer for (Walden^^
burg), 108
Respiratory movements, mechanics of
the (Ransome, &c.), 14
lifDEX.
531
Respiratory mucous membrane, histology
of the (Boldysew), 11
— murmur, agophony (Stone), 107
— muscles of neck, detrhnental develop-
ment of (Korner), 108
Retina, disease of, visual sense m (For-
ster), 364—66
— hsemoiThages in, in leucocythemia
(Reincke), 69
Retinal pulsation in aortic disease
(Becker), 340
Revaccination, on, 431
Revillout, on pneumonia, 118
— prevention of pitting in smallpox,
63
Reyburn, case of unilateral dislocation of
the fifth cervical vertebra, 260
Rheumatic pains in diabetic patients
taking lactic acid (Forster), 74
— scarlatina, titles of papers on, 43
Rheumatism, autopsy of a pig affected
by (?) (Roth), 74
— case of (Andrew), 24
— case of, with chorea, &c., autopsy
(Ferber), 73
— gonorrhceal (Bond), 282
— ice in (Esmarch), 74
— no definite duration (Jones), 74
— titles of papers on, 74 — 75
— various drugs tried in (Jones), 74
Rhino-plastic operation (Stokes), 330
Rhino-scleroma, papers on, 187
Rib, exostosis from the, removal of
(Birkett), 240
Ribs, enchondroma of the (Menzel,
Billroth), 241
Richards, on snake poison, 453
Richardson, amputation through femoral
condyles, 212
Richardson (Dr. J.), on blood- corpuscles, 6
— on transfusion, 420
Richet, absence of uterus, &c., 371
Richter, micrococci in warts, 79
Rickets, development of teeth in (Heisch-
mann, 75
— on, 428—29
— temperature in (Ritchie), 75
— titles of papers on, 76
Riegel, case of aortic insufficiency, 142
— fall of temperature after section of
spinal cord, 22
Right-handedness in animals (Ogle), 30
Rindfleisch, brown induration of lungs,
121
Rinecker, autopsies of cases of infantile
paralysis, 97
Rin gland, sudden death after labour, 424
Ringworm in calves and men (Tuckwell),
79
Ritchie, on diagnosis of rickets, 429
Ritchie, temperature in rickets, 75
Rivington, extravasation of blood after
dislocation of humerus, 248
Roberts, on Bright's disease, 168
— case of double uterus and vagina, 371
— removal of fibro-cystic tumour of
uterus, 381
Robin, on colourless bile, 165
Robinson, outbreak of relapsing fever, 57
Roy, case of rupture of kidney and of
liver, 165
Rockwell, cases of amenorrhoca, 372
Roessingh, treatment of acute phosphorus
poisoning, 440
Roger, on infantile paralysis, 96
Rohrig, absorption by the skin, 4
Rokitansky (Carl), on artificial induction
of labour, 403
Rolleston, on cholera, 50
Rosenstein, formation of urea by the
kidneys, 19
— hypertrophy of kidney, 170
Rosenthal, case of analgesia in hysteria,
80
— on infantile paralysis, 97
Ross, case of double uterus, 371
— diseases of lungs from inhalation of
dust, 123
— pregnancy in case of double uterus ,
399
Rosse, on cholera infantum, 157
Roth, autopsy of a pig, 74
— multiple lymphomata, 189
Rothe, on cholera, 50
Rbtheln (see rubeola), 62
Rommelaene, variola and varicella, 63
Routh, action of gastric juice on cancer
of uterus, 382
Rubeola, case of (Foss), 62
— cases of, and titles of papers on, 62
— epidemic of (Dunlop), 62
— symptoms of (Fleischmann), 62
Ruckert, chemistry of mushrooms, 452
Ruduew, on hydrophobia, 42
Russell, case of laryngeal obstruction,
101
— on cerebro-splnal meningitis, 44
Rutherford, excitability of nerves, 21
Sacro-iliac disease, leading to abcess and
htemorrhage (Baker), 207
St. John, plastic apparatus in fractures,
255
Salinger, on diabetes, 73
Salivary glands, list of papers on affec*
tions of the, 152
Salkowski, on action of carbolic acid, 445
— elimination of salts from the body, 19
— gangrene of lung, 122
— urine in leuchsemia, 69
53^
ll^DEX.
Salleron, dislocation of the bones of the
pelvis, 249
Salter (Hyde), auricular pericardial fric-
tion, 130
Salts, alkaline, elimination of, from the
body (Salkowsky), 19
Samt, autopsies of two aphasics, 86
Samuel, experiments on injections of
various seci'etions, 34
Sanderson (Dr. Burdon), on development
of bacteria, &Cm 2
— development of microzymes, &c., 36
— on serous membranes, 4
Sarcinse in blood (Lostorfer, Ferrier,
Bastian), 36
Sarcina not a living organism (Bastian),
36
Sarcomata, development of (Neumann),
187
Sargent, case of diaphragmatic hernia,
290
Savory, cases of popliteal aneurism, 209
— case of sanguineous tumour of the
neck, 238
Sawicki, amount of uric acid excreted by
the kidney, 30
Sayre, on treatment of hip-joint disease,
326
— vertebrated catheter, 272
Scabies, treatment of (Monti, Weinberg),
185—86
Scaglia, on the different forms of ovari-
tis, 387
Scapula, excision of portion of the (Hill),
231
— excision of the (Spence), 231
Scapulo-humeral periarthritis, on (Du-
play), 332
Scarlet fever and smallpox coincident
(Brunton, Sansom), 60
— and varicella coincident (Brunton,
Musket), 60
— at the age of fifteen days (Meynet), 61
— epidemics of, &c., 487
— heematoma in case of (Huber), 60
— morbid anatomy of, and relation to
enteric (Harley), 61
— fever, mortality of (Ballot, Fleisch-
mann), 59
— necrosis of clavicle during (Kelly,
Nowlan), 61
— origin of (Carpenter), 60
— rheumatic, titles of papers on, 43
— titles of papers on, 61
— treatment of (Hofmann), 58
Scattergood, case of poisoning by nitrate
of silver, 442
Sohaefer, poisoning by opium, 452
Schaffer, on rectal lithotomy, 278
Schapringer, effect of tensor tympani, 25
Schatz, case of deformity of the urinb*
genital system, 371
— cases of incomplete union of the
female genital organs, 371
Schauenburg, cases of poisoning by sul-
phuric acid, 441
Schede (Max), removal of atheromatous
tumours of neck, 243
Schiefferdecker, cases of injury to nerves
of the upper extremity; 23
Schiff, artificial respiration, 14
— on extrication of heat during activity
of brain, 77
— functions of spinal cord, 21
— influence of section of cord on respira- J
tion, 13 ^
Schiffer, coagulation of the blood, 7
Schleissner, on cholera, 49
Schlesinger, cause of the uterine move-
ments, 406
Schliep, on dilatation of the stomach, 154
Schlisch, on effects of stretching of
nerves, 21
Schloemann, on cholera, 50
Schmiedeberg, action of certain poisons
on the heart, 10
Schmidt, cause of the coagulation of the
blood, 7
Schobl, termination of nerves in bat's
wing, 24
Scholz, treatment of typhoid, 54
Schultze, cases of ovariotomy, 390
— on still-born infants, 425
Schultzen, on phosphorus poisoning, 440
Schutz, treatment of diphtheria, 106
Scissors for removing sutures (Smith),
233
— self-opening (Noyes), 363
Scleroderma, cases of (Curran, Dufour),
179
— papers on, 187
— post-mortem appearances in (Fagged
178
Scleriasis (see scleroderma), 178
Scurvy, analysis of the blood in (Chal-
vet), 8
— cases of (Hayem), 75
— epidemics, &c., of, 490
— examination of blood in (Chalvet), 75
— titles of papers on, 75
Secretions, results of injection of various
(Samuel), 34
Seegen, on presence of sugar in normal
urine, 172
Seitz, case of multiple tumours of nerves,
188
Senator, abscess of lung, 122
— intermittent and relapsing fever, 57
Senses, special, papers on the, 25
Septicsemic poisoning, mode of, 36 — 37
INDEX.
533
Septicaemic polsonirig, size of red cor-
puscles in (Manassein), 6
Serous membranes, absorption of solids
by (Auspitz, Neumann), 3
— do., arranj^ements of lymphatics in
(Klein, Sanderson), 4
Sesary, study of maximum temperatures
of health resorts, 190
Shepherd, hydatids of kidney, 171
— report on medicine, 33
Sherman, case of rupture of the heart,
145
Shoulder, dislocation of {see dislocation),
247
— excision of the {see excision)
Sichel, circumscribed choroiditis, 36G
— on herpes frontalis, 175
Sigmund, on subcutaneous injections of
mercury in syphilis, 308
Sikorsky, lymphatics of the lungs, 11
Silbert (Vincent), on apomorphine, 469
Silver, nitrate of, case of poisoning by
(Scattergood), 442
Simon, on aphasia, 87
— case of heart disease, with embolism,
&c., 141
— on guramata in liver, QQ
— prodromal exanthem of smallpox, 62
Simpson, on cancer of uterus, 383
Singing, power of, with aphasia (Jack-
son), 88
Skin, absorption by the (Auspitz, Neu-
mann, Rohrig), 3 — 4
— affections in pellagra, 67
— amount of carbonic acid eliminated
from the (Aubert), 14
^ bacteria in, in smallpox (Weigert), 63
— bronzing of, cases of, 76
■ — changes in the involuntary muscles of
the (Neumann), 173
— disease of the, cases of, statistics of
(Smith, Anderson), 173 — 74
— diseases of the, list of papers on, 186
—87
— do., symmetry of (Mussy), 174
— disturbances of the secretions of the,
183
— grafting, on (Oilier), 335
' — imbibition of poisonous fluids through
(Bennett), 37
— parasitic affections of the, on, 184 — 86
— thickening of the, case of curious
(Ullersperger), 179
Skoda, on phthisis, 126
Skoldberg, cases of ovariotomy, 389
Skull, abscess within the, trephining for
(Smith), 268
— fracture of {see fracture)
— gunshot injuries of the, 265
Smallpox, albuminuria in (Cartaz), 63
Smallpox and measles coincident (Auchen-
thaler, Brunton), 60
— and scai'let fever coincident (Brunton,
Sansom), 60
— bacteria in skin in (Weigert), 63
— carbolic acid in (Salkowski), 445
— case of inoculation of, 431
— cause of death from (Huchard), 63
— epidemics of, &c., 487
— extravasations in, on (Wyss), 63
— hemorrhagic, after labour, 423
— incubation of, in utero, 432
— in a foetus, case of, 432
— mode of formation, &c., of pustules o«
(Vulpian), 63
— mortality of (Ballot), 59
— nervine symptoms of (Gubler, La-
borde), 63
— prevention of pitting in (Revillout),
63
— prodromal exanthem of (Simon), 62
— relation of, to varicella (Rommelaere),
63
— titles of papers on, 64
— unsymmetrical (Clemens), 62
Smith (Angus) on air and rain, 491
Smith (Dr.) case of absence of the uterus
and vagina, 371
— on ankle-joint amputations (American),
213
Smith (Henry), case of passage of artifi-
cial tooth-plate along alimentary canal,
287
— laryngotomy for removal of foreign
body, 320
Smith (Dr. S.), mode of production of
fractures of odontoid process, 259
Smith, case of disease of the heart, 138
— cases of skin disease, 173
Smith (R. N.), trephining for abscess
within the cranium, 268
Smith (R. W.), on incomplete fractures,
255
— supra- sternal dislocation of clavicle,
246
Smith (Spencer), compound dislocation
of foot, 255
Smith (T.), case of vaccino-syphilis, 306
— on cleft palate, 232
— opening the stomach for cancer, 299
— scissors for removing sutures, 233
— tubercular disease of urinary mucous
membrane, 269
Smoke and dust, on (Tyndall), 2
Snake poison?, on (Fayrer, Richards), 453
Snelling, subclavian bruit, 132
Socin, ophthalmoscopic appearances in
brain disease, 90
— on typhoid, 483
Sodium, chloride of, use of, 462
534
INDEX.
Sodium, on use of sulphovinate of (Rabu-
teau), 461
Solids, absorption of, by serous mem-
branes (Auspitz, Neumann), 3
Solowieff, on dysmenorrlioea, 373
Sommerbrodt, experiments on phthisis,
126
Sonnenschein, on detection of blood-
stains, 458
Sorby, on the spectroscopy of blood, 459
Sousino, dyspepsia for starchy food in
infancy, 429
Southey, intestinal obstruction for con-
genital constriction, 295
Sparks, primary cancer of the lungs, 124
Spectroscopy of blood, on the (Sorby),
459
Speech, cerebral mechanism of (Broad-
bent), 84
— defect of, with convulsions (Jackson),
87
— loss of, cases of (Baginsky, Simon,
Jackson), 87
— loss of, on (Bristowe, Hammond), 86
—87
— loss of, titles of papers, on, 88 — 89
— unaffected, with right-sided hemi-
plegia (Down), 88
Spence, case of fusiform femoral ancu-
rism, 209
— excision of the scapula, 231
— cases of false aneurism, 210
Sperling, injections into the arachnoid
cavity, 89
Sphygmograph, on a cardio- (Garrod), 9
Spiegelberg, cases of distortion of the
pelvis, 410
— diagnosis of cancer of uterus, 382
— paracentesis in diagnosis of abdomi-
nal disease, 392
— pregnancy and heart-disease, 398
Spinal cord, anatomy of the (Dittmar),
31
Spina bifida, cure of, by tapping, &c.
(Cabrai, Morton), 326
Spinal affections, titles of papers on,
95—96
— cord, on chronic inflammation of the
(Hallopeau), 93
— cord, effects of division of the (Riegel),
22
— cord, effects of division of, on respira-
tion (Leichtenstein, Schiff), 12—13
■ — cord, functions of, as a conductor
(Schiff), 21
— cord, histology of, in tetanus (Allbutt,
Joffroy), 98
— hemiplegia, cases of (Fieber), 84
— infantile paralysis, cases of, &c.
(Damaschino, Roger, &c.), 96 — 97
Spinal cord, on itritative lesions of the
(Charcot), 95
— meningitis, on, 43 — 45
Spine, dislocation of {see dislocation)
— fracture of (see fracture)
Spleen, affections of the, authors on, 165
—66
— course of the blood in the (Wedl,
Stoff, Hasse), 19
— disease of the, with leucocythemia
(Wood), 69
— function of the (Hosier), 19
— size of, in children (Steffen), 165
Sputum, peculiar (Whitehead), 109
Square, case of haemorrhage after litho-
tomy, 277
— removal of loose cartilages from knee-
joint, 326
Squarey, cases of absence of uterus, 371
— causation of acquired flexions of the
uterus, 384
Squire (Balmanno), on parasite in mol-
luscum contagiosum, 182
Squire (Mr.), direct inguinal hernia in
the female, 288
Squire (Dr.), vertebrated catheter, 272
Staphyloraphy, 232—33
Staples, amputation at the knee-joint,
213
Starch, action of ptyalin on (Paschutin),
16
— wide diffusion of a ferment acting on
(Lepine), 16
Stauungspapilla, 353
Steffen, on hooping-cough, 117
— on size of liver and spleen in children,
165
Steiner, blood in peritoneal cavity in new-
born children, 165
Steinraann, rapidity of current in veins, 9
Stenosis of pulmonary artery after birth
(Puul), 142
Sterco-bilin, on (Lair, Masius), 17
Stern, case of imperforate anus, 299
Stevens, case of intermittent hasmaturia,
170
Stevenson, case of poisoning by nitric
acid, 442
— report on materia medica, 461
— report on medical jurisprudence, 433
— report on public health, 472
Strieker, on keratitis, 33
Stricture dilator, a new (Hill), 272
— of the oesophagus, spasmodic (Paget),
285
— of urethra, perineal section for, case
of (Hulke), 272
— of the urethra, on (Stokes), 272
— do. (Thompson), 272
Stoff, course of blood in spleen, 19
INDEX,
635
Stohr, transfusion In cases of urseujia, 170
Stokes, on amputation of the foot, 213
— on arterial compression, 209
— case of injury to the head, 267
— rhinoplastie operation, 330
— rupture of the female bladder, 277
— on stricture of the urethra, 272
— supra- condyloid amputation, 212
— temporary deligation of the femoral
artery, 208
— tracheotomy twice in the same person,
321
— on Zeis' cheiloplastic operation, 330
Stoltz, hyperffisthesia of the vaginal
sphincter, 386
Stomach, affections of the, list of papers
on, 155
Stomach, cases of disease of (Habershon),
154
— dilatation of the, cases of (Affleclc,
Schliep, Crisp), 153—54
— glands of the, secretion of the (Eb-
stein, &c.), 16
— medullar^'^ sarcoma of the (Ward), 153
— opening the, for cancer, 298
— softening of the, during life, case of
(Mayer), 155
Stomata in lymphatics, 4
Stone, on segophony, 107
— etiology of heart disease, 132
Strassburg, on blood, 6
— detection of biliary acids in urine, 17
Struve, colouring matters in blood, 5
Strychnine, action of, on blood pressure
(Mayer), 10
— antagonistic to chloral (Ore), 439
Sturges, on pneumonia, 118
Subbotin, on elimination of alcohol, 18,
464
Subclavian aneurism, case of (Bicker-
steth), 201
— ligature of the (Fergusson, Gay, Lane),
201—2
Subcutaneous division of neck of thigh-
bone (Adams), 234
— osteotomy at knee for anchylosis
(Little), 225
— injection in tumours (Heine), 244
Suffocation, ecchymoses after (Lukom-
sky), 460
Sugar of liver, on (Dalton), 17
Sullivan, notes on yellow fever, 46
Sulphuric acid, cases of poisoning by, 441
Sulphurous acid, action of, on germs, 492
Sunstroke, on (Thin, Macdonald, Clap-
ham), 58
Suppuration, experiments on {see pus),
33—34
— in muscles after typhoid (Kraft-Ebing),
53
Suppuration, list of authors on, 34
Supra-renal capsules, changes in, 76
Surgery, report on (Tay), 193
Sutton, on Bright's disease, 168
Sutui-es, marine grass for (Burow), 349
— method of removing (VVarlomout),
349
— scissors for removing (Smith), 233
Swain, excision of the ankle and removal
of the tarsal bones, 226
Swayne, support of perinajum during
labour, 409
Swelled leg of fevers (Begbie), 41
Sycosis, parasitic and non-parasitic, on
(Neumann), 185
Sympathetic, section of, causing diabetes
(Cyon, Aladoff), 20
— ophthalmia (Cohn, Mooren), 355 —
60
Syme, statistics of removal of breast,
233
Syme's rhinoplastie operation, case of,
330
Syphilis, corpuscles in the blood in (Los-
torfer, Strieker), 8
— corpuscles in blood in (Lostorfer,
Wedl, Strieker, Vajda, Biesiadecki),
64—65
— diagnosis of, by the microscope (Los-
torfer, Strieker, Wedl, Biesiadecki,
Vajda), 64—65
— hereditary, bone disease in (Wegner),
307
— hereditary, latent, on (Simon), 66
— reinfection of (Kobner), 306
— subcutaneous injections of mercury in
(Sigmund), 308
— titles of papers on, QQ — 67
— vaccino-, on, 430 — 31
— do., cases of (Smith, Hutchinson), 306
— do., cases of, 430
— with albuminuria in a child (Bradley),
m
Syphilitic choroiditis, &c., on (Gale-
zowski), 368
— dactylitis, on (Taylor), 308
— disease of brain, diagnosis of (Rees),
65
— disease of small intestine (Oser), 65
Tachard, use of electricity in midwifery,
409
Tsenia solium, portions of, passed at the
age of three days (Armour), 79
Tait, on muscular irritability in phthisis,
128
— new ovariotomy trochar, 390
— vaginal fistula?, 386
Tamamscheff, structure of nerves, 21
Tampon, tracheal, on the (Junker), 319
336
INDEX.
Tar, on administration of (Magnes-
Lahens), 467
Tarso-metatarsal joints, excision o£
(Holmes), 227—28
Taste, on the nerves of, 25
Tay (Waren), case of intestinal obstruc-
tion, 294
• — case of haemorrliage after lithotomy,
277
- — congenital fibrous tumour of arm,
243
— fatty matter in a ranula, 284
— report on surgery, 193
Taylor, case of embolism, 91
— case of intestinal obstruction from a
knot, 295
— on dactylitis syphilitica, 308
— on mechanism of uterine inversion,
418
Teake, removal of plate of bone from the
larynx, 321
Teakle, tumours of dura mater, 93
Teeth, development of, in rickets (Fleisch-
mann), 75
Temperature, action of alcohol on the,
464
— effects of alterations of, on size of
blood-discs, 39
' — effects of exercise on the (Allbutt,
&c.), 15, 40
— effects of, on the heart (Brunton), 133
— in animals during movements (Man-
assein), 39
— in healthy children during day, &c.
(Pilz), 39
— in rickets (Ritchie), 75
— increase of, with intense headache
(Vergely), 40
— influence of high, on low organisms
(Burdon- Sanderson, &c.), 2
— list of authors on, 41
— lowering of the, before death, 40
— relation between perspiration and the
(Padzinowitsch), 40
Temporal bone, periostitis of the (Hutch-
inson), 333
Tendons, absorption of lymph by (Ge-
nersich. Lesser, &c.), 3—4
Tennent, cases of relapsing fever, 57
— on relapsing fever, 486
Tension, ocular, mode of testing, 339
Tensor tympani, action of the (Schar-
pringer), 25
Teratoma myomatodes (Virchow), 109
Terry, cases of excision of the knee, 223
— excision of the os calcis, 227
Testis, cancer of imperfectly descended,
on, reference (Arnott), 281
— removal of, for neuralgia (Annandale),
281
Testis, transition of, into perineum
(Adams), 281
— tuberculous, treated with actual cau-
tery (Verneuil), 281
Test types (Burchardt), 343
Tetanus, fatal cases of, after abortion,
403
— histology of cord in (Allbutt, Joffroy),
98
— quantity of albuminous compounds in
muscles in (Danilewsky), 27
— neonatorum, 428
— titles of papers on, 98 — 99
— treatment of, by various drugs, 98
Thigh, fractures of the, in the newly
born, 427
Thigh-bone, subcutaneous division of
neck of (Adams), 234
Thin, on sunstroke, 58
Thinking, physiology of (Bastian), 85
Thomas (Gaillard), on chlorosis, 372
— on enucleation of sessile uterine
fibroids, 378
— malignant disease of the ovaries, 388
— excision of half of lower jaw, 229
Thompson, action of ergot of rye, 421
— case of intra-cranial osteophytes, &c.,
89
— on cholera, 49
— on dilatation of the heart, 138
— rupture of the heart, 144
Thompson (Dr.), removal of piece of
bone from the rectal fossa, 300
Thompson (Sir H.), choice of operations
for stone in the bladder, 276
— improved flexible catheter, 271
— on prevention of calculous disease, 279
— removal of piece of bone from the
bladder, 277
— on stricture of urethra, 272
Thought, cerebral mechanism of (Broad-
bent), 85
— on the mechanism of (Broadbent), 25
Thoracentesis {see paracentesis), 112
— titles of papers on, 115
Thorax, carcinomatous mass in (Clarke),
111
— growths in, 109—12
— growths within, titles of papers on,
112
Thrombosis, titles of papers on, 136
Tibia, bullet in head of (Stokes), 208
Tilt, on hysteria, 80
— uterine inflammation after the change
of life, 392
Tinea (see parasite)
Tobacco, on texicological effects of
(Vohl), 450
— smoke, chemical constituents of (Vohl,
Huebel), 450—51
INDEX.
537
Tongue, abscess of the (Pooley), 284
— cases of removal of the, 284
— congenital hypertrophy of the (Law-
son, Simon, Clarke), 284
— fatty tumour under the (Churchill),
284
— fibrous tumour of the (Pooley), 284
— on the nerves of the (Lussana,
Ihlder), 25
■ — new method of removing (Jordan),
283
— removal of, for epithelioma, by gal-
vanic wire (Gozzini, Puceioni), 283
— unilateral atrophy of the (Clarke), 335
Tonometry of the eyes (Monnik), 338
Tooth-plate, artificial, extraction of, from
the oesophagus (Matthews), 287
— artificial, passage of, along alimentary
canal (Smith), 287
Torsion of arteries (Callender), 198
Touch, on the comparative anatomy of
the organs of (Jobert), 25
Tourniquet, double, a (Bulley), 210
Townsend, case of aneurism of the left
ventricle, 139
Trachea, stricture of the (Trendelen-
burg), 324
— tube removed from the, 321 — 22
Tracheal tampon, on the (Junker), 319
Tracheotomy for parotitis (Packard), 322
— for removal of foreign bodies, cases of
320—21
— in croup, cases of, 105 — 7
— in diphtheria, cases of successful, &c.
(various), 104^ — 6
— in laryngeal obstruction, cases of
(Boelt, Russell), 101
— tube, removal of by operation, 321 —
22
— twice in the same person (Stokes), 321
Tracy, cases of ovariotomy, 390
Transfusion, cases of successful, 419 — 20
— instrument for (Aveling), 419
— in ursemia (Stohr), 170
— of blood, on, 329
— on (Richardson), 420
Transmutation of form in certain pro-
tozoa (Johnson), 3
Traube, on blood in urine, 173
— case of bronchitis, &c., 116
Traumatic erysipelas, on (Wilde), 318
■ — fever from gunshot wounds (Hueter),
315
— fever, on (Billroth), 311
Trendelenburg, on stricture of the
trachea, 324
Trenholme, on irregular*contractions of
the uterus, 408
Trephining for abscess within the cra-
nium (Smith), 268 .
Trephining for gunshot (Halstead,
Howard), 265
— in cerebral disease (Pepper), 268
— of skull for fracture, cases of, 266—68
Treves, excision of the knee-joint, 222
— on joint disease, with necrosis, 325
Trial, the Wharton-Ketchum, 456
Triceps, atrophy of, after fracture of the
olecranon (Hutchinson), 257
Trichinosis, cases of (IJdhe, Kittell,
Maurer, Zenker), 77 — 78
— in rats (Zenker), 78
— titles of papers on, 79
Trismus nascentium, on (Bailey), 428
Troup, opening the stomach for cancer,
299
Tubercle, identity of grey and yellow
(Moxon), 125
— inoculability of (various), 38 — 39
— of brain, case of (Pleischmann), 92
— of the cerebellum (Cordier, Jackson),
92
Tubercles in the choroid (Fninkel), 91
Tubercular disease of urinary mucous
membrane (Smith), 269
— meningitis {see meningitis), 89
Tuberculosis after typhoid (Birch-Hirsch-
feld), 39
— experiments on (various), 38 — 39
— on (Korner), 108
— relation of, to pneumonia (Fox, Kor-
ner, Skoda), 126
Tucker, method of delivery in arm pre-
sentation, 414
Tuckwell, case of Addison's disease, 76
— cases of chorea, 81
— ringworm of cattle communicated to
man, 79
Tumour, congenital fibro- cellular, of
buttock (Bryant), 243
— congenital fibrous, of arm (Tav),
243
— cystic, of neck, removal of (Hardie,
Atlee), 237
— cystic, sanguineous, of neck (Savory),
238
— fibrous, of the tongue (Pooley), 284
— fibrous, removed after labour, 419
— of antrum, from canine tooth (McCoy),
234 ■
— of antrum from distension, reference
(Haward), 235
— of lower jaw, myeloid (Maunder),
235
— of palate, removal oP, by dividing jaw
(King), 238
— do., removal of, through the mouth
(Bickersteth), 239
— peculiar, from abdominal cavity, 189
— scrotal, removal (Bickersteth), 243
^38
INDEX.
Tumour, atheromatous, of neck, removal
of (Schede), 243
— cystic, of breast, reference, 234
— development of (Neumann), 187
— intracranial, cases, and titles of papers
on, 92—93
— mediastinal, 109—12
— do., titles of papers on, 112
— naso-pharyngeal, resection of axillas
■ for removal of (Burns), 235
— heart, 233—31.
— papers on, 190
— removal of, from bone (Paget), 242
— treatment of, by subcutaneous injec-
tion (Heine), 244
Turner, poisoning by carbonic oxide,
444
Turning, cases of, 415
— impossible in a case of shoulder pre-
sentation, 414
— in deformed pelvis, 411
Turpentine, on absorption of, 4G7
— absorption of, by the unbroken skin
(Rohrig), 4
— oil of, in phosphorus poisoning, 440
Tympanites, on gastro- intestinal puncture
in, 157
Tyndall, on dust and disease, 37
— on dust and smoke, 2
Typhoid, causes of (Massachusetts report),
54
— changes in intestine in (Mnrchison,
Maclagan), 52
— emaciation in (Allbutt), 52
— from special poison, alvine (Latham),
53
— hajmatoma during recovery from
(Gueniot), 53
— incubation of (Murchison), 41
— outbreak of, at New Barnet (Ratcliffe),
54
— do., near Cambridge (Latham), 53
— do., near Oxford (Mayo), 54
— peritonitis after, followed by suppura-
tion from umbilicus (Gluge), 53
— fever, state of capillaries, &c., of in-
testine in (Heschl), 52
— spread of, &c., 482—85
— suppuration in muscles after (Kraft-
Ebing), 53
— titles of papers on, 55
— treatment of (Lissauer, Scholz, Popper,
&c.), 54-55
— tuberculosis after (Birch-Hirschfeld),
39
— with fatal paralysis, &c. (Clement), 53
Typhus, direct contagion of (Virchow),
56
— - incubation of (Murchison), 41
— in India (Lyons), 56
Typhus, on " war " (Virchow), 56
— on cerebro-spinal meningitis, case of
(Campbell), 56
— spread of, &c., 485
Udho, on trichinosis, 77
Ulcus serpens cornea?, treatment ot
(Pagenstecher), 348
Ullersperger, case of, thickening of skin
of soles of feet, &c., 179
Ulna, osteoid cancer of (Bell), 244
Ulzmann, cases of cystine calculi, 279
Underbill, tracheotomy in croup, &c., 105
Urasmia from atrophied kidney, case of
(Murchison), 169
— transfusion in (Stohr), 170
Uranoplasty, 232—33
■ — nasal mucous membrane used in
j (Lannelongue), 334
i Urates, chemistry of (Barclay), 172
Urban (D'), amount of oxygen in blood
of different arteries, 13
Urea, distribution of (Gescheidlen), 19
— excretion of, on (Falck), 172
— in liquor amnii (Gusserow), 17
— on formation of, by the kidneys (Ro-
senstein), 19
Uretero-uterine fistula, cases of, 417
Urethra, irritation of the prostatic caus-
ing orchitis (Hutchinson), 273
— stncture of the, on (Stokes), 272
— stricture of, on (Thompson), 272
Urethral fever, fatal, after catheterism
(Banks), 271
Urethroplasty, cases of (Wood, &c.), 273
Uric acid, amount excreted by the kidney-
(Sawicki), 30
Urinary mucous membrane, tubercular
disease of (Smith), 209
— umbilical fistula?, on, 427
Urine, amount of organic matter in, 172
— detection of biliary acids in (Strass-
burg), 17
— diagnosis of source of blood in, 172
— experiments on (Wernich), 172
— incontinence of, as a symptom of re-
tention (Hutchinson), 273
— list of papers on the, 173
— on secretion of (Ustimowitsch), 19
— retention of, case of, in pregnancy, 399
— state of, in leucocythemia (Salkowski),
69
— test for sugar in the (Falck), 172
Urticaria, with herpes (Broadbent), 176
Ustimowitsch, experiments on secretion
of urine, 19
Uteri, cervix, mechanical dilatation of
the (Duncan), 416
— OS, hypertrophic prolypus of the
(Barnes), 385
INDEX.
539
uterine disease, treatment of nervous
disorders in, 402
— expression as a means of delivery
(Chautreuil), 409
— prolypi, fibrinous, on (Prankel), 403
— sound, novel method of using (Rascli),
384
Uterus, abscess of the, 370
— absence of the, cases of, 371
— amputation within the, on (Barnes),
393
■ — action of quinine on the, 420
— anatomy of hypertrophy of the
(Barnes), 385
— cancer of the, cases, &c,, 382 — 83
— cancer of, diagnosis of early stages of,
382
— cancer of, effect of gastric juice on,
382
— causation of acquired flexions of the
(Squarey), 384
— cause of the movements of the (Oser,
Schlesinger), 406
— cases of ruptured, 417
— determination of sex of child within
the (Hutton), 396
— "displacements of the, 383 — 84
— double, 369—70
— double, with pregnancy, 399
— external examination of, in labour
(Halbertsma), 415
— extirpation of an inverted (Valette),
378
— extii-pation of, for tumour (Bryant,
Atlee, Roberts, Gayet), 380—81
— fibroid in an inverted (Hay), 378
— fibroid of the, disappearance of a, with
ergot of eye (McClintock), 330
— fibroid of the, removal of, by abdomi-
nal section (Wells), 379
— fibroid of the, septicajmia after removal
of a (Emraett), 379
— fibroid of the, spontaneous separation
of a, 380
— fibroids of the, absorption of (Gueniot),
380
— fibroids of the, enucleation of sessile
(Thomas), 378
— fibroids of the, on (Kidd), 379
— fibroids of the, treatment of (Meadows),
379
— gravid, complete prolapse of, 399
— gravid, rupture ot^ at seventh month,
401
— hydrocele of the round ligament of the
(Hart), 391
— inflammation of the, after change of
life (Tilt), 392
— influence of nerves on the (Reimann),
405
Uterus, injections in chronic inflamma-
tions of 'the, 392
— injection of iodine into, in post-par-
tum hemorrhage, 420
— injury to gravid (Ling), 400
— inversion of the, cases of, 417 — 18
— inverted, removal of an, 377
— involuted, anatomy of, 424
— irregular contractions of the, on (Tren-
holme), 408
— mechanical treatment of displace-
ments of the (Pepper), 384
— movements of, excitement of (Oser),
31
— phlegmon of the broad ligament of the
(Delpech), 391
— polypi of the, on (Duncan), 380
— procidentia of the, etiology of (Duncan,
Konrad), 383
— procidentia of the, functions of peri-
nseum in (Duncan), 384
— psammoma of the, 377
— recurrent discharge from the, during
pregnancy (Brown), 394
— removal of an enlarged (Atlee), 307
— reposition of displaced cancerous, 399
— retroflexion of the, a cause of abortion
(Phillips), 402
— rupture of the, during labour (Four-
rier), 416
— sarcoma of the (Hegar), 375
— structure of the, on (Beck), 381
— tumours of the, diagnosis of, from
ovarian (Wells, &c.), 381
Vaccination, Bryce's test for (Beardesley),
431
— influence of, 488
Vaccine particles, on (Ferrier), 36
Vaccino-syphilis, cases of, 430 — 31
— cases of (Smith, Hutchinson), 306,
430—31
Vagina, absence of the, 370 — 71
— cysts of the, on (Winckel), 385
— double, cases of, 371
— hyperaesthesia of the sphincter of the
(Stoltz, &c.), 386
— stenosis of the (Ebell), 386
— termination of nerves in the, 387
— tumour of the, cases (Byrne, Barnes),
386
Vaginal fistulae, on operation for (Tait),
386
— injection, peritonitis after use of,
375
— thrombus, case of (Jalland), 419
Vajda, corpuscles in blood in syphilis,
65
Valentin, on muscles of the embryo,
31
540
INDEX.
Valette, case of inversion of the uterus,
378
Vallin, case of pleuritic effusion, 113
Valvular disease {see heart)
Vance, on epilepsy, 83
Vanilla ice, symptoms of poisoning by
(Maurer), 452
Varicella and scarlet fever coincident
(Bunton, Musket), 60
— relation of, to smallpox (Rommelaere),
63
— titles of papers on, 64
Variola {see smallpox), 67
Varix, congenital, lymphatic (Paterson),
210
— treatment of, by injection of ergotin
(Vogt),211
Vascular murmurs, on (Nolet), 10
Vaudry, on the use of arsenic, 463
Vaulair, histology of elephantiasis,
181
— microcythemia, 70
— on a variety of fungus, 185
Vedie, rupture of the heart, 144
Vegetable parasites, 79
Veins, jugular, ulceration of the, on
(Gross), 326
Vensesection, effects of, on arterial cur-
rent (Gatzuck), 9
Verga, inoculation of tubercle, 38
Vergely, case of headache with increase
of temperature, 40
Verneuil, case of rupture of internal caro-
tid, 84
— surgery of arteries in gunshot wounds,
263
— suture of the eyelids, 349
• — on tuberculous testis, 281
Vertebra, ^fifth cervical, dislocation of
(Reyburn), 260
Vesico-vaginal fistula (Bell), 282
— case of double, congenital, 371
Vessels, condition of the walls of, in in-
flammation (Durante), 33
— passage of corpuscles through walls of
the, 34
Virchow, on chlorosis, 373
■ — on direct contagion of typhus, and on
" war typhus," 56
— on typhus, 485
Visual sense, on the, in disease of the
choroid and retina (Forster, Hippel),
364
Vital phenomena, influence of barometric
pressure on (Bert), 13
Vitriol, white, poisoning by (Tardieu),
443
Vogt, case of progressive muscular atro-
phy, 71
— ergotin in treatment of varix, 211 .
Vohl, toxicological effects of tobacco,
450 _
Voit, tissue changes in phosphorus poi-
soning, 441
Volkmann, on relative mortality in civil
and military practice, 26
Volvuli, list of cases of, 15
Vomiting of pregnancy, on the (Hewitt,
«&c.), 400
Vulpian, pustules of smalljjox, 63
Vulva, hyperesthesia of the (Mussv, &c.),
386
Wade, on chlorosis, &c,, 372
Wagoner, on structure of muscle, 27
Wagner, on tubercular lymphadenoma,
188
Wagstaffe, case of fibrous tumour of the
heart, 138
— case of injury to the head, 267
Waldenburg, on a manometer, 108
Waldeyer, on diphtheritic puerperal
fever, 421
— on fibroid of the ovary, 387
Wallace, diagnosis of pregnancy, 401
Waller, nerves of deglutition, 15
Wallowicz, on action of alcohol, 463
Wanklyn, on composition of urine, 172
Ward, medullary sarcoma of the stomach,
153
Wardell, case of exfoliation of the female
bladder, 400
Waring-Curran, abscess of the lung,
122
Warlomont, iridectomy knives, 364
— removal of suture pins, 349
Warner, case of absence of the vagina
and uterus, 371
War typhus, on (Virchow), 56
Warts, micrococci in (Ricbter), 79
Water, kinds of, for use, 490
Waters (Dr.), on hay fever, 43
— scirrhous cancer of lung, 124
Watson, case of rupture of the heart,
145
Watson (Dr. Eben), calculus in female,
278
— cases of tracheotomy for laryngeal
disease, 321
— excision of the ankle, 226
— excision of the astragalus, malleoli,
&c., 226
— excision of the elbow for anchylosis,
217
— excision of extremity of humerus for
anchylosis, 218
— excision of the lower jaw, 228
— excision of wedge of bone at knee,
225
Wecker, on corelysis, 348
INDEX.
541
Weclier, on extraction of cataract, 344
Wed], bloodpath of the spleen, 19
— corpuscles in blood in syphilis, 65
Wegner, bone disease in hereditary syphi-
lis, 307
Weigert, bacteria in the skin in small-
pox, 63
Weil, on physiological action of digitalis,
470
Weinberg, on treatment of scabies, 186
Weiske, results of giving food poor in
lime or phosphoric acid, 29
Wells (Spencer), diagnosis of uterine from
ovarian tumours, 381
— extirpation of suppurating ovarian
cysts, 391
— on fever following surgical operations,
317
— on ovariotomy, 388
— ovariotomy statistics, 301
— removal of uterine fibroid by abdomi-
nal section, 379
Wernich, analysis of the urine, 172
— on weight of infants, 425
West, removal of nsevi with the ecraseur,
211
Westcott, case of rupture of the heart,
145
Westphal, epilepsy in guinea-pigs, 82
— production of epilepsy in guinea-
pigs, 23
Weter, on phosphorus poisoning, 440
Wettengel, delivery of a dicephalous
monster, 412
Wharton- Ketchum trial, the, 456
Whipham, case of disease of the tricuspid
valve, 141
White, cases of inversion of the uterus,
417
— case of poisoning by carbolic acid,
446
Whitehead (Dr.), cases of cleft palate,
233
— cases of stricture of the rectum, 299
— on membranous enteritis, 156
— peculiar sputa, 109
Whitney, case of emphysema during
labour, 418
Whooping-cough, on (Stefien, McCall),
117
— titles of papers on, 118
Widerhofer, on rickets, 429
— tetanus neonatorum, 428
Wilde, on traumatic erysipelas, 318
Wilks, on adherent pericardium, 136
— case of hseraatidrosis, 183
Williams, on phthisis, 127
Willy, on excitation of nerves, 21
Wilson (E.), cases of prurigo, 178
Wilson (E.), case of erythema solare, 174
Wilson (J. G.), case of eruption after
application of belladonna, 423
Wiltshire, case of rupture of the heart,
145
— fatal tetanus after abortion, 403
— on the colour of the eyes of the newly
born, 426
Winants, on case of transfusion, 330
Winckel, cases of sarcoma of the uterus,
377
— vaginal cysts, 385
Wire, removal of, after operation for
ununited fracture, 256
Wohlrab, on typhoid, 483
Woinow, astigmatism after cataract ope*
rations, 347
— diagnosis of colour blindness, 340
Wolferz, innervation of lachrymal glands,
25
Wolffbey, tension of carbonic acid in
lungs and blood, 15
Wood (Prof. H. C), effects of atropine
on pupils of pigeons, 449
— on nitrite of amyl, 466
Wood (Mr. J.), an improved gag, 233
— on urethroplasty, 273
— leucocythemia, 69
— on nephritis, 167
— use of bromides, 462
Woodward, case of inversion of tlie
uterus, 418
Wounds, dressing of (Callender), 198
— on open treatment of (Kronlein),
195
Wrany, embolism, &c., after endocar*
ditis, 134
Wright, a new self-retaining cathetei*,
271
— method of bisecting foetus, 4l4
Wrist, dislocation of (Erichsen, Adams),
248
— drop, from injury to nerve in fracture
(Erichsen), 256
— excision of, cases of, 218
Wyss, extravasations in smallpox, 63
— on herpes zoster, 175
Xanthelasma palpebrarum (Hutchinson),
183
Yarrow, case of Caesarean section, 413
Yeld, case of fibrous tumour removed
after labour, 419
Yellow fever, on, 46 — 47
— titles of papers on, 47
Zahn, on detection of blood-stains, 459
Zallonis, inoculability of tubercle, 38
542
INDEX,
Zehnder, report ou cholera epidemic,
480
Zeis' cheiloplastic operation, 330
Zenker, on trichinosis, 78
ZiUner, cases of colloid cysts, 188
Zimm, case of poisoning hj carbolic acid,
446
Zimmer, on diabetes, 72
Zinc, sulphate of, on poisoning by (Tar-
dieu), 443
Zuber, case of hydatids in lung, 79,
125
Zuntz, on poisoning by carbonic oxide,
443
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