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A PRACTICAL TREATISE 



ETIOLOGY, PATHOLOGY, AND TREATMENT 



COWGEMTAL MALFORIATIOKS, 



RECTUM AND ANUS, 

By WaLIAM BODENHiUlEK, hL D. 

JLLOSm^TED BT SnKTBBN PL4TBB AND TWO UUNPaBD AND BTOfttTY-SBTZH QABW. 

One volume, ootoTO^ sabstontiaLly boimd in dothi Frioe $2 00 
Bngl& oopiei post-paid, hf mail, ibr tbfi retail price. 

SAMUEL S. & WILLIAM WOOD, Publishers, 

Xo. 389 Broadway, New York. 
THE 

PHYSICIAN'S HAND-BOOK 

OF PRACTICE AND MEMOllANDA, 
FOR 1801, 

WII.L HE BEADY EPf ^EIFTBMBEB. 

It Ib the mo3t comprehensive and eonTenient Pocket-Mannol for tbe Phyiidaai erer ' 
iBBued^ and wUl save raany times its eost in a single j<?Ar. 

Miilied free to bqj part of tbe United States for $125; Bnuthwaite one year, and 
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^^ Sec reconuuendntionB and oontenta on Becond and third pages of oover. 



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So. 46 WALXEK STREET, HEW YORK. 



THB St ^7 (ij^ 

RETROSPECT 



PRACTICAL MEDICINE AND SURGERY, 



^ ^df-ijearla Joumol, 



OONTAINIKO A EBTROSPECTIVB TEBW OF EVERT DISCOVERY AND PRAOTIOAL 
IMPROVEMENT IK THB MEDICAL SCIBNOE& 



EDITED BT 

W. BRAITHWAITE, M. D., 

LEOTUEBB 0» OBSTETRIC MEDICINE AT THE LEEDS SCHOOL OF MEDICINE, BTO. 

AND 

J. BRAITHWAITE, M. B., 



Part XLTI JANUARY 1801. 



UMFOBH AUEBIOAir EDITION. 



NEW YORK: 
W. A. TOWNSEND AND COMPANY. 

1861. 



a A. iXVOBD, PBINTEB, 16 YANDEWATSR 8TBEET| NEW YORK. 



Ih this Yolume the reader will find a large amount of infannation which 
we have collected &oqi various sources within the last six months* We 
have endeavoured to take the "cream oflF the bowl,** and to throw the old 
milk awa^. At the same time we ought to say, that we have been obliged 
to reject numerous papers of the highest value, but whieh we did not con- 
sider sufiioiently practical for our purpose. Passing over, as aimost too 
nniDorous to notice in this introductory summary , the numerous and highly 
interesting papers in the body of the following pages on the various subjects 
in Me die me and Surgery, we have to point out here, many interesting facta 
and suggestions which have been published within the last six monthsi on 
*^ Midwifery i and ike Diseases of Women *^^ 

Few special branches of our Profossiou now engross more of the attention 
of Medical practitioner a than docs this subject, and when we iuclude tho 
Diseases peculiar to Children, this branch of Medicine, becomes still more 
comprehensive, and requires still more iuduitry and reading to keep up with 
the literature af the day* For these reasons we have for some time re- 
printed, from each of our larger volumesi a pamphlet whieh tbe Medioal 
practitioner tnlght easily carry in his pockett and read at the bed-sidc« whibt 
passing E^ome of thoie wearisome hours which Mb irksome duties call upon 
him to speud. 

In this little pamphlet the Obstetric practitioner will find most of the facta 
and Ideas which have been published in varioas papers during the last six 
months, on the subject of Midwifery and the Diseases of Women, It will 
thus save him immense trouble and labour in referring to all the published 
' literature of Great Britain, Ireland, and America, and enable him in an hour 
or two, to make himself master of thinga which have taken us many weeki, 
and even monthsi to collect and condense. Amougst other things, wo will 
first direct the reader's attention to a new pair of ForccpSf in great use in 
America* and especially by l>r. Knight » of Baltimore, We hare long 
thought that the forceps required improvement— that they might be made 
smaller and fit the head better, thus running less risk of lacerating the per- 
ineum. The forceps of Dr. Knight, described in the first article on Mid- 
wiferyr seem to us to deserve the attention of the British practitioner. They 
are smaller, more easily applied, fit the head better, have no fenestra, and 
possess other advantages which Dr. Knight describes. 

It often happens that the child is low down in the pelvis and all ready for 
delivery, but the pains abate, the powers of the mother give way, and the 
practitioner feels convinced that if his fingers were a little longer and a lit- 
tle stronger, he could easily deliver. We want, then, a pair of very small 
forcepB, so as to be useful at the outlet of the pelvist to fit the head better, 
and to be able to introduce the upper handle without bringing the patient to 
the edge of the bed. This last can only bo accomplished by making the 
handle of the upper blade with a hinge in it, so as to bend at any angle dur- 
ing its introduction, and keep the handle from the bed i or to make this up- 
per blade in two parts, the lower part or handle to be filed to the blade 
when thin bos been introduced. The patU to \ie v?«i\\ m^Mt^^ ^Vi^xv^^ \^^- 



^ 



p 
I 

b hi 



eeps haye fitted well. The simple intTaduQtion of suclt a pair of blades* 
with very little traction, would often save the patient and the practitioner 
hours of pain and suspense. These remarks will apply aot only to Dr# 
Rnighfa forceps, but also to a good paper by Dr. Doig^ <jf Louth, who ha« 
compared the uses of the Forceps and Perforater, Why ahoiild we sit 
days and nights by tho bed-side doing nothing, when, by the judicious ase 
of the forceps, wo might end the business at once, with safety to both mother 
and ohild? 

Dr. Braxton Hicks suggests that the old method of Turning the child in 
the womb may frequently be im pro red. He describes his method in the 
following pages : but wo confess that we cannot agree with his praotioe, as 
there are few or uo coses, in which turning Is required, where it cannot be 
done with perfect eaJ^e in the usual way, oxcept in cases of imp act ton low 
down in the pelvis; and in these last-mentioned eases it can be accomplish* 
ed with comparative ease, even when the head of the child is very low down 
indeed, by getting hold of one leg and securing it by means of a hit of strong 
tape, or the end of a pocket handkerchief. By this contrivance we have 
great power of traction with the left hand, and can at the same time push up 
the head with the fingers of the right hand, so that there aro no cases which 
require turning which we cannot treat with safety and ease. Why, then, 
have recourse to this external manipulation so weli described by Dr, 
Hicks ? Let the reader, however* peruse the paper, and judge for himself. 
There are some good ideas in it which may require to be adverted to here- 
aftor. 

It is becoming a more and more important opinion, first brought promi- 
nently before us by our eminent friendi Dr, Simpson i and mentioned at great 
length inpne of our former volumes with several wood-cut illustrations, that 
there are numerous eases of Deformity of the Pelvis, or unusual size of the 
child* a head (in which hitherto labour has been obliged to be aecompUshed 
by instrumental aid, either by the forceps or by cranio to my,) which can be 
terminated safely both to mother and child by moans of torniug, Dr, Rob- 
ert Barnes's paper in this volume illustrates the truth of this opinion well, 
and tiie operation of turning in the early stages of labour, when the oa uteri 
l»well dilated or very dilatable, is really so easy, especially since we can 
dilate the part still more by tho use of chloroform, that wo shall not be sorry 
to see this praotioe still more carried out in cases of ditJicultv and tardiness, 
where either mother or child are in danger. Dr* Barnes truly says, that in 
certain cases the forceps may be used with great success, but in other cases 
"this instrument will not effect delivery, obstructed through disproportion, 
with less risk to the mother or with more Bafcty to tho child than can be at- 
tained by turning.'* By getting hold of the leg or legs and turning, we 
have in fact a degree of power given to us which we can exercise with great 
safety and with wonderful success. 

Puerperal Convulsions are often of the most alarming description. We are 
often unable to administer any remedy by the mouth ; a single drop of cro- 
ton oil on the tongue moistened with a little water is, perhaps the only 
i^binj^r we can do when the eonvulsions are iticessant. Dr. Scanzoni, of Wurtr,- 
imrg', sa^ests tlmt we should inject subcutaneously a solution of meconate of 
*rpAiaf In tb& manner lately reoommendod by Dr. Woo4, o! l^aViiWi^^^, m 



othdr catea. Of all the preparatloiis of opium we have found none go good as 
the Mectmate of Morphia ~ Praotitiotiers will find it to bo followed bj very 
few of thp bad effects of opium* At the eame time we may here say that* 
next to the delivery of the women, we hav« fou»d no remedy to exceed in 
valuo the injection of an enema composed of half an ounce of spirit of tur- 
pentiiie» well mixed with the yolk of an egg and thin water gruel; this to be 
repentedi if necessary, every two, three, or four hours* We have rojieateinj 
known this instantly to fstop the moi^t violent convukions. We even ve»» 
tare to think tiiat, tit most oonvulsioua dependent on sc^me crccntric cause 
(either in the abdomen or pelvis), whether hi women or children, this reme- 
dy is superior to till otherst especially in children when the convulsions are 
owing to tome intestinal cause. In thie case a ten spoonful or i^mall dessert* 
spoonful of turpentine will be enough. 

Mr. Spencer Wells records some good eases of Ovariototnyt and warns us 
against the too common exhibition of opium in the after- treatment. Hesajs 
that opium and not the operation itself, is sometimes the cause of death ; and 
in other cases stimulants^ too incautiously given have done as much harm ai 
opium. At the same time starvation and purgatives may be equally objeo- 
tionnble. One great secret of success in the after-treairaent of these casest 
is perfect rest, in a we 11 -ventilated room. 

An interesting question has arisen lately, respecting the Diagnosis of 
those cases which have been called Tregnancy, in which the feet us has 
seemed to be absorbed , «r in some way to disappear. Dr* Jamps Jones, of 
the Metropolitan Free Hospital, gives us a case of tins kind. The menses 
disappeared — the movements of the child were evident^the abdomen en- 
larged and the breast increased— and there were all the most important symp- 
toms of pregnancy » In nine months labour seemed to commence, but dis- 
appeared; and in eighteen months the abdomen had lessened and was occu* 
pied by a finn mass, more like a fibrous tumour than a child, ^uch^ in fact, 
would naturally be the opinion of most practitioners when the diagnosis could 
be thus apparently verified ufter so long a period had elapsed after parturitioa 
was due. But we do not take this view of such a case. We bavt^ our^a elves 
lately had u case very similar to the above, and ivhich ban rnded in tbe same 
tihrous enlargement of the womb* But in our case this additional symptom 
of pregnancy was present — the fo'tal heart t?ould he distiuetly heard, both 
by the senior and junior editor of this work, and not once or twice, but re- 
peatedly I this fcetal pulsation was too well-marked to bo mistaken^and jet 
this patient had all tlio most important symptoms of pregnancy with the 
most energetic movements of the child. All this has now disappeared^ the 
patient is much improved in health, the abdomen has coniderably subsidf^dn, 
leaving a iiard fibrous enlargement of the womb, but no labour has come on, 
and no child has been expelled- One curious feature of this case was, that 
we could never find the os uteri, which seemed completely occluded. As far 
as the finger could roach in all directions, especially backwards, where we 
might have expected to find it, we carefully sought for this oriiice, but never 
fimud it, and up to our latest eiamination we faiJed to do iO« 

With this case in our own praetioe wo were the more interested with the 
case of Dr. E. J, Fountain, of Davenport, Iowa* which resembles our own In 
inajjy partJcolars, except that he had t\\c advatittv^fe,\j^ l\i^ \^\jttswxS^ i5is^>iKsvs>Ti 



r 



* 



ol tbe fstua itself^ of proving the correct nene of h'm own diagnosis* The case 
will be aeen related at page 267 of thi^ vo]um<». Tbo woumn became preg- 
nfkut nbaut JuBe* nud conttuued to enlarge till Doc«inber> From this time 
the onlargenient ceased to iucrease, and gradually decreased. The move- 
ments of the child were evident, and the usual eymptotni of pregnancy pre«- 
6&t — yet at the end of eleveD months no labotir had com© on* and Dr, Foqq- 
tain thought fit to bring it on artificially, when tliere was expelled ** the re- 
maiDs of tt foetus, cdv eloped in its membraDce unbroken, with tbe plucenta 
attnchadT" and not larger than a good-sized orange. It was greatly com- 
pressed and emaciatedi the flesh had been almost entirely ahsorb^d« leaving 
Uttle more tlian the {skeleton partially covered with a thin remnant of mus- 
cular tiBi^ue. From these oases, therefore, it seems possible for a woman to 
be pregnant, and eventually for the fcetus to be more or less, If not entirely 
absorb edf or to disappear so far as not to interfere with the functions of 
health* 

Mr^ Erich sen has given us some valuable hints about Tumours of the 
Breast, particularly those small cystic tumours, with a considerable degree 
of hardness, wbicb are not unfrequently mistaken for cancer by tbe most 
ezperiouoed surgeons* The great thiug to observe is to try to find out 
whether there is a degree of elasticity about them, or whether they are oh- 
xtirehf elastic on deep pressure* If so, iatroduoe an exploring trocar {not a 
gro&vcd needle-} Eren in cancer this trocar can do no harm, and if it he a 
oystic tumour the fluid will ooze out and settle the diagnosis. The trocar 
must be pushed directly into the tumour and not sideways, else the &kin will 
form a votive, and only blood will eecupe, thus confusing the diagnosis. The 
trociir alone will often cure the cyst ; if not, you may Inject it with iodine, 
or cut a bit of the cyst out, or introduce a seton* All these things are well 
known and often practised, but we are surprised not to find metittoned what 
we have before recommended in similar circumstances, viz. ; — the introduc- 
tion of a f^ood largo silver probe, well charged with nitrate of silver, which 
we havo found most useful. Tho art consists in changing the probe, the 
principle of which may be carried out either on small probes for cysts in the 
eyelid, or on larger probes for cysts any where else. You may either melta 
little nitrate of silver in a silver spoon and dip the probe in the fluid, coating 
the end with it thick or thin ; or you may make the probe itself hot (if in a 
hurry) and it will adhere at once to the required size i»f the nitrate, which 
oan be warmed arid made to fit the probe better by being applied near a gas- 
light. In treating cysts, then, make a puncture with a bistoury {and this can 
be done directly or valvularly), and after evacuating it, immediately intro- 
duce the charged probe and poke it about the cavity. Cystic tumours of the 
breast are sometimes so mixed up or surrounded by condensed fibrous matter, 
that the diagnosts may be very obscure; they may eren degenerate into 
cancer. 

In the diseases of women, let us always remember that there is the greatest 
connoction or sympathy between the symptoms of disease in the Rectum and 
disease in the Womb. You may at first think that certain symptoms are 
uterine when they are owing to disease iu the rectum ; this can easily bo 
M&own by Hii ezaminatson. WheUt therefore, you cannot find sufficient ovi* 
ofdisemsBin the womb iUeUto account forQertamsyif\Tjitoccvftv«'X^m\t\a 






vii. 

the reotnm. Mr. I. Baker Brownt with his usual practical skill, has pointed 
this out clearly. In many cases there will be found a^^xure just within tiitf 
sphincter, (the same as in males), and apposite this fissure a small penduloH9 
polypoid hody^ which will often drop into the fissure like a pea. In this case 
diyide the fissure by Copeland's blunt-pointed straight bistoury, tie or stran- 
gulate the polypus, or twist it off, and plug the rectum well with lint soaked 
in sweet oil. Do not disturb the plug for forty -eight hours, after which time 
there need be no fear of union by the first intention. Let us adyise oar 
younger brethren to be attentive to such apparently little things, which are 
daily occurring in practice, while the more important operations happen only 
a few times in one's life. 



CONTENTS OF VOL. XLII. 



PRACTICAL MEDICINE. 



DISEASES AFFECTING THE SYSTEM 6ENEBALLT. 



ABTICLB. AUTHOB. PAO& 

1 On Typhus and Typhoid Fever . . . .Dr. Henry Kennedy It 

2 On the Distinctions between Tjrphus and Enteric 

Fever Dr. W. T. Gairdner 18 

3 On the Treatment of Typhus Fever . . . Dr. Alex. Tweedie 21 

4 Clinical Remarks on the Cure of Typhoid Fever . Dr. Brinton 24 
6 On the Treatment of Intermittent Fever by the In- 
halation of Quinic Ether 25 

6 On the Treatment of Chronic Rheumatic Diseases 

by Congelation Dr. James Amoit 26 



DISEASES OF THE NERVOUS SYSTEM. • 

1 On Affections of the Spinal Cord . . . Dr. 0. E. Brown-Sequard 29 

8 On Tetanus Fred. C. Skey, Esq. 42 

9 On the Treatment of Acute Traumatic Tetanus by 

Tincture of Aconite 46 

10 On the Treatment of Hemicrania by Injection of 

Morphia Dr. John K. Barton 46 

11 On thQ Hypodermic Action of Morphia . . . John K. Spender^ Esq. 4t 

12 On the Treatment of Neuralgia by Powerful Cur- 

rents of Electricity M. Becquerel 48 

13 On Chronic Alcoholism .Dr. Wilshire 49 

14 Chronic Alcoholism, with impending Delirium Tre- 

mens, treated by Suspension of the Stimulus . E. Canton^ Esq. 69 

15 Three Cases of Delirium Tremens, treated without 

Stimulants; Fatal Result in two . . , Dr. Anderson^ and Dr. 

Sibson 51 

16 On Delirium Tremens Dr. J. A. Marston 53 

17 Treatment of Delirium Tremens by Digitalis . G. M. Jonts, Esq.^ Dr. Bed- 

lard^ Dr. WiUiams^ and 

Dr. Webster 69 

1 8 On the Treatment of Alcoliolism . . . .Dr. Smirnoff 63 

19 On the Theory of Simple Epilepsy . . .Dr. 0. Bland Badcliffe 64 

20 On the Use of Faraday's Electricity in Chorea 70 

21 Is the Brain in a State of Congestion or not during 

Sleep? John Hilton, Esq. 71 



ORGANS OF CIRCULATION. 

22 On the Signification of the Heart's Throb . . J. Maclise, Esq. 71 

23 On the Prevalence of Heat Apoplexy among Sol- 

diers during the Hot Weather Campaign in 1858 Dr. G.Alex. Gordon 78 

24 On the Use of Larch-Bark in Hemorrhages . . Dr. J. M. O'FcttoML ^^ 

25 On the Laryngoscope ^"^ 



X CONTENTS. 

ORGANS OF RBSPIBATION. 

▲snouB. AirrHOB. paos. 

26 On DemoDstrations with the Laiyngoscope . . J. Hutchison, Esq, 80 

27 The Diagnosis of Phthisis by the Microscope . Dr, Fred. J. Brown 82 

28 On the importance of the Functions of the Skin in 

the Pathology and Treatment of Tubercular 

Consumption Dr, IMmin 84 

29 On Dyspnoea as a Mechanical Cause of Congestion 

of the Lungs Dr. Andrew R Smith 86 

30 Observations on the Treatment of Asthma . . T. L. Pridham, Esq. 87 

31 On the Essential Nature of Asthma . . . Dr. H. Hydf. Salter 92 

32 On the Proper Use of Stramonium in Hay- Asthma Dr. Edwd. Lawfo^d 93 

33 On the Value of Tonics in Asthenic Dropsy . .Dr.R. S. Sisson 93 

34 On Paralysis of the Bronchial Muscles . . . Dr. James F. Duncan 95 

35 The Successful Treatment of Hooping-Cough^ by 

increasing Doses of Sulphate of Zinc and Ex- 
tract of Belladonna Dr. Fuller 98 

36 On Ciironic Bronchitis and Emphysema 99 

37 Pills of Carbonate of Ammonia in Chronic Bronchitis Dr, John Williams 100 

ORGANS OF DIGESTION. 

38 On the Dietetic Inventiveness of Hunger . . Captain Marcy 100 

39 On the Absorption of Substances at the Stomach, 

and their Excretion in the Urine . . . Dr. Lionel Beak 101 

40 On the Use of Creasote in the Treatment of Dysen- 

tery Dr. W.T. Gairdner 101 

42 On the Use of Santonine in the Treatment of Lum- 
, brici . . Dr. J. Brisbane 102 

42 On Hydatid Tumour of the Liver . . . . Dr. Garrod 103 

43 On some Chemical Questions in Connexion with 

Diseases of the Liver, and their Treatment . Dr. Thudichum 106 

URINARY ORGANS. 

44 On the Tests for Albumen in the Urine . . Dr. Lionel Beak 107 
46 On the importance of Albumen in the Urine in a 

Clinical Point of View Do. Ill 

46 On Renal Casts Do, 113 

47 On Morbid Changes Affecting the Structure of the 

Kidney Do. 114 

48 On the Treatment of Acute and Chronic Albu- 

minuria Dr. George Corfe 116 

49 On the Tests for Diabetic Sugar . . . . Dr, Lionel Beak 118 
60 On the Method of Detecting and Estimating the 

Quantity of Sugar in Diabetic Urine . . Dr. JamxS ITGhie 123 

51 On the Determination of the Proportion of Solids 

in the Urine of Health and Disease . . .Dr. William Seller 124 

62 On the Frequent Occurrence of Phosphate of Lime, 

in the Crystalline Form, in Human Urine, and 

on its Pathological Importance . . Dr. A. EtU HassaU 131 



SURGERY. 

AFPBOnONS OP BONES AND JOINTS, ETC. 

A? ^a»fi» of Excision of the Knee-Jomt 136 

^^ On Excision of the Hip- Joint .... John Erichsen^ Esq, 140 
^^ On the Pathology and Treatment of Scrofulous 

Diaeaaea of the Sjraovial Membrane of Joints . fiicKard BcwrtBeO^ Esq. \^ 



CONTENTS. 



60 LooiSG Cartilage la the Enee-Joint— RetJioviil , W- FLrgtmon, Eiq, 
S7 Ciise of Dislocation of the Ulna Forwards nt itm KI* 

bow* without Fracture of the Oieemnon Pmcess Ed^in C(ii\ttm, Esq. 
53 On tilt? Trealment of Laieral Ctimitijre of the Spitie Holmes CkfOii-^ Ksq. 

59 On the Dressing of Stumps after AmpuiaUoQS * F. ^yrn.&nds, Esq. 

60 Od Talipca Kquiuug It W. Thmplin, Esq. 

61 A Kuw Trephine . , . , . . . Br, G. A. D. Gait 



148 



6S 



OEQAKS OF OlECtOATtON. 

New Mode of mtkirig Fresaure in Popliteal An* 



B3 On the Treatment of Aneurism from Anastomosta 

hj Kxeiaion , * Olitw PemdertoHj Jig, 

M Qinical Eeniarka on Varices, &c., and the Bar- 
Needle and Ckap *...«. J<xmea jSto^Jin, J!^. 



AMMSNTABT OAKAl*. 



6li A New Metliod of Opera tiuj^ for Hare-Lip . , K Woakts^Jitn.^ Esq. 

B6 On a ConTeuient Needle for the Ready Application 
of Metallic SuturcR in the Operations of Cleft 
Pflliite, Veiiico-VflfriTjal Fktnia, &o. , . . F. 0. /ViV^. Esq. 

61 On the Redaction of Stran^^nlated Henjin * . Watl&r Jirssop^ Esq. 

€B On the Use of Chloroform in Slnitig^alated Hemin Thos. Bryant, Esq, 

6Q On Ulceration of the Lower K.Ttremitj of the Ree* 

turn ; ita Varietiefi, Diagnoeiia, atid TrieaiDieQt . Jam^ Kousij Esq, 



163 



ITO 



OBOAFB Of 17RIHK JLXD QSNSBAnOK. 



10 On Inflammation and Absccsg of Ihe Prostate 
Gland 

71 Eeport on ih© Condition of the Prostate in Old 
Age, founded on tlie DigLsecLion of One Hundred 
Bpecimeoa m Individuals gver Sixty Yeani of 
A^e ........ 

12 On a New Form of Catheter for Dilating Strictures 

73 New Operation for Phymosia . * . , 

74 Two Caaca of Stricture of the Urethra Suecessfullj 

Treated by the Urethretome Dilator 
TB Oij AUarloTi'a Operation for SEono in the Bladder . 
T6 On Allartoa'a LiUiotomy Operation 
T7 On Litbotoray ,..,... 



R H. Mead^ . 



Dr. J. C. MtAstr 
Bu^hri ShiUii/}e, Mq. 
M. Mulreau 

John Wmd^ Esq. 
Barnard Uott, Ki% 
Nathanid Ward, Esq. 
Fro/. N. K. Siniih 



174 



DISEASES OF THE SKIS, 



78 Statistical Analysts of Forty-two Caaea of Rodent 

Ulcer ........ 

79 On the Treatment of FaroB * . . . , 

80 Glyesrine in Skin DiaeaBea 

81 Treatment of Kruptions around the Anna 



X IIukMmon^ Esq. 
Dr. W. T. Guirdmt 



82 On the Thenipeuticfll Methods of Preventing Pit- 
ling of tlie :^aos in Confluent Sraall Pox . 



Jost^h Bdl^ Esq. 
Dr. Stakes 



I 



i&a 



SISEASKS or THE EYX ASD EAA. 



83 On Corelysls 

ii Ou Irldeetomj jaQlancoma . 



J, E Stn^feHd^Esq. 



IM. 



xU CONTENTS. 

ASnOLX. AUTHOK. PAOB. 

86 On Glaucoma and its Surgical Treatment . . J, W. HtUke, Esq. 206 

86 On the Division of the Ciliary Muscle in the Treat- 

ment of Glaucoma as compared with Iridectomy Henry Hancock^ Esq. 208 

87 On Division of the Ciliary Muscle in Acute Glau- 

coma 212 

88 Cases of Glaucoma treated by Division of the Cil- 

Muscle . . . ' . . . James Rouse, Esq. 213 

89 On Glaucoma and the Optic Papilla . . .Dr. Mackenzie 216 

90 On the Ophthalmoscope and its Application . Haynes WaUon, Esq, 218 

91 On the Surgical Treatment of Short Sight . . J. V. Solomon, Esq. 226 

92 Rheumatic Ophthalma treated by the Galvanic 

Current Harry Lobb, Esq. 221 

93 A Simple Mode of Treating a Frequent Form of 

Entropion M. Sichel 227 



MIDWIFERY, 

AND THE DISEASES OF WOMEN, ETC. 

94 New Pattern for the Obstetrical Forceps . . Dr. Samuel T. Knight 229 

95 The Forceps and Perforator Compared . . Dr. Gfiarles D. Doig 231 

96 On a New Method of Version in Abnormal Labour Dr. Braxton Hicks 235 

97 On the Operation of turning in Labour Obstructed 

through Coarctation of the Pelvic Brim . . Dr. Robert Barnes 240 

98 Pregnancy with'Duplex Uterus .... Prof. Kussmaxd 241 

99 Puerperal Convulsions Successfully Treated by 

Subcutaneous Injections of Morphia . . . Prof. Scamoni 242 

100 Post-partura hemorrhage P. Hvbheri, Esq. 244 

101 On the Diagnosis of Dropsy of the Fallopian Tube Dr. J. T. JSimpson 244 

102 Case of Spontaneous Expulsion of a Fibrous Tu- 

mour of the Uterus Dr. J. G. Swayne 245 

103 On the Diagnosis of Ovarian Dropsy . . . M. Boinet 247 

104 Four Cases of Ovariotomy T. Spencer Wilis, Esq. 251 

105 Case of Tumour in the Abdomen with a History 

of supposed Pregnancy Dr. James Jones 255 

106 On the Diagnosis of Tumours of the Breast . . John Erichsen, Esq. 256 

107 Recurrence of an Adenocele or Mammary Glan- 256 

dular Tumour afler Three Successive Removals ; 261 

ultimate Cure John BirkeU, Esq. 261 

108 Singular Case of Inversion of the Urinary Bladder 

during Pregnancy Henry Johnston, Esq. 262 

109 On the Treatment of Vaginitis and Superficial In- 

flammation of the Neck of the Uterus by Tannin 

Ointment Dr. Ibitcfier 264 

110 Clinical Reports on some Diseases of the Rectum, 

Ac /. Baker Brown, Esq. 265 

111 Death and Almost Entire Absorption of a Foetus 

of Six Months' Development . . . . Dr. E. J. Ihuntain 267 

112 On Deodorisation in Obstetric Medicine . . Dr. Thos. Skinner 269 



MISCELLANEOUS SUBJEOTa 

113 On a New Malformation of the Lower Lip, with 

several other Malformations occurring in the 

same Family J. Jardine Murray, Esq. 272 

114 On the Preservation of Urinary Deposits . . Dr. Lionel Beale 276 

115 Chloride of Zinc moulded into Sticks for the pur- 

pose of Cauterisation • 280 

Jiff Preservation of Bodies for Anatomical Purposes . Prof. Budge 280 
JIT Cases of Broachooele SuccessfuJJy Treated by 

StryohniA Dx. Mumey 281 



CONTENTS. xUi 

AUTBOK. PAttli 

118 On Ventilation : McKiuneirs Treatment 282 

119 Fatal Disease produced by the Trichina Spiralis ; 

artificial Propagation of the Parasite 284 

120 Influence of Animal Food on the Colour of the 

Skin 286 

121 On Periodicity as a Character of Disease . Dr, E. J, Tilt 286 

122 What is Disease? M. Claude Bernard 286 

123 On the General Effects of Medicinal SubsUnces . Do. 287 

124 On Fermented and Aerated Bread, and their Com- 

parative Dietetic Value Dr. J. Dauglish 290 

125 On the Nature of Death from Chloroform . . Dr. Charles Kidd 294 

126 On the Influence of Belladonna on the Pneumo- 

gastric Nerve ....:.. Dr. Richard JSugJies 296 

127 Opium and Belladonna Plasters . . . A F. Hasdden, Esq. 297 

128 Cases lUustrative of the Influence of Belladonna . Dr. Richard Hughes 298 

129 Influence of Fatty Bodies on the Solubility of Ar- 

senious Acid M. Blondlot 300 

•130 On Peroxide of Hydrogen Dr. Richardson 300 

131 On the Significance of the Contraction and Dila- 

tation of the Pupil produced by Opium and Bel- 
ladonna respective^ Dr. Richard Hughes 301 

132 On the Physiological effects of Opium . . .Dr. George Bodington 308 

133 On Opium as a Remedy in Poisoning by Datura . Dr. Thos. Anderson 309 

134 Tannin as Antidote to Strychnine » .Prof.Kwrzak 311 

135 Detection of Phosphorus in Cases of Poisoning . M. Scherer 312 

136 Examination of the Superficial Portions of the Kye 

by Means of Natural Light Laterally Reflected 

from a Double Convex Lens . . . M. Laborie 313 

137 Recovery from Strychnine Poisoning . . Dr. Part 313 

138 Two Cases of Narooctic Poisoning : suggesting a 

Modification in the Use of the Stomach Pump . Dr. Evelyn Crook 318 

139 On the University of St Andrew's, with Remarks 

on the Degree of M. D. obtained there . Dr. W. Braiihwaite 314 

SYNOPSI& 
INDEX. 




» 



i 




Dr. Henrj Kennedyi of Dablin, in a paper published in th© ** Edinburgh 
MedJealJournal," lays down the following propositions as the result of his 
c on f*[ deration of the relationship betw^een the varioua typei oi fever* 

** L Typbua and typhoid fevers eiist in Paris, Londooi Sweden» parts of 
America^, and Dublin ; and relapsing fever in Great Britain and Ireland, 
J2, In Dublin^ other types offerer exist, equally diatinct from any of these; 
of which gastrio, remarkable for ita great duration, the congefltive typhus of 
Armstrongt th&febris nervosa of Hmham^ and In summer, the inflammatory 
fevers may be adduced aa examples. 3, These may eiist in the same fam- 
iljp and at the same time. 4, When a whole family is attacked at onoe. 
iome may exhibit spots, and others not, 5. Two crops of eruption, as ob- 
lerved long since by Grant, are not uncommon in the typhus of Dublin ; 
and either may precede the other. 6, Ouo of theso may be a bright red, 
ajid the other of a much darker hue ; and thoy often coexist, 7\ Petechiae 
may exist with typhoid fever ; and bright lenticular spots without this fever, 
8. Bright lenticular spots may be followed by peteciuEe. 9. It would seem 
as if typhus and typhoid fever could exist in the same patient, and at the 
name time, Vk Whilst in London intestinal hemorrhage is common in ty- 
phoid fever, it is much rarer in Paris and Dublin, 11- In Dublin the same 
hemorrhage is not uncommon in typhus. 12. Cerebral complication is more 
common to typhoid fever than is usually taught.'* 

Dr. Kennedy has been led to believe, contrary to the opinion of Dr, Jen- 
ner and other pathologistSj that typhus and typhoid fevers are the result of a 
common poison. The variation in the typo* he is disposed to attribute 
especially to the influence of temperament, of habits, of constitution, and of 
the amount of the poison taken into the system. To refute the idea of the 
loss contagious nature of typhoid than of typhus, he refers to the papors of 
Dr* William Budd, which tend to show the contagious nature of typhoid 
fever* As to their non-occurrence in the same locality, an answor is found 
in the work of Dr. Husa ; who states that tbe two forms often arose under 
the «ame circumatancesi and in the same house — an intermediate form being 
somettmes developed. 

In speaking of tho treatment of typhoid fever. Dr. Kennedy states that 
the practice in Dublin is to give stimulantja, not as a nuitter of course, but 
because the particular ease requires it. He believes that stimulants are 
used too indiscriminately. 

** It seems," he says, " to be a very general impression, that if stimulants 
are to be used, it matters little of what kind they are* Hence brandy, wine, 
beef- tea, etc*, are constantly spoken of as being given to the same patient. 
This is surely not the proper way of dealing with such a matter, With the 
knowledge we now have of the varied composition of these fluids — ^for tho 
most of them are fluids — it appears to me to i*e injudicious to use them as is 
done at present: and I would particularly notice hore the difference between 
wine and bfief-teai For a long period I have been convinced in my own 
mind tJiat these two cannot be used iudiscriminately ; for it has been matter 
of obsorration to me that their effecta are \Ttv M^insttl. ^l ^^a \.^^^ ^sbSw 




18 PBACTICAL MEDICINE. 

contrary to what is usually thought, wine may he given with much less risk 
of unpleasant or injurious effects following, than beef-tea ; and when the 
latter is ^ven indlscreetlT, either as to time or quantity, it is very apt to be 
followed oy secondary inflammations, which oftencause fever cases to be so 
precarious in their results. It appears to me that the differences spoken of 
as resulting from the use of the two fluids are well accounted for by a con- 
sideration of the difference of their composition ; the amount of nitrogenous 
material — chiefly in the form of fibrine — being so very much greater in the 
beef-tea than in the wine. On the other hand, the latest, and, as I believe, 
the best analysis of wine, that by Mulder, shows us that it contains, but 
only in the very smallest quantities, several of those matters which are 
essential to our frames; such as albumen, iron, etc. And this analysis 
bears out, curiously enough, the remark of two of our ablest physicians on 
fever — Drs. Cheyne and Barker — made above forty years since ; viz., that, 
after a trial of whiskey, which was used for the sake of lessening expense , 
they foimd that it would not supply the place of wine. The point brought 
under notice, and which I am not aware has been specially alluded to oy 
any writer, would seem to be one of very considerable moment, as bearing 
directly on the treatment of not only fever, but of other acute diseases. 
Enough, however, has been advanced to call attention to the subject, and 
show the discrimination that is to be exercised. Cases, of course, will occur 
where both classes of stimulants may be used at the same time, and with the 
greatest advantage. But the point is, that they are not necessarily to be so 
used, and that mischief may result if a proper judgment be not exercised.*' 

Of carbonate of ammonia, he says that he does not think it suitable for the 
treatment of fever ; nor has he for many years used it in this way. 

** I had observed that diarrhoea was exceedingly apt to follow its use. In 
cases of typhoid fever this would not have been so remarkable ; for diarrhcea 
is there a symptom of the complaint. But it also occurred in cases where 
there was no irritation in the intestinal canal ; as, for instance, erysipelas, 
pneumonia, and other chest affections. In tliis way my attention was drawn 
to the effect of the medicine ; and I have now little or no doubt that very 
great caution should be used when ordering it in fevers, more particularly 
those of the typhoid type. My own conviction on this point is so strong, that 
I would not give it at all ; and the effects of the medicine on the blood, as 
shown in Dr. Richardson's very able work, go far to oonflrm the opinion 
advanced." 

Dr. Kennedy's treatment of typhoid fever is the following. If there be 
pain in the right iliac fossa, a few leeches are applied — care being taken 
that they do not bleed too long ; if they be not required, a blister is applied, 
and after it a warm poultice. As internal medicine, he gives dilute sulphu- 
ric acid ; prescribing from one to three drachms in an eight ounce mixture 
with from two to five drops of laudanum in each ounce ; an ounce is given at 
intervals suited to the urgency of the case. In its administration, however, 
care must be taken that it do not suddenly check the diarrha3a. In cases 
where the diarrhcBa suddenly ceases spontaneously, its cessation being 
attended by dangerous chest or head symptoms. Dr. Kennedy has adopted, 
he believes with benefit, the plan of keeping open a blistered surface for 
some days, generally on the chest. — British Medical Journal, Sept. 15, I860, 
p726. 

2.— ON THE DISTINCTIONS BETWEEN TYPHUS AND ENTERIC 

FEVER. 

By Dr. W. T. Qairdneb, PhTslclan to the Boyal Infirmary of Edinburgh. 

[The cases mentioned in this paper are four cases of enteric fever which 

occurred in the fever ward of the hospital a little before this lecture was 

delivered bx Dr. Grairdner.J 

Observe, now, that judging from our cases, tlie characteristic phenomena 

oftbia fever are not to be found either in its duwAion, ox 'yelyVa ^^x^xVV^^ ot 



PBACTTCAL MEDICINE, 

in iti 80-cttllc*(l ** tjpljmd" chamctfir*^* Tlio prcpenoe or abuflnceof fleliriuits, 
or of stupor, or of dry tonguo, nftords ni^ ground of diistuiction. One i>f our 
cas<?s Lml severe and protracted delirtuiTit tippronching conm ; anotbot had 
no dolirium, but was verj deaf and aptitUettc, witk a foul and dry tongue for 
many dtiys; the other two had hrirdly uny ^* typhoid" symptoms at alL The 
boat of skin was equally variabk^; in one it w»a gearcely ever much ele- 
vated i in all tlie others it varied greatly at different periodic, a a also did tbo 
pulso. In not one of the cases was thfro a rapid and decided eriiiia ; but 
one br-grtn to amend about tho eleventh day, another about the twelfth day, 
whilu the two remaining eases wore excessively protracted, and can hardly 
be said even now» after nearly seven weeks, to ho out of danger; the fever 
having in one of the two depfeaerated into a kind of hectic type, exceedingly 
like that of subacuto phthisis — a consequence, let me remark, which is very 
much more to be dreaded in enteric fever than in any other form of specific 
fever with which I am acquainted* 

Nothing', then, can wen ho more variable or less chEiracteristio than the 
gentjral symptoms of this fever. I have s«en It rr^(?Ive itf^df hi ten dtiy»» 
with tho symptoms of fehricula only, or of a mild remittent fever; I have 
eeen it, on tho other hand, last nearly as many weeks, and piiss impercepti- 
bly into organic disease. It mimics in turn oot only all other fevers, out 
many other general or local diseases — ^phlhisis, pueumonia» uieuiugitis, per- 
haps niTire frequently than most others, 

Nexl, as regards complications, we find that in two of our four cases there 
was intense dejifness; in one, if not in both, with disorganizatu^n of the ears. 
In tbo same two there was pulmonary com jdieat ion ufconsriilenible intensity, 
and douiilful issue ; in one of them resembling broDcho-pnoumonia, in tho 
iither tubercular disease. Tlie olher two cases were almost perfectly free 
from pnhoonarj or other severe complicotion, and but for a little diarrhtea 
at tlio commencement might have been said to be free from complication 
altogether. 

But there iooi diarrhsEftt vwre or less^ in (M th^ fmir cases. This, I need 
hardly say. is tho partloular symptom from which the namo ** enteric,*' as 
applied to tlii^ f«ver, is derived. Diarrhoea, without known cause, with 
light-colored ochrny, or blood*tinged stools, and with a tympanitic state of 
the abdomen, gurgling on movement, or tenderness on pressure in tho right 
tltac foMsa, arc symptoms as nearly character! stio of this fever tn any that 
can bo named. And yet I would not have you to trust to theie symptom& 
t^o much, fur sonic of them arc absent iu the majority of cages; and even 
diarrhoea may ho very transitory, ait it wai in two, at lo^st, of our cases (not 
lasting beyond a few days, or even hours) ; or it may appear to have been 
determined by a purgative. Further, there may be no diarrhoea; and ©von 
in fatal case?, with great ulceration of the intestines, diarrhoea may not ap- 
pear till a very late period* Besides, in typhus fever, and, indeed^ in all 
fevers whatever, diarrhoaai as oa incidental symptom^ is by no means iin- 
oommoB. 

Now observe, further, that in aU our four casts there was a pecidiar erup- 
lion on the skin. Thif, when present, and iu sufticient amount to be identi- 
fied, is the great criterion of enteric fever, ai the eruption of typhua is also 
of that disease* I will not dwell on the characters of these eruptions here 
m the class-room* t will ask you to study them carefully in tho ward^ 
whenever you have opportunities, and parti cnlarly to contrast them with 
one another. Of tho maculated eruption of typhus, you have two excellent 
example f) under observation at present. I will only recall to your attention 
now the fact, fully demonstrated to yon before on many occasions, that iu 
most of our cases of enteric fever the eruption has been very scanty, and 
that we have not unfrequently hesitated for a day or two to make a diagno- 
sis. Indeed, the first crop of tho eruption is rarely quite decisive ; but as 
soon as successive crops, even of two or three spots each, appear, all doubt 
is removed. But la order to be sure, it is usually requisite in this disenae, 
when tho erux*tion is scanty, to mark each individual s\(y>i^V\.\iv%\^v;\ ^^y^\ 
41 wax ns to distingimh accuratoly the period ot \la ix\i^^ft,t&ti&^ % ^\i\<^\^x^- 



20 PRA.CTICAL MEDICINE. 

caution against error, accordingly, you saw me take in all these four cases. 
This in typhus fevor it is usually unnecessary to do, and from the number of 
the spots it would be impossible even if it were necessary. 

As regards the characters of these eruptions, I may refer you for details 
to the excellent descriptions and illustrations of Dr. Jenner in the thirty- 
third volume of the * Medico-Chirugical Transactions,' with which I entirely 
concur. 

As regards the characteristic phenomena of typhus, and particularly the 
relation of the eruption to these phenomena as we have lately observed them 
in Edinburgh, I have no time to enlarge at present, and I will therefore take 
the liberty of referring you to a short paper of mine in the number for July, 
1859, of the * Edinburgh Medical Journal,' on the changes that have occur- 
red in our fevers during the last ten or twelve years. You will there find 
that typhus, like enteric fever, (though not certainly to the same degree,) is 
a disease of exceedingly variable severity and duration ; that its general 
febrile characters, though following on the whole a certain type, are by no 
means to be depended on in individual cases ; that its complications are few, 
and follow no regular rule ; and that therefore, still more decidedly than in 
enteric fever, we have usually to fall back on the eruption for its diagnosis. 

You will observe, then, that in the diagnosis of enteric fever, as compared 
with our old and familiar (but, happily, not of late very familiar) typhus, I 
rely not so much on any of the characters of the fever itself, though these 
are often very peculiar and distinctive when taken all together ; but chiefly, 
and in some cases exclusively, on the eruption. And the eruption I believe 
to be characteristic thus far, that when sufficiently abundant and well mark- 
ed, it shows forth quite decidedly which of the two diseases is present. 
When scanty in amount, and present only for a short time, it sometimes 
leaves us in doubt, not only whether the fevor present is typhus or enteric, 
but whether it is an eruptive or specific fever at all. Thus you saw that 
in one of our four cases, I remained in suspense for two or three days, but was 
afterwards quite decidedly enabled to pronounce that the eruption was that 
of enteric fever. And as regards typhus, some of you may have observed 
that, in the two cases now in the ward, I did not for a single instant admit 
of a doubt. The eruption, being a well-marked one, was, to my mind, a 
conclusive evidence of the nature of the disease, without a single inquiry 
as to the symptoms or antecedents of the cases. The same perfectly dis- 
tinctive character of the eruption, at the first visit, has often occurred to 
me in the case of enteric fever. 

Now I presume you will ask, and you certainly will do well to ask, what 
proof can be presented that the two eruptions alluded to (admitting them, 
as I think you will do, to be distinguishable from each other in the great 
majority of cases) indicate two diseases, and not mere accidental varieties 
of one disease ? I have already fully confessed to you that, unless the 
eruption makes the distinction, there is no sufficient and constant distinction 
in the symptoms ascertainable during life. Of course there is the additional 
fact of the ulceration of the Peyerian patches — by far the most noteworthy 
single fact, pathologically speaking, in the natural history of enteric fever. 
But it will not do to found on a fact like this in the matter of diagnosis ; 
and,, besides, after you have settled that there are cases of fever with ulcer- 
ated intestines, you have still to settle whether these cases are different in 
nature from other cases, in many respects similar, in which the intestines 
are not ulcerated. 

[In the summer of 1859, Dr. Gairdner made a very careful survey of the 
whole ** fever field" of Edinburgh, but without any result giving rise to a 
suspicion that typhus had given rise to anything but typhus, or enteric fever 
to anything but enteric fever.] 

I beg you to notice very particularly these facts ; for not only are they 

faU of instruction as to the danger of associating typhus cases with enteric 

fever, or indeed with any other fever, in the same ward, but they form the 

most conclusive of all possible proofs tViat t\ic tvfo diseases are distinct (Ws- 

oases. TjrphuB fevei is not subject to a relapse ; au^VV^V* a ^\«\q\\"& \ixv^ W 



PRACTICAL MEDICINE. 81 

disputable law with respect to it, that it almost never attacks ac^nin, at least 
within a period of years, those who have had it before. Yet here we have 
three members of one ftumily, within a few weekv^, seized with two di8tinot 
febrile attacks, with two distinct eruptions, the attacks beinc separated the 
one from the other by a perfectly distinct convalescence. To make these 
oat to be mere varieties of typhus fever would require the whole laws of 
that fever as ascertained by innumerable observations here and elsewhere, 
to be set at nought in this particular instance. — Lancet^July 21, JtitK), j). M. 



3.— ON THE TREATMENT OF TYPHUS FEVER. 

By Dr. Alexjlxdeb Tweedik, F. R. S., Physician to the London (Fever lIoHpital. 

In the progress of typhus, generally in the second week, but sonietimoB 
earlier, symptoms of exhaustion become evident, and indicate the necessity 
for stimulants ; hence wine, or some form of alcoholic fluid, beconies one of 
the most important remedies in the treatment. The precise period, however, 
when they should be given must bo regulated, not so much by the duration 
or stage of the fever, as by individual circumstances. Symptoms of ex- 
haustion or sudden collapse, for example, may sunervene at any period, 
even at the very commencement, and require stimulants to be at once ad- 
ministered, and in quantities which can only bo roffulatod by their ett'oots. 
The state of the circulation, as indicated by the pulse at the wrist, but still 
more surely by the sounds of the heart, is the usual practical index to the 
determination of the question. In a former lecture I drew your attention to 
an excellent paper on this subject by Dr. Stokes, in which it is shown that 
the cardiac sounds form the only certain guide for tho proper administra- 
tion of wine in fever. When, therefore, wo find the first or systolic sound 
80 weak and abrupt as scarcely to bo distinguished from tho second, (in ex- 
treme cases it is nearly anniliilatcd,) and the pulso at the wrist beating In 
sympathy with tho heart, soft, compressible, and rapid, there must bo n(» 
hesitation in at onco administering powerful stimulants, the cfTect on the 
hearths action being tho guide as to tho amount of either wino or brandy, 
while medicinal stimuli — ammonia, chloric ether, or other remedies of this 
class — are given in the intervals. It is especially necessary in such cases 
to enjoin that in the night, when tho depression is generally the most nuirk- 
ed, nourishment, and even wino, be given at proper intervals, and not to ad- 
mit the too common excuse offered by the nurse for withholding thc^m — that 
the invalid was in such a sound sleep that it was not doomed prudent to in- 
terrupt it. Many a patient has thus been allowed to pass int^) hopeless col- 
lapse, when, in all probability, by constant judicious stimulation, recovery 
might have taken place. 

ft is always necessary to watch the effects of the first few doses of wino, 
and if the pulso abates in frequency, becomes soft and fuller, tho tongue 
moist, and the heat of tho skin not increased ; and, when there has been de- 
lirium, if tho patient becomes more calm, and has intervals of sleep, we 
may feel sure that tho wine is doing gmid. On the other hand, if the pulse 
increase in frequency and strength, the skin become hotter, and the patient 
restless, flushed and excited, with throbbing of the tfjmporal and carotid ar- 
teries, we may conclude either that wine is not suited to the case, or has 
been given too early, and should therefore be withdrawn. But, as a general 
rule, it is perhaps better to give wine a little too early than a little t(»o lato, 
since, if it appear to disagree, it is easy to suspend its use ; but it may be 
very difficult to restore the vital powers if they have been allowed to re- 
main too long unsupported. 

Nor should the wine or brandy be discontinued until convalesc^jnce hi 
fairly established ; but as the symptoms for which the stimulants have \nnstt 
prescribed disappear, the quantity should be gradually abridged by giving 
smaller portions and at more distant intervals. 

In regard to the amouDt of irine and alcobiUc «lViau\aai\A ^i)EkAX \&a.^ \i^ %&r 



22 PBACTICAL MEDICINE. 

rainistorod in typhus, no precise rules can be laid down, as the over-yarying 
circumstances presented by individual cases can alone determine this. It is 
prudent to begin with half an ounce or an ounce, and to repeat this amount 
at longer or shorter intervals, according to the efifect produced. From six 
to twelve ounces may be considered to be an average daily allowance, but 
sometimes it is necessary to give two or three pints, or even more, in twen- 
ty-four hours, and, it is surprising to observe, without the slightest intoxi- 
cating efifect, even when the patient has been previously unaccustomed to 
stimulants. Indeed, in low fevers, the exhausted stite of the nervous sys- 
tem appears to be an antidote to the eflfects of stimulants — in short, to cre- 
ate a ttlerance of wine and diffusible stimulants. 

The wine should always be conjoined with nourishment, in order to assist 
its due assimilation, though in many cases the digestive powers are so feeble 
that they are unable to elaborate even the lightest articles of food, and there- 
fore the wine or brandy may be given simply diluted with water. 

I have just alluded to the daily quantity of wine that it may be necessary 
to prescribe in typhus, and stated that no precise rules can be laid down, as 
the circumstances of each case must determine it. You are doubtless aware 
that there is a great tendency in the present day to revive the Brownonian 
system, which nourished for a time in the latter part of the last century, in 
all acute diseases, including fevers, without regard to individual peculiari- 
ties. The doctrine inculcated by some teachers with respect to inflam- 
mation is, that this process being a deranged nutrition, involving Fupply 
and waste, and the waste being considerable while the inflammatory process 
lasts, there must be a compensating supply ; that as the supplies for the 
formation of the abnormal products of pus and lymph must be drawn from 
the blood, or from the tissues, or from both, the vital powers become ex- 
hausted, in proportion to the organic disintegration that takes place. Hence 
it is concluded, that the more the inflammatory process draws upon the. 
blood, the greater will be the exhaustion of vital force, and the consequent 
efifect upon the whole frame. 

Upon this physiological theory of the phenomena of inflammation is based 
the overthrow of established therapeutic principles, on which the treatment 
has been for ages conducted. But surely even the abettors of this theoreti- 
cal view must admit that the object of treatment is to anticipate or prevent 
those so-called destructive processes ; in other words, to promote resolutitm 
by all available means. Is this to be accomplished by extravagant doses of 
wine and brandy, regardless of the ever- varying condition of the sufferer or 
period of the disease ? 

Similar reasoning is adduced in regard to the phenomena of fevers, what- 
ever be their type or special circumstances. It is against the indiscriminate 
employment of stimulants in fever that we protest, being convinced that 
their proper administration requires as much consideration as is generally 
bestowed on other measures employed as curative agents. 

The enormous quantites of wine and brandy recommended in even the 
early stage of fevers, whatever be the form, the individnal circumstances, or 
whether tnere be local affections prepent, have often surprised me, and in- 
clined me to doubt the accuracy of the statements. I have certainly seen 
intercurrent inflammations materially aggravated by the injudicious stim- 
ulation adopted, and on more than one occasion all the ordinary characters 
of acute delirium tremens supervene when the unlimited administration of 
brandy had been left to the discretion of a nurse, who fancied that she was 
only obeying instructions when she poured down dose after dose of pure 
brandy. There is surely no practical philosophy in such indiscriminate abuse 
of a really valuable remedy when given on rational principles ; and I deem it 
the duty of every physician who is convinced of the dangerous tendency of 
the Brownonian doctrine applied indiscriminately in the treatment of diseases, 
acute as well as chronic, to express his opinion boldly and decidedly, that 
the young and inexperienced practitioner may be warned of the dangerous 
consequences of this reoontly-rovived doctrine. 
-& regard to the class of winos best suited iot i©\exa> c\^t€>V oiV^iiv wi^^cta 



I 



PRACTICAL MEDICINE. 23 

well, and muj be employedT unless a more powerful stiuiutant be required. 
With moat patients it suits well to commence with* and mixed wltb water is 
a grateful beverage. It bas also the advantago of being- less^ stinmlatlngT and 
more likely to suit in cases in which tljc employment of wine is doubtful. 
The stronger wines, — port* cherry, or miidcira, — properly diluted, are, bow- 
erer, generally preferred. Brandy is often very useful, especially when a 
more powerful ^stimulant ia indionted, or when wine is either not relished or 
di gag roes. In hnspiJal prnctice, for obvious reasunSt tileoholic fluids! — g-in, 
whiskey, Uriti^h briindy (whteb Is merely malt spirits disguised by colouring 
matter) — ^nre generally prescribed* 

In the Fever Hospital, Capo irine, of the best quality, and British brandy, 
are used^ 

Malt liquors are sometimea employed ; but they are suited only to tbe 
stage of convalescence, When» however, the patient has a desire for them, 
from having been previoussly accustomed to their use as an article of diet* 
they may be allowed in addition to wine or spirits* 

It is necessary, in many ca«ef^, to calm the nervous system; and tbia 
brings me to the Gonslderation of the cshibition of narcotics, from the judi- 
cious employment of which so much benefit is occasionally derived, 

Wakeiulneas, or want of sleep, so common in typhus, requires the oraploy- 
ment of opiates ; for nothing is more exhausting than two or three nights 
passed without sleep. Of the different remedies of this class, esporience 
has led me to give the preference to opium^ or its alkaloids ; but I generally 
Buccced with a much smaller doso than is uauallyprescribed^ — with, perhaps, 
ten or twelve drops of Battloy's laudanum, or ot the liquor morphJEe, — re- 
peating the same quantity every two or three hours until sleep is procured. 
But we ought to proceed on sure grounds, and if there bo undue vascular 
excitement, indicated by headache, acute delirium, flushing and conjunctival 
injection, the narootic must be postponed until the symptoms are subdued. 
In my last lecture I alluded to the beneficial effects of a combination of tor - 
tar emetic and laudanum in the cerebral affections of enteric fever, and 
need not do more, in the pregent instance than state, tliat it answers equally 
well under the same circumi«tftnces in typhus, at the same time administer- 
ijig. In the severer forms, winch so closely resemble delirium tremens, wine 
or brandy in such quantities and at such intervals as the case requires. 

Though opium generally acta better than any other of the narcotic clasSf 
it disagrees with some patients ; and when such idiosynerasy occurs, we must 
give a trial to some other remedy of the narcotic class, such as henbane, ex- 
tract of poppy, or Hoffman n^s anf>dyne liquor. Some speak highly in favour 
of the f*xtract of belladonna us a narcotic when the pupil is so contracted as 
to ho thought to contra-indieate the employment of opium; but I have no 
oxpeneneo of it. I have often observed, howevert that when patients, or 
those around them, have intimated that opium disagrees, if gtven by enema, 
it acts like a charm in aootbiog the nervous system and promoting sleep, 
concealing, of course, that opium is administeredi Twenty or twenty -five 
drops of laudanum, added to three or four ounces of any bland tluidi is ofton 
sufficient, and isjin many cases, a preferable mode of administering an opiate. 

As to the repetition of opiates, 1 would observe, that when the purpose for 
which they have been given has been necomplished, the remedy need not be 
repeated, unless the same circumstances recur* The remedy, however, 
should always be at hand to be administered if necessary* 

In no disease are the beneficial effects of blisters more satisfactory than in 
these severe cerebral affections. Bat we must be careful not to apply them 
if there he subacnte iuflammution going on. When this is subduiHl, the 
blister may be applied to the forehead and tho tomplest which is pret'erabla 
to blistering the nape of the neck, in which situation vesication is often at- 
tended with much iscomfort froDi the constant friction to which the surface 
Is exposed. 

In the pulmonary affections to whicb I shortly adverted in a former leo- 
ture, — whether they assume the form of bronchitis, pneumonia^ or, more 
rareljr of pi euriis/,— special local treatment becomes ti^^ftWirj » \!>^H. \V 



PBACTICAL MEDTCmE. 

imist be remembered that not only is tlie local malady itsalft 
thenio eharucteri but the general or cons tit iition&! pmirers are o 
consequently, active remodica not only foil in their objectf'' 
farther to lower the strength- Cotmter-irrltation of the chesf 
Btupes, or sinapisms, or the application of a bHsterH, often mv 
lief. The fccretion of the pulmonary membrane should at the 
promoted by antimony or ipecac uan, while the general powers 
by wino and nouriihment. 

The management of the conTaleseent stage of typhus is nol 
though often neglected- Much benefit ia derived from Yariou 
the tonic el&i^ — quinine cepecially, or some bitter infuBLOUi si 
cascarilla, calumbai or gentian, to either of T^hich the comp 
ammonia may bo usefully added. The diet should be light n 
and suitod to the (digestive powers of the patieot, and it is alw 
make careful inquiry into the previous state of the aBsiuiilal 
order that a fiuitahle tlie te tic plan may be laid down. No ger 
be given as each ease must be regulated by its own peculiartt 
care be obser^'ed in eliciting these, there will be seMom gr 
adapting the detaik.^ — LanctU June 16, I860, j?. 590. 



4,-CLINICAL REMAEKS ON THE CURE OF TTPHt 

By Br. Dumrra^^ Ph jslelftU to tbo Eojftl Free HoftpitiL 

[The use of emetics in the earlier stages of many febrile dison 
old date, but had somewhat gone out of use till revivetl by S: 
land, in his elasBlcal work * Sledical Notes and RefiectionB.*] 

In studying the act of vomiting some ten years agOi I madi 
menta, (Lancet, 1853* 'On tht* Treatment of F'evtfr;' and *' 
Anatomy,' article *Btomach'), which justified the conclusic 
vomiting of certain drugs from the stomach, there was inciden 
determination of tliese drugs to the gastric and adjacent intf 
membrane ; by virtue of which afflui the vomiting they pro^ 
object and effect of removing them from the system. 

Extending this conclusion to the study of typhoid and other f< 
then and soon after I was treating numerous (about 100) case! 
epidemic charaoter, I was led to recognize, in the earlier syc 
malady, a specific determination of the feverous poison to the 
tary tract of mucous membrane ; and especially to its upper ] 
sented by the stomach. And as a corollary to this view, it 
while to try the effect of agents which, like emetics, seemed, 
researches, to determine an increased afilux of blood to this 
brane, as well as an increased secretion, and even excretion fri 

In plain En glitch, however dangerous the facility of such a n 
theory in general, there seemed to be special physiological i 
validity in this instance* On the other hand, trained by tl 
large epidemiof, I believed myself little likely to mit^takeforf 
cula or slighter malady ; and eould see no possible harm in re 
Cially, an act which I had felt, in my own person, gave so 
relief to the terrible symptoms which usher in a typhoid fever 

Without troiabling you with the details by which 1 had slowly U 
self that this meosure was really successful, I venture to sum up t 

1* Emetici, early in fever, aro most advantageous : with j 
tiODi, always harmless ; tn most inBtances, extremely bene£ 
oases, positively cutting short the malady by a speedy cure. 

2* They ought only to be given in an early stage, for whici 
erally find an arbitrary limit in the ^vai four days from that of 
rigorsT but which is practically better defined by the access a 
tbe nauj^^a or vomiting of this epo^h* 

d. Later than this period, they seem to have much less i 



PRACTICAL MEDICINE. 




:!i it for about six minutos. DtiHng tli*? lu.^t hulf *>f this periodi the skm 
wliit4>, hnrd, and inst*nsiblp. WIibh tbi-* ctni^olation hat] cotisedt u small 
|iii E V of patiuded ieo was placed across t\w anklc?3 in order to j>r*^vont th^ 
i;^ \vliich would have otherwise aocompanied the returning senBationj 
' pHtlent was desired ti> keep the ico applied fnr a quarter of an hoar^ 
,^ r than this, if tho f^marting- should return on its removal, 
im>4tAneei prevented my seeing the patio jit until the third day afler- 
vlion she exp reined in very energetic torm^T her thankfulness for the 
■luck had been afforded. There had been no return of pain ufter the 
tirjn, and consequently no interruption of her VQ^t at nights All that 
frit wtii a eease of Btiffnesa ofthe jointa. Thero had been heat and 
nfthfl akin, particular! J on the second day after the frjgorifio had 
hut thii Bnehad qnickly removed by sponging the part with iced 
tho congektimi had not heeu kept up so long as it aomctimea is, 
la-^n no vesication producedi and consequently* none of lliat ten- 
the ekin wUleb follows vesication. The stiffness and weakness of 
«*'fn tinned far some time, but not m auoh a degree as to prove nfc 
• : and had the disease been of shorter du rat ion, these effects of 
■•ndd not have existed. On the other hand, when tho dii^easo 
>] for a very long period, and produced organic change in the 
I nil suffering' may be remove d| tho stiffuess will probably ho 

T'^tion did not last four minutes; ii>r hein^ desiroua to avoid 

'Uv Amu I should have preferred repeaUng-the milder applica- 

ttiis annoyance from ono of greater duration. In determiuing 

tumI dnring which the part should ho kept coii|;^ealed, it is ne- 

'. ' into the account the strenp;fh of the frigorinc mixture v^m* 

41' <]imntity of well -pounded ice and salt, applied when the 

ilog i4trougIy on each other, will produce a more dee}>ly pen- 

iiMro liistlngcold than a smaller quantity not so well prepared- 

MOL- which 1 liave known of healing by the first intention being 

: ail operation performinl under congohition, proceeded from its 

loo long continued when produced hya very powerful frigorifio; 

Mrr tho^o cireunistances there ivould probably have beim no im- 

ii;d an appropriate mode t^f dresiing the wound been adopted. 

;ri'Vdlenee of two errors nnist the imperfection In the treatment of 

Hi be cbiei^y attributed. One of these is the undue indui?nee which 

ones of tho nature of the dlacaie hare been permitted to exerolse ; 

i^ the false view that ban lieen taken of the di qmsit ion which rhett- 

nmrnation hai* to extend from one part of tho fibrous system to 

4>r of what has been termed metastasis, 

1- '^"-y of tho nature of acute rhouraatiftm ot present Iq vogue is r% 

, hut it ought not to be reUed upon to the degree that would 

vHhLJo.'* *if ex:pen*»nf.p which »re apparently contrivdictnry to it 

rhat uiiii^M i\j N abnonnally in the blood, there can, 

niidfttAtnih H j.ltoie, be little doubt; but whether this 

:^j of lt« numerous effects, or what 

, lie, are points to be yet ascer- 

. Todd the elinrinating mode 

udministratiuu of large doses 

Uiis theory; hut the well-attested 

"Tljia the bark, opium, and lomnn- 

-1; a!t*o, though the supposed 

f^are in favour of the idea 

- iirnurnce, the immediata-^ 

.1 I r, j:;otit^ lifter q) rains, ^ 

lE conohmon. Ono 

rnatio fever, imme- 

L est atttieks of gout 

i^f strict uro of the 



26 PRACTICAL MEDICINE. 



6.— ON THE TREATMENT OF CHRONIC RHEUMATIC DISEASES 
BY CONGELATION. 

By Dr. Jamks Abhott. 

Among the various purposes served by the new remedial agent, congela- 
tion, the most striking, if not the most important, is its use in the various 
forms of chronic rheumatism. I do not bring it forward as a remedy which 
may occasionally bo of service, for this may bo affirmed of numerous 
other plans of treatment, but as one which extensive ey)crience of its use 
has shown to be capable, in the great majority of instances, of immediately 
and permanently relieving the pain and subduing the inflammatory condition 
of the part to which it is applied. Indeed so few have been the cases in 
which considerable advantage has not been obtained from its use, that I have 
attributed the apparent failure more to error in the diagnosis or to a compli- 
cation of rheumatism with other affections, than to the inefficacy of the rem- 
edy. It is almost unnecessary to add that this agent can have no influence 
on any constitutional affection co-existing with that which is local ; but the 
existence of such a general affection is only known by the local symptoms, 
and when these aro permanently removed the disease may bo said to be 
cured. 

If this (or indeed any disease) can be cured by the application of local 
measures, instead of those whose agency pervades the system, the local 
measures should be preferred. Few internal medicines of an efficient char- 
acter can be long persisted in without incurring some degree of danger ; 
and, after all, though the whole constitution is pervaded by them, their ben- 
eficial action may be limited to the seat of disease. A coroner's inquest was 
lately held at Chatham to investigate the circumstances of a death caused 
by an overdose of opium, administered for the cure of rheumatism ; and two 
days ago, 1 was requested to visit a gentleman dying from an attack of 
bronchitis which owed its fatal severity to the extreme debility caused by a 
protracted course of active medicine for sciatica. A vulgar and pernicious 
prejudice against local or external remedies is that they " drive tne disease 
inwards ;" but when internal remedies succeed in "driving it out," they too 
often cause, or (or as in the instance just mentioned) predispose to, a worse 
disease in its stead. 

Of the modus operandi of congelation in chronic rheumatism it may be 
difficult to afford a satisfactory explanation. Some may deny that there is 
any new or peculiar action exerted by it, contending that it is only the tho- 
rough development of the antiphlogistic and narcotic virtues of cold applica- 
tions ; while others may regard it as only an appropriate mode of producing 
counter-irritation, or as a combination or succession of these two remedial 
agencies. A rational explanation of the mode in which a remedy operates is 
always very desirable, but experience is the only real test of its utility. The 
following case illustrates the mode of using the remedy, and its usual effects. 

A woman, between fifty and sixty years of age, employed as a cook in a 
gentleman's family, was, after an exposure to cold and dampness, affected 
with pain, swelling, heat, and slight redness of both ancles. She walked with 
great difficulty, and her sleep was much disturbed by an increase of pain 
during the night. There was no fever, nor other symptoms of constitutional 
disturbance. I saw her nine weeks after the commencement of the disease, 
and learned that the colchicum, iodine, quinine, and other remedies, which 
she had taken, had proved of no avail. On the contrary, her sufferings had 
increased, and it was proposed to send her into the country for change of 
air. On the 26th of February last, recourse was had to congelation. About 
three-quarters of a pound of ice, enclosed in a small canvas bag, were, by 
means of a flat iron, broken into a fine powder, and rapidly mixed with about 
half their weight of common salt. The mixture was then poured into a piece 
of ^^auze, and applied to both sides, successively, of each ankle, while the 
foot rested on the edge of a basin. The gauze bag covered a circular space 
of akin of between throe and four inches diameter, and woa kept in contact 



PBACnCAL JIEDICLSB. '22 

Tith it 5»r ilioat -ax miaurcs. DuHnff thi? luat lialt it zhls 7«?ri«i»i. the "jkin 
wTu TTiinf. aar>I. anil nx^wDr-ibiH. Wbt^a ciiis •.'*juir^tud«/n liuii ctrUfWii, i <uiulU. 

ijiti tiiu ^a:ieac -m* «iesir^d a» k^en :he ict; upr>iied r'.T i '{'itirtiir -iC naauur, 
ir I»»a:r»jr rhitn this* if tho «mar!iu :;:»•> aid r^cum -jq :c* rHuio»ai. 

Cin.'amstanc*?* prjvijaced 317 -HifLiu: ^*? indtiuc 'ixicil riie diir»i 'iuv :iitet*« 
TTiris^ Tiitfa «n? •ixyKs^vd ia rerv I'liirrtT-ri** Cirrus. j»?r uiiuit&r'iliie^ D7r dw 
r»ii« :r!i;i:a aad ijuea 1 J?nwd. Tbnn; j.iti b».'«n n*} rvtum .t* yain jfter d» 
eoDiT'tiitiiJn. ind coQ^i'i lendv nD in^trr'i^jcioa !r h»ir r»i>c a: aiicas- Aii aafc 
Atf 31 >w sL-It TTT* a AnrH? of •«ti£i»iS* ■f tiie ji.»:iu.*- Tb^'n* bad ai.'«?n bt'us.uid 
anirLni Jt die «kin. aortic tilair^j -la rii«» •w«:'»nd iiij irtier die iT!y?»r:fe lal 
beta laed. but diis Ae Kid t^iiciLlv T*imi}'p\:d b^ >pi.'n:x'JT:f :ae ^ars wi:a icetl 
water. A* rhe oonffylacit^a bad aoc bi^en i-jpc up so u.-n:^ as> is 5caj*.'C:3ie» r»» 
tJiere ba«i iwea 30 ▼^sicarion prjd'i«:ed. aad c»jn.-*e«{i«:n*:y, auae *ji tbas ten- 
•teraei*** oc ihe ikla ▼bicii p.-iit-'W'* ▼»i<it,*adi;a. Tbe >Gjfiit;** xnd wenkae^w 'if 
nie rtin.Ti' coaciniied pjr ^time dme. b'lc ni»c in **n-'ii :i Jii^rv^ a:* if; vr^.-v-.-ac 
aer 'nJkin^: aad bad the -ilseaise been ?c ih^jr^^^r d'lraciot:. tb^-se -iiffc^j vt 
itpn.ijabij ^>uld ai>c baT* ^jxisteti. i>j :be '.Th-^r baail, "vbt^n ?he ■i:?^.-iw 
bo:! C'.'atiiiJied P;r a T-rnr Ii.-nz pericd. aad ^:r*:di*:*:d orx'snl': oaa:;^?? ::r zb*/ 
}t}mu iii»t2^ all sa&riii^ aiar be waio^ti the <cL£i»;S6 will pr-btiLIv bij 
perTnaaeat. 

Tbe LM.-njeladtJii 'iid a«rc Ta^c ^our 3:I:i*:e*: f«.T beJaj: 2^*:-::^:* r> i^^yijl 
T9sicari«:a ■;£ Cte <ki3. I sbori'd ba^e pr>;:Vrrfd repeatiiij :b'r KLlo^r ij.yLi-jtfc- 
tioa 6> •,"» liiair rb:.-* .laai.^T-iace tr^ni oae ■. f .rrv i:er liTa:!'. ;:. In Iv^cvrr.-i'iia^ 
tie piT-'rer -•;rltM diriaj: -shlcb :be pert <b-^i.M b*i k-iyt c;r:^:-i^';':« r: i* ae*- 
wsBurj cj iikk^ iafio rae a^-eoaa: :iie *:r L-jrtb. -.t ti:rr tr-\p.T'r:',- niA:;rv v^nx- 

auuerial^ are a*:d:zu: *zr:a^.j :a ^ii.:li ..■•!i'-:r. will pr-'di-.-e :i :i:'.T*,'-i'.'eyI_vpeflt» 
«ni:ia;r i^d a Tn>?re Li*t;3j:«:v'M :i:aa 4 ^araiiHr '^xi::r!:_v -j.^j; 51 » -t^LI vr».-varvd. 
The oclj Lascaace -ybir-'ii I biT*; iz-.-w-j. =: b- iliaj: ?v t^ie dr>5 ::;:<?:::«:?i ?eia^ 
iaiT?e«i»?«i ifbcr aa orifriri-.'a rerf.-jm:-.-! j-.Irr v-'-.r-'-i-i-'a- v^.v-^ ■:.'■: :.\»c;i iw 
oariar :eea tot? if:zz c*^:::: -vW'iwcfa : r'.'izv**. i :■/ x^rzy •.■•.'w*:rtj.. rri^'.^riac: 
ba^ eTea •ia.d**r tb-irA: olr*: ;-jL>cu.a.:t< i»^rv -^ i" I pr-^iti-lv b.iv * 'iv.'*::: a.> bai- 
p€»:iz:-? cr. idd az. a? p ?? p ri irv* zi»:d-i ^- z -l •>: ?s: • ^ :hr? w- .■ -j.- 1 be-: u i i .• p :^;rd. 

To ra-* pr»:TaI-fao» or :w.» ■:rr»>r< :::i*: :crf Lx;.»:rr.v'"::'.^"i L'l :iv' :r^vi£i>ritt rf 
rti-: Tixarf *n» b-e ck:e dj atrr: : -i::: d- ^.h: ■? v : :L? e*e : 5 ib -e Tii: i i ^ : i •• *-f zice w b x*2i 

zl^ •:^^r L* ta^ filse rirw dias b-is bir«=r: zjk-.a '.': :1: vl:<>'<:i-.'U'*b:-'b rb-:r-2- 
aia^ij iadiciaratioa bx* :•> t:x:eai tn:.n o~* \\izz ■.; lb:? r.r'.'i* >v*:tfjau> 
aa^xbitr. or ot what tis beva teru-.-d •j^c:i>:3^:<- 

Tb«» tbeorir of ihe a-iMre '^z a: .lie rc.i L:i:i>ra i.' pre ^^ as luv-.-i^ue :* » 
plaa>;": Ir oa'*. b^: it '/"iib: r-»5 t^» le rvli^d uv-.-r: t,' :b-* d^c^-^ tbj.? wv^uisi 
r? ad^^ r :b i-5e :•» -ss-.^c s •;■ f e j[ r e ri-?a o-e w biN.- a a r»? Ap >a rr-'Ay c- * l : ri I ! v- :o ry i> it 
Ir*# :::!3 rt***:Te. Th*: *a 4-.:I r3.i>:* abi; r-.**!!;.- ii zb^ ":\vd. tb.rv caa» 
reasonir s cr«?ai ohtoiijil Aailys-j sl.,^a^. b^ li:rlv d.».:b; : bi: wh-.thifr thi* 
acli be ib-* ca-ss* of th-e disedse. -^r oi:Iy c::^ vf i:< ai-i:-.r.*,i5 i^zfc:^ vr wb»t 
the :™p»>rtinoe of «?av-b f rb^^je tZcVt* niij b^, ar? '.v:'ut> :■> b^ yet a^cer- 
tiiacd." AVbat has t^rra terrjvi Vy :b^ U:o l>r. T>ll the tl;u:;:*i:lr^ :TXs5e 
of trc:a:aienu aad wbivb L:.;i: > o^. c.-^*'.* ::» :bo ad:::;iL:s:r;i::.^u .f l*r-^.- d-.vi^f* 
of 5».^=:e alkailae s'-bstxr.vr, i».'0-^rd> w::h ihis tbe«,^ry : bit the wt'l-^tteste^ 
adxiataje* prvveedia^ fr>:a what are kaowa a* th-. Cirk. ovii:a, aiii Vr^^a- 
jiioe Ei>de5of trearriea: are advt r*e to ::. So a'>N>, tho-^-S Tbo *.:p>>'5e4 
coaiZi-^a oa3*os of rhea!r.a;:>as. cold aad r.v :>:un:', are in fiVvv.r of i:.^ :de«k 
tea: the raiaaci.>ne5 of the ski a are cl.**<d by their i::a.ie;K'e* the luiiLneNllAW 
tXNrarrcaoe of this disease, aad of the aaal-v-'i* d:>ri<<'. i>^.:« al^^r spnias, 
woaad*, aad xirethral irritdtrc-cs, would lof.d to a il L^Vrt::: o^'::K*..:?ioa. V^sw 
of the m.>5t sovere attacks whiob I Lave aitt with vf rh -.*•.;•.:•:* :1k* iVvtr* ixtue- 
diatelr fv>llowrd the bite of a horse: aad v^no of ::io *evt'r\>: :,:::'.ok5 o: p,*at 
was the cc«se^*jeace of sudden dil.\:atiju or raptor.* ^.*f s:rlc:ar\^ v^f tiit? 
urethra. 



28 PRACTICAL MEDICINE. 

The common opinion rospecting the metastasis of these diseases is founded 
partly on imperfect observation and partly on imperfect theory. Inflamma-? 
tion of the heart sometimes precedes inflammation of the joints in rheuma- 
tism ; and is so common an event during the continuance of the disease, that 
Dr. Watson has only known two oases of rheumatic fever occurring pre- 
viously to puberty in which the heart was not affected. That rheumatic in- 
flammation of the heart often takes place about the same time that inflamma- 
tion ceases in a joint, is indisputable; but this coincidence no more shows 
the connection of cause and effect, than the occasional coincidence of dreams 
and events shows that dreams are prophetic. Rheumatic inflammation ex- 
tends to various parts of the flbrous system, just as common inflammation 
attacks successively various parts of the respiratory mucous system ; and, 
doubtless, the part last affected may act in some degree as a counter-irritant 
in removing the inflammation previously existing in other parts. If it be 
true (and the idea is, to a certain degree, supported by the pathological 
researches of Dr. Garrod) that the articular inflammation is produced by the 
deposition of a materies marbU it must follow that, as inflammation so uro- 
duced would impede this secretion or deposition, whatever is calculated to 
moderate or remove it, will, instead of repelling the poison into the blood, 
not only promote its deposition in the joints, but, by preventing a febrile 
disturbance of the tystem from the violence of the local affection, facilitate 
its excretion by the skin and kidneys. If we take it for granted that rheu- 
matism is a blood disease, we must admit, with Dr. Graves, that the poison, 
in certain favourable conditions of the system, may pass off by the emuncto- 
ries without exciting local disturbance — just as electricity may pass &om the 
clouds to the earth without injury to buildings on its surface. 

Before concluding, I may mention another circumstance calculated to op- 
pose the general introduction of congelation in chronic rheumatism ; I allude 
to the imperfect manner in which it has been too often used for antiphlogistic 
and other purposes. To this cause principally I would attribute the failures 
in its use mentioned in a work on rheumatism recently published by Dr. 
Fuller. He states that, out of five cases of lumbago in which he employed 
congelation, there were two failures. As this differs widely from my own 
experience, I can only explain the difference by the supposition that the 
remedy was applied by him in a different manner ; and this opinion is con- 
firmed by finding it stated in his book, that congelation is objectionable from 
the pain produced by it both during and after the application. When prop- 
erly used, the smarting or tingling caused by it is too little to be complained 
of, and will certainly never be deemed by the patient a counterbalance to 
the immediate and permanent relief of the suffering from the disease. Dr. 
Fuller thinks that these failures of two out of ^ve cases supported his the- 
ory, that rheumatism of every description arises from lactic acid in the 
blood, which must be neutralised or expelled by internal medicine. But 
surely, instead of the two failures, it would have been more reasonable to 
have adduced the three successful cases as a corroboration of this theory. 
What appears a metastasis or shifting of inflammation, probably arises from 
the poison (assuming the truth of the theory) being carried by the vis medi- 
catrix to a now outlet or excreting texture, when the previously excreting 
texture or former outlet has been obstructed or disturbed by inflammation set 
up by the excreted matter ; and, consequently, what would continue or re- 
store the excretion in a joint already affected by removing this disturbing 
cause, or, in other words, by arresting the inflammation, would appear well 
fitted to prevent its extension to other parts. The truth is, however, that 
there is too great a dissimilarity between the various forms of acute and 
chronic rheumatism to authorize reliance on reasoning of this description, 
far less the substitution of such reasoning for the results of experience. — 
Med. Times and Gazette, July 14, 1860, p. 28. 



PRACTICAL MEDICINE. 




BISEiSES OF TDE NEBlfOUS STSTEM, 
7.— OK AFFECTIONS OF THE SPIKAL CORD. 

By Dr. C. E, Biowir-BiaxrAA9t F.B^B., PhyulcTiui \n tUn Natlon&l Ho«plU] for tlie PanlyMd mdthe 

iDr, Brown-Si^qunrd has published in tlu^ Lancet a fierios of most interepting 
eotures on thia subject, from whioh we havo ondeayoured to oollect aotne ot 
the innst prnctical retnarks.] 

On the Diagnosis and Trealment of iJie Principal Forms of Keflex Para' 
plegia. — [The present rirtiolo treats of reEei paraJjsia from variouB causea, 
A I) amber of eases are first related,] 

I. Coses of Paraplegia due to THsease of the Uterus. — In lB55i a joung 
Indy con salted me for what shD called an extreme weokneait whleh was 
really a paruploffia^ alraoBt complete at each menetnml pciriod* No diminti- 
tion of anj kind of sea sib Hi ty ; no paralysis of the bladder vt the rectum ; 
no symptom of hysteria* Djsmenorrlioea, anteflexion Qi the uterus, whfoh 
wft3 extremely flensitive, very larg© and oongeetedi bcario^-dowD imn^ d:o. 
In a few days after the use of a bandage to support the womb, a great ame- 
lioratioa was oyident ; and, in leas than two weeks, the paralysis had eatirely 
ceased. It had lasted six moDthav and had been treated in vain by strychnia, 
galvanism, shower-baths, steol, and other tonics. 

Lhfranc (* CLiniqae Chirurgioale de la Poti("%* vol ii., p. 109, 1842) men- 
tions the case of a lady* compTf?telely paralysed of the lower limbs, who was 
Taiiily treated, by tbe most actiTO remedies, for a euppo^ed affection of the 
Ppinal cord, and who became better only when troatod for a chronic inetrltiB. 
Tho propfreia towards a complete cure, whieli was obtained after a long pe- 
rird, took place gradually, the change in the paraplegia following Ibal of 
the in tk initiation of tlie womb, Lisfrano mentions another case in which also 
the gradual aincUoration of the paraplegia corresponded with that of the dis- 
ease of the uterus, and a complete care was obtain^di 

An eiccUont observer, Dr, Nonat, has seen seven or eight cases of para- 
plegia* depending upon an affection of the womb, in which the paralysis was 
quickly cured after the care of the disease of the uterus. Those cases show 
that when tho uterine affection is limited to one side tho paralyt^is is also 
limited to the lower limb on the same side, The cases have been published 
by a pupil of Or, Nonat, Mr. Esnault, (* Des Paralyaies SymptoinutJquos 4e 
la Metrite et du Phlegmon UtMa,' Paris, 1857.) 

Mr. Henry Hunt, of Dartmoutht Professor Hombere, Dr. Wolf, of Bonn, 
Leroy d'EtioUes, jun.^ aud others, have also mentioned cases of paraplegia, 
following a disease of the womb, and more or teis quickly cured after the 
cure of this disease. 

What ia the mode of production of paraplegia in those cases 1 Wo cannot 
admit that paralysis was dae to a pressure upon tho nerves of tho lower 
Hniba, — ^at least in most of those instances, — aS the enlargement of the organ 
was not sufficient to produce such an effect. Resides, in those cases sonei" 
hiiity waa hut slightly or not at all dimioiahed, whieli excludes the idea that 
it waa chledy or solely a pressure oo tho nerves of the lower limbs that 
caused the paralysis, Wc must therefore admit that it is either through a 
peculiar influence upon the spinal cord, or In consequence of some alteration 
ill the blood, that paraplegia takes place in cases of disease of the womb. 
This last explanation, of which I would not have spoken if it had not been 
reprcseuted to me as the right one, we must reject* because thcro ii no rea* 
son whatever why an alter,ition in the blood should rather produce a paral- 
ysis of the lower limbs than of the othor parts of the body. We must con* 
elude, then, that it !s through a peculiar agency upon the spinal cord that an 
affection of the wtmib produces a paraplegia. What this agency ia w© will 
try to fhow in another lecture, 

2*. Cases of Paraplegia due to a Disease of (he Uretlira. — ^Gravei (* Clinical 
Lectures on tho Practice of llcdioine,* '-lu4 ©^t,, ft^lj^^ \i^ i.'^.l^^\'@^ax^ , 



30 PRACTICAL MEDICINE. 

M.D., 1848, vol. i., p. 554) relates the case of a sailor who was treated by 
Dr. Hutton, for a stricture of the arethra, due to gonorrhoea. There were 
chills, dysuria, and loss of power in the lower limbs. " A very remarkable 
amendment took place in his back and lower extremities in a few days after 
the first introduction of the instrument: in fact, it was almost sudden." The 
paraplegia was soon cured, together with the disease of the urinary canaL 
Several cases, more or less similar to this one, are related by Leroy d*£ti- 
olles, jun., and other writers. 

3. Cases of Paraplegia due to Inflammation of the Bladder, — In a patient 
whom I saw in one of the wards of the Charite Hospital at Paris, under the 
care of Rayer, and whoso case is published at length by Leroy d'EtioUes, 
jun., (* Des Paralysies des Membres Inf^riours,' &c., Paris, 1856, pp. 57-59,) 
the lower limbs became weak after an incontinence of urine, due to a gonor- 
rhoea. Cystitis appeared, soon followed by a notable but incomplete para- 
plegia. Gradually the paralysis diminished, while the inflammation of the 
bladder was subsiding and a complete cure was obtained. Several other 
cases like this are recorded by Leroy d'EtioUes, Macario, and others. 

4. Cases of Paraplegia due to a Disease of the Prostate. — A patient con- 
sulted Rayer, Magendie, and Leroy d'Etiolles, sen., for an enlargement of 
the prostate, which was followed by a paraplegia. The swelling proved to 
be due to an abscess, which opened, and continued for some time to give out 
pus. When the suppuration stopped, the paraplegia began to diminish, and 
was quickly cured (Leroy d'Etioiles, jun., loc, cit., p. 83.) Other cases* 
nearly similar to this one, have been observed by Civialo and others. 

5. Cases of Paraplegia due to a Nephritis. — Rayer has published several 
cases of this kind of paraplegia in his classical work on Diseases of the Kid- 
ney (* Trait6 des Maladies des Reins,* vol. iii.) In one case, weakness ap- 
peared in the lower limbs of a patient some time after he was attacked with 
nephritis. An amelioration soon took place in the nephritis and in the 
paralysis, under a treatment directed against the former. The patient left 
the hospital ; but a short time after ho was suddenly attacked again with 
acute symptoms of nephritis, and lost the power of standing on his feet. 
Cupping and diuretics quickly cured the inflammation of the kidney, and in 
less than a fortnight he was also cured of the paraplegia, It must be re- 
marked how quickly in this case the symptoms of paraplegia appeared and 
disappeared twice after the production and the cessation of a nephritis. 

6. Cases of Paravlegia due to Enteritis. — Two cases are recorded by 
Graves, (loc. dt., vol. i., pp. 547-9,) in which the lower limbs were paralysed 
after an attack of inflammation of the bowels. There was no numbness, no 
pain, no formication. In one only of these cases the bladder and rectum 
wore a little paralysed. In both patients there was a marked loss of the 
muscular sense. They both recovered. Zabriskie mentions a case of cure 
of paraplegia in three weeks, after the cure of an inflammanion of the colon, 
which seemed to have caused the paralysis (*Gaz. M6d. de Paris,' 1842, p, 
296). Several cases ofparaplegia, apparently due to dysentery, and cured 
after the cure of this afi^ction, are also on record. (Macario, * Gaz. MM.,' 
1858, p. 161.) 

To the cases of inflammation of the bowels we may add those of irritation 
of these organs by worms. Such cases of paraplegia cured immediately, or 
in a short time, are indeed far from being rare. We will only say that in- 
stances of this kind have been observed by Bremser, by Moennich (* Biblioth. 
M6d.,'vol. Ixi., p. 269) and by Dr. Calvert Holland ('Edin. Med. and Surg. 
Journal,' 1845, vol. Ixiii. p. (&5). 

7. Cases of Paraplegia due to an Affection of the Lungs or the Pleura. — 
Three cases of this kind are recorded by Macario (*L'lJnion Med.,' 1859, 
p. 276). I have seen a similar case (in 1849) at the Charit6 Hospital, in 
raris. The patient I saw was cured in a few weeks. Two of those seen by 
Macario were cured, and one died. 

8. Cases of Paraplegia due to Diphtheria. — Maingault (* De la Paralysie 
Dipbt4rique, * Paris, l360, p. 45) relates the case of a young girl who, after 

an attack of diphtberiat became completely paraplegic. For a fortnight no 



PKACTICAL MEDICINE. 



31 



cliang^i but from that time gradual recovery ; complete euro in tKree montliB. 
Trousseau bas seen a simimr fact iu a cbild dido years old ; and i^i^llerier 
Has eeen paraplegm^ following diphtherin, cured in a month, in a gtntleman 
forty years old (Maiugault* loc. ciL^ p* 4C.) I will try to show, hcrt'tifter, 
tbat paralj'f^is due to diphtheria ought to be coneldered iu tho »ame lighl as 
the eases of piiralyftis moro evit^cntly of a reflex origin. 

9* Cua^ (if Paraplegia dut to Teething. — I have seen a very interesting 
case of this kind in which tbe paraplegia, which had appeared at tlie very 
beginning of the second dentition, in a boy five years old^ increased and de- 
creaseil alternately at tho time of» and afteif tho cutting of each of three 
molars. In that case there was a slight contraction in some of the paralysed 
muscles, Sitjiple hygienic means, shampooing, galvanism, and a decoction 
of cinchona bark, wore employed "with snccess. Tho child was cured two 
months after the cutting of all hts teeth (eseept the so-called ** wisdom 
teeth**). Underwood has ^een a case of paraplegia appearing after everj 
cutting of a tooth. Fliesa and otherst have alrea<!j shown the relation be-* 
tween teething and paraplegia, and it would not bo difficult to prove that 
those very able writers (egpeciitUy Dr* Kennedy and Dn West) who think 
that it is chiefly the condition of the bowels in teething tliatcausos paralysis 
have been mhled by tho faot that very frequently enteritis precedes paraly^ 
sis. Usually, enteritis iu teething, as well shown by Dr. Cain and l>r. 
Fraeer CaGipbelh is produced by a reflex action, and paralysis seems to be 
generated in the same way. 

10. Cased of Paraplegia from Irritation of Nems of the Shin* — Amongst 
these cases are the very numerous ones due to cold and wet» Graves {toe* 
ciL p. 5fK3) relates the case of a geatlenian, fond of shooting, who became 
paraplegic after having eixiosed his lower extremities to wet. There was 
no pain in tbe back ; no tenderness on pressure. He was but ineompletely 
cured. This is the kind of reflei paraplegia which usualty is most diflicult 
to curo» However, it maj be completely and very rapidly cured, as shown 
by two cases, one mentioned by Dr. T. Watson in his classical work **" On 
the Principles and Practice of Pbysic,'^ in which case the cure was obtained 
in a few days, and the other by Dr. W. Moore, of Dublin (The ** Lancet," 
vol, ii. 185J>, p. 282), in which case the patient, who owed hxa paraplegia to 
a long eitposure to a heavy rain, was cured after six or seven days of treat- 
ment 

Graves (loc. eii,^ p. 557) gives a case of hemi-paraplegra due to the irrita- 
tion of cutaneous nerves by eryHi[>elas, occupying the calf and Inside of the 
fight leg* The erysipelas yielded to troatmenti but for several days the 
patient was altfigethcr destitute of any power of motion in the aifected 
limb* It is evident (says Gras-es) that this mujst have been a reflex pnraly- 
sii, as the muscles which move the k'g on the thigh lay for above the part 
in which the ery :?iipelatous inflammatlou existed. 

11. Ca^s of Parapltgia arising from Disease of the Knee-joinL — I have 
had under my care a nentleman, who, according to all appearances, became 
paralysed of the two Tower limbs in consequence of the imtntion starting 
from an acute inflammation of tho synovial membrane of the left knee-joint. 
The paralysis at first was limited to the left limbt but fioon appeared in the 
other. The arthritis became chronic, and then it was ob^erved^ a great 
many times, that every increase in tho pain, due to this intlammation, was 
followed by a corresponding increase of the paraplegia, and that the reverse 
occurred, as regards tbe paraplegia, when tlie pain diminished or ceased. 
There was no special symptom ot any affection of tho spine or Its contents 
— except, of course, the paralysis, and a notable degree of muscular atro- 
phy* The patient, after live months of treatment, was very much improved, 
mA could walk pretty well, except at times, when there was a return of the 
ptin m the knee. 

12. Canes of Paraplegia due to a Nturalgia^—T^o jears ago I saw a cast 
of this kind in consultation with Dr. Gordon^ of Boston, U. 8. As this is 
not a case of rapid cure, I will not speak of it now^ Several cases of para- 
pkgiai with or without atroph/ of the paralysed uiuEcles^ ^% tns^tkUo^u^Vki 



32 P&ACTICAL MEDICINE. 

Notta (** ArohiTes de Med./' Nov. 1854, p. 556). All the patients liare 
been cured of the paralysis some time after the core of the neuralgia. 

The abore cases, and many others which we could mention, show that 
the production of paraplegia may be associated with irritations starting firom 
Tery different parts — such as most of the viscera, the skin, the mucous mein» 
branes, and the trunks of nerves. In all these cases we find that parapleeia 
has followed the outside irritation, which we consider as its cause, and l£at 
the cure of this paralysis has been more or less quickly obtained after ibm 
supposed outside cause had been suppressed. Besides, in many of these 
cases we find the supposed effect increasing or decreasing gradually, in cor- 
respondence with the outside irritation, and in several instances we find that 
even without treatment the paralysis disappeared after the cessation of its 
supposed cause ; while, as a general rule, no treatment of the paraplegia 
seemed to have the least influence so long as the outside irritation was not 
alleviated, or had not entirely ceased. In some cases we find that paraple- 
gia appears and disappears altogether, twice, or many more times, in cor- 
respondence with the renewed pniduction and cessation of the ouside irrita- 
tion. Can there be more decisive proofs that it is the outside irritation 
starting from some sensitive nerves in the various parts of the body which 
produce paraplegia ? 

Those persons who, perhaps, are not struck by the evidence in the fore- 
going facts and reasonings may argue against the view that paraplegia is 
uie effect of an outside irritation in the cases we have mentioned : 1. That 
there is no need of admitting such a view, as other explanations of the vari- 
ous cases can be given ; 2. That it is not possible to explain by a reflex ac- 
tion the production of a paralysis. 

The nrst of these objections may in appearance be well grounded, as it 
may be said — 

1. That, in cases of disease of the uterus, this organ produces paralysis 
by pressing upon the obturator nerve and the sacral plexus. 

2. That, in cases of disease of the prostate, the urethra, or the bladder, 
the urine, not being freely expelled, becomes altered, and some of the al- 
tered principles are absorbed and act as poisons, producing paralysis. 

3. That, in cases of disease of the kidney, paraplegia is due to urasmio 
poisoning. 

4. That, in cases of toothing, of diphtheria, and of disease of the bowels, 
the lungs, or the pleurae, paraplegia is due to an alteration in the blood, 
caused by the disturbance of digestion or respiration. 

5. That, in cases of paraplegia due to the action of cold and wet, we 
ought to place this affection in the category of rheumatismal paralysis. 

G. That, in cases of pain in the skin, in joints, or in trunks of nerves, 
paraplegia has no other relation to this pain than that of being produced 
together with it by some affection of the spinal cord. 

I am ready to admit that in some cases paraplegia is produced in the vari- 
ous ways just related ; but in most of the cases in which a paralysis of the 
lower limbs follows an outside irritation from the womb, the bladder, or most 
of the other organs, when there is no evidence of an organic affection of the 
spinal cord or of the surrounding parts, it is not possible to explain the pro- 
duction of the paralysis by a pressure on nerves, an alteration of blood, etc. 
This I must show, as, lately, Romberg, one of the promoters of the view 
that paraplegia may be caused by a reflex action, has acknowledged that he 
was ready to abandon it on account of objections advanced by Hasse and 
Yalentiner. 

1. As regards paraplegia depending upon disease of the womb, we will 
remark that, except in cases of very great enlargement, as sometimes in 
pregnancy, pressure upon the nerves of the lower limbs cannot be the cause 
of the paralysis. In tne case I have mentioned, of a young lady who was 
cured by using a bandage, the uterus was certainly not larger than in a 
woman at the end of the second month of pregnancy. 
J^. It J3 possible that in cases where urine accumulates in the bladder, and 
remaiiiB there a long ^hi\& in an altered condition, Eome of its principles may 



PRACTICAL MEDICINE. 33 

be abBorbcd and act as a poison; but, on the one hand, howevor possible this 
is, there is no proof that a paralysis has ever been produced in that way ; 
and, on the other hand, we find that it is with the degree of pain that para- 
plegia has relations in oases of paralysis of tlie lower limbs following on 
affection of the prostate, the urethra, or the bladder, and not with retention 
of urine, as there is no change in this kind of paraplegia, whether the blad- 
der is carefully voided or not, at every time there is a certain amount of 
urine in it, unless the irritation starting from either the bladder itself, or the 
prostate, or the urethra, be diminished. 

3. Certainly, in cases of nephritis, there may be paralysis due to urasmio 
poisoning ; but this kind of poisoning does not manifest itself only by a par- 
alysis. On the contrary, it causes other and most striking symptoms, none 
of which has existed in the case I have cited, and in other more or less sim- 
ilar cases. 

4. I am willing to admit that there is some alteration in the blood in diph- 
theria, or even in dysentery, in enteritis, etc. I am also willing to admit 
that this alteration may cause a degree of paralysis, but that a complete 
paraplegia, withoat any diminution of voluntary movement elsewhere, may 
be due to a cause which, as it is supposed to be in the blood, is circulating 
everywhere in the body, I think no one can admit. 

5. It is true that cold and wet often cause rheumatism ; but when, after 
an exposure to cold and wet, a man is suddenly seized with paralysis, without 
having the least symptom of rheumatism, we certainly have no right to 
place his affection in the vague group of rheumatismal paralysis. 

6. No doubt that diseases of the spinal cord and its membranes very often 
manifest themselves by pains resembling neuralgic pains, and located either 
in a joint or along the course of a nerve ; but besides the fact that, in such 
cases, paraplegia, when it appears, is accompanied by symptoms indicating 
a disease in the spinal cord or its membranes, which was not what occurred 
in tlie cases I have mentioned, there were real inflammations (of a joint, or 
of the skin) in two of those cases, instead of the referred pain due to a cen- 
tric cause. 

We think we may safely conclude, from this examination of the above ex- 
planations, that they can be considered as valuable only for a small number 
of those cases in which paraplegia has appeared after an irritation in some 
sensitive nerve of the skin, the mucous membranes and various organs. On 
the one hand, therefore, most of those cases cannot receive these explana- 
tions ; and, on the other hand, I have already shown that the period of appa- 
rition, the variations of intensity, the progress, and the cure of paraplegia, 
in the cases I have mentioned, are in perfect correspondence with the view 
that paralysis depended upon an irritation from a sensitive nerve. 

I have now to examine the objection that it is impossible to understand 
how a paraplegia can be caused by a reflex action, it is, indeed, very easy 
to show how a paralysis can toko place by a reflex influence through an irri- 
tation starting from a sensitive nerve. There are two modes of reflex ac- 
tion by which such an irritation can praduce paraplegia : — 

Ist Reflex Contraction of Bloodvessels, — As it is now well established that 
bloodvessels contract with energy, and sometimes even are seized with n 
real and prolonged spasm, whether by a direct influence of their motor 
nerves, or throutrh an excitation, which, from some centripetal or excito- 
motor nerve, has been reflected upon them by the cerebro-spinal axis, there 
is no need of showing here that bloodvessels are just like muscles of animal 
life as regards their relations with the nervous system. This being the case, 
it is extremely easy to understand how a paralysis of the lower extremities, 
as well as that of any other nart of the body, may be paralyzed by a reflex 
action. In three different places a contraction of bloodvessels may cause 
paraplegia — ] , in the spinal cord ; 2, in the motor nerves ; 3, in muscles. A 
contraction of bloodvessels in the spinal cord I have seen (in the vessels of the 
pia mater) taking place under my eyes, when a tightened ligature was ap« 
plied on the hilus of the kidney, irritating the renal nerves, or when a 
similar operation was performed on the bloodvesBels aad UQivet oC t&:kA «^^t»r 



34 PRAOTIOAL MEDICINE. 

renal oapsoleB. Generally in those oases the oontraotion is much more eri- 
dent on the side of tlie cord corresponding with the side of the irritated 
nerves, which fact is in harmony with another and not rare one, obseryed 
ftrst by Comhaire (ns regards the kidney), and often seen by me after the 
extirpation of one kidney or one supra-renal capsule— i. e., a paralysis of 
the corresponding lower limb. It is probable that irritation starting from the 
urinary and other organs produce a paraplegia by a contraction raSier of the 
bloodvessels of the spinal cord, than of uioso of the motor nerves and mus- 
cles. However in this form of paraplegia, it is not rare that a notable dimi* 
nution of temperature of the paralyzed limbs shows that the bloodvessels of 
these parts are also contracted. 

2nd. Morbid Reflex Influence on Nutrition. — ^This influence, proved by 
many experiments on animals and by pathological facts of daily occurrence, 
seems usually not to exist in reflex paraplegia, except in that form in which 
muscles become progressively and rapidly atrophied and altered {wasting 
palsy). But this morbid influence may take place at any moment in the 
course of a reflex paraplegia, so long as the irritating cause has not ceased 
to act, and a myelitis or some other affection may be generated by it. 

We think that it will now be considered possible, if not probable, that the 
production of reflex paraplegia is due to a contraction of bloodvessels and to 
the insufiiciency of nutrition that follows this condition of the vessels. In ad- 
dition to the reasons we have given to show that the paraplegia caused by 
an outside irritation is due to a reflex action and probably to a reflex con- 
traction of bloodvessels, we will say that very often in this peculiar kind of 
paralysis there are reflex convulsions in muscles of the trunk, the head, and 
the limbs, before the paraplegia appears (us in cases of teething, of worms, 
6co.) or when it has already existed some time, (as on the passage of a ca- 
theter, urinary paraplegia.) We might also have pointed out the influence 
of the urethra on the spinal cord, by mentioning the well-known and very 
frequent fact of the production of chills and tremor on or after the introduc- 
tion of a catheter in persons who are or who are not paraplegic. 

There is another series of facts of which we have now to speak, that show 
that reflex paraplegia is not due to an evident organic affection, which may 
be found in a post-mortem examination. We will very briefly mention some 
cases of autopsy made on persons who have died after having presented the 
symptoms of a reflex paraplegia. 

Before concludiug this lecture, I wish to say a few words on a most im- 
portant point, to which we will again turn our attention in the succeeding 
lectures : I mean, the treatment of reflex paraplegia. I have already said 
that the various kinds of paraplegia may be classed into two general groups ; 
one in which the amount of blood circulating in the spinal cord is too con- 
sidernble ; the other, in which the opposite condition exists. Of the various 
remedies, which, as I may perhaps oe allowed to say, are too often blindly 
(!mployed, there are some that diminish the Quantity of blood in the spinal 
cord, such as mercury, ergot of rye, and belladonna ; while others, on the 
contrary, such as strychnine and brucine, increase that quantity. If these 
last assertions be correct — and I will, by-and-by, try to prove that they 
are, — it is quite evident that to employ a remedy of either of these two kinds 
in both of the two groups of paraplegic cases is a most dangerous thing. 
Keflex paraplegia, as pointed out by its whole history given in this lecture, 
is accompanied and most likely produced by an insufficiency of the amount 
of blood in the spinal chord ; it ought not, therefore, to be treated by those 
remedies which diminish the quantity of this fluid in the spinal nervous 
centre. How often, however, is not mercury employed in that affection ? 
On the other hand, myelitis which is accompanied by an increase in the 
quantity of blood in the spinal cord, is often treated by the very remedy 
(strychnine) which has the most powerful influence in increasing the amount 
of blood in the spinal cord. How important, therefore, is it to know exactly 
to what group of affections (as to the quantity of blood in the spinal cord) 
belong a paraplegia, before we give a remedy included in either of the two 
CMtegoriea above- meat ioned 1 



lejfore jtpenking of the trcntmeut of cases of reflex pariiple|»int Dr. Brown* 
Seqtiard p rem i nee ft few reirmrki* on several forma of patftplegia presenting 
some anaEogtes with reflex pamplefTJa.] 

Amon^T^t these forms or kind^ of paraplegia^ one of the most intereji^tlng 
is the paraplegia due to an obstaete in tiie cireulation of blood in the aortal 
or in iti$ principal ramitientinns in the pelrts, Thi!^ ktad of paralysis hae 
bften well studied bj veterinary surgeons, as it is frequent in horses. Several 
cases have been observed in man by Mr. Barth, Dr. W, W. QulU and my 
friend Pr* Charcot* Bpsides the i^ympfotp^ duf? to the cause preventing the 
circulation (generally an aneuritsrn), ttiiA kind of paraplegia will bo distin- 
guished from the reflt'i paraplegia by the absence of the causeB of this last 
form of paralyii^iit, by the nlteraiiona of nutrition and pains in the paralyzed 
limbs* and especitdly by the rapid increase of the paralyeb after ^yerj nota- 
ble exertion of the lower limbF, and the retum of some power after rest. 

There is another kind of paraplegia in which in «ome degree, a pressure 
on the large bloodvessels (arteries and vein j?) of the pelvis has a share in the 
diminution or los« of power. This kind of paraplegia exists frequently* in a 
alight degrets at the end of pregnancy ; it m chiefly due to the pressure on the 
nerves of the 1 umbo -sacral plexus* During pregnancy * or in casps of a tu- 
mour in the pelvis, a complete paraplegia may bo caused by pressure upon 
those nerves, Tliis kind of paralysis of the lower limbs will easily be dia- 
tioguished from the rf^fles paraplegia by the existence of violent pains in 
the pelvis and in many parts of the lower limbst by tlie production of 
cramps, &c* 

The so-called idiopathic paraplegia !s not to be taken into aeoonnt in this 
liistory of the differential diagnosis of the reflex and other forms of paraplegia- 
We do not know any ease of paralysis of the lower limbs that deserves the 
name of idiopathic. Most of the pretended cases of that kind, published by 
Macario and by H. Leroy d'Ktiolles, are either crises of reflex paraplegia or 
a real a flection of the fipinal chord f especially congestion and serous eft us- 
ion). We do not mean to say that it will always be easy to decide during 
the life of a patient, or after a post-mortem examination, what is the cause 
of a paraly!?is of the lower limbs. Wo think that sometimes this caut^e will 
not be found out, and we only mean to state that it is impossible to admit 
the existence of a special kind of piiralytio aftectinn, deserving to be oalled 
e^jmnliul or idiopaihic paraplegia— an attection not more charactertjied by 
special flymptoms than oy special anat^m^ical lesions. 

Of other forms of paraplegia* such as those which are ognneeted with 
gi>ut, rheumatism, or those which follow grave feverst cholera^ Acc*i we will 
only say that usually they depend upon a serous eft'usion in the spinal canal 
Of a venous congestion, and that BomctimeB they belong to the group of ro- 
riex paralysis. 

In concluding our remarks on the diagnosis of the reflex paraplegia w(* 
need hardly say, that for thii afilectioni as well as for all other diseases of 
the nervous system, it is not necessary to And together all the cliaraetertstic 
symptoms to be convinced of the existence of a reflex paraplegia. This 
affection is almost sufliciently characterized by the absence of the special 
A^mpiomtf of an organic dismse of the. spine or Ha ctftitentA, and the erisUnce 
(fan incfimpletc paraljfsis of tfie wwtr Ihnhs that has appeared sometphat sloid}( 
afttr a disease of the urinart^ or genital orgafts^ or of some oilier abdominal 
tfiset/s ; after an inJlamrfiatioH of the lungs or pleura! j or qfier some other kind of 
irritation of a nerve in its trunk or cutaneous ramijications. In a great nmny 
cases of refleac paraplegia we shall find nothing else upon which Uy ground 
our diagnosis. But usually, in a short time, a much greater probability of 
the accuracy of the diagnosis will spring from the correspondence between 
changes in the degree of the pav-^atysia with ohanj^es in the vi>ceral disease or 
external irritation that is supposed to have produced the paraplegia. 

The prognosis of the reflex pariiplegia depends, in a groat measure, upon 
tiiat of the external afleotion which has produced it. The whole history of the 
reflex paraplegia show^sthat it usually increases, diminishes, or disappears with 
the e xte rnal mo r bid co n di tion wh i oh h as pr oduce d It * A.nk ^^sinstttX t>i\ft %tft Vss^ 



36 PRAOnOAL HEDIOINE. 

as this morbid condition lasts, the paraplegia persists, and it 
quickly, and sometimes without any special treatment, after the cure of thfa 
morbid condition. In some cases, howerer, paraplegia persists long after 
its external cause has been completely cured. It is so especially when the 
paralysis has been produced by cold, or by a disease of the bowels. The 
reverse is more particularly observed after the evacuation of worms, or after 
a cure of a stricture of the urethra, or of an affection of the womb. 

Of the two forms of reflex paraple^a, one of which depends upon an in- 
sufficiency of nutrition in the spinal cord, the other upon an alteration of 
nutrition in the muscles of the lower limbs — the first is almost always com- 
ble when the external irritation which has caused it has ceased; while the 
second is very frequently incurable, whether its external cause has ceased 
or not. It is, therefore, most important for the prognosis to ascertain if there 
has been, or not, a rapid atrophy of muscles in cases of reflex paraplegia. 

Treatment of the Reflex Paraplegia, — It is evident from all that we have 
said concerning the reflex paraplegia that, for this affection more than for 
any other, we must employ every effort to cure or alleviate the disease or 
irritation that has produced it. At the same time the paraplegia itself mnst 
not be neglected, and the oroper means must be employed against it. There- 
fore the treatment of a reflex paraplegia ought to consist of two distinct parts : 
I St, the means to be employed against the external cause of this affection: 
2nd, the treatment of the paralysis itself. As regards the first part, we will 
say nothing here, as we cannot enter into the details of the treatment of ne- 
phritis, cystitis, pneumonia, enteritis, and other morbid states that may oause 
reflex paraplegia. As regards the direct treatment of this affection, we will 
first lay down the general rules of the treatment, and then we will enter into 
the most important details concerning this treatment. 

1. When it has been ascertained from what organ or from what nerre 
starts the nervous influence which causes a reflex paraplejopa, besides the 
treatment that is appropriated to the nature of the local affection (of that 
organ or nerve), it is of the greatest importance to try to prevent or to di- 
minish the transmission of any nervous influence from the diseased nerve or 
organ to the spinal cord. All the means usually employed to alleviate pain 
will be of service in such cases. If possible, we must try to paralyse ror a 
time the sensitive nerves that convey the morbid influence to the spinal cord. 
£ven a momentary suspension or diminution of the transmission of this in- 
fluence may be very useful. Narcotics ought to be employed in injections,-^ 
in the bladder, if that organ be the place from which starts that morbid influ- 
ence ; in the vagina, if the uterus be the place ; and in the rectum, if the 
large intestine be the place. Narcotics ou^ht to be taken by the mouth if 
the stomach, the small intestines, or the kidneys are affected. In case of a 
pneumonia producing a reflex paralysis, inhalations of chloroform (which, by 
the way, have been successfully employed against the inflammation itself) 
may prove useful. We will say by-and-by what narcotics should be pre- 
ferred. 

2. The object of the means just proposed is to diminish the cause of the 
paraplegia; the object of the means we will now speak of is just the same, 
although it may seem to be quite different. Excitants or revulsives applied 
to the skin of the legs have been warmly recommended by Graves, who has 
obtained good results from their use. Probably the mode of action of these 
means consists in producing for a short time the same effect as the irritation 
which is the cause of the paralysis — i. e., a contraction of the bloodvessels 
of the spinal cord : but, according to a well-established law, if such a con- 
traction becomes considerable, the muscular fibres are soon exhausted, and 
a relaxation of the contracted fibres takes place, and, as a consequence of 
this relaxation, a dilatation of the bloodvessels occurs. Of all the causes 
of irritation capable of prodncing a contraction of bloodvessels by a reflex 
action, none has more power than cold. In consequence of this fact, I 
tA/nk gome of ihe modes of application of cold to the spine ought to be em- 

plojred in oases of reAex paraplegia. But the excitation in those cases mast 
oe very powerfaU and able to produce a very cona\den26\Q ^e^g€%« ot <jon- 



FBAOTIOAL MEDIOINK 37 

traction, so that the oonseqoent exhaustion and dilation may bo obtained. 
With the same yiew, we may employ galvanism. 

3. Another important principle, or rather another part of the same gen- 
oral principle of treatment* consists in making use of the following means 
to increase the quanlity of blood in the spinal cord : — ^Every niffht, and often 
in the course of the day, the patient should lie down on his back, placing 

/his head, his arms, and his le^s on high pillows, so as to produce by gravita- 
tion a congestion in the spiual cord. This simple means, which isfUso appli- 
cable in cases of hysterical paraplegia, and in almost all the cases in which 
there is an insufficient amount of blood in the spinal cord, is just tho reverse 
of what should be done in oases of inflammation or congestion of the spinal 
cord or its membranes* or of disease of the spine, &c., in which cases the 
patient ought to lie flat on the abdomen or on one side of tho body, and have 
his feet and hdnds on a much lower level than that of the spine. 

4. As regards the remedies to be taken by patients attacked with a reflex 
paraplegia, they must essentially be those which increase the amount of 
blood in the spinal cord, and augment the vital properties of this nervous 
centre, and also those remedies which render the blood richer in nutritive 
principles. 

5. As regards food and the hygienic rules, patients attacked with a reflex 
paraplegia must have the most substantial aliments, so as to improve the 
deficient nutrition of the spinal cord. They must take a great deal of ex- 
orcise in the open air, and especially make use, as much as possible, of the 
paralysed muscles. 

Before giving the details of the rules of treatment, we will sum up in the 
following propositions what we have just said : — 

1. Try to prevent, even for a short time, the continuation of the contrac- 
tion of the bloodvessels of the spinal cord by the use of narcotics, to be ap- 
plied, as much as possible, to the organs from which starts the external 
cause of the paralysis. 

2. Try to produce by revulsives such a notable increase in the contraction 
of the bloodvessels of the spinal cord that an exhaustion of -the contracted 
muscular fibres, and, as a consequence of this exhaustion, a dilatation of the 
bloodvessels, will soon take place. 

3. Have the spine placed much lower than the head, the arms, and the 
legs, when the patient is lying in bed, so as to increase the amount of blood 
in the spinal cord. 

4. Employ those remedies that have the power of augmenting the vital 
properties of the spinal cord in increasing tne amount of blood in this ner- 
vous centre. 

5. Give the kind of food and employ those hygienic means that are most 
fitted for increasing the quantity of blood and tor improving nutrition in all 
parts of the body. 

On the one hand, experience has proved all these rules of treatment to be 
the most effectual ; and on the other hand, these rules are in perfect harmo- 
ny with the theory of the disease that we have given : so that experience 
and theory furnish a confirmation to each other. 

On Inflammation of the Spinal Cord. — To understand well the symptoms 
of inflammation of the spinal cord, it is important to bear in mind the fol- 
lowing facts : — 

1. That the gray matter of the spinal cord in its normal condition is not 
at all excitable* and that irritations upon it are followed by sensations or 
movements ; while, on the contrary, when it is inflamed it is excitable and 
able to give all kinds of sensations, and to produce cramps or partial con- 
vulsions. 

2. That the white matter of the spinal cord is not composed of motor and 
sensitive fibres coming from or going to the brain. 

3. That a pressure upon the spinal nerves, or upon the spinal cord, able 
to produce a paralysis accompanied by cramps, may either produce anes- 
thesia or not, while it causes various sensations. 

It is not our intention to speak here of the aoute m^c^'fi.^ qj^wvck^tasAXs^ 



36 PRAOnOAL MEDICINE. 

as this morbid condition lasts, the paraplegia persists, and it ceases Terj 
quiclily, and sometimes without anj special treatment, after the core of thia 
morbid condition. In some cases, howerer, paraplegia persists long after 
its external caase has been completely cured. It is so especially when the 
paralysis has been produced by cold, or by a disease of the bowels. The 
reverse is more particularly observed after the evacuation of worms, or after 
a cure of a stricture of the urethra, or of an affection of the womb. 

Of the two forms of reflex paraplegia, one of which depends upon an in- 
sufficiency of nutrition in the spinal cord, the other upon an alteration of 
nutrition in the muscles of the lower limbs — the first is almost always cam- 
bie when the external irritation which has caused it has ceased; while the 
second is very frequently incurable, whether its external cause has ceased 
or not. It is, therefore, most important for the prognosis to ascertain if there 
has been, or not, a rapid atrophy of muscles in cases of reflex paraplegia. 

Treatment of the Reflex Paraplegia. — It is evident from all that we have 
said concerning the reflex paraplegia that, for this affection more than for 
any other, we must employ every effort to cure or alleviate the disease or 
irritation that has produced it. At the same time the paraplegia itself must 
not be neglected, and the nroper means must be employed against it. There- 
fore the treatment of a reflex paraplegia ought to consist of two distinct parts : 
1st, the means to be employed against the external cause of this affection: 
2nd, the treatment of the paralysis itself. As regards the first part, we will 
say nothing here, as we cannot enter into the details of the treatment of ne- 
phritis, cystitis, pneumonia, enteritis, and other morbid states that may oause 
reflex paraplegia. As regards the direct treatment of this affection, we will 
first lay down the general rules of the treatment, and then we will enter into 
the most important details concerning this treatment. 

1. When it has been ascertained from what organ or from what nerre 
starts the nervous influence which causes a reflex paraplejopa, besides tlie 
treatment that is appropriated to the nature of the local affection (of tiiat 
organ or nerve), it is of the greatest importance to try to prevent or to di- 
minish the transmission of any nervous influence from the diseased nerve or 
organ to the spinal cord. All the means usually employed to alleviate pain 
will be of service in such cases. If possible, we must try to paralyse for a 
time the sensitive nerves that convey the morbid influence to the spinal cord. 
Even a momentary suspension or diminution of the transmission of this in- 
fluence may be very useful. Narcotics ought to be employed in injections, — 
in the bladder, if that ormn be the place from which starts that morbid influ- 
ence ; in the vagina, if the uterus be the place ; and in the rectum, if the 
large intestine be the place. Narcotics ou^ht to be taken by the month if 
the stomach, the small intestines, or the kidneys are affected. In case of a 
pneumonia producing a reflex paralysis, inhalations of chloroform (which, by 
the way, have been successfully employed against the inflammation itself) 
may prove useful. Wo will say by-and-by what narcotics should be pre- 
ferred. 

2. The object of the means just proposed is to diminish the cause of the 
paraplegia ; the object of the means we will now speak of is just the same, 
although it may seem to be quite different. Excitants or revulsives applied 
to the skin of the legs have been warmly recommended by Graves, who has 
obtained good results from their use. Probably the mode of action of these 
means consists in producing for a short time the same effect as the irritation 
which is the cause of the paralysis — i. e., a contraction of the bloodvessels 
of the spinal cord : but, according to a well-established law, if such a con- 
traction becomes considerable, the muscular fibres are soon exhausted, and 
a relaxation of the contracted fibres takes place, and, as a consequence of 
this relaxation, a dilatation of the bloodvessels occurs. Of all the causes 
of irritation capable of producing a contraction of bloodvessels by a reflex 
action, none has more power than cold. In consequence of this fact, I 
think some of the modes of application of cold to the spine ought to be em- 

plojred in oases of reflex paraplegia. But the excitation in those cases most 
be vetj- powerful, and able to produce a very conaVdenSbYe ^«^g€%« of con- 



FBAOTIOAL MEDIOINK 37 

traction, so that the oonseqaent exhaustion and dilation may bo obtained. 
With the same Ttew, we may employ galvanism. 

3. Another important principle, or rather another part of the same gen- 
oral principle of treatment, consists in making use of the following means 
to increase the quanlity of blood in the spinal cord : — ^Every niffht, and often 
in the course of the day, the patient should lie down on his back, placing 

/his head, his arms, and his le^s on high pillows, so as to produce by gravita- 
tion a congestion in the spiualcord. This simple means, which is also appli- 
cable in oases of hysterical paraplegia, and in almost all the cases in which 
there is an insufficient amount of blood in the spinal cord, is just tho reverse 
of what should be done in cases of inflammation or congestion of the spinal 
cord or its membranes, or of disease of the spine, &c., in which cases the 

Eatient ought to lie flat on the abdomen or on one side of the body, and have 
is feet and hands on a much lower level than that of the spine. 

4. As regards the remedies to be taken by patients attacked with a reflex 
paraplegia, they must essentially be those which increase the amount of 
blood in the spinal cord, and augment the vital properties of this nervous 
centre, and also those remedies which render the blood richer in nutritive 
principles. 

5. As regards food and the hygienic rules, patients attacked with a reflex 
paraplegia must have the most substantial aliments, so as to improve the 
deficient nutrition of the spinal cord. They must take a great deal of ex- 
orcise in the open air, and especially make use, as much as possible, of the 
paralysed muscles. 

Before giving the details of the rules of treatment, we will sum up in the 
following propositions what we have just said : — 

1. Try to prevent, even for a short time, the continuation of the contrac- 
tion of the bloodvessels of the spinal cord by the use of narcotics, to be ap- 
plied, as much as possible, to the organs from which starts the external 
cause of the paralysis. 

2. Try to produce by revulsives such a notable increase in the contraction 
of the bloodvessels of the spinal cord that an exhaustion of -the contracted 
muscular fibres, and, as a consequence of this exhaustion, a dilatation of the 
bloodvessels, will soon take place. 

3. Have tho spine placed much lower than the head« the arms, and the 
legs, when the patient is lying in bed, so as to increase the amount of blood 
in the spinal cord. 

4. Employ those remedies that have the power of augmenting the vital 
properties of the spinal cord in increasing tne amount of blood in this ner- 
vous centre. 

5. Give the kind of food and employ those hygienic means that are most 
fitted for increasing the quantity of blood and for improving nutrition in all 
parts of the body. 

On the one hand, experience has proved all these rules of treatment to bo 
the most effectual ; and on the other hand, these rules are in perfect harmo- 
ny with the theory of the disease that we have given : so that experience 
and theory furnish a confirmation to each other. 

On Infiamtnation of the Spinal Cord. — To understand well the symptoms 
of inflammation of the spinal cord, it is important to bear in mind the fol- 
lowing facts : — 

1. That the gray matter of the spinal cord in its normal condition is not 
at all excitable^ and that irritations upon it are followed by sensations or 
movements ; while, on the contrary, when it is inflamed it is excitable and 
able to give all kinds of sensations, and to produce cramps or partial con- 
vulsions. 

2. That the white matter of the spinal cord is not composed of motor and 
sensitive fibres coming from or going to the brain. 

3. That a pressure upon the spinal nerves, or upon the spinal cord, able 
to produce a paralysis accompanied by cramps, may either produce anes- 
thesia or not, while it causes various sensations. 

It is not our intention to speak here of the aoute m7Qi\i\i» ^a^asl^'gIvAVs 



38 FBAOnCAL MEDICINE. 

fiBTer, as in almost all cases of that kind there is at the same time an aoate 
inflammation of the spinal meninges, and also because we onlr intend to 
show what the symptoms are in those oases of paralysis of the lower limbs 
of long standing that depend upon a chronic inflammation of a part of the 
spinal cord in the middle or lower parts of the dorsal regions. 
The characteristic symptoms of this local myelitis are : — 

1. A constant pain at the part of the spine correspimding with the npper 
limit of the inflammation of the cord. 

2. Whether a constant pain exists in a rery marked degree or not, it is 
almost always found that pressure upon the spinous process of the vertebm 
(sometimes even a slight one), when made at the upper limit of the inflam- 
mation, causes an acute pain. 

3. The passage of a sponge, filled with warm water, along the spine, giTes 
a normal sensation of heat in all the parts above the seat of the inflamma- 
tion, but a burning sensation at its upper limit 

4. The passage of a small lump of ice along the spine gives the nataral 
sensation of cold everywhere, except at the level of the inflammation, where 
the sensation is that of burning. 

5. Most patients complain much of a sensation as if there were a cord, or 
some other ligature tied round the body, at the limit of the paralysis. In a 
few patients there is but a very slight sensation of that kind. This symp- 
tom seems to exist in all cases of myelitis, and to depend chiefly, but not 
entirely, upon a state of cramp of some part of the muscles of the abdomen 
or the chest. 

6. Various sensations, resembling very much those which follow the pres- 
sure upon a nerve, such as formication, a pricking by pins and needles, and 
sometimes a feeling of burning or intense cold in the feet, legs, and thighs, 
less frequently in the abdominal walls. These sensations exist with as 
much, if not with greater violence, in parts deprived of sensibility, as in 
parts which are still sensitive. They originate from the irritation of the 
fftey matter of the spinal cord, and are referred to the limbs and abdomen, 
just as the pressure upon a nerve produces sensations in its ramificationa. 
They are important indications of myelitis. 

7. Cramps in the feet or calf of the legs are very frequent. There are 
more or less of them in every patient. Frequently there are cramps also 
in the large abdominal muscles, besides the circular and linear cramp that 
gives the above-mentioned feeling of tightening. A cramp limited to a part 
of one or several abdominal muscles, may remain almost permanently for 
days and weeks, forming a kind of lump, which may be mistaken for a 
tumour. 

8. Whether myelitis exists only in a small zone of the spinal cord, or oc- 
cupies the whole of the dorso-lumbar enlargement, the paralysis of move- 
ment exists in all the parts of the body that receive their nen^es from the 
portions of the spinal cord that are below the upper level of the inflamma- 
tion. The degree of paralysis varies extremely in different patients, but it 
is nearly the same in the various muscles in the lower limbs in the same 
patient. 

9. Paralysis of the bladder and of the sphincter ani is almost always 
present in inflammation of the lower part of the dorsal region of the spinal 
cord ; but when the seat of the inflammation is higher up in the dorsal ro- 

fion, there is rather a spasm than a paralysis in the sphincters of the blad- 
er and anus. Often then there is retention of urine, owing to the paraly- 
sis of the bladder while the sphincter vesicsB is more or less in a spasmodic 
state. 

10. One of the most decisive symptoms of myelitis is the alkilinity of the 
nrine. There is no patient attacked with myelitis in the dorsal region of 
iha cord whose urine is not frequently alkaline. At times, especially after 
certain kinds of food, the urine is acid, but the alkalinity soon reappears. 

JI» AnsBstiieBiA, or at least a diminution of sensibility, always exists in 
mjrelitis, except when the grey matter is not tb© seat of the disease, which 
y rorjr nwe. Usually ^ the iidiammatioii begins m tYie centt^X ^«btV« ^i \W 



f:kactical MEmciirE. 



3!l 



giry triTitter, and then ti dimination of seiisibiltty ia one of tlio fiTst symp- 
timK-*, That peculiar kind of fiensibUity of muscle a which sorvos to direct 
our movements is espocially impaired in the vory beginniu^. 

1*2, When tho dorao-lumbar enlargement is in flu mod, reHcx movemeni.s 
can hardly be excited in the lower limbs, and freiiuently it h iniposssible tu 
excite any^ On the contrary, energetic rt^fler movements cnn always bo ex- 
cited when tbo disease is in the middle of the dorsul region, or higher up. 

On the 7V€afment of Ckronic 3%difw,— [Myelitis^t in tht* acute form is 
almost always fataU Bat tho subacute and chronic fornix are frequently 
stopped in their progress, when properly treated* and floim^times an almoit 
oocQplete cure may be obtained. Any actual injury, howi*vpr, which the cord 
may have sustaincdT ts aimast irreparable. Chronic myelitis is an fifl'ection 
of very ?\ow development, and still shiwer progress?. In the treatment, the 
first and moBt important rule is* to dlminit^h the congesfion of the spinal 
cord. To thi« end the patient must avoid these posituniN of the body in 
which by gravitation the amount of blood in the cord will be incr cabled. 
Hence the imtient must never lie on the back. Dry cupping daily on the 
yariou!? part** of llie Rpine will prove of service.] 

Amongst the remedies to bo employed internally, the most active an* 
thofi© which have the power of dimi[iishing the congestion of the E^pinaL 
cord. The two which seem to be moat powei"ful in this rej?pect are bella- 
donna and ergfit of rye* Experiments* ujion animals have shown to me, in 
the most positive manner, that theae two remedie!? are powerful excitants or 
unstriped muwoular fibrils, in blood vesBtds, in tho uteruj«t in the bowcla* in 
the iris, &c* Both of tbcm dilate the pupil \ both are employed with sue- 
oesii to produce contractions of the uterus ; but each of them has more pow- 
«T in certain parts than the others so that we tind belladonna acting mori' 
than crgiit on the bloodvessels of the iris (which is the principal cause of th^ 
dilatation of the pupil) — on the bloodvessels of the breae^t (which is the prin- 
cipal cause of the cessation of the secretion of nulk j— ^)n the muscular nbren 
of the bowels (which is the mode of its action in canee of strangied hernia)— 
cm the sphincter of the blatMer (which is one of the causes of its sueceiss 
against nocturnal incontinence of urine i, ^c. ; while, on the contrary, wi- 
^nd that ergot acta more than belbidonna on the muscular fibres of thr 
wombi on the bloodvessels of the spinal cord, &c. We cannot give her© the 
proof of the exactitude of these assertions on the mode of action of these two 
remedies, but we must at least answer an objection which probably will 
arise in the mind of many persons. It will be asked — How is it that, of two 
remedies that are able to excite con tractions in smoytii muscular fibrei*, om* 
produces them n ore in one place, and the other more in another plaoe I 
The auHwer to this objection is indeed very simple. The excitability oi 
smooth tibres* as well as that of striated muscles, varies exceedingly in dif- 
ferent parts of the body. An exciting agent (whether galvanism, cold, heat, 
or beliadonna and ergot of rye) will produce powerful contraction in sonn' 
places, and hardly any in other places. The smaoth fibres of the uterus 
cnn tract more than those of the bowels or the bladder, and less than thosii* 
of certain bloodveissels when stimulated by galvanism ; the smooth Jihres of 
certain bloodvessels contract more than those of the uterus under the exeittv- 
tion of cold ; still more the bloodvessels of the cerebral lobes and of the face, 
which contract ao much when their nerve (the cervical sympathetic) is irri* 
tated, contract but very little when excited by belladonna and ergot, wliiln 
these two excitants produce powerful eontractions in the bloodvessels i^f the 
sjiinal cord. 

Not only have I seen the diminution in the calibre of bloodvessels of tht! 
pia mater of the spinal cord taking place in doge after they had taken large 
doflCB of belladonna or ergot of rye, hut 1 have aho ascertained that the re- 
flex power of the spinal cord (most likelyastaeonseauenceof the contraction 
of bloodvessels) becomes very much diminished under the influence of thenc 
two remedieB, which in so doing act just in the opposite way to that tit 
strychnin**. 

Led by Eire knowledge o£ the above faetih ^^ Wy^ eTsv^\ok^«i^>!ws^^^^^MEL\v 



40 FBACTICAL MEDICINE. 

and ergot of rye in cases of paraplegia dae to a simple congestion or ft 
chronic inflammation of the spinal conl and its meninges, and we have ob- 
tained a greater success than we had dared to hope for. Whatever be the 
value of our experiments on animals as regards the mode of action of these 
remedies, it is now certain that they have really a great power in diminish insr 
the amount of blood in the spinal cord and its membranes. It is very well 
known that many French physicians, especially Bretonneau, Payan, Bar- 
bier, and Trousseau, have for many years employed with success belladonna 
and ergot of rye in cases of paraplegia. Of course we do not claim to have 
been the first to make use of these remedies in paraplegia, any more than we 
claim priority as regards employing strychnine in various forms of paralysis. 
But we claim to have pointed out, as clearly as we could, in what cases of 
paraplegia strychnine or belladonna and ergot of rye are to be employed or 
avoided. To indicate this distinction is the principal object of these leo- 
tnres. 

In the beginning of the treatment of chronic myelitis, we usually employ 
ergot of rye alone internally, and belladonna externally in a plaster applied 
to the ftpine, over the painnil spot. The dose of ergot, when the powder is 
used, which is almost always the case, is at fir^t two or three grains twice a 
day ; gradually the dose is increased until it reaches five or six grains twice 
a day ; and in a few cases we have given eight grains twice a day. We do 
not think it necessary to make use of the very largo doses employed by M. 
Payan. The belladonna plaster applied to the spine must he a very iarg« 
one, four inches wide, and six or seven inches long. If there is no amelior- 
ation in a few weeks, we give the extract of belladonna internally in doses of 
a quarter of a grain twice a day. 

When we find that the patients, after six or eight weeks of treatment by 
ergot of rye and belladonna, do not get better, we give iodide of potassium 
in doses of ^ve or six grains twice a day, in addition to the preceding reme* 
dies. When there is any reason to suspect that there is a degree of menin- 
gitis together with myelitis, we begin at once the treatment by the iodide of 
potassium with the ergot and belladonna. 

On Paralysis of the Lower Extremities. — [One of the most frequent causes 
of this kind of paralysis is probably inflammation of the spinal cord ; another 
cause is softening, caused by alterations in the bloodvessels preventing a 
proper interchange of matter between the nervous tissue and the blood.] 

Usually patients attacked with the non- inflammatory softening of the spi- 
nal cord at first complain only of weakness. They gradually become 
weaker, although their general health may seem to be as good as ever. They 
feel the weakness especially at the knee and ankle-joints; they find it very 
diflicult to go up or down stairs, to go in or out of a carriogc, and their gait 
becomes tottering, especially when they cannot direct their movements with 
the help of the sight. When lying down, if they see the lower limbs, they 
can move them pretty freely, but without force. After a time the paralysis 
becomes much more marked, and then sensibility in the whole lent^th of the 
lower limbs and the power of the will over the bladder and the rectum are 
also found much diminished. There is no pain, or hardly any, in the spine 
or paralysed parts. Very rarely is the urine altered. The temperature of 
the lower limbs is often higher than it is in health, especially when the pa- 
ralysis is complete or nearly so. 

Hemorrhage in the Grey Matter of the Spinal Cord. — Paraplegia due to 
this cause is characterized by the suddenness of its production, by a pfiin at 
the part of the spinal cord where the hemorrhage occurs, owing, probably, to 
the distension of the posterior roots of the nerves in the grey comua, by a 
pain in the spine after pressure upon it, and also by a pain in the parts of 
the body where are distributed the nerves originating from the part of the 
spinal cord which is the seat of the disease. The sphincters of the bladder 
and rectum are almost completely paralysed from the very first. It is not 
miv that an inBammaiion supervenes in the parts of the cords surrounding 
tA0 oJot, and then all the symptoms of myelitis occur. 
According to the seat and the extent of thebemoTrViage W\^ f^^\iv^\.om^^wrj 




UPM 



Practical MEBrciHE. 



tx tamely. Tf Iho amount of blood effuaed be very etnall, the sjmptoms 
may be very slight, and the patii^nt may recover in a few months, as hi a 
case recorded by Oruveiibier» If the amount of blood is considerable, it de- 
scends along the whole length of the central canal of the spinal cordt and 
also eometimes breaks through the grey corniia, ei^pecinlly the anterior 
ones* The lost* of sensibility and of voluntary power is then complete, ond 
the temperature of the paralysed limbs h incrt^necd- If the bemorrhagc la 
limited to one lateral half of the grev mutter*— ns in & most intereatlng case 
recorded by Munod, and in another by Mr, Ore, — there is lot^s of movement 
in the side of the heninrrhage, and loss of f^ensibihty in the opposite ^ide. 

It m a remarkable feature of paniplegia due to hemorrhage in the grey 
matter of the ftplniil cord* that n diminution of senHbllity is always one of 
its first symptoma; and that when the whole of the grey matter in altered 
by the erfased blood, the ana^slhessia if* complete. 

Diagnosis of the Hem&rfhngr in Iht Spinal Cord. — The anddenneaa of tb^ 
production of parnptegia is almost suBicieut to show that it is due to efifused 
bloodf but it remains to decide whether the blocid is in the tissue of the spi- 
nal cord, or in the vertebral canal, outsldo of this nervous centre. In thif* 
last case, there k more pain in a ^eat eilent of the spine then In the pre- 
ceding; and also tctiinic convulsions are not rare when the blood ia effused 
outside of the ^piuiil cord ; while » hemorrhage in the cord has never pro- 
duced convulsions, so far as I know> Besides, there is more marked an^r^- 
thesia in oases of etfuston of blood in the tissue of the spinal cord thun out- 
side of it* 

It h usually very easy to distingnish a homorrhnge in the spina) cord from 
a white softening of this organ. The suddenness of the producti<m of the 
paralysis and the extsti^nc© of the pains will auflioiently character! jje the firsit 
of these aflfections ; and in thoae CEsejs of almost sudden paroplegia* owing 
to softening, the absence of pains (in the spine dec.) will serve to di?^tinguisii 
this form of paraplegia from that due to a hemorrhage. I need not say that 
thet*o two afiPections — i, e», softening and hemorrhage^-do not rarely co-exist. 
This co*exi«tcnce will not be surprising to any one who knows that in tlie 
spinal cordi as well as in the brain, the same morbid conditiou of blood ves- 
sels h usunJly the cause of both these affections. 

Pmgnosu of Paraplegia due to While Sojlening or Henwrrhagt in the 
Spin€fl Cord. — The great indication for the prognosis in cases of sttftenlng or 
hemorrhage in the spinal cord is the extent and degree of the paralysis. A 
softening limited to the lower part of the dorsal region of the spinal cord 
may admit of a very prolonged duration of life. A hemorrhage is a mure 
grave affection than a softening, becnngo there is always a great chance of 
ita heing reproduced, and also Tiecanso llie blood effused may cause very ex* 
tensivo alterations. We do not know a single case of complete euro tif pa- 
raWsis of the lower limbs caused hy softening or hemorrhage in the spinal 
cord ; but, as far as diagnosis not confirmed by autopsy may be relied on, 
we can say that we have seen many cases of non- inflammatory softening of 
the spinal cord arrested in their devekipment* and still more, tlmt in five or 
six case?, a very notable amelioration has taken place. 

Tre^ment of Paraplegia due t& Whitt Sofitning of the Spinal Cbr^ .^Tho 
treatment of this affection ought to be pretty much the same as that of hetn- 
iplcgia caused by a no u -inflammatory Hnfteningof the brain* We will not 
enter here into the discussion of the various mtidus of treatment which have 
been proposed or empbiycd in this last case ; wo will only mention the gen- 
eral plan of treatment w« have ejnployed with some appearance of success 
in many cases of siiftening of the spinal cord. 

1st, Iodide of potassium is tlie principal uf the remedies that may be re- 
lied upon. We generally employ it in dof^efi of five grains twice a day, 
mixed with nearly the same doses of sesf|ui-oarbonato of ammonia, in a 
dccootion of cinchona bark, or an infusion of calumba or rhubarb. We 
insist upon tiie importance of taking this mixture before food in the morn- 
ing and nn hour before dinner, to avuid the dec'impoaithui of the iodide by 
the gnsinc juhe and the sotting free of t\ic \wiVu«, ^x\\ici\l aQ\ftSit\mc.% \:^hs.% 



42 PRACTICAL MEDICINE. 

place, and oausos a gastric disturbanoe, erroneously attributod by some 
practitioners to the iodide itself. 

2ud. Besides the preceding remedy, we prescribe Tarioos tonics, such as 
iron and cinchona-bark wine. 

3rd. Strychnine may be employed with some profit in those oases where 
the paralysis is slight ; but it must be remembered that, on account of the 
congestion produced by large doses of this alkaloid in the spinal cord, there 
would be danger in making use of it in cases where, the paralysis being com- 
plete, or nearly so, there is reason to think that the bloodvessels of the spi- 
nal cord are much altered, and that therefore a hemorrhage might be the 
consequence of the action of strychnine. I need hardly say that those rem- 
edies which diminish the amount of blood in the spinal cord (such as bella- 
donna, ergot of lye, &c.) should not be employed in this form of paraplegia. 

4th. Besides the use of some of the above remedies, I recommend, as an 
excellent means of improving the nutrition of the spinal cord, the daily use 
of the cold douche or the cold shower bath appplied to the spine. Sea- 
bathing may also be of service. 

5th. The patient should lie down flat on his back at night ; he should lire 
upon the most nutritious food, drink wine and beer in a moderate quantity, 
and take as much exercise in the open air as possible, without however ex- 
hausting his diminished power of motion. Shampooing and galvanism may 
be applied with profit to the paralysed limbs. 

TrecUment of Paraplegia due to Hemorrhage in the Spinal Cord. — ^The 
same rules are to be followed in cases of this kind of paralysis as in casee of 
softening of the spinal cord, with these slight differences : that, Ist, three 
doses of iodide of potassium, instead of two (of five grains each), ought to be 
given every day ; 2nd, strychnine ought not to bo employed ; 3rd, constipa- 
tion, lying down on the back, and all other causes of congestion of the spinal 
oord, should be carefully avoided. 

Symptoms and Treatment of Paraplegia due to Hemorrhage in the Vert-- 
ehral Canal. — A hemorrhage between the spinal cord and its bony envelope 
is fortunately an event of rare occurrence. I have seen but one case of this 
kind of hemhorrhage, which proved fatal in less than two days. The blood 
is effused either between the pia mater and the arachnoid, or (more rarely) 
between the dura mater and the vertebrae. The first symptom is usually a 
pain extending along the spine from the seat of the hemorrhage to the lower 
extremity of the vertebral canal. Almost immediately a complete paralysis 
of the lower limbs and very often tetanic convulsions appear. In almost all 
oases this hemorrhage is rapidly fatal, either in consequence of its influence 
upon the circulation or respiration, or, indirectly, in consequence of an acute 
and extensive meningitis. Our object being here to study paraplegia in its 
chronic forms, we will not say more upon the symptoms of this affection. 

As regards the treatment of the hemorrhage in the vertebral canal we will 
only say : 1st, that, at once, all the most active means usually employed in 
the various cases of visceral hemorrhage should be made use of; 2nd, that 
the patient should be placed in bed on one side, and not on his back ; 3rd, 
that pounded ice should be applied, in bladders, all along the spine ; 4th, 
that if the patient survives several days, the same treatment as is above pro- 
scribed for cases of hemorrhage in the grey matter should bo employed. — 
Lancet^ April 28, May 5, June 9, July 14, Aug. 18, and Sep. 8, 18G0, »/>, 
415, 437, 563, 27, 155, 229. 



8.— ON TETANUS. 

By FREDiaiOK G. Skit Esq., F.R.S., Sargeon to 8L Bartholomew's Uospitul. 

[All the known foots of tetanus go to prove that the disease is centred in 

the nervous system, and that the circulatory system is but secondarily af- 

/bcted.J 

No sooner is the nervous centre sent to sleep tban the disease appears as 

Muddenljr to cease. Notwithstanding this improTemeiit, w> ^^^i^^Xvy^ wA 



PBAOTIOAL MEDICINE. 43 

insidious, it is obriotis that morbid actions predominate, and I doubt whetlicr 
such temporary improvement, plausible and indeed marvellous as it is, can 
be said to indicate an arrest of the disease in however slight a degree. 

A boy, aged fourteen, was brought into St. Bartholomew's Hospital, with 
a hand greatly mutilated by machinerj^. The house-surgeon decided on 
consideration, — and I thought wisely decided, — to make the attempt to re- 
store the hand. For twelve days ho proffressed favourably. On the thir- 
teenth, he complained of stiffness in the back of his neck. When I saw 
him, at the expiration of some hours, spasm of the muscles had extended to 
the chest and abdomen ; but none of the muscles were severely or painfully 
contracted. Still the signs were distinct. The boy was the subject of teta- 
nus ; and as I had never had a succesful case, I was the more anxious to adopt 
some more promising agent than any I had hitherto employed. With tins 
view I determined to test the efficacy of the woorara poison, which had been 
employed with some effect by Mr. S. Wells in three cases of tetanus. By 
the kindness of Mr. Savory, who had a small quantity of the fresh poison, I 
was enabled to obtain sufficient for the purpose. We dissolved two grains 
in an ounce of distilled water. The boy bein^ placed under the influence of 
chloroform, I amputated the hand immediately above the wrist-joint. My 
intention was to have applied two drops of the solution to the wound, and, ob- 
serving the consequences, to have increased the quantity applied according 
to the effect produced. On recovering his consciousness, it was obvious 
that what had been done for the boy, whether the removal of the hand or the 
administration of chloroform, had been in the direction of good, the pulse had 
fallen from l!iO to 100, and the rigidity of the muscles was greatly diminished, 
and continued so. The pain was also reduced, and the countenance was more 
tranquil. He could open his mouth to an extent sufficient for the introduction of 
food. The rigidity of the muscles was by no means great, nor did he suffer the 
degree of pain usually attendant on severe cases of tetanus. It is very true 
that the sterno -mastoids, pectorals, abdominal muscles, and, indeed, the mus- 
cles of his trunk generally, were involved; but their contraction was compara- 
tively slight and certainly was unproductive of considerable pain. The use of 
the woorara was postponed, and I ordered the boy tincture of opium, ten 
minims;, compound spirit of ammonia, half a drachm; brandy, half an 
ounce, every two hours. On the following day I found he had had a tolera- 
bly good night ; his pulse had slightly risen in frequency; the rigidity of 
the muscles had not increased ; on the contrary, it appeared somewhat les- 
sened. His countenance was more anxious, which appeared rather attributa- 
ble to mental than bodily suffering, for he had only recently become cog- 
nizant of the removal of his hand. By two o'clock on that day, the boy had 
consumed four ounces of brandy, half an ounce of spirit of ammonia, and 
eighty drops of laudanum. Still 1 had no excuse for the trial of the woorara. 
Doubtless the boy was in a dangerous condition ; but it was obvious that the 
condition was not attributable to the morbid contraction of the muscular sys- 
tem, but to something beyond it. His bowels were constipated. I ordered 
him calomel and jalap, castor oil, enemata of turpentine, croton oil in no 
insignificant doses ; but I failed to obtain the desired result up to the time 
of his death. In other respects, the same treatment was continued. On the 
third and fourth days his condition was not materially changed. He took 
food without difficulty, as also his medicine at the required intervals. The 
ammonia was increased to drachm doses. On the fourth day, his pulso 
had increased to 135, and his countenance was more pallid. The rigidity of 
his muscles had not increased in any positive degree, and those of the ex- 
tremities were entirely free from spasm. On the morning of the fifth day 
he had taken, without producing any marked effect on his system for good 
or for evil, about forty-eight ounces of brandy, one ounce of tincture of opium, 
and four ounces of spirit of ammonia. And we may form some judgment of the 
severity as well as the prostrating influence of the disease under which this poor 
boy was labouring when we consider that such an enormous power was inade- 
quate to produce the smallest impression on his system. On the last visit I 
j>aid except that he appeared somewhat weakoi^ I caiiTioX. va.'^ ^^\&^ia 



44 PBAOnOAL MEDICINE. 

poBitiTely worse. He could open hifl moath saffioiently wide for the introdoo- 
tion of nourishment, and he tools food freely throughout the greater part of 
his illness. His pulse was a shade weaker, but not materiallj so. His spaams 
were not severe nor considerable, and assuredly they were not a source of 
pain. Of this the boy gave me full assurance on many occasions. On the 
evening of the fifth day he died. His body was not examined. 

If the nature of the disease wo call tetanus could be ascertained by dissec- 
tion, we should have acouired this knowledge long ago ; but, so far as I know, 
we have obtained no intormation by such means, except negatively, on which 
to found a theory, or to obtain a guide to practice. The total amount of 
knowledge consists in this : that at varying intervals after the occnrrenoe 
of more or less violent local injury, and occasionally — but in our latitude 
very rarely — independently of injury, we observe rigidity of the muscukur 
system, commencing with the muscles of the jaw and extending to the neckf 
trunk, and finally to the extremities ; that it is accompanied by groat pain in 
the contracted muscles, a quick pulse and respiration, and constipated bow- 
els ; and that it terminates, in from two to six or eight days, in death. Such 
is nearly the sum total of our knowledge of tetanus, and it may be doubted 
whether we are even now occupied in the right path of inquiry. Wo fix our 
attention on the local spasm of the muscular frame, as though that condition 
of the system constituted the essence of the disease, of which it is only a 
symptom. We rather search for remedies that will abate spasm, than for 
such as will attack its cause. The above case exemplifies negatively this 
fact. The boy died of tetanus, but not of spasm. At no period of his case 
was the contraction of his muscles so rigid as to cause pain of a severe 
character. He complained of his arm; he sufiV^red from a sense of illnoM; 
he desired to be let alone, and not to be disturbed ; his expression betok* 
ened serious illness ; but he did not die from pain nor from spasm : he grad- 
ually sank from utter prostration of nervous power, which every remedy 
employed was incompetent to contend against. And it is by no means un- 
common to observe, towards the close of life, that the most prominent symp- 
tom of the disease — ^namely, muscular rigidity — ^gradually subsides, whue 
the real disease advances towards its fatal crisis, in the whole range of dis- 
ease, I do not recollect any evidence of the existence of what we term the 
nervous system more remarkably or more conclusive than is derived from 
the influence of anaesthetics in tetanus. How absolutely is the morbid infla- 
enco of the nervous system on the heart and respiratory system suspended 
by chloroform ! and how suddenly too ! The pulse falls to its natural stand- 
ard, the equilibrium of respiration is restored, all expression of suffering 
subsides under the reality of tranquil sleep. So complete is the extemu 
manifestation of health, that it would astonish a bystander, ignorant of the 
nature of the case, to be assured that in a few days, possibly a few hours, it 
would terminate in death. Suspend the remedy, remove the influence of the 
anaesthetic agent, and the entire train of fatal symptoms starts, as it were, 
into existence — ^the pulse rises, the respiration is ouickcncd in proportion, 
and the muscular spasm, with its usually inseparaole companion, pain, bo-' 
come again dominant. Nor do we observe that the disease, to whatever 
extent it may have reached, is retarded or even diminished by the treatment. 
On the contrary, its progress is unremitting ; and both the violence of the 
spasm and the severity of the pain are regenerated with an increa.se of in- 
tensity proportioned to the duration of time during which they have been 
suspended by anaesthetic agency. In the above case, I was fully prepared 
to test the curative properties of the woorara poison, as recorded by Mr. 
Wells and recent French writers ; but I really had no excuse for its employ- 
ment. The boy did not die either from or with spasm and cannot per- 
suade myself that wo shall ever discover in the woorara poison a curative 
property capable of rousing the vital powers, already oppressedby mysteri- 
ous morbid actions going on within the frame. Still I am quite prepared to 
acknowledge that all reasoning, more especially on a subject so obscure as 
ietanuSf sinks in comparison with practical observation. Other authorities 
Hr yjew the subject in a different light; coid it wVW ptOT© no vqgl«XV «a^%- 



PRAOTIOAL MEDICINE. 45 

Bion to our knowledge should we discoTer in this or in anj other untried 
agent the power to arrest so hitherto fatal a disease as that whioh forms the 
subject of the above brief remarks, — Lancet, July 7, 1860, p, 1. 



9.— ON THE TREATMENT OF ACUTE TRAUMATIC TETANUS 
BY TINCTURE OF ACONITE. 

Of all the vegetable preparations, aconite is known to be one of the most 
powerful in its action upon the spinal nervous system ; hence its value in 
tetanus ought not to be inferior to the many other anodyne remedies whioh 
are occasionally employed. In the pages of this journal (vol. i., 1846, p. 
484) we have recorded an instance, under the care of Mr. Page, at the Cum- 
berland Infirmary, Carlisle, in which a recovery took place under the use of 
Fleming's tincture of aconite. Another example also appears (ibid, p. 494) 
from Mr. Newton, of Newcastle, treated by the same remedy, which proved 
unavailing, for death ensued. We now give another, in which life was 
saved by the administration of aconite ; but whilst we feel disposed to give 
due credit to the influence of the drug upon the disease, we can hardly at- 
tribute the entire cure to it, when the period at which its employment was 
commenced is remembered, for the tetanic symptoms had been existing 
twelve days before it was had recourse to. 

We recollect a case of acute traumatic tetanus at Guy's Hospital in the 
summer of 1858, under the care of Mr. Cock and Dr. Wilks, treated by as 
many as 110 doses of cannabis indica; but the cure was attributed more to 
the quantity of wine and beef-tea taken than to the medicine. In Mr. Fer- 
guson's second case, reported to-day, aconite was found ineffectual, and 
woorara was substituted for it, with, tiowever, no better result. 

The patient in the present case, a lad aged 15 years, had always enjoyed 
good health. On the dOth of August, 1858, while wearing thin boots, he trod 
on a rusty nail, which pierced the ball of his foot. He withdrew it directly ; 
the wound bled but little, and healed in a few days. On Sept. 6th the boy 
felt stifl&iess about the neck and lower jaw, which increased daily, and on 
the 12th he was unable to open his mouth, and could not walk owing to the 
stiffness of his back. He was admitted into the hospital on the 16th. There 
was then well-marked rigidity of the muscles of the neck and jaws, and the 
risus sardonicus was characteristic. He was unable to turn his head or 
separate his jaws; abdominal muscles very tense ; complains of much pain 
in the neck and back ; has not slept for two or three nights ; bowels open ; 
perspiring ; pulse 80, moderately full. A hard cicatrix in the sole oi the 
foot was excised. He was at first put upon strychnine, one-tenth of a grain, 
every two hours ; carefully watched ; soon diminished to one-twentieth of a 

Sttin, but the symptoms continued to increase. Twitchings began in the 
igh, and great difficulty of respiration, and finally severe general spasms, 
with woU-marked opisthotonos. 

On the 20th, the plan of treatment was changed, and tincture of aconite 
was given, at first nve minims every two hours, then eight minims. This 
was continued till the 27th. The dose was then administered every four 
hours, and on the 28th every six hours, and on the 6th of October it was 
left off altogether. The diet was throughout the most nourishing that could 
be taken — strong beef-tea, brandy, &o., and the bowels kept open by tur- 
pentine injections. From the time the aconite began to take effect an im- 
provement took place in the severity of the symptoms, and he has been 
steadily and gradually progressing, though very slowly. First the general 
spasms and opisthotonos ceased, then the convulsive twitchings of the ex- 
tremities ; these lasted till about the 1st of October, at which date he could 
sit up for his meals, could separate his teeth about half an inch ; ate and 
slept well ; face almost regained its natural expression. 

Has been slowly convalescing since then. Can now (Oct. 22d) walk 
about, and appean In good health and spiritB \ oiAy «W\V ioeVft «k\\\X\A i^iSw 



46 PRACTICAL MEDICINK 

about the nmsoles of the back, and cannot yet qaite separata the jaws as 
wide as natural. 

He was discharged from the hospital well on Nov. 2nd. — Lancet^ AMg, 
18, 1860, p. 162. 

10. — ON THE TEEATMENT OF HEMICRANIA BY INJECTION 

OF MORPHIA. 

By John K. Barton, M. B^ Sargeon to the Adelaide Hoftpitol. 

[The following case is interesting, as showing the successful results which 
iu many cases follow the employment of the hypodermic administration of 
morphia. The patient was a pale anasmic-looking woman, debilitated from 
monorrhagia. A first attack of hemicrania was cured by quinine, bat it le- 
turned worse than before, and the same treatment was again tried, and failed* 
Chloroform and opium relieved the pain, bul only for a time.] 

Upon the 2nd of March I dissolved a grain of the muriate morphia in s 
drachm of water, and injected exactly ten drops of this into the subcutane- 
ous cellular tissue of the back of the neck, selecting this place as the patient 
pointed it out as that from which the pain seemed to proceed. The opera- 
tion was performed without giving scarcely any pain to the patient, and with 
perfect accuracy as regards the exact quantity injected, by means of the 
graduated glass syringe, with a sharp-pointed perforated nozzle, as origi- 
nally 1 believe used by Dr. Wood. In about an hour after this injection the 
pain had disappeared ; it returned slightly towards evening, but she pasaed 
a good night, sleeping more soundly than she had done since the attacj: com- 
menced. 

Upon the Srd the injection was repeated, the chloroform draughts being 
entirely omitted. The note taken upon the next day stated that the pain 
had entirely disappeared after the second injection, and she had remained 
free from it until evening, when there was a return of it for about an hour, 
but that she slept soundly and awoke free from pain — a feeling, as if the 
skin was sore along the side of the neck and head, remained for a day or two. 
Upon the 9th there was a return of the pain, whereupon ten drops of the 
same solution was again injected, with the effect of giving immediate relief^ 
the pain returning at night for about half an hour, as upon the 5th, and dis- 
appearing entirely again. 

Upon tne 12th the patient at her own request left the hospital, being quite 
free from pain since the last injection, and 1 have not heard of her since. 

The great severity of the pain in this case caused the e£foct of each rem- 
edy tried to be more distinctly seen than in other less marked cases, and no 
doubt the morphine injection was the first of the many means employed 
which gave decided, and more important still, permanent relief, for the pain 
did not return with the same intensity after this treatment was employed, 
and after the third injection it disappeared altogether. I confess that this 
was more than I anticipated, for I had tried the same treatment in two or 
three cases before this, and in most of them I had obtained temporary relief 
only ; but some consideration of the nature of these cases may perhaps ex- 
plain this. FirsU I employed it in a case of severe and long-continued 
sciatica in a strumous unhealthy countryman, who had been constantly ex- 

Eosed to wet and cold in cutting turf, and other country labour. Repeated 
listering, &c., and cupping had been put in operation before ho had come 
to town, without any effect in removing the pain. The injection was re- 
peated several times, and was always foUowed by an abatement of the pain, 
which sometimes lasted for several days. I found it necessary, however, to 
resort to some other treatment, and gave him the corrosive sublimate in de- 
coction of bark, and under this, with the continued injections, he recovered 
so far as to leave the hospital and return to the country nearly quite free 
from pain. 
S€con{/ly. I employed it in another case of sciatica occurring in a middle- 
^g:ed beaJtby^ woman^ who had got a very sevcto weUin^^. She had sat in 



PRACTICAL MEDICINE. 47 

her wet clothes, and shivered before the attack of pain came on. In this 
case relief was obtained fn>m the injection for two or throe hours after it 
was employed, but no penimncnt benefit arose from it. Again, 1 cmplo^red 
it in a oaso whore there wn8 intense pain in the lumbar region, arising from 
caries of the lumbar vertobne, hoping to relievo the pain until the issues 
which had been inserted should begin to have their effect ; but without the 
least benefit, even temporary resulting. 

From these ciises it would appear that this treatment was of no use what- 
ever in a case where there was active inflammatory dii«euse (caries of bono) 
producing the pain ; that it was of temporary benefit in a case of severe pain, 
originating in inflammation of the nerve itself; that it was of more decided 
benefit in a case of the same kind, but in which the inHammat4)ry sympUnns 
were less marked ; and finally, that it was of very marked and decided 
benefit in a case where there was no inflammation whatever, and where the 
pain was of a purely neuralgic character, depending upon general ana^nia. 

In such cases as this latter I would therefore recommend its ompU>yment 
Tery decidedly, ten drops of a solution, such as I employed, with one grain 
of the muriate or acetate of morphia to a drachm of water, will be £>und 
quite enough. Women are more easily affected than men, so that ten drops 
is as much as ought, under any circumstances, to be injected when the pa- 
tient is a female. Care should be taken that the needle has penetrated into 
the cellular tissue beneath the skin before the injection is made, otherwist) 
the solution will flow out when the instrument is withdrawn. — Vub, Ho9' 
pUal Gazette, Aug. 1, I860, p. '22^. 



11.— ON THE HYPODERMIC ACTJON OF MORPHIA. 

By John K. SpK!fi>Bit, Esq., Snrgoon to tbo Eastern DiBpenMirj, Bath. 

[The following is an outline of four cases of neuralgia, in which the author 
administered a solution of the acetate of morphia by the hypodermic 
method :] 

C(ue 1. — A female, aged about 35, of spare and delicate habit, came first 
under my care in 1857, for acute rheumatism ; subsequently, for heinicrania 
and other quasi- rheumatic pains ; and lately, for sharp and porsintoiit pain 
in the inframazillary nerve of the left side. I need not enuuterate tliu vari- 
ous devices, local and constitutional, which were resorted to ; suflic.e it to 
say, that they gave scarcely any relief, even for a few hours. At length, I 
determined to inject some morphia under the skin, and first gave, according 
to this plan, ten drops of Pharmacopa^ial solution of acetate of morphia. 
This caused sound sleep for two or three hours, which was followed by con- 
siderable remission of suffering. On the next occasion, I injected fifteen 
drops of the Pharmacopoeial solution, and afterwards increaned it, dose by 
dose, to twenty-two drops, which was the quantity introduced last Friday 
evening. The ultimate effect now resulting is complete relief from pain for 
about three days, and it then returns with less intensity than before. There 
are particular circumsttmccs about this caso which render it unlikely that the 
neuralgic disorder will over be cured ; but it is noticeable that whenever 
morphia was given by the mouth, no appreciable effect on the pain was ever 
produced. 

Case 2. — The second cabc was that of a lady, aged about 50, who had 
for many years past suffered from paroxysmal attacks of neuralgia in the 
upper maxillary nerve, especially in the spring and autumn. All that I 
had been able to do, when consulted by this patient on several occasions, 
was to bring about a gradual removal of the pain by iron and nuininc, and 
thos to alter the condition of blood on which the disease might be supposed 
to depend. She was always an amemic subject ; and, furthermore, often 
had her sleep disturbed by being obliged to wait on a sick husband. Alx>ut 
a month ago, I was sent for to see her one evening during an intense neural- 
gic attack. I took my apparatus with me, and injected at once fifteen drops 



48 FRAOTICAL MEDICINE. 

of the officinal solution of the acetate of morphia. Next day, I found that 
the operation had beon followed by sleep for mix hours, with almost complete 
reliet from pain ; the only complaint now made being some amount of eore- 
ness over the course of the affected nerve. Complete rcco venr took place ; 
and it is to be remarked that in this case the administration of narcotioa in 
the ordinary way had only stupificd the sensorium, without in any way re- 
ducing the local hyperaesthesia. 

Case 3. — My third case occurred in Dispensary practice, and was a poor 
middle-aged woman, who is suffering from apparently malignant disease of 
the orbit. The eye- ball is pushed forward, the left side of the frontal bone 
is raised, and the malar boue of the same side is protruded downwarda and 
outwards. The pain is often of an excruciating kind, and had scarcely at 
all been alleviated by enormous doses of opium. It was obvious that the 
utmost that therapeutics of any sort could do must be of a bare palliative 
kind ; but I injected one day fifteen drops of solution of acetate of morphia, 
with considerable relief, though at the expense of such severe sickness that 
I was not allowed to repeat the process. The pain, of course, soon returned, 
and there does not seem anything further to be done. 

Case 4. — A few days ago I injected ten drops of the solution of acetate of 
morphia into the areolar tissue of an elderly gentleman who has long suffered 
from subacute neuralgic dis^order, attributable to suppressed gout. The re- 
sult was an agreeable determination to the skin, and a generally soothed 
state of the nervous system. 

The region which I have always selected for the injection of the solution 
is the areolar tissue of the upper ami ; but the posterior part of the neck 
would probably auswer equally well. Mr. Hunter has described the injeot- 
iug instruments and the mode of using it. It consists of a glass barrel, with 
a pipe made of silver, which screws on and off the barrel at pleasure : the 
end of the i)ipe being sharpened like a needle, and perforated on one side by 
an oblique opening, through which the drops of the solution are expelled. 
Having charged the syringe with the narcotic fluid, hold it in the right hand 
at the junction of the barrel with the pipe, and with the left hand take up, 
between the finger and thumb, a fold of the skin of the patient : having made 
it tense, let the point of the syringe be passed through it with a quick steady 
movement, and sufficiently- deep that the point can be distinctly felt under 
the finger. The piston must now be pressed very slowly down with the 
thumb of the right hand, and the escape of the fluid into the areolar tissue 
will be indicated by a circumscribed elevation of the epidermis. After the 
instrument is withdrawn, a small strip of plaster should be placed over the 
aperture caused by the needle. 

According to the best authorities, we should never use more than half the 
ordinary stomachic dose for males, nor more than one-third for females. 
The specific action of any medicine is developed with much greater cer- 
tainty when it is introduced hypodermically, chiefly because the whole quan- 
tity of a substance given in tliis way is absorbed, without being submitted 
to the dynamic influences of the gastric and intestinal secretions. 

I regret to say that intense sickness is a frequent and troublesome sequel 
of the hypodermic injection of morphia. In three of the cases above related 
this symptom was very severe, and in some measure obliterated the sense of 
relief otherwise obtained. In one instance, a temporary cutaneous eruption, 
like urticaria, was also noticed. 

A due discrimination of cases ought to be made for this plan of treatment. 
To practise it in every example of neuralgia would be unwise and useless ; 
for nerve-disorder often depends upon such trivial causes as an error of 
digestion or over fatigue, and vanishes spontaneously when the exciting 
ngent is removed. The cases in which success can most probably be hoped 
for, are those in which the system has been long worn by pain, and in which 
a general spansemic condition exists. The administration of morphia in the 
hypodermic method appears then to act as a narcotic shock, which power- 
/hJJ^ and almost instantaneously soothes the whole nervous system, and 
deatroyg the local bypertesthetiia. Sometimes ih\B teaxAX \a \v©rmanent, some* 



PRACTICAL MEDICINE, 49 

tlmen not according to the permaneut or temporary ageucj of the cftuafiB of 

tlj^,dfsm-(Ier< But however abort the interval of ease, it ought to be re ry 
welcome ^ for I btlieve that the great hiiidraiice to our successful treatment 
of ueamlgia haa been our obstinat© thcorining about tta etiology. While 
we are hu^y lu cUsiiifying our supposed materia morbi(no clu^sioal pbraee 
has ever exercised so complete a tyranny ovttr U8)» and are applying our 
choniicHl and dynamical drugs accordingly, we are apt to forget the simple 
cliDict^l fact that a human being lies in agony by our i^idei and supplicates 
relief for that one symptom — pain. Let us if we can, first utterly over- 
whelm aud ubolii^h tbi» paiu ; porhapi it will never return ; hnt at all events 
when our patient Is to a grattful titupoTf there will be time to philo^^opUiT^e 
about the origin af the mahidy whteh we are calb^d upon to Bubdue, 

It must be admitted that there are certain triding practical ditficulties in 
tbfi wuy of the hypodermic admin istratiou of medieinea. The introduction 
of a pointed jn^^trument under the flewh causes a momentary pangt whJoh 
cannot bo evaded. \Yo may liken thiss pang (a?t we can with perfect truth) 
to the prick of an ordjuary needle j bat the infiictton of a punctured wound 
even OT this simple kind niav be a terror to ehllilrenf and to nervous adultH 
of both gejeg. — British Metl^ Jottrftui, June 9, IStiO, p. 437. 



1 

I 



12* — The Treatment of Neuralgm hjf Powerful Currenls of Elfetrieiit/. — 
In a paper read before the Academy of Medicine, M. Beccjuerel strongly 
recommends the treatment of neuralgia by this method, which haa prcjvcd 
highly successful in bis practice, statistics being furnished wbioh slniw tbar 
nioeteen caees of sciatica, and twenty-tbroc cases of lumbar, iutt'rcostiil, 
crural, and trifacial neurfilgia, many of which were of old i^tanding and not 
amenable to other remedies, were all perfectly cured by the judicious use 
of powerful electric currents. 

The principle upon which this mode of treatment depends is as followa : — 
If intense currents of electricity are applied in the course of a nerve, il.s 
iousnry power is benumbed for a time; an analogous effect is produced if 
an electric shock be communicated to a nerve wbieh is the seat of neuralpe 
pain, the mnrhid sensibility becoming diminished and annihilated under the 
influence of strong currents repeated at rftpid interrals. 

Sometimes the disease disappear* entirely after a single operation, but it 
more generally returns after a variable period of from a few hours to a day 
or two, As the electrisation is repeated, the recurrence of the neuralgia irt 
alv?ays at greater inter vaU, and the pain becomes less intense, nntiU finally, 
a cure is completed, for the perfection of which from three to fifteen appli- 
cations, each of two to five minates^ duration, are necessary. 

In employing this treatment in cases of trifacial neuralgia great precau- 

t inn is requisite, as otherwise, either cerebral congestion, or obstinate bead- 

' ache, never in themselves dangerous, but yet alarming and distressing to 

the patient, may occur, — Buileiin de V Aauiimie* — London Medical JournaU 

July, 1800, p* 48, 

la.— ON CHRONIC ALCOHOLISM. 

By Dr. WiLiaiiiaR* 

[A good deal of discussion seemi to be going on respecting the eihibitifm 
of Hlouhol in such cases as follow* Both sides are right, Practioo, after 
all, and along list of successful cases, induce the older physicians to bear 
two things in mind in these cases i 1. When a patient has an attack of deli- 
rium tremens, or is threatened with one, in :!onaequeuce of drinking fiir a 
week or two to excess* it is best to witbdrav? all stimulants, aud not to give 
opium — the case will right itself, 2* When a patient has for years almo?4t 
lived on alcohol, and it is now from some circumstances withdrawn, it will 
most likely end in delirium tremens. The first case ta caused by drinking 
alcohols the second by suddenly withdrawing it* The two cauaea ^\^ <\ULVtQ 
Xhlh-4 



i 





PRACTICAL MEDICINE* 

{JitiTerent; ccin«eq«(*iitly in the seeomi case we muM caTfjfully gi^e small do«^a 

o£ aledbo) mid as rnucti tititrition at tbo stotuneh wi]l dlj^e^t. We tfaink ihAt 
thoao who oppose tiiis opiriion will some day be oblig^^d to (liter their views. 
The folio wiirg cases woald Heem to cantradict ub, but all we tnaint&in is« 
that fiUliotig'h you may do without stimulnnts in many casoa, and all the bet* 
ter if you caiit yet in many other causes you will loi*e the patieut if you fol- 
low this out itrictly*] 

The nolf^s of the following case were taken by Mr. C* B€<nnet, clinieaj 
cli^rkf Charing Cross HotpitaL 

Edward S,, nged tbirty-sii, wc4l educated, now an ftttomey'a clerk « bat 
formerly in India and China Jis a soldier for ten yeurs. He there had dys- 
entery twice, and what he sujiposes c ho lor a. When nbroud he drank very 
hard ; indeed, the fleas and insects annoTed the ^oldii^re eo much that tUey 
were ohli(3:<»d to get drunk to enable them to go to sleep. At bis period of 
greatest drinking he took* perhapFi, one quart of EtptritEi In tbe day* besides 
any other tiling he nngbt bappon to get no]d of; baa seen some of bi<} com- 
rades drink a pint of spirits before going to bed ; sometimes they wen^ found 
dead in tbe morning; has seen unme of bis officers drink a pint of spirits in 
the aftwrnoon. He bad hiiniself sleepless attacks, with delusions* when in 
India; but he maintains he never hud delirium tr<^meus* In 1840 ho eamo 
to London; tstill drank pretty bard; was taken ill at Croydon, when his 
medical attendant stopped his drink. His friends had a physician from a 
well-known London bospitxil to see htm, who satd the medical man wa^ kill- 
ing him, and ordered him brandy and water. Two years af^o he had typhus 
fever. Ho was then drinking hard, chiefly gin, and rum in his tea of a 
morning ; at eleven he took some more. Ho next took stout at bis dinnef. 
In tbo afternoon he again took some gin or rum ; and in the evening be bad 
ioine porter, witb, what he calls* a Miff tumbler of grog* He waa then* he 
states, well for three mcuiths. He tben hegnn to feel very ill and wretched ; 
his hand was unsteady ; was obliged to reijign his dutit^a. Having no pro- 
vision for his family, he got some law -re porting to do for I lie cheap journals. 
At last, however, be could not write ; be could not eat ; he bad bile in the 
morning, and coafilnnt belching ; tbe bowels were rather irritable; be got 
yet more shaky ; required more stimulunts ; hii* face became bloated ; beg^an 
to waste about tbe b^gs; hcd involuntary seminal cuiiFsions without erec- 
tions* At lengtb a large patch of eczema mipetiginodes bw^ke out upon the 
right hand and forearm. He now came to tbe boifpitiil (Oct. iBth, IS^9) npon 
the advice of a. medical man and a hiwyer*s clerk whom he knew. He trem- 
bled a gfmd deal, had a coated tongue, congested eyes, atid was (as he bag 
since informed Dr. Willshire) scarcely able to get into tbe room from debil- 
ity and nervousness ; and that when he was told to sit down be was glad, as 
he could not have stood a minute longer. He had been drinking latterly 
just as much as hi?* means would allow him to procure; he was firmly im- 
pressed with the idea that he must have spirits, and when told that he must' 
ijot have ft drop, he fancied he must die, Dr, Golding retained bim for two 
or three days after he came into the boi^pjtal, and then transferred lum to 
tbe care of Dr* Willshire. All fermented fluids were strictly forbidden, full 
diet given him, and a mixture of carbonate of ammonia for a few days. 
Poultices, lime-water, powdered calamine, and zino ointment were used to 
t!ic hand. All the skin came o£r like a glove from the hand and fingers, and, 
by the 10th of November, the band was almost well; he bad gained flrsh, all 
trembling had left him, had plenty of confidence in himself, and felt alto- 
gether a different being. Latterly be has been taking f^uinine and sulphate 
of Bine, with tincture of valerian, purgatives, und as much as be likes to eaU 

Nov. J 7th. — Improves; complains of not sleeping, boweveri since he has 
left off the morphia pills ; hand and arm comparatively quite well. — Lancet, 

^>jj^8, I860, ji. gar, 

14.^Ckr&nh Ahikolism^ with impending DeUrium Tremens^ treated hy 
^t$9p£/tsf&n of the jSViwtt/w^,— (Under tiia care oi Mr, CiiXTON, — For tlie 



"pHAGTiC^ MEDICINE. U 

notes (^f this case we are l&debtedto Mr« J. Reere ShurtOt lutehouB^'Buigeon 

to Iho hospital* 

JatuL^s W , aged thlrty-eix, raarriod, a general dealer, was admitte<3 into 

the Clmriug-orosa Hospital on Nov, 14tii, 1^51). With tlii?i oxceplion of what 
IS meniioii@dbelow« he has always enjoye d tolerable health- Hla babite, how^ 
ever* have been most intemperate, he boinj^ aoeufltomod to take eight or tea 
gtai^ses of gin diiilvi bei^ides two or thf^e pijits of porter, and threu-qoarters 
of an ounue of tobacco for ^moking^ He ataleti that ho lives well, and takoa 
tn*?at daily, ^Jtcepting whon he more than usual iy exceeds in drmkinjj, when 
for a wot'k or «o he is unable to take any soUd food, but confiueB uimself 
to slops, broth, dec. At these periods also he ia escecdinijly nervous. About 
two years ago he waft admitted into Kiiig*s College Hospital with idiopathic 
delirium trenion*?. He was there treateifwith brandy, beer, and opium. He 
rpmained ia the ho&pital twc^Ive days. Nine months afterward he had another 
ettaekt and iix inonthn aq^o a third, for hotb of whioh he remained at home, 
and treated him*!Glf by freely talking spirits and beer* 

Nov. 14thi For the past weok he has been, as he denominates itt ** f^ut on 
the drink,** During the whole of to-day he has been indulging, and he hai 
taken seven glasses of hot rum, besides gin and boer, and incessantly 
smoklugi He has taken no 84:)lid food to -day* Toward evening he got into 
a row, and received a wound' over the temple, which bled rather profusely - 
He applied at the Chariug-cross Hospital for tbjs, and, his wound being dres- 
sed, be was ailmltted an in-patient under Mr. Canton, who prescribed an 
opiate* In appearance he is the very picture of a man who i^ addicted to in* 
temperance. His face is bloated ; hiii eyes are expressionless, and have a 
peculiar unsettled stare ; lus hand trembles very Jnueh, as also his tongue 
(which is coated white), and his whole aspect betokens the enfeebled con- 
stitution of a con finned drunkard. 

15th* Very feeble. He has obtained no sleep. He spontaneously asj^urea 
the house-surgeon that he apprehend.-i another attack ot dellriuni tremens if 
he is not allowed some spirits; and when told thut it was intended that none 
should he given him, he was much astonished, and feared he would not re- 
cover. Ordered aiiunonia and bark, with eblorie ether and opium, every four 
hours, aud, as hLs stomach was irritabte, some bee f^ tea ; to have an opiate at 
bedtime. 

16th* Better, He has had some iloep* He is not so nervous, and is more 
tranquil in hist mind. To have full moat diet daily, but no beer or spirits. 
Ordert-d a grain wnd a half of quinine, twenty minims of cyorio etlior, and 
fifteen of tincture of opium in water every four hours. 

17. FeuU much better. He says he experiences the same sort of relief 
from taking this quinine mixture aa he usually doea from imbibing his dram 
of spirits. 

21 at. Still improving. The wound in the temple is almost well* The nar- 
[ Tousness he complained of has ahaost departed* 

I A few days afterward he left the hospital ouredi — Laacelt StpL 8, 1850, 
[p. 237. 



15. — Three cases of Deliriurn. Tremens^ treated mth&ut SlimutanU i FdtM 
\ Mesuti in 1\do* < Under the care of Dr. Aluerson and 0r. 8ihson.) 

In the annexed cases no alcohol Btimalants were given after the patients 
I were admitted into the hospital^ as will be seen by the details, but some one 
lof the preparations of opiums eombiued with ammonia, instead. In two a 
I fatal result ensued, probably mainly brought about by the meehanical re- 
latraint employed. The prohibition of this terrible source of exhaustion can- 
Imot be too stringently enforced; for, as was recently observed in some clin* 
Bcal remarks on this disease made by Dr* Brinttni at the Royal Free Hospital, 
J** no matter to what degree reason taajr be degraded or dethroned, the de* 
flirions patient always seems sensible ot tbe debasement and brutiility implied 
ill/ straps and bands,** (Liuicet, voL i., l6Gih 2' ^^^') ^^ attendants counot 




riCAL MEDlCmE, 

lie procured to gtiutljr reitrain and watch the patienit it were better uudet 
such cLrcumatnne<?B to adniUiister chhjrnfonn, wiijch we bave knowrn to do 
more good than all tbo struit watstcoatg; and we have recorded ca^e« whieh 
wVeep having been induced by its einplojment in the L*»ndoii Hospital, tarni- 
iimtcd in recorery, (Lancett vol- iu, 1858i p. 449. J The notes of tbe sub- 
jiruied cases were kindly fumbhed bjDr. \W H. Broadbcnt, medjoal registrar 
til the boapttaU 

liobert 8-- » aged fcrty-five, butler, was admitted into St» Mary's boa- 

pltatt (ladeT the care of Dr. Aldcr^on« May iGtb. He had been engaged in 
hia occupation as butler up to the date of hl^ adniiss^iont enjoying good healtb* 
but drinking largely. When brought to the bospital, bia counlienaiice bad a 
wild eipres.^ion/there was general tremor, and be wai apprehensive of fiome 
Intcntiun to injure hi in on the part of his fellow-servants 5 the skin was per- 
spiriug; pulfio quick; tongue white and creamy. He was ordered tw<> f:rralns 
of opium ut oncCf and a gmin c'vury hour til! sleep should be iuduet^d. 

May 17th. In much the aanio cutidttion ; cnn answer n quei«tion rationally, 
but is unable to fix the attention on any subject. The following miiture was 
lubatitutcd for the crude opium ; sesquicarbonatc of ammonia, four grains ; 
aolution of morpbiaf twenty minima ; tincture nf laveuderf fifteen minims ; and 
acetate of ammonia miiturci one ounce^ every four bours. — Eleven p* m. 
Very noisy; sweating profusely; in other rejects abnut tbe same. Aa it 
was found that be and another patient sutifering from phrenitis were mutually 
exciting each otberi and disturbing the ward^by responding in loud shouts, 
he was removed to a separate wnrd. During the night ht* became violcot* 
and tbe attendant, without oonaulting the hou«e-wurgeon, put on tbe strait 
waistcoat. At four a*m* the ho Ui*e -surgeon was called, Hii* struggles had 
suddenly ceased, and he was found unconacious; pupils filed and dilated ; 
surface cold and e lain my ; (flight convulsive movements of tbe extremities* 
and twitching of the mouth ; pulse impeTceptible; respiration suspirious* He 
died in ten uiinute^. 

At tbe post-mortom examinatfoti nothing was found beyond slight sub- 
arachnoid eiiusion. 

Tbiimas C » aged thirty- six, admitted, undur tbe eare of Dr. Aldorson, 

June 4th, 18fs0. He h a pipe-maker, and, iu carrying round his pipes to 
public-housesi bas been iuthe habit of drinkiug much gin and beer» Ho has 
bad several attacks of deliriunj tremens. When admitted, bad not slept for 
two or three nights, but hud imagined that people were jumping about out- 
side hts window, and deriding him. Hand and tongue unsteady ; skin cool ; 
pulse 88 ; tongue white and moist ; no actual delirium. Ordered two ounces 
of compound senna mixture, to he followed by twenty minims of solution of 
I # muriate of morphia, with three grains of sesquicarbonate of ammonia in cam- 

pbor mixture, every four hours. He bad a pretty good nigbtt continued to 
improve, and on tbe 12tb was discharged cured, 

Thomas M , aged thirty- four, admitted, under the care of Dr. Sibson, 

March 16th, 1860. For the last six months has been suffering from oougb, 
with pain in the side and expectoration, and he bat* been in the bohit of taking 
half a pint at least of brandy daily. When admitted, he was agitated, trem- 
ulous?, apprebensive, but not delirious. Skin moist ; pulse 90 ; tongue white 
and moj^st. He was ordered ten grains of colocyntb pill with cah)mel^ and 
mixture of the acetate of anmionia, with excess of ammonia; at night he had 
forty minims of Ilattley's solution, and twenty minims every three hours till 
aleep was produced. Diet, broth, with a pint of porter. 

March 17tb. He bad a little wleep iu the night, and seemed about the same. 
The opium to be repeated at night, 

J 8th. Did not sleep, and now inj^ists on going home, imagining that iome 
mischief to bim was* intended* He was easiily persuaded to rot urn to bed; 
but he required constaut watching during the day, and toward evening bo 
came violent. Battley's solution to be given every two hours, 

kj9. Very much excited, and with difficulty kept in bed ; imagines that he 
IS to bepanmhed for some crime. Hand* tremulous ; skin perspiring freely i 
ptiise 98^ resplmtioii 24. As be became mote MLtliaot^ \wAe\i,t, mmI aa be 




PHACTICAL MEDICDTE. 

was nn exceedingly powetful man, and could not be re^trained^ lio waii r©- 
movod to a soparote ward^ and th** stratt wamtcoat wa$ ptit un» HU effort* 
to free liiniJieU werc^ fearful, tiud tbou/^b the opium was iacreaBed in qnantitj, 
and given at shorter iutorvals he had no sleep. 

At about eii a*m, on the tlQtb lie ceased to struggle, and seemed t*i sleep ; 
but it was soon seen that this was not sleepf and before tbe house-Burgeon 
con Id he called be was dead. 

On post* mortem examinutioni both lungs wfire found universally ndberent 
and groatlj congiested. There was slight subarachnoid effusion, and both 
lateral vontriclefi of tbo brain were greatly distended by fluid. — Lanceti 



Ill* Delirium 

complicated 
with 



ric J' Dia 



16,— ON DELIRIUM TREMENS. 

Bf Dr, JEFFiEi^r A. Mamtton, Ai^eiatant Surgonn, Buy a] ArLlJjery^ MilitA. 

[The fallowing paper by Dr, liarston is a mo^st sensible one, and they wbo 
4ire now trentijtg ul! ciises of deli nam tremens without alcohol will do well 
to o^insider it, Fow are more strenuous advoontet* nf total ubstlntmce ftom 
nil sHiuuiants than oyrsolven in cases of heulth, but in certain dl^imsesi we 
bare found it iudidpensabto to citrry tbo patient over certam poriodd of ex- 
haustion. Dr. Mars ton says:] 

First of all, let us see that our terms are precise and clear. I would say 
that there are tbre« separate and distinct forms of tbe di!M*ase in question : 
that if any one plan of treatment bo purauod in alb and if» without reference 
to their distinctive features, they be individually aud severalty heaped to- 
getber under one bead, we can obtain no reliable data* Not a little m irtc on- 
ce ption, it see ma to me, has arisen from this very source : 

I. Delirium o potu, or Delirium Ebrietatis pro|ierly so called. 
IL Dehrium Ebriosorum, 
' Renal 

Hepatic 

(iastro- Enteric \^ Diaea&es. 

Cardiac 
^ Central 

Professor Todd* in one of his clinical lectures^f has some admirai>le remarks 
upon the two firs^t forms* and their distinctions. The first I would illustrute 
tbusi^lt happens in tbe younger and more acute drunkardn (if 1 may so 
term them)* The disease Uj11ow« quickly after n debauch — within 24 or 48 
hours. The symptoms are — the tongue very foul and tremalous ; great head- 
ache ; face rather flushed ; tenderness often upon prossure of the epigastrium ; 
nausea ; Bometimos voimtiug ; perfect anorexia ; sleeplessness ; treaiors ; hal- 
lucinations; illusions; restlessness; an excited manner ; a quick, soft, and 
tolerably full pulse ; and often there is present a smell of spirit* Now, these 
cases are by fur the most frequent* The disease occurs in a man whoso 
means pri*vent a regular steady soaking, but in on© who drinks very hard 
whenever his pocket allows it. However frequently this may be, there is 
alt^ays a good and distinct interval^ weeks or months. The subject of the 
disease goes in for a heavy night or so at a time— his money is exhausted- 
he does or does not go to prison, but ut any ruto be doeg not drink again for 
some period, for the best of all reasotjs^-wftnt of means. Here is the ordin- 
ary form of the disorder : An acute alcobolism^tbe drink being in the man. 
An emetic-purgative, with quiet and repose for two or throe days, sets him 
all right again. 

Tbe second form is a delirium of drunkardsi in contradistinction to a de- 
lirium from drink* Thy tlluBtration of this fctrni will be r — The subjects of it 
are older— have tiii> outward and vi,«?iible signs, and bring tbe hif^tory of a 
habit of drinking; hard drinking indeed, if the iiggregato L>e leaked t^^tho 
steady weekly consumption of spirits, to wit— but less hard than the first 
variety in a given space of time. Those men have kept out of the guard- 
room, and are ibrewd encmgh to keep aloof from thek <iffiififet^\ V^t la. ^wA 



FEACTTCAL MEDICINE 




f^gimental chare cter; are ftcldom, if ever, in bospital; and 
gusp(^et<?d in tho ri>gjtnent of bcnng secret clTmjknrdg, yet ore onlj proved ^ 
bj some accident— ae turmag out at night to a fire^ — or ndrtii«*k*n Into ho^ 
pitftl for some trrvinl ilit^ease. At Itiit ho tt* caugbtt and l(jdf»^ed in the guard* 
room ^ or by «ome lueiuia or other he li with all suddciiaeBs deprived of bis 
drhik; and delirium trenien!i Bots in, appearing from the second to tha 
ieventh day after confjuenient, while perohauce the man is awaiting his 
court -martial. 

In short, you get the history of a man who hai drank for years and y^ari; 
during whicii time be ha* performed hia duty under sharp »uperTigion, and 
has not aufiPered from any diseuse* lie li deprived tuddeislj of his stitDuloi, 
end takes delirium tremeiii. I 

Cfimplicaicd Jbrm. — -This variety will take in the various symptoms of uny J 

organic disease preieBt, and eompii eating the case. It would l>e impossible | 

and need leas to enumerate the various compiieatitms, further than to remark | 

J that their recognition and diagnosis is all-iuiportant; the difficulty of their , 

treatment very great % and tlmt the mortality far exceeds that of the other * 

I and simpler forms of tbe diiteaf^e* ^ 

The viieeral or glandular deraageinents become evident for the first time 
during the attack of deUritim tremens — the man never having been before in ; 
hospital, — and are then only arrived at, from the fact that some unusual 
symptom;^, as convulsions, jaundice, oedema, persistence and peculiarity of ' 
the delirium, or albuminous urinC} make them apparent, 

Tbe treatment of such eases must necessarily be modified according to the 
d ideated f^tate and its indications. 

Having premised this much, let ns turn to the points in diapute, wbtch ; 
appear to be; That tbe theory of the causiatiun or etiology of tbe dif^ease 
hitherto propounded is wrong, its pathology wrongly stated, tbe indleatiaDfl 
for its treatment in i.^ understood, and the special mipdes of treatment them- I 
selres (particularly that by opium and stimulantsj have been erroueoasly 
and injuriously pursued* 

It is often better to wutcb than to correct, and I would ask bowmiiny cases ! 
classed under tbe jirst form have been enumerated with the second arjd third 
varieties? I fancy that by far the larger number of the so-called statistics 
consUts of individual eases of the first form, and if so, tbe generalization 
from them cannot fail to be vitiated, when applied to the whole disease. 

Dr, Watson expressly says* that some cashes occur utter a long deb no ch. 
and others in which the patient has not abstaim^d, but is continually fud- 
dled ; and here the disease arises bpoause the man goes from bis OTdiiiiiry | 
positive to the comparative degree. 

There is no doubt that those ca^es are numerous, and their plain Inference 
ia *' poisoning;" but so much has been made of them, as virtually to exclude 
the occurrence of other forms. 

Etiology. ^-Tukitjg tbe objections seriatim, the etiology ; Watson says, 
tbe predisposing enu^e h drink; the exciting eause, the privatiim of it. 
Against this view there is urged the frequency of the disease following a 
debaucbt &c,, without any privation; in short, the frequency of the first 
form. Such frequency it is argued, proves the disease to be tbe result of 
poisoning, and the sufficiency of the poison alcohol to form at once tbe ex- 
citing and predisposing cause. The occurrence of some disease, such as 
catarrh, inflnenzn, gastric disturbance, in a drunkard, may be also an exciting 
cause- Lastly + tbe statistics of prisons are against tbe theory, it is said, of 
privatloUt Tbe first objection is shortly this, that we have proof of on© 
cause (toxaemia from alcohol) being sufficient, and bonce it is un philosophical 
to seek a second* I can only meet tliis by staling, that there are dilferent 
forms of the disease, which may have different causes, nay, a plurality of 
causes. Besides, I shall adduce positive evidence of the disease following 
the withdrawal of alcohol. W^ith rcgfird to prisons, I can only speak of 
military ones. No cases occur in them, I am aware, and am not surprised 
ai the fact; hut tliej occur antecedently, coming on in the guard-ri>om, 
where, if a mnu he fried, he awaits his court-martVal, -^ro^iobl'y fox T&^xiy 



PRACTICAL MEDICmE, 

dft^B; &nd I fttate aa a fact, thntf c^i^a of delirium tremens oommonlj occur 
frum the first even to the seventh day nfter the privation of liquor. The 
guard^room statii^ttcs would honce be every bil as etrong the other way- I 
am aware that statistics do not settle the fnct, they do not prove cause and 
effeof, viz., deprivation of acKjastoniGd stimuli ah a cause of delirium tremens ; 
but they cannot certilaly be urged against it, for they support at Icaet the 
view r*f this privation being frequently an antecedent to the appearaucG of 
the disease. Is it a necessary antecedent? I believe it is In some cases. 
Take the following: 

Sergeant D-t tieU 89 yeatSi^in daily expectation of a good-conduet 
medaU — Admitted April 13, ftufForing from a small boil u]>on the lobular 
appendage of the riglit car ; m perfect healtli apparently. Upon the after- 
noon of the 1 4th I noticed that he was very tremulous and nervous, and 
a^ked him privatetyi about his habits. He denied^ in the most positive and 
awful term St that he drank hard, and refused my offer of a glass of brandy. 
Upon the morning of the l.^tht I learnt that he had slept badlVf and found 
Uim suffering from a decided attack of delirium tremens. He talked In- 
cessantly, was bathed in perspiration, had illusions, and fancied he aaw 
strange omimals, and heard strange notses. His tongue was coated, and 
very tremulous ; the eyes ferrety, the pupils moderately contracted. He 
wfis ordered a sharp purgative, and cold douche to the head, followed by a 
basin of beef-tea. At 12 noon he took 3 i ef laudanum, but was sick, 
vomiting nearly it all ; at 2 p. tn* he had some warm brandy and water, 
with 3 js of laudanum, which he kepi dtpwn ; about 3 p^ m. he had more 
beef-tea, and said ho thought he should sleep, lying down for that pur- 
pose ; I happened to be iu the ward at the moaientt and my attention was 
arrested by his livid face and heavy breathing. In about a quarter of an 
hourthe had an epileptiform convulsion ; two or three followed after a short 
interval, and in about three-quarters of an h<iur lie died with symptoms of 
apncea* Besides cold douche, artificial respiration h)' Marshall llalPs methodt 
and enemata of brandy, wpre tried without a vaih The jio»i-m^riem was made 
most carefully by myttelf, and I could detect no iirgonic disease to account 
for his death. The Jeft ventricle of the heart, however, was iu an ad- 
vanced degree of fatty degeneratiou ; and, besides some venous congestion 
of the mem bran cfi of the brain, there ware a few drachms of fluid in the 
cerebral ventricles. 

Now, I would remark how strong Is tlie tendency of the evidence, negative 
and positive, of the facts hero. A man is entitled to a good-conduct 
medal— which presupposes eighteen years' absence from the deiaulters* book 
as regards court s-nmrtiah I learnt from his wifu* subsequently, that for six 
or eight years he had drank very hard, and that, altljough she had never seen 
him drunk, yet she could not say that lie was ever nerfectly sober any night; 
that she did not remeuiber Ins having over been in Uospital, or suffering from 
any disease. He comes into hospital. Is deprived of his liquor directly, and 
in fifty-six hours is dead. This appears U* me a strong case, but it is not 
by any means an isolated one ; and others equaUy positive will be citedt far 
more than sufBcient to meet the logical requirements of one grain of j^ositive 
against a bushel of negathe evidence. 

Palhologi/. — Dr. Watson's views may he epitomised thus : — The diieose 
ia "Exhaustion with nervous irritation;" the remedy, *' sleep.*' Against 
this is urged the toxamiic view, and the positive chemical evidence of the 
presence of alcohol in the cerebral ventricles, and that sleep is an effect and 
sign of the improvement in the disease, and not the cause of it. 

Dr. Watson uses his terms advisedly. He does not pass them for more 
than they are worth. Are there not certain acquired physiological condt- 
tiona or states of system which produce uncontrollable eravinga and desires? 
and are not these cravings instinctive desires r>f a need felt by such an ab* 
normal system 1 and supposing theai unyielded to, do we not get nervous 
ethauition and depression ? Is it true that horses fed upon arsenic fall into 
a bad state of licalth. when its exhibition is discimtinued 1 The facts related 
of the Stjrrian aud Hungarian ponsanlry relative t^ iWvi Ct(^^vi^ii\A VL'Siii tit ^i- 




•PRACTICAL MEDICINE. 

Fsentc, and the ©vi 1b which almost invariably arise from its ^!«e*mtinti«ine* ; 
the ftlinnut universally spread ioatinct in mmi to the ma of narcotics, sflrfi- 
uiantPi dec* (such aa opium, betel uut, tobacco, cocoa, with th© rest) ; the 
growth of the cuetoni itito a hribit, and tho war ifi ivhich men are inim-tled 
to tlie continuance of that habit, from tbo fear of the chain of morbid phen- 
omena which fnllow tho cessatiuii of it; — do not these run very parallel to 
the facts we observe from the use and abuae of alcohol ? Chossat's eiperi- 
mentis upon the effect of atnrvation on animals w^iuld indicate that the ner- 
voiiE tissues nndt'rfjo remarkably littlo relative bif*s compared with the other 
tJHSues^ in spite of the gn at quantity of fat they contain, ami thol^ alniij^t 
fluid oonMstence. This has been held to explain the cauise of the curious 
pRychical phenomena preceding death by starvation. Hestlessness, de^iriumt 
and prolonged sleeplessness, are common precursors of death in such cases. 
Now it will be said, that no analogy can be establi^^hed between such eases 
and the same phenomena following the withdrawal of alcohol. But I am not 
convinced of that. The whole doctrine of diets, however satififactorily it 
may be settled of a chemical basiaf is decidedly not settled upon equally 
certain physio logical data^ We have facta in abundance to prove that the 
chemical value of food is not tho physiological onci and that both man and 
animals live and grow upon substances, ajid in proportions, perfectly different 
from what a chemical view would indicate, or conceive pogsible. When w*» 
observe how spirit is meat and drink to a drunkard ; how his synt^^m affords 
the proof of an altered and abnormal nutrition ; how, in short, he has a spe- 
cial physiology of hii* own, it seems to me a natural and rational con^^e- 
([iienc«*, that the poison to him is uo poison, hut, on the contrary, a specinl 
fuel for his untrition and devehipmont,— uHieit diseased. Lieblg has shown 
how the diemlco -physiological theor}' of the action of stimulants upon the 
human system^ is in accord with the actual experience of landlords and 
othert!, viz., tl>at a far larger amount of food is consumed by the abstainer 
from alcoholic fluids, than bj^ one who partakoft a moderate quantity of them. 
It seems to bo a we lU ascertained fact, that alcohol economises the food and 
tissue?, by arresling the amount of secondary metamorphosis. Then we 
havj tbo influence of tiio custom producing a habit, and its known effeete 
upon the body. Can any habit be suddenly discontinued and broken with- 
out some, nay, even a grave effect upon the nervous system ? 

There seems to me to be no end of evidence to prove that the sudden 
curtailment or withdrawal of any habit may produce nervous exhaufition ; 
and if so, whj, irritability is a necessary concomitant and index of that 
condition ! 

In regard to sleep, A drunken sailor knows very well that if he cnti 
"sleep it off," it is the best and most natural way of terminating his fit. 
No doubt the tendency to sleep is a sign of impi-ovemont in a ease of deli- 
rium tremens. Dr. Watson and others urge that sleep is the neces«sary pre- 
cursor of improvement ; but if I understand the objection raised to this view 
aright, it aniounta to this, that before a patient recovers from delirium tre* 
mens, afid as a sign and effoi^t of his improvement, ho sleeps— very pro- 

Ibable ; but I am sure the pojii ho^^ Is often a propter hot, via., not tliat he sleeps 
after he improves, but he improves because he has slept. 
Caife,— G. S„ aged 80, admitted June 8, 1858, from the guardroom, where 
he had been confined two days. Had been for years a hard drinker. It was 
stated (but not upnn reliable evidence), that prior to enlistment he had been 
Gonflned for a few months in a lunatic asylum. Upon inquiry, it was found 
that he had been drinking very hard for some daj^s, and that the debauch 
terminated about three days prior to his admission into ho*ipital. He was 
laboring under all the symptoms of unmistakeable delirium tremens. After 
the administration of a purgntive and a saline antiinonial mixture for twenty - 
four hourp, without any amendment, opium in gniln doses was commenced, 
and continued until his pupils became somewhat contracted, when it was 
omitted. He was allowed milk diet, with a basin of soup at bed- time. 
^orty-eight bourn /lavtng elapsed in hospital without any sleepi and bift deli- 
rjumf tromor^ and symptoms of exhaustion augmeTit\ng,\tM^ft ^^\^timLV\ve4ta 



I^ivo him ehlorofijrmt for which purpose another assiiitaut-surgron with mv- 
Ki'lf, nUernivteljT Hot at his bedside all night: and he wns kept^ at intcrvnfs* 
under its influence for eight hours, during the greater part of wliieh timp he* 
Blept ^mmdly. At the ei pi rati on of this period he awoko» and partook of 
some broth. Ho ftppoiircd fur lei^s tr*^inulous^ hnd lost hia rapid dolirmus 
conversation* hut retained hiii guspiciouii^ mannorf and wtm evidently haunted 
by illu-siiins* After some interval he was again put nndor the intluenee of 
chloroform* and slept for four hours deeply. Awaking, ho was still more 
rational and restored ; and after drinking two bottles of porter, ho spontan* 
eously ftdl asleep. In thiK state he continued six hours, and awoko rational 
and well Hci wait retFiined in the hospital for some period, on account of 
Bomc dyspeptic symptoms and boils, and with tho view to invaliding on ac- 
count of his uncontrollahle habft of drinking. Thta man was a dipsomaniac 
iudtic^d* I think I never beheld features po expressive of a true drunkard in 
my life* Daring his fits he seemed to have laooured under certain dominat- 
ing pas^tons^ and the^ e had left suck impressions upon the facial mujKsles an 
to have permanently altered his whole ptjysiognomj* 

Now, hore we have a case of delirium ocauring in a chronic drunk nrd, 
who had been deprived of his stimnlus for two diiyn* lie is* adnuttcd int(» 
hospital, and docs not sleep, Ium .symptoms becoming worse; hv the aid of 
ohioroform be slept for six or eight hours- — improves-^and by the adminis- 
tration of mora oUioToform with the aid of porter, ho steeps again, and is 
cured. 

A. B., ri mesa sergeant in a line regiment, had always been suspected of 
drunken habita* Quo day he absct'nded with somf* money, wai* caught* and 
confined hi the guard-room, Whilat therei he became the subject of delirium 
tremenj», and wan Imnight to hospital, with the history of having endeavoured 
to poison himself with arsenic. This case waa a very severe one, for the 
patient had an ever- pre sent spnse of bis crimei a fear of puniEihmentt and 
was, moreover, auffenng from qU the symptoms of the disease. Numerous 
means were used (including opium) without any benefit, and a fatal prog* 
nosia wtis formed of his ca*-^e. The regimental surgeon administered chloro- 
form by inhalation, and procured artiticial sleep for many hours. Tho man 
awoke so mnch improved, that its administration waa recommenced, and be 
was quite restored by its aid, 

Rcjre we hare the symptoms eontiauing for a GOTtain period without any 
improvement, while induced artificial sleep or narcotism waH attended ^vjth 
such marked improvement, as to have impressed the medical attendant with 
the belief that bis patient owed his life to the chloroform. 

It would bo tedious to cite other cases proving the same thing* I con- 
eludo from them, that to procure sleep is sound, excellent advice, the good 
effects of which are borne out by actual experience. 

7V«?rt/me^^— The use of stimulants (alcoholic) in cases of delirium tremens, 
with the view of removing the exhaustion, allaying the morbid irritation, 
and procuring sleep, would be looked upon as evam more wrongly direetod. 
If the etiology usually propounded be radically and totally erroneous, then 
we are guilty of adding more poison to an already poisoned blood, to pro- 
euro what is not needed^ and what tho presence of alcohol in the system Is 
pre ven ti n g — si e ep , 

G* If M aged 4^, but grey, and looking much olden w-ai admitted iuto hos- 
pilal fi»r some gastric disorder. This man was, and had for years l>een, a 
very hard drinker, and his features, particularly the no^Ci indicated "pota- 
tions deep." One morning (after he had been in hospital for some days) I 
waft called to him, He appeared insensible, wa& breathing very heavily, the 
face and lips dark and turgid, the pupils contracted- Whibt examining 
him he had a oonvuL^ion of a tetanic charade r, the body being arched in tho 
position of opisthotonos. The muscles of the fore -arm were so tense that 
the radial pube could not he felt. The hearts* impulse was scarcely per- 
ceptible. Having thrown a bucket of cold water over the head, I took ad- 
vantage of a few moments of apparent consciousness to pour a glass of hot 
brandyr and water into his stomach ; and he recovftxcd ^W'a^l \mm^^>ssXP^^ % 



d 




m PRACTICAL MEDICINE, 

BO tnacTt so, tbnt th^ mc^ilical ciflicier^ whose p^tiojit bo was, coul^ iCBTcelj 

orcilit the § tnte in ivhicli I iVrund Uhn* 

G. P,, tiged 0*3, admitted Aprii 14, 1858* frrim the guar<l-ro<>m» where h« 
had beeti confine*] two dajj*. His distjuse iva« uneijuivncoily ^eHnum fremitus, 
nud no rornedml tnc*asures seemed to benefit him. Ha was tpemubus, rest* 
luj»S| deliriouSf and did not sWo ereu with the aid of tho frc^nh ad mi uie^t ra- 
tion cif fipl^tei. Two bottles af porter were given htm at bed-time» aiid he 
WHS observed to smoke daring the daj some strong tobaccn. Ills hisiiidswere 
BO tremulons that the orderiy had to hold the pij>e in his mxmth- Hy thi 
means* he slept, and slept welU and made a ^oi^d reeovLTy, after having ' 
dosed tirmvaiJin^'lj for four dnyA previously to procure that result. 

At tld^"^ momeut I have a ioldler in hoif]jital who ha;^ always drank free] j. 
He has been ttnder treatment upwards uf ejf^ht days fur triv]4it bntncbitiii, 
and symptoios of iuclpletil deitrium tremens appearing nowi necesMitaUt the 
use of alcohol and opium with manifest advantage to the mna, as reg^ards 
sleepi appetitei and the diseaBe itself. 

These cases il lust rate two points ; the actual occurred c© of deliriatn 
tremens after and during the prlvntiun of liquor; aiid tlie i*peedy remoial 
of tlio symptoms by tho re~e»tabH3hment of the custom, when olher means 
failed. 

I have purposely selected these eases, because they illustrate also the feel, 
that whilst the men were taking tbeir accustomed sthnnli, they ooiitmaed 
wolU for they were men who never appeared at bos pi till at all. 

I shall not give cases of apparent cure by tho adininistrutton of opimn+ 
aa tliey ean be found in any work ; and, after all, they arc no proof thut 
jour patient recovered by the treatment^ but, perhaps it wlU be urged« lu 
spite of it. 

Tho most curioua cases are those In which tho delirum continues for a 
long period, but in a modified degree ; tho patient sleeping tolerably every 
night, eating and drinking, and performing all his funotlon« wolL It is well 
to look out here for some complication (particularly fonal or hepatic disease), 
for it is surprising how hmall an amount of urea circulation in the system 
may give rise to a portiistenec of anomalous syniptomB. Besides the uraoaic. 
we have a peculiar and difticultly treated form of Uiedi!*ea&e when jaundieo 
is present, whether aHiii^g from fatty degenevation^ cirrhosis, or other hepa- 
tic disease. These case:*, of course, are more freqvitmtly fatal; but 1 find 
that, after local depletion, purging, or diuresii*, stimulmits, more particuliir- 
ly gin, are not only not contra-indieated, but are decidedly useful, more 
particularly if the patient be an old ehrooic drunkard. 

The most fatal form by far is that In which we have delirium tremens oc- 
curring in a person already the suhjeet of typhoid fever — casies by no means 
uncfimmon in this climatOi Having separated, however, these cases, there 
will remiiin nmny in which a chrouic derangement of the nervous S3*stiim is 
manifested, tho patient sleeping night after night, for longer or shorter in- 
torvalc^, and performing all his functions well. 

In a few eases, opium given in full doses at bed- time will secure a deep 
ileep and manifest improvement. In others, a liberal but regulated allow- 
ance of stimulants will prove advantagcotis, when everything else has been 
tried in vain. In some, no plan of treatment will succeed, although the 
patients frecjuently recover after a long iuterval, while others lapse inte 
chronic mania, melanchoha, or some form of iusauity, ending their days in 
a lutiatio asylum. 

With reference to that singular pha^^e of our mental life-sleep, Sir Henry 
Holland advances viewsj which my ohservatiim of the sleep of delirium tre- 
mens patitMits has led me to think perfectly trulhfuL 

He is <if optnifui that sleep is not a unity of state, but a series and succes- 
sion of (States, ever varying from moment to moment* These variations hav- 
ing every degree of diversity, from complete wakefulness to the most per- 
fect sleep of which wo have eognbance* It hati long occurred to me tliat 
*^i*p of druiiknrds and in deliriam tremens differs much from the normal 
rd «?/ mtonsUy, Every one must have ex^emv^ced la hU own pcrsott. 



Jr 



when he was flnitoue to awake at a c<?rtairi houTy how ho awakos at that i}m^^ 
with a ffj^Ung that he ha^ uot slept woU, ur at altf although he may he adsurtd 
that he has slept very soundiy. 

Sir H. HoUttTid^a observatioua are so goo^ upon sleep and dream inj^, in re- 
lation to delirium and insanity* that I shall qaote his words : — ^" I know of 
no prtnciple ho cupable of ivffording^ a ptiiJet aa that which views all tha 
forms of insanity, including delirium, in the-tr relation to corre?pondi«g 
healthy states of mind, tracing this connection through those loterinediatP 
grades, which are so uuineroueiiy exposed to n^ in the various conditions of 
human eiiatenee. The diversitieB of mind in what is arcountud its healthy 
stato, the e fleet of passions in suddenly alterin|^ its whohi Condi tion» of 
slighter ©motions in gradually ehanglng it, and of other incidents of life in 
affttcling one or mor« particular fucultips; its subjection periodically to 
sleep, ind oasuaJly to the states of in tosi cation, somnatnbulUin, and revene; 
its gradual transition in fever from a state where there is coneiousness of 
vague and wandering ideai» to the fitate of perfect delirium ;— all these furn- 
ish so many paj^sages through which we may follow sanity into insanity, and 
connect tho dift'erent forms of disordered intellect as well with each other aa 
with the more natural and healthy functions of the mind*^* 

To sum np, I would jsay that the first and most frequent form among mil- 
dlcrs of thi^ disiause renuires rardy indeed opinm, particularly at the com- 
meucement of the attack; in short, no specifac treatment ia necessary. In 
the second variety, i would give it cautiously in moderate doses, after free 
purgationt provided I did not find my patient improving by rej^t and tran- 
quil ity. The opium had better he given at any rate in a full dos*' before 
the accustomed hour of sleep* Should it not BUoceed, my DSpt'rience would 
indicate a **hair of the dog that bit him,'' in the shape of porter or hot 
brandy and water, spite of what has been urged to th« contrary. If the 
iurgoon avoid both opium and stimuJants, and his patient goes on badly, de- 
pend upon it the chances aro in favour of another doctor advising one or 
both of these nojiclous agents, with much advantage to the patient, to the no 
Uttle chagrin of the tirtiit medical attendant. Where great irritability of the 
Htomach is present, there is notbing better than a sedative dose of calom^i 
(gr* vj.), with or without opinm, and a large enema, 

SuppO!»ing the physiological efTeets of opium upon the wyf*tem to r>e muni- 
foiited, without sleep or improvement foUoivingr I should omit its use for 
some howrj^, give my patient some good brotlu flavoured with brandy ar 
wine, and induce artificiid sleep at night by the aid of chlorofurm. 

I trust it will be Moen that thu u*ie of opium is advocat<'.d as a measure re- 
quiring discrimination and caution, but a^ a reliable one in many instances. 

Of o^mrse the comidientfrd fitrms require that the greatest di^^cretion 
should be eiercised in it*' administration. Where an embarrassed circubt- 
tion exists, niark<'d by venous congestion of the mocoiw membranes and 
duskiness of the face, it is better avoided altogether* Pulmonary emphy- 
sema, if extensive, cardiac disease, or indeed any thoracic complieution, 
will require also great care, if they do not indeed prohibit opium in any 
form — Edinburgh Monthly Journal^ Oct. lyGO, p. 300. 



17.— TREATMENT OF DELmiUM TREMENS BY DICMTALIS. 

By G. M> J<JKE!A, EsQ^ Dr* B^nt^iim, Dr« Wit.LiA;aft, mid Dt. WKtoTiut. 

[Mr, JoKTKS, of Jersey, treats these cases on a novel plan. Ills opinion 
is always valuable. From most other people we tthould di!*sent if they gave 
such an opinion, but Mr, Jones is truly trutitworthy. tie was led to give 
digitalis from mere accident* He says: ] 

As to the dose, experience has timght me that tlie best dogo is haff nn 
cunce of the tinctunj given in a little water. In some few case.^ thia ono 
dose Is enough, but genernlly a secoud dose is required four hours after th© 
fifst In Bome cases, but very icldom, a third doa<i va cisdkd fot ^ Wl tfc^a 




m FHACTTCAL HEDTCIXE, 

liftrdlj ever need eicepd two drachms, Th<3 largest quntititr I hare *>Tpr 
given was half*an-ifttnre nt fir;*!, hal/'annunre four bours after wards* tttii 
ftnother kalf-an-ouncc six haurs uft^r tbat^maklng an ouueo atid d-hiilf In 
ten bours. 

As to the effect of thesp doseSf my impres?simi is that the action ts on the 
brain, not on tho heort* The pulse, S(* far from bfing- Iowor(?d iu forcd be- 
linmes fuller, and stronger, and mere reg-ubr, boou after the first dosp. The 
«old cbmmy pergpiratlonfl puss off, and the skin becomes wanner. As soon 
US the TotnocJy produces it* full effect, sleep for jive, siii or sev^n hours 
commonly follows; sleep m thtJ guide as to the repotitlon of the dose. N** 
motion on tho kidneys is evidenced by any unusual secretion of urine- 
Bnuietiines the bowels are slightly acted on, but not commonly, 1 haTu 
never once seen any alarminc symptom follow the use of these large doses 
of digitali!*. The only case I have lost since adopting this treatment had a 
tumour in tlie brain. In three only was other treatment adopted after dig- 
itftlis had failed to procure sleep; in other words, in sixty-seven out of eer- 
enty cases dig) talis was tho only medicine used, and siitly-Pix of these pa- 
tients recovered, I do not mean that these are the exact numbers of those 
treated ; I am certain as to the deaths but I may have had more recoverieB, 
I am well within bounds in saying seventy cases In twelve years, and that 
all of them were well-marked cases of delirium tremens. Slight eases of 
nervoaa derangement after drinking I have seen in great numbers; but I 
speak here only of such oases as i^equired active treatment. My previous 
experience of the results of the treatment by opium* or some of its^ prepara- 
tions, by antt-spasmodics, &c,, had certainly been much less successful; 
the pr<JiKirtion of deaths was larger, and the recovery much less rapid- 
Again ; T have treated more than one patient BuccessfuUy by digitalis, who* 
in subsequent attacks elsewhere, has been treated by opium and died ; and 
in many of the ca^es in which I have used digitalis successfully, opium had 
been previously given without any good effect. 

I will only allude to one case in illustration : — On September 9th, I860, 1 
was culled to see a gentleman, 48 years of age, who was in a very alarming 
Btate, having^ been without sleep four days and nights, having been ** mud- 
dled*' fnr two months before, and having previously had ** fits of the hor- 
rors." Ho had been treated by another practitioner by opium in moderato 
doses, but had become worse, ami when I was sent for it was the opinion of 
Mr, Spencer Wells and Mr, McCrea — who accompanied me in my nrst visit 
— ^that tho ease was as bad a one as th^y had ever seen ; cortainlyt / never 
saw a worse. The puUe was almost imperceptible ; tho skin covered with cold, 
clammy perspiration; tho face deadly pale ; the lips blue ; the hands tremu- 
ously grasping the air; the eye expressive of great fear ^ tho mind gone; ho 
was muttering incoherently. With some difficulty I passed half*an -ounce of 
tinctare of digitalis down his throat in the presence of my friends. In a few 
minutes he became more tranquil, the pulse was felt more easily, and we left 
him. After four hours I found that he had not slepti but he was rather more 
sensible, loss tremulous, and warmer* I accordingly repeated the dose. Three 
liours after that, as be had been still without sieep^ though in other respects 
improving, 1 gave two drachms more^ miiking ten drachmH in seven hours* 
After this he had some s^eep, and had slept at intervals during the night. 
The nejct morniug Dr. Ballard saw him, with my other friends, and all of 
tham were much pleased with the great improvement manifested. He was 
Hensible, his fears had disappeared, ho was very slightly tremulous ; the skin 
was warm, the tongue moist, and the pulse full and regular at 90. Tho 
hearths sound and impulse were normal; tboi bowels had acted once, antl 
urine had been passed in natural quantity. After this he took some broth i 
drank freely of imperial and lemonade, but took no Btimuli of any kind, or 
any othi^r medicine. Ho slept uninterruptedly for thrive hours aud a-half in: 
the afternoon, and at intervals in addition. The nest night was a good one ; 
/!//£/ whtm hi* vvns seen by my friends again the next morning ho was almost 
9r€^//^ ^rjd calling' out fi*r a mutton-chop. 
I trtint that thin narrative of tho roBuUs of my ex^eriowcie Wk^t'j m^\i*iG ^Shfe.- 



1 




PEAOTICAL MEDICINE. 

tn to follow what I believe to bo a very valuable practicnl lea son ; liut I 
must warn those who do ho not to try, aa I liave doae, ^tiy stDaller doses limn 
those I JmvD n^eommcndcd^ Thej would not only lo^tf valuable time by ao 
doing, but I believe would do barm. Dosea of half-a-drachm or a dracbtn 
do no good whatever ; and tbe puleef in eome cases where I tried tbeiOi be- 
came intermitting. I have never aeen tbi^ eSff^ei from the larger doaca ; on 
the contrary, a feeble intermittiiig pulse has generally goon become fuller 
and more regulart proving^ 1 thinkr a^ I «uid befi>ro» and aa I again wish ta 
imprc*sf? on tbe profession, that the curntivo action is on the nervous system 
priniarily, and not on tho organs of circulation. — Med, Times and Gazette, 

[Dr. Ballard, of laliugtont corroboratea Mr. Jonee^a opinion, and states 
ad follows what he t^aw in two other cases, one in tho hoapital, and another 
in private lodgings.] 

The former was a man apparently about fifty years of age, the other a 
young man about twenty-five or twenty -six years. Both had been drinking 
hard up to the period uf seizure. In both, tho characteristic symptoms of 
the disease were clearly marked, the skin cotd, and tbe pulse very feeble ; 
in tlie hospital patient scarcely perceptible. In both oaseSt the earliest op^ 
eration of the medicine waa seen in tbe abatement of the nervous phenomena. 
In greater quietnesa of manner^ and in the disappearance of delusion. Coin^ 
cident with this the warmth retumefl to the aarfaee, tbe pulse reaumcd ita 
natural fulness, and a healthy per^ pi ration appeared npon the skin. After 
thia improvement had proceeded to a certain extent, both patients slept, but 
I could not regard tbe uleep a a any thing but an index of the favourable prog- 
ress of tbe case. The improvement in the general condition clearly did 
not depend upon its production ; firat, because marked amendment had pre- 
ceded it, and, next, because it waa not prolonged beyond a very few houra. 
In no one of the three cases was there any unnatural Increase in the quan- 
tity of urine passed. My surprise at witnessing the success of this remark* 
able treatment waa only equalled by my admiration of the boldness and 
courage of the man who could introduce so startling an innovation of our 
practice* It certainly is not what any one would have expected : that a 
fee Illy -acting heart would be roused inlo normal action by a medicine like 
digitAlis ; yet this is one of ifc^ earliest effects in the dose given by Mr* Jonoi* 

From time to time very daring doses of digitalis have been adminiatered. 
Dr. Pe^reira, in his " Elements of Materia Medica,** mentioned the practice 
of Mr. King, of HaxD^undlmm, who was in the habit of giving, in acute in- 
flammation, doses of tbe tincture amounting to half -an -ounce or an ounce, 
without the production of any dangerous symptoms. A pupil of Mr. King 
once informed me, however, that during this treatment the maintenance of 
the recumbent posture was rigidly enforced. In uoitberof the caf^es which I 
saw treated by Mr, Jones did any pains appear taken to ee cure this precaution. 
In truth, the action of the drug upon tbe circulation^ when it is used in in- 
flammatory dii>eaj^e and in delirium tremens, seems utterly different. The 
efieot in the former cutie, according to Mr* King, is to subdue the pulse and 
to render it irregular, an operation confirmed by Dr. Fereira*s own eiperienoo 
of large doses ; in the latter, tbe pulse increases in force and fulness. 

My own impression, from what I have seen and heard from Mr. Jones, is 
that in tincture of digitalis we have a true counter-pGtAon^ — an addition to 
tiiat class of mutually-antidotal poisons of which opium and belladonna have 
been the most receut eiamplea. Alcohol is the remedy by which we coun- 
tc^ract the depression produced by dif^italia ; tbe converse is also true, — 
digitalis is most remarkably an antidote to alcoholism. 

At a meeting of tbe Medical Hociety of London, May 12, 1828, Dr^ Thos, 
Williams related an instance of a drunken butcher having taken two ouncca 
of the tincture of digitalis in two dosea of an ounce each, in quick succes- 
sion^ without the ali^teat inconvenieGce ensuing. Thia ia quoted by Dr, 
Pereira. 

When Brat I heard of Mr. Jonen^s treatment, 1 tialUTivWy ua^^^^^je^i ^^ 
qaaJItjr of his tinQtare ; but on mentioning tbb, Tae a&sur<i^ m.% \\v^t \i^ ^^'^ 




PKACTICAL MEDICINE. 

employed ttncttire from a variety cjf iourcoB, und among tli© rest from 
Apothecaries^ Hallf am] ali^^nys with the asms resuJt. — M^d, Times and CJa* 

z€tu, Oct, la iB4m, p. 3Ga 

[Tfiis practice of Mr. Jonos ii re commended also by Dr. A Wyhn Wu>? 
LI A MS, whc^ae opinion U as follows.] ^ 

Tiiat such doses are as a rule not dan|pjeroug when th**re is any unnatural 
eicitcmc^nt of tho nervoua centrest j« fullj bonie out hy the fact tlmt even 
ounce-doaea of tincture of digitalis have been prescribod twenty years 
to ward off epileptic attacks* when there was any preliminary warning' 

^.tiieir approaeh. I was under the iinpresrion that it was Dr. Billing who 
w ordered it, but I eannot now find that ho did so in any of the editions of 
his works. In such cases I hare been in the habit of proscrihing it in half- 
oanoe doses for many years, and have found It by far the moat effieacioua 
remedy- 

The following in a ftiot-note, written by myself, many years ago* under 
the head of EpuepsjM— ** I hnvo certainly averted the impending paroxysm 
by administer J ng very liirge doses of digitalis, which does not itpp^ar to be 
BO nnmanageablo and iincertain in its effi^ctj* in large doses as in continued 
small ones. I have given as much as half-an-rmnee of the tincture on the 
threatened approach of a paroxyFai^ and never aaw any ill effects arising 
from administering so largo n dose* One patient alwaya kept a draught of 
the above dose in the bouse.'* 

There is one form of excitement of thp brain which I have never h»wl an 
opportunity of adniinistenng it in, namely, pncrperal convulNons* In this 
lormidable di^^^ease, f decidedly think it deserves a trial. — Med* Tlme$ and 

[Dr. WtJB^TER, Physician to the NorthBOiptou Infirmary, althoagh he 
wouldt bo Bays, be timid in adopting Mr. Jone.sV treatment by digitalis, gives 
the opinion and prnetic^e of Mr. Wood, of Heene, Worthing! who treated » 
OHse of t!iis kind with large doses of digitalis. Dr. Webster says ;] 

Corroboralive testimony to the innf^cuoasness of such a dose of our usual 
pharameopa ial preparation of that tincture, in our elitnate, to the averages 
constitalion of our patients, can from one or the other no doabt be supplied, 
(Dr. Wy nn Williams hast given us one); and T would try to report a some- 
what armlogouB case, mentiotjed to me by Mr. F. B. Wood, of Heene^ Worth* 
ing, and until rccontljpractjjiing tn this t*iwn, hoping that others may there- 
by bo induced to furnish their quota of experience pmot con, Mr^ Wood 
writes to me as follows : — 

** In rfjferonee to a plan recently suggested in the Mediral Times and 
Gazttit^ by Mr, Jonesof Jert*ey^of treating of delirium tremens by tincture 
of digitalis?* in compliance with your wish I !*end you a narrative of the ease, 
in which (many years ago) I treated a patient labouring under furious deliri- 
wm, with, as I then thought, hirge doses of the same drug. I (should coin- 
meiice by stnting that 1 had never previously attended the patient, but had 
learnt from reliable authority, viz., his previous medicid attendant, that the 
patient, in the sii or seven preceding years had three or four similar violent 
attacks. The treatment then ado]Ttod had been — venesection picno nvo 
from both arms at once, and freqaently repeated; hundreds of leeches to 
the forehead, by twenties, and twenty -fours at a time; large tjuantltes of 
calomel, and long continued drastic pargation* There were also several, 
and severe ndapses on each of these oceasiouB ; ond in one instance, after 
an interval of three weeks from the first seizure. On the last two occa^inns, 
when convalescent, the patient waa in such a low and melancholy state, 
that daily and nightly watching, for three or four weeks, had to be main- 
tained, for fear of the commission of suicide. I was sannnoned \a} attund at 
the last attfick, in October* 1844 or 1845, and the residence being several 
miles away from Northampton — and having been forewarned of the probabie 
nature of the case — I went armed with two ounces af the tincture of digita- 
}l3. VpoYi m^ arrival I at once gave a tea -spoonful of the tincture, and re- 
pe/ifeJ ji overjr hour for fovit do^eE (the second dtme htivrng been given in 
'niher less tiniti \. The patient then becoming muc\i t\unaWx» i^ixi ti\tesi\iil\u(tx 



1 




^iher less tinie). 




I 



PHACTICAL MEDICINE, 

iitenQW, I rp3i]u*ed the dose to hQlf-n-'drochm every twn, thrcGt aiitl ut last 
four boiLrfi, during the rprnjiiiiclor of the first twenty-lVmr hours frotii tho bimz- 
lire. The patient had only tu'o or thruo flight ri'liiiMVi^t itud tliL^se uithiu tlio 
first four daysp On the third day, wboii tlitrc was a alight relapte, the phy- 

tiaii who hod prBv^lously atteudcd wan gumtnoued in consultation. He ap> 
twelve hachG3 to the templea and forehead, continued the digntalid, 
ordered a fair quantity of ealomel and colocynthv This was all the 
Idood withdrawn ou tbis.oceaf^ion, and I confess even that afjain&t iny judg- 
ment. However, when oonvaloBcence was establishedt thcro wore none of 
the old symptoms of dobility, melonchtdy* &:Cm as in previnui attacks* 
Akof^etherthe patient took ahont fourteen draehnis of the tincture of dlgita- 
Us« lu the iirbt four hundred hours of his lUneBflJ' 

Ar« this patient has been under my supervision from time to time sint^e 
Mr. Wood left this tetwn, I win eorroborato the faet of there having been no 
return of the eomplaintt even though there has too often heen a sufficiently 
adequate amount of the aocustomed p rcivocati on i—ilfec^ Ttmes and Qazttiu 
Oct. 13, 18430. jj.3<>l» 

18- — On (he Treatment of Almholkfn, By Dr- SMTTtKOFF. — Dr, Smirnoff 
etate« that he has become convinced by repealed tnab that the asarum Euro- 
poatim well de^erveft tbo reputation it lias obtained in Hui^sia of being an ei- 
cellent remedy for the effects of drinkin|^» Tbe influi-nce of a continuous 
abuse of alcoholic drinks is tirst exerted locally^ but afterwards dyspepsia 
i» produced; and the nutrition and functions of the entire economy, es]>ecial- 
ly of the central portions- of the nervou/ sy.stemt becoming interfered with, 
tht^ blood itself Wm^ loaded with an injurious foreign male rial* the di/scra-- 
sia potatorum is at last eompletely CHlablis^hed. Tho asarum fulfils various 
indications, acting beneficially on the alimentary canal in thoBC casps in 
which tho digeKtive powers are so much at fault* Its aromatic pvinciplo 
confers upon it a st onachic power, and regulates tho condition cjf loe intt^i^- 
tinal diachargps, producing vomiting and purging when given in largo df>eie»* 
Its most beneiiciai actton, however, is manifested on the detect ive appetite, 
and by its counteracting the invincible longing for alcohol. The horrible 
sinisalion.^ with which the drink r^r awakes in tlie morning, and which hnpols 
him to seek tern porn ry and dcjlubive ndief fnnn renewed libations, are much 
blunted and mitigated by means of a glaj^jij uf !?trong infusion of as-aruui and 
some other nervine^— f,^*, valerian. Its iminediate effect is often to produce 
vomiting, and AometimcB purging; but the painful sonaatious at the epi- 
gaatnum undergo relieft and tho appetite becomes invigi>rated. iVrsona 
who have been long hahituatcd to alcoiioUc drinks cninmt, however, have 
these suddenly suppressed with impunity; and in such cases tho author 
gives the alarum in brandy, applying at tho same time a blister or an issue 
to the pit of tho stomach. By this meaoE^ the normal activity of tlio stomach 
booomes eicited and the longing for ale oho J diminished. The autiior, how* 
ever, cannot agree with thosae who would still allow a small quantity of s[iirits 
Ui habitual drinkerft, even when the morbid desire for it has hecome appoas^ed. 
The continuous useof a decoction of asarumt even vrhen it does not »uccf^cd in 
extinguishing the desire for alci^holt always supports the powers of the pa- 
tient: and It is remarkable in some canau^ in which the individuals have 
been long accustomed t*> periodical intervals of drunkenness, ending rn deli- 
rium tremens, how much longer these intervals will become, and how much 
less likely delirium tremens it to recur. The patients themselves are some- 
times flurprised at the comparative impunity with which they can continue 
their drinking. The author prescribes three or four glasses a- day of an in- 
fusion made with § iij* of asarum root, |j* of vale ri an root, and 3 4 of 
orange-peel, hut be does not state tho quantity of water employed. In 
ctLseii of drunkenness another formula ia composed of decoction of asarum 
(made by boiling from 3 i to %}. of the roi:it) | vj* tinct of valerian lij. to 
^nj., Bjd^/ihtim's hudmntm gtt xij., syrup of oraivge-\^ee\ \\, K V^i^^Jya 
wpoouM ofthia is takim every two hours. He find^ ttom i\?o \ja %.s% ^tt».\a 



J 



PRACTICAI- MEDIC IKE, 



'^ 



iif biFmulli taken four times a-day a valuaMo adjunct* Ho bas a1sD found 

tli(^ f<4iowiug popular Hussiari reuicdy i>f fienict* in cases of driinkenDes»: — 

^* Amnion carb, |4; HCftl vhiif Ibj. ; i»xyiael. ecill., ? i. Two table* 

ppoonfuls cvc'ry two hour^,— Med. l^mcs and Gaztltt^ July 28, 

1860, p. 9L 



la^^N THE THEORY OF SIMPLE EPILEPSY. 

Bf I>r, CuAHUBB BU.NP lUi^iCLTFrK, PhyiJeLiin to th^ Weatm^nster noiptUl. 

In tlifl epileptic fit itself^ tbe fpictt?, when fairlj rcadt admit of one con- 
eluMon, and one only* At tlio ingttvnt of the fallj a corpse- like pallor over- 
**preadg the conntunuiico and the puleo dies out at the wrigt^pheuoDDenft 
which seem to bo only jntelligible on the fiupposjtitm that the arteries ar<^ 
nearly empty of red blood, A monicut or two later, and the black and hlont- 
ad face, the choking soundsi and the absolute su«^pensioD of all respirator^' 
movements, show verj" plainly that the formation of red blood ia arrested for 
the time. During tho whole <jourse of the convubion, indeed^ the stato in 
one 4 if f^uffocatitnu Daring the convulsiont that m to &uy^ the supply of H.r- 
tcrinl blood is cut off at the fountain-head* 

There ig, however, one fact which, at first glance, might seem to show 
that there is an IncreaBed injection of arterial blood during the convulsion. 
8uch injection i^ raanifeptly very imperfect at the onset of the ilt, for upon 
no other suppoMtion canwc explain the corpse-like paleness of the counten- 
ance, and tlio feeble and imperceptible pulse. But if the iioger bo kept upon 
the wrist during the convulsion, it will be found that the pulse will go on 
rising until it has acquired a force and fulness which it never had in the 
inteqmresyiimal period ; and if the hand bo placed on the tireaati it will be 
fouml ulbo that this rising of tho pulse is accompanied by increased action 
of the heart. These fact8 are evident and unuiistakable, but they do not 
show, as without refleotion they Jnightseem to do, and as they are often sup- 
poaed to do, tlmt ted hhod h being injected in greater quantity into the ar- 
tertea during tho convulsion. 

When the process of rPFptration ia arrested, the right side of the heart 

and tho venous system generally are soon gorged and distended with black 

blood. Under these circumstances, indeed, tho gorged and distended state 

of the right side of the heart may reach a point in which the folds of the 

tricuspid valve are forced widely apart, and an opening left through which 

the beatings of the ventricle are made to tell almost as much in driving the 

blood back through the auricle into the veins, as in sending it enward through 

the pulmonary artery into the lungs. But it is not right to suppose that 

tho left side of the heart and the arterial trunks are empty of blood; and 

this may readily verified by watching the changes which take place in the 

carotid and jugulars of a rabbit during the proeot^s of suffocation. On ex- 

! l">!*i*ig tl^^ vessels, the artery is seen to be filled with red and the veins with 

I fdflck olood. On suffocating the animal by tying a lignturo around its wind- 

}iipe, the color of the blood in tho artery darkens raiddly, and in about two 

I minutes and a half it is every whit as bhick as tlial of the blnod moving in 

i the neighboring rein, Nor is the vein gorged and diatended and the artery 

I comparatively emptj. Oti tho contrary, tho artery is felt to pulsate as 

] htrongly under the rush of black blood as it did previously under tho rush 

of red blood* Nay, the pyUe fff the hlack blood is actnaily gironger than iht 

pulse of the red blood ,■ for, on tet^ting with the hajmadynometor, the hite 

ProfeSiSor John Keid (who first directed attention to these facts, and who has 

investigated the condition of the circulation in asphyxia more carefully than 

"* any other observer) found the mercury highest at the moment when the 

blood in the artery had become thoroughly venous and black. 
' A full pulse and a throbbinyg- heart* therefore, must be looked upon Bd na- 

I ii^rni aeci^mpummeutfi of asphyxia ^ find thus the full pulse and the throbbing 

heuvt of the epUepth parosjHUit instead of sbo\Ting t\iat a. Wg^ ^^ua.vilvX.'j ^ 



I 



PRAOTIOAL MEDIOIllfE. 65 

red blood is being injected into the arteries at the lime, may show that thesis 
vessf-ls are then labouring under a load of black bloody as they do iu as- 
phyxia. And that the full pulse and the throbbing heart of the epileptic 
paroxysm must have this latter significance is evident, for the livid, black, 
and bloated head and neck, and the complete suspension of all respiratory 
changes, show very clearly that black and not red blood is coursing through 
the vessels at this time. 

When the convulsion is over there is little to notice in the state of the 
circulation and respiration. When the spasms cease, the respiration is 
speedily re-established, and the re-admission of arterial blood into the sys- 
tem may be attended with some transient and inconsiderable febrile reac- 
tion ; but this reaction has nothing to do with the convulsion, for when reac- 
tion is present, convulsion is absent; and if convulsion returns, it is not till 
every trace of reaction has first taken its departure. 

Kegarding, therefore, these facts — the corpse-like paleness and the com- 
parative pulselessness at the onset of the paroxysm, and the signs of positive 
iiud unequivocal suffocation by which this stage of paleness and pulseless- 
ness is succeeded — and remembering the previous arguments, which show 
that the convulsion is not to be ascribed to the presence of the stimulus of 
venous blood, there appears to be only one c<»nclusion, and this is, that the 
convulsion of epilepsy is connected with the want of a duo supply of arterial 
blood in the vessels. 

Nor is it an objection to this view that the convulsions cease when the 
blood has become thoroughly deprived of its arterial properties. In order 
to discharge their office of conductors, it is certain that the nerves must be 
supplied with a sufficient quantity of arterial blood. If, for example, the 
principal vessel of a limb bo tied, the nerves of that limb, wanting their due 
supply of bl<K)d, are unable to carry messages to the mind, or to transmit 
mandates from the mind to the muscles, until the collateral circulation is 
sufficiently established ; and hence it is a fair infiTcnce that there must bo 
a point in the process of suffocation where, wanting a due supply of arterial 
blood, the nerves must cease to be conductors, and where, consequently, the 
convulsions will come to an end ; fi>r, upon any hypothesis, the convulsions 
will come to an end when the nervous centres cease to be in proper ccmuox- 
ion with the muscles. 

But, it may be asked, is there no change in the blood itself? Is there not 
some important truth in the ** humoral theory of epilepsy," as recently ad- 
vanced in this place by the late lamented Dr. Todd? ** I hold," said this 
distinguished physician, ** that the peculiar features of an epileptic seizure 
are due to the gradual accumulation of a morbid material in the blood, until 
it reaches such an amount that it operates upon the brain in, as it were, an 
explosive manner ; in other words, the influence of this morbid matter, when 
in sufficient quantity, excites a highly polarised state of the brain, or of cer- 
tain parts of it, and these discharge their nervous power upon certain other 
parts of the cerebro-spinal centre, in such a way as to give rise to the phe- 
nomena of a fit. A very analogous effect is that which results from the ad- 
ministration (»f strychnia, which is best seen in a cold-blooded animal, like 
the frog. You may administer the drug in very minute quantities for some 
time without producing any sensible effect; but when the poison has accu- 
mulated in the system up to a certain point, then the smallest increase of 
dose will immediately give rise to the peculiar convulsive phenoniona. This 
is the humoral theory of epilepsy. It assuuies that the essential derange- 
ment of health consists in the generation of a morbid matter, which infects 
tlie blood ; and it supposes that this morbid matter has a special affinity for 
the brain, or for certain parts of it, as the strychnia, in the case just cited, 
exercises a special affinity for the spinal cord. The source of this morbid 
matter is probably in the nervous system, — it may be in the brain itself. It 
may owe its origin to a disturbed nutrition — an imperfect s(^condary assim- 
ilation of that organ — and in its turn will create additional disturbaucQ \u 
iHie faoct'wns ana nutrition of the brain." And agam; ^^ lL<iGOT^\Tv^\;aVio»fe 
humnml theory, tbo variety in the nature and severity oi \.Vl^ ^\» ^'Ci^^\A^«^ 

XL II. — 3 



a6 PRAOnOAL MEDICINE. 

thft qaftntitr of the poisonons or morbid material, and on the part of tho brain 
which it chlpfly or primarilr affectfl. If it affect primarily the hemisphere*, 
imd spend itself, as it wore, on them alone, you have only the epileptic rer- 
tifr^^* If it affect primarily the region of the qaadrigeminal bodies, or if the 
affection of the hemispheres extend to that region, then you have the epilep- 
tic fit fully developed." 

This theory is based upon the well-known connexion between the presence 
of urea in the blood, or carbonate of ammonia resulting from the decomposi- 
tion of urea — the result of defectiTe renal action — and one form of epilepti- 
form convulsion ; and it might also have been based upon the connexion be- 
tween convulsion and blood overloaded with bile. But if there is any 
evidence in these facts in favour of the existence of this hypothetical morbid 
material, there is none in favour of the idea that the modus operandi of the 
material is in exciting a highly polarized state of the brain, if oy this state Is 
meant anything like a condition of excitement. On the contrary, it is cer- 
tain (as will be shown in the next lecture) that the action of the brain and of 
the nervous system generally is reduced to the very lowest ebb at the time 
when convulsion is brought about by the accumulation of urea and bile in 
the blood ; and it is not loss certain that strychnia, instead of acting as Dr. 
Todd supposes it to act— that is, by exciting a highly polarized state of cer- 
tain parts of the nervous centres, acts by reducing the stimulating powers of 
the blood, and by diminishing tho electrical action of both nerve and 
muscle. 

There is little doubt, however, that retained excretions must play an im- 
portant part in the production of epilepsy. A free discharge in the office of 
excretion, not only in the kidneys and liver, but in every excretory organ, 
is essential to the preservation of healthy blood ; and it may well be believed 
that an imperfect discharge of the office of excretion, in ont or other of the 
excretory organs, may lead to the accumulation of effete matter in the blood, 
and that this accumulation of effete matter may be a not unimportant cause 
in bringing about an attack of epilepsy. But there is no reason for suppos- 
ing that the blood under these circumstances becomes more stimulating. 
On the contrary, the conclusion which arises out of the history of the cases 
where the urine or bile is suppressed, is the natural conclusion, and this is, 
that blood thus altered is less fit to discharge its several offices; in other 
words, less stimulating. 

Nor does there appear to be any reason for supposing that venous conges- 
tion has a more important part to play in the production of epilepsy than 
that which has been assigned to arterial injection. No doubt the veins of 
the head and brain generally are congested from a very early moment, but 
there is a moment antecedent to this in which the death-like pallor of the 
face is a sufficient proof that the veins were emptier than usual before they 
became congested. At any rate, the acknowledged anatomical difficulty 
must be overcome before it can be supposed that Dr. Marshall Hall's hv- 
pothesis of trachelismus— or the prevention of the return of blood from the 
brain by the spasm of certain muscles in the neck — ^has anything to do with 
the causation of epilepsy. 

It would seem, then, as if there was something utterly uncongenial be- 
tween epilepsy and arterial excitement. It would seem, indeed, as if the 
spasms, as well as the loss of consciousness and sensibility, were connected 
with want ot arterial blood — empty vessels in the first instance, vessels 
filled with black Mood afterwards. It is not improbable, also, that the blood 
may have been previously rendered less stimulating by the retention of 
something which oueht to have been eliminated by one or other of the or- 
gans of excretion. In a word, the phenomena are entirely in harmony with 
the previous considerations respecting muscular motion ; for according to 
them, the action of arterial blood is to antagonize contraction, and not 
cause it. 

Interrogating the nervous system, the facts are found to have that theo- 
retioal 8igDi£caace which the state of the circulation and Te^^VwiUoii would 
Jead U9 to expect. 



PRACTICAL MEDICINE. 07 

These facts will scarcely warrant the idea that epilepsy is connected with 
anything approaching to over-action of the brain proper. On the contrary, 
everything seems to point to a state whicli is the very opposite of over- 
activity. Thus, the comparative want of memory, intelligence, fancy, and 
purpose, which marks the interpnroxysmal condition ; the utter annihilation 
of everything mental in the fit itself; and the gloom and prostration follow- 
ing the fit, arc facts which can have no double moaning. 

Nor is a contrary opinion to be drawn from the morbid appearances which 
are disclosed after death. If these chance to indicate previous inflamma- 
tion, it does not follow that convulsi<»n had any direct connexion with the 
inflammation as inflammation ; on the contrary, the convulsion may have 
liappencd before or after the inflammation, when the energies of the 
brain were prostrate or exhausted — an alternative which we shall see to be 
the correct one when we come to speak of epileptiform disease connected 
with special disease of the brain. And surely it is not possible to draw any 
but one conclusion from the appearances which are common to epilepsy 
and dementia — pallor of the grey substance, atrophy, chronic softening and 
induration, dropsical effusion and the rest? 

But what of the state of the medulla oblongata 1 for, as Professor Schroeder 
Van der Kolk has well shown, the seat of uie characteristic spasms, the bi- 
lateral character of the spasms, and the appearances presented after death, 
all p«>int to this organ as one which is specially concerned in bringing about 
the epilectic paroxysm. 

The spasms of epilepsy begin in muscles which receive nerves from the 
medulla oblongata — in muscles, that is to say, which are supplied by the 
facial, the accessory, the hypoglossal, and the portio minor trigemini; in 
slighter cases they are limited to these muscles. The spasms of the walls 
of the chest and abdomen, which are the most prominent and marked fea- 
tures in the complete attack of epilepsy, and which may be so fierce and 
unyielding as to cause fatal suffocation, also point to the same nervous cen- 
tre ; for a similar state of things is brought about by the action of a strong 
•timulus upon the great afferent nerve of this centre — the pneumogastrio. 

The bilateral character of the spasms is another argument that the me- 
dulla oblongata is especially affected in epilepsy. The lateral halves of this 
organ are connected in the most intimate manner by transverse fibres and 
commissures — much more intimately than the lateral halves of the brain and 
spinal cord ; and hence it is that the corresponding nerves belonging to the 
two sides of the medulla oblongata are under a stronger physical necessity 
to act together than that which rules the corresponding nerves beUmging t(» 
the two sides of the brain and spinal cord. In the case of the two latter 
centres, the nerves belonging to one side may be paralysed or otherwise af- 
fected, without any obvious injury to the nerves of the other side ; but not 
so in the case of the latter centre. Indeed, it is evident that the actions 
which emanate from the latter centre — the play of the features, the motion 
of the tongue, the vocal adjustments of the larynx, the respiratory move- 
ments, &c. — must at once come to an end unless there be the strictest sym- 
pathy and concert in the action of the corresponding nerves of the two 
sides. Now, in epilepsy the spasms are always more or less bilateral, and 
for this reason, therefore it may be supposed that they have some special 
connexion with a nervous centre of which one lateral half cannot act with- 
out the other. 

The appearances after death point also to the medulla oblongata as espe- 
cially coucenied in the production of epilepsy. In an early stage of the 
disorder, we may fail to find any characteristic changes; but, in confirmed 
cases, the texture is harder than natural, from the interstitial deposit of a 
minutely-granular albuminous matter, or else softened, swollen, and exhib- 
itinff signs of evident fatty degeneration. The posterior half of the me- 
dulw oblongata is redder and more hypersemic than it ougUX V> \)e\ ^cci^^ «a\\ 
examining the blood vestseJs in this congested portion, tVicy atQ^()\iTv^\n\:i« 
of thrice their natural duoeosioDS, and with their ^aWft mxicXi lVi\cVviWfe^ %Ti^ 
sJiered^thiB dlJatation and oitention being chieay m Wie cot^>x^ o\vi%x« 



G3 PRACTICAL MEDICINE. 

nnd in the coureo of the hypoglossus in the case of epileptics who bite their 
tongue, and in the course of the roots of the vagus in the case of epileptics 
who do not bite their tonf^ue. 

It is evident, then, that the medulla oblongata is especially affected in 
epilepsy; but it does not follow, as Professor Van dor Kolk supposes, that 
the essential cause of the convulsive affection is to be found in un exalted 
sensibility and activity of the ganglionic cells of this centre. 

In favour of this view, — that epilepsy is dependent upon exalted sensibil- 
ity and activity of the ganglionic cells, — appeal has been made to the fact 
of spasm, to tlie presence of a full, bounding pulse, and to the freedom from 
attack which is for some time the fruit of an attack, particularly if this has 
been violent; but the onswer is not necessarily that which Professor Van 
der Kolk supposes it to be. After what has been said about muscular mo- 
tion in the first lecture, it is not possible to allow that spasm in itself is an 
argument in favour of exalted sensibility and activity in ganglionic cells. 
After what has just been said about the phenomena of the circulation in 
epilepsy, it is impossible to allow that the condition of the circulation fa^ 
vours spasm by bringing about a more active state of the medulla oblongata, 
(the functional activity of this, as of every other organ, being in direct 
proportion to the activity of the circulation of red blood in the organ;) for 
it has been seen that the bounding pulse, to which reference is made, is filled 
with Hack blood, and not with red. Nor can the freedom from attack, which 
is for sometime the fruit of an attack, bo appealed to as a certain proof that 
the attack is the sign of the discharge of some overcharge of excitability 
previously present. On the contrary, it may be argued with some degree 
of plausibility, from certain facts which have to bo mentioned in the next 
lecture, that the attack was preceded by depression of the circulation and 
innervation, that the convulsion supervened when this depression had reached 
a certain point, and that the recurrence of the attack was prevented for a 
time by the state of reaction in the circulation and innervation, which is a 
consequence of the convulsion. The case may be one, indeed, of which the 
history of the rigors of ague may serve as no inapt illustration ; for here we 
have, first, the circulation failing more and more until the bathos of the cold 
stage is reached ; and, secondly, a state of reaction which banishes the rig- 
ors most effectually so long as it continues. 

It would even seem as if 'appeal might be made to the appearances after 
death, and to the actual condition of the circulation in the fit, for positive 
arguments against the idea of anything approaching to exalted action of the 
medulla oblongata. 

The signs of fatty degeneration can have but one significance — under- 
action, not over- action. The interstitial deposit, also, implies an equivalent 
absence of healthy nerve- structure, and so does the dilated condition of the 
bloodvessels ; and this absence of nerve-structure must necessitate a corres- 
ponding absence of nervous action. The appearances after death, indeed, 
if they show anything, show that the medulla oblongata of the epileptic is 
damaged in structure^ and because damaged in structure, weaker in acttout 
than it ought to be. 

The great argument against the idea of anything like over-action of the 
medulla oblongata in epilepsy, however, is to be found in the state of the 
circulation ; for if, as may safely bo assumed, the activity of any organ is 
in direct relation to the activity of the circulation of red blood in that organ, 
how far from anything like over-action must be the state of things in which, 
as is the case in the epileptic paroxysm, the vessels are at first compara- 
tively empty of red, and afterwards completely filled with black blood? 

Nor can the curious discovery of Dr. Brown-S6quard, that certain inju- 
ries of the spinal cord are followed by an epileptiform affection, be construed 
into an argument that there is anything like a state of exalted action of the 
spinal cord in epilepsy. This curious result, which is brought about by 
puncturing or dividing more or less completely almost any part of the spinal 
cnrJ, is developed^ Dot immediately, but in the course of tVitee or four weeks 
after the injury. The attacks, once developed, occui spontBu^oxx^^y bX. N%r 



PRAOTIOAL MEDICINE. 69 

rious intervals, often several times a day ; they may also be brought on bj' 
pinching or otherwise irritating the portion of the skin which corresponds 
to the region of the whiskers in man. This excitable spot is supplied by 
twigs belonging to the sub-orbitary, the auric ulo- temporal is. the second, 
and perhaps the third cervical nerves ; and it is a curious fact, that the ir- 
ritation which brings on a fit when applied to the skin in which those twig:« 
terminate has no such effect when applied to the twigs themselves. Any 
other part of the skin may be pinched or irritated with impunity, but this 
one spot can scarcely be touched without at once bringing on a fit. 

These facts are very curious, and, in the main, very unintelligible ; but 
this much at least is evident, they do not countenance the idea of any over- 
action of the spinal cord in epilepsy. The fact that the epileptiform affec- 
tion does not make its appearance until four or five weeks after the injury 
would appear to show very clearly that the fits have nothing to do with 
that local inflammation in the cord which may be supposed to have been set 
up in the first instance by the injury. After such a lapse of time, indeed, 
is it not the natural conclusion, that any over-action of the cord arising 
from the inflammation produced by the injury must have died out, and left 
the cord damaged, weakened, under-acting ? Nor is a contrary conclusion 
to be drawn from the excitable condition of the nerves proceeding from the 
neighbourhood of the cheek or cheeks; for both sides of the face are thus 
affected, if both sides of the spinal cord have been injured. What the full 
significanco of this curious fact may be we may have yet to learn, but at any 
rate there is no reason to suppose that this excitable condition of the skin 
implies an over-acting condition of the nerves or nervous centres concerned 
in the phenomenon. The excitable portion of skin is not over-sensitive, for 
the animal manifests no signs of uneasiness when it is handled immediately 
after a fit. ^Over-sensitiveness, moreover, would seem to have nothing to do 
with the matter. At any rate, pain, and not convulsion, is the consequence 
of handling those portions of the skin of the animal which may have been 
rendered highly hyperaesthetic by the injury to the cord which brought on 
the convulsions. It is certain, also, that a somewhat similar condition of 
excitability is brought on when, as in several experiments related in the 
first lecture, the skin is cut off from the full influence of the nervous cen- 
tres ; and hence the natural inference would bo, that the action of the ner- 
vous centres in the epileptic guinea-pig is minus rather than plus. 

As in the former instances, however, so here, we turn to the condition of 
the circulation and respiration in order to know wliat is the actual functional 
condition of the spinal cord in epilepsy; and so turning, we see that the ac- 
tion of the cord under these circumstances must be almost or altogether nil. 
For what action can there be when little or no arterial blood is injected into 
the vessels ? 

A similar argument will also dispose of the idea of over-octivity of the 
ganglia of the sympathetic system as a cause of epilepsy. It is very possible 
that the contracted state of the arteries, which is implied by the death-like 
pallor of the countenance and the comparative pulselessness at the wrist, 
may show that the coats of the vessels are in a state of spasm ; and it is 
also possible that the cause of this spasm may have to be sought in the 
sympathetic system ; but it does not follow that over-action of this system 
is the cause. On the contrary, the experiments of Drs. Kussmaul and Ten- 
ner show most conclusively that strong epileptiform convulsion is possible 
when the action of the sympathetic ganglia is entirely suspended by arrest- 
ing the supply of blood to these organs. 

And certainly no opposite conclusion is to be drawn from the vague and 
undefinable sensations or movements, very varying in character, but all 
comprehended under the term aura — sensations of pain, numbness, tingling, 
or a feeling of cold vapour; movements of shuddering or spasm, begiai\vw% 
in a distant part and travelling towards the head ; for t\\<i m^^sV \>TC^^^\^^A^ vtv- 
terpretation of these symptoms is that of Dr. Watftou — ^\\\a\. X^^-^ «>x«k va 
0nme degree analogous to the uumb and tingling foeVmc* 'w\\\cYv «kxe >i?c^^ ^^^- 
queat precursors of paralysis and apoplexy, or to the gVoXjua ol V^^Xft^^'—' 



70 PBAOnOAL MEDICINE. 

phenomena which bj the most perverse process of reasoning can scarcely 
be supposed to indicate other than a state of defective innervation somewhere. 

Butf it may be asked, is there nothing else ? Is there no peculiar state 
of the nervous system in epilepsy? Is there no morbid irritability ? In 
order to answer this question, it is necessary to ask another — What is morbid 
irritability ? It is not inflammation; it is not fever; it is some indefinable 
and negative state which occurs frequently in teething, in worm disease, in 
uterine derangement, and in many other cases — a state in which the patient 
is unusually depressed by depressing influences, and unusually excited by 
exciting influences. But what is this state ? Is it anything more than 
mere exhaustion ? In difficult teething, the strength is worn away by pain 
and want of sleep ; in worm disease, the parasites help to starve and exhaust 
the system ; in uterine derangement, the health is undermined, in all proba- 
bility, by pain and by sanguineous or other discharges. In each case there is 
unequivocal exhaustion of body and mind, and the signs of morbid irritabili- 
ty appear to be nothing more than the signs of such exhaustion. A weak 
person is more affected by the several agencies which act upon the body 
from within and from without, and he is so because he is without some of 
that innate strength which belongs to the strong person ; and the person who 
is morbidly irritable is, in reality, one who, for want of this principle of 
strength, responds impatiently to the several stimuli, whose office it is to elicit 
his vital phenomena. In a word, this undue morbid irritability may bo 
nothing else than the natural consequence of that general want of power, 
the signs of which are written so legibly upon the vascular and nervous sys- 
tem of the epileptic. There is no necessity, then, to look upon this morbid 
state of irritability as an evidence of the existence of any peculiar condition 
in some part of the nervous system ; for, thus interpreted, it only shows 
that the state of muscular contraction is ill antagonized by nervous influ- 
ence. Thus interpreted, indeed, morbid irrita'bility only becomes another 
name for inefficient innervation. 

The theory of simple epilepsy ^ therefore, which may be deduced from a con- 
sideration of the facts relating to the nervous system is in harmony with that 
to which we have been led by a review of the state of the circulation and 
respiration in the epileptic; and this theory is one which tallies as com- 
pletely with the view of muscular motion set forth in the first lecture, as 
it disagrees with that commonly received opinion according to which the 
muscles are supposed to contract convulsively because they are subjected to 
excessive stimidation. — Lancet, May 26, 1860, p. 512. 



20. — On the Use of Faraday^ s Electricity in Chorea. — In this disease, the 
action of this therapeutic agent differs widely, according as it is applied to 
the skin or transmitted through the muscles. Faradization of the muscles 
checks the irregular contractions, during the whole time of the passage of 
the current; but when this is intermitted, chorea reappears with the same 
violence as before the operation, and no trace whatever remains of the elec- 
tric action. Muscular faradization is therefore inefficacious for the cure of 
chorea; but it may bo advantageously resorted to to contend with asphyxia, 
one of the most dangerous symptoms of the disease. To effect this purpose, 
the current must alternately be transmitted through the inspirator and the 
expirator muscles. Faradization of the skin, on tne contrary, is applicable 
to all cases of chorea, and occasions a very rapid and marked diminution 
of the movements, and frequently effects a prompt cure of the malady. 
M. Briquet applies Faraday's electricity to the skin every day or every other 
day, during five or six minutes, along the entire length of the affected limbs, 
and chiefly upon the parts most convulsed. In eight choreic girls so treated, 
the complete cessation of the irregular muscular action was obtained once in 
ff/ffht, in a second in twenty-one days, and in the others in twenty-four, 
rwentj-vigbU thirty'tbree, thirty-six and forty-seven daya, Oivvs ^tvWcvvl W€t 
i/j0 hoBpHal after a fortmght imperfectly cured. In like ma^oiiXy oi ii3!a.^ e«a«* 



PRAOTIOAL MEDICINE. 71 

tho usual methods of treatment bad been unavailinglj resorted to for a space 
of from six to eight and twelve weeks ; the faradization of the skin may 
therefore be asserted evidently to hasten tho cure of chorea. — Dublin Hos- 
pital GazctU, May 15, 1860, p. 158. 



21. — Is the Brain in a state of Congestion or not during Sleep? By John 
Hilton, Esq., F.R.S., Surgeon to Guy's Hospital. — (The general opinion 
ig that during sleep, which is a kind of slight coma, tlie brain is in a state of 
congestion, that the pia mater and other plexuses are more or less pressing 
slightly on the brain. Mr. Hilton brings forward some experiments by Mr. 
Dunham, one of tho Demonstrators at Guy's Hospital, to prove that this 
opinion is at the least very doubtful.) 

A dog having been chloroformed, a portion of the bone, about as largo as 
a sixpence, was removed from the parietal region of the skull by means of 
the trephine; the subjacent dura mater was cut away, and tho surface of tho 
brain exposed. As long as the animal continued under the influenco of chloro- 
form, the smaller vessels of the pia mater were turbid with dark coloured blood, 
and the larger veins were considerably distended. No difference in colour 
between the arteries and veins could be recognised. The exposed portion 
of the brain manifested a tendency to rise into the opening through the skull. 
By and bye the immediate effects of the chloroform passed off, and the ani- 
mal sank into a comparatively natural and healthy sleep. A very marked 
change in the appearance of the brain accompanied this change in the stato 
of the animal. As sleep supervened, the vessels gradually emptied them- 
selves; the veins ceased to attract notice by their distension; the exposed 
surface of the brain sank down to, or below, the level of the opening, and 
became pale ui colour. In the course of a short time the animal was roused, 
and irritated. A blush seemed to start on the surface of the brain ; tho ves- 
sels of the pia mater became fuller and fuller, and of a bright arterial hue. 
The contrast between the appearance of the brain during this state of func- 
tional excitement and the previous state of quiescence was most striking. 
The more the animal was excited, tho fuller of blood did its brain appear ^l 
become, and the higher did the exposed portion rise above the general level. 
When the animal was allowed to return to its state of repose, the brain 
again sank down, and roassumed its pale aspect. A full account of these 
and other confirmatory experiments and observations will be read at tho 
British Association meeting at Oxford. — Lancet, Sept. 1, 18G0, p, 206. 



DISEASES OF THE ORGANS OF CIRCDLATION. 
22.— ON THE SIGNIFICATION OF THE HEART'S THROB. 

By J. Maclibb, Esq., F.R.C.8. 

In daring, now-a-days, to state my conviction that the throb of the heart, 
as felt in the left pectoral region of man or animals, is due, not to the sys- 
tolic action or contraction of that organ, but really to its diastolic motion or 
expansion, it may well be said that I should be furnished with good reasons 
for such belief, since tho enunciation of it is in opposition to all recorded 
physiological opinion and the consequences thereby incurred. 

When we renect, however, that the opinions of even the highest authori- 
ties on a question of this nature cannot be otherwise, under the anatomical 
oircamstaoces, then more or less speculative, according as the veiled phen- 
omena happen to be interpreted, this should give a place in the arena of de- 
bate to any one disposed to enter. The heart, as functional within, tlv^ c^tvc\o%- 
iog thorax, is impossible to be demonstrated. Its mt^tVotift ol %^«\jc\q ^\i\ 
SmsioJe, which we infer, (and reasonably) to be necessaxy iot eXtCivA^NXoTv^ 
sr» peiiormed out of view. And when, irfter expcximoiiUA m\k\Ii\!eAAfi.u ^i 



72 PBAOTIOAL MEDICINE. 

form and mochani^in, the heart is exposed, we see, instead of the free ex- 
pansion and contraction which we expected to witness of such an organ, hut 
ti mere alternating spasm and relaxation of its muscular fihres without pro- 
ducing any change in the capacity of its interior. ' Whether the heart lio. 
detached from its connections and removed from the thorax, or still holding 
its natural relative position by its^ vascular trunks, it manifests characters 
in common with all muscular substance. In neither condition can we dis- 
cover the organ performing that motion, which would account for its throb — 
its measured, positive, dynamic impulse anteriorly against the left thoracic 
side ; and, because there are anatomical facts to prove that the heart's sys- 
tolic action cannot effect this beat, and hence leave us no choice but to regard 
it as the effect of diastole induced by some physical condition of the organ 
in the thorax of the living body, and only when so situated, I have no hes- 
itation in laying before your readers the two following propositions : — 

1 . The hearVs throb cannot he caused by its systolic action. 

2. The hearVs throb can he caused by its diastolic motion. 

Amongst the anatomical evidences which appear to mo to prove the first 
proposition directly, and the second indirectly, I need only mention a few, 
for these are sufficient : — The living heart in situ is enveloped by the lungs 
in all parts of its periphery with the exception of a portion of the right (an- 
terior) side of the right ventricle, near its base, which portion, of gi*eater or 
less area in different cases, is ]>laced close behind the fourth, fifth, and sixth 
left costo-sternal cartilages. The apex of the heart is at all times, both 
during inspiration and expiration, covered by the left lung intervening be- 
tween it and the thoracic wall. The apex, therefore, cannot strike the tho- 
racic left side, as it is supposed to do by those who believe that the heart's 
throb is owing to systolic action ; and, even if such a locomotion of the heart 
were otherwise possible, the closely investing bag of the fibro-serous peri- 
cardium, which oinds the organ to the diaphragm, would bo sufficient to pre- 
vent its occurrence. If, then, to any particular part of the heart, by reason 
of its being in close apposition with the thoracic parietes where the throb is 
most appreciable, that impulse can justly be assigned, it can only be that 
portion of the body of the right ventricle which is permanently uncovered 
by the left lung ; and, in respect to this part, it remains to be considered 
whether the throb is caused by its diastolic or its systolic motion. 

The physiological phenomena which, I think, should induce us to ascribe 
the heart's throb to diastole of the body of the right ventricle, and to this 
part only, must of course negative the assumption that it can be the oftVct 
of systole, or of any other of those many various and oftentimes futile causes 
which have been recorded. 

The heart, as a hollow muscular organ, must perform its contractions, al- 
though these be vital, according to the physical law — that is to say, the 
larger space which the heart, while diastolically full, occupied in the thorax, 
must in respect to that organ be diminished when this is systolically expell- 
ing its contents from its cavities through the arterial system. The diminu- 
tion of the heart by systolic contraction on the blood is answered by the dil- 
atation of the artery as recipient of that fluid ; and, conversely, the diastolic 
enlargement of the heart as recipient of blood must be answered by recession 
of the artery as conductive of the blood. This being the, so to*speak, natu- 
ral librative motion of the organ and its arterial vessels, it ought to appear, 
I think, at first sight self-evident that of the two states — viz., increase of 
volume or capacity, and decrease of the same — the former is the more likely 
to cause the pectoral impulse or throb, and as if signifying that the diastolic 
heart knocked at the breast for larger room, so as the more amply to receive 
and pass the rising venous tide. 

When the heart has performed systole, all its diameters have become les- 
sened towards a common centre, which is in its septum ; and consequently 
it may be reasonably assumed that the external paries of the right ventriclo 
muat tend rather to separate itself from the thoracic wall than be impelleil 
against It, for now the blood is in efflux from t\\« OTgan. Ou tVvo coutrary, 
w/ien tbo heart is being set in diastole, all its diametota \>©com© Vn^ix^tx*^^ 



PRACTICAL MEDICINE. 7-3 

from the same cardiac centre ; and necessarily, the wall of«the rif^ht ventri- 
cle mu[?t become suddenly pressed against the front of the left tliciracic wall, 
for now the blood is in afflux to the heart : and that its entry into the organ 
is sudden, I, for my own part, find every reason to believe. Sy>tolc, or ac- 
tion, is followed by diastole as quick, as reaction ; and these being the only 
two motions of which the heart is capable, and in the performance of which, 
alternately, without interval, through life it is engaged, the latter motion, I 
am persuaded, for the reasons specified, is the cause of the pectoral heat. I 
have found it possible to imitate it in the dead subject in this manner: — 
Having tied the brachio-cephalic veins as closely as possible to their origin 
in the superior vena cava, the free-vented nozzle of a large syringe full of 
size solution was Inserted into the inferior vena cava close to the forann ii 
quadratum in the diaphragm. The thorax was left, as naturally, entire ; and 
the lungs were fully dilated through tiie trachea, so as to support the heart 
laterally and posteriorly, and keep the right ventricle in apposition with the 
left costo-sternal region. On placing my hand over this region, while tin* 
syringe by a quick motion of the piston-rod suddenly injected that ventricl**, 
I felt an impulse similar to the heart's throb. Again, in order to prove that 
it is to the diastolic part of this ventricle which is uncovered by the luni;, 
and not to the systolic apex of the heart, that the throb is due, the heart, 
circumstanced as above, was injected with wax, and this allowed time to wt, 
when, on exposing the organ, the body of its right ventricle was found to 
have been flattened against the corresponding part of the thorax. This flat- 
tening I take to be indicative of the natural tendency of the diastolic motion 
being sternal, and therefore that it is this motion which causes the throb. 
With this conclusion all the other vital phenomena accord. The heart'i* 
beat and the arterial pulse are not synchronous, which necessarily they 
would be if the former were the effect of systole. — Lancet, Juhj 28, 18(»0, 
p» 95. 

23.— ON THE PREVALENCE OF HEAT APOPLEXY AMOXCJ 
SOLDIERS DURING THE HOT WEATHER CAMPAIGN IN 1858. 

Bj Dr. CnAJtLZS Alkxandeb Gusdox, C.B^ Surgeon, 10th Reflrimcnt. 

[Generally speaking, it is not among the soldiers who are permitted to go 
out freely during all seasons and in the heat of the day, that sunstroke \a 
most liable to occur. Confinement of the men to their barracks during a 
great part of the day in the hot season, is a fertih^ source of tulx-rcular dis- 
ease, yet this practice is extremely common in India.] 

It is the subject of common remark in India, that one of the metereolorrical 
conditions under which **heat apoplexy" chiefly occurs, is when the breez** 
for a time ceases — the sky becomes obscured by a film of dark, negatively 
electrified clouds, and a sense of oppression hangs like a weight upon the 
mental as well as bodily energies. At such times, not only do men bec(»me 
the subjects of this disease, but the lower animals are not unfrequently at- 
tacked, and die suddenly from it. 

During the operations against the rebels in the Arrali district, a very re- 
markable influx of cases of this disease occurred among the Briti.'-h portion 
of our force on 2;3rd and 24th May, 185H; and from h-tters subseqm iitly 
received, we learned that a very remarkable number of seizures occurreil oti 
the same dates amrng the soldiers employed on field service tiiroughout th«t 
Presidency. 

This circumstance tends to confirm the opinion, that the proximate vi\\\*n 
of the disease is lost balance of the cercbro-spinal and sympath«-tic nervous 
power, induced, no doubt, by particular modifications in the crmditions of 
atmospherical influences, the precise nature of wiiich our present means of 
investigation do not enable us to detect. 

Recent occurrences in India have attracted attention to iVetv\.\\A \Tn\\\ ^Vt\X 
J3 emUed Mon-strake more thaa heretofore; the experience c»i n\v<\\t\\\ o^tfrx^ 
la ihMi coaatrjr impreaeing them frith the opinion, tV\at wAvWoi* \^ wiA %'»^- 



74 . PEACTIOAL MEDICINE. 

hausted by long previouH service on a campaign, run comparatively little 
risk of attacks of this nature, however great may be their exposure, so lon^ 
us they are successful in the military operations in which they are em- 
ployed. 

It is far otherwise, however, when the system is lowered by previoos 
severe duty, insufficient food, by disaster, or any other of the ordinary causes 
that depress the vital energies; under such circumstances the men are prone 
to become affected by the disease when exposed to the sun, more especially 
if they have to march in ** close order'' through jungle tracts, where there id 
very imperfect circulation of air. 

Mr. Hill publishes a tabular summary of all the recorded cases of the di^ 
ease to which he has access. The table contains records of 47, and of this 
number the following are the alleged causes of the attack : — 

Exhaustion, fatigue, and exposure to the sun ... 5 

Exposure to sun alone 9 

Cause not noted 2 

Heat in camp 6 

Drink and exposure to sun or hot winds .... 9 

Drink, exhaustion, and heat (whether with exposure not stated) \2 

Heat, without exposure and without drink .... 2 

Heat alone (not stated whether or not with exposure) . . 2 

— Indian Annals, July, 1858. Total . 47 

We thus find that exhaustion or fatigue has had more or less to do with 
the disease in seventeen of all the cases above noted. 

Next to depression from long-continued fatigue or imperfect food, the most 
prevalent predisposing cause of heat apoplexy is the habit of dram-drinking, 
in which all soldiers indulge more or less. During the hot season of 1855, 
it was found that men of the Bengal Artillery, stationed with the 10th Re- 
giment, died in great numbers from sun-stroke, while our soldiers did not 
suffer in an unusual proportion from the disease. Inquiry elicited the fact, 
that the men of the Artillery, each day at noon, ran through the intense 
heat from their barracks to the canteen, rapidly swallowed their allowance 
of rum, ran back, partook of a heavy meat dinner, and threw themselves 
upon their cots, where they snoozed away, in half-unconsciousness, till the 
time arrived for them to dress for their evening exorcise. The men of the 
10th Kegiment, at the same station, were never permitted to partake of 
spirits until after sunset. This plan was subsequently adopted in the Ar- 
tillery, and the disease ceased. 

In Indian Annals of July, 1858, it is stated that when the 67th Regiment 
was ordered from St. Nicholas Mole, St. Domingo, upon an expedition up 
country, the troops, previously to marching off, were supplied with a full 
ration of spirits. It was, as might have been foreseen, speedily consumed ; 
and the men marching through a dry, sultry country, that furnished ^no 
water, fell down at almost every step. Nineteen actually died upon the 
road. 

The system of allowing the soldiers to dine in the middle of the day, while 
there is a prevalent tendency to heat apoplexy, is objected to by many medi- 
cal officers. While we were employed on field service during the hot season 
of 1858, the soldiers were permitted to dine, when praticable, and they 
wished to do so, in the evening. The experiment was upon too small a 
scale to justify any conclusions beiug drawn from it, nor did any particular 
result follow. If we are to judge from what occurred in the 20th Kegiment 
at Lucknow, however, the dangers of the soldiers of talking heavy mid-day 
meals at such times is apparent, and seems among these men to have in- 
duced this disease. 

Dr. Cheans states, that "On 10th June, (1858), the 20th Regiment 
marched out of Lucknow, and reached AUumbah about 9 a. m. From want 
of tents, the men were exposed to the sun^B rays andYieat oi VVi^ ^\x\x for mv- 
ejTiJ hours. 



PRAOTIOAL MEDICINE. ^ 75 

'* Before erening, 56 admissions had taken place in a force of 497. Threo 
men died within four hours. Next day, 23 admissions from fever; on 12th, 
5 admissions, 4 of which showed symptoms of apoplexy, 1 proving fatal 
about 3 a. m. ; the fifth was a case of cholera. 

** Daring the remaining three days there occurred 6 cases of heat apoplexy, 
1 of which proved fatal ; 2 of cholera; and 79 of fever. It was particularly 
observed that most of these cases of heat apoplexy occurred between the 
hours of 3 and 7 p.m., when the men had dined, and the sun falling, the heat 
hod become more sensible and oppressive.'' 

It is certainly not a little remarkable that notwithstanding the severe duty 
and exposure to which our men were subjected at different times between 
Ist April, 1857, and 31 st March, 1858, not one became affected with heat apo- 
plexy ; dysentery having been the disease by which almost the entire mor- 
tality was occasioned. Vertigo and other premonitory symptoms occurred 
by no means unfrequently ; but they did not attain that degree of intensity 
that would constitute pure sun-stroke, — cold affusion and brief seclusion 
from direct solar heat being all that was necessary for their recovery. 

Other regiments, however, were less fortunate; and personal knowledge' 
enables mo to say that soldiers were most liable to the disease when, afti^r a 
debauch of spirits over night, they were forced to march armed and accoutred 
during the heat of the succeeding day. This was only what might have 
been anticipated, 

In an inquiry into the proximate cause of heat apoplexy, wo shall find the 
remarks of Mr. Hill to bo well worthy of our consideration. 

This author alludes to one of the well-known efiects of exposure to great 
heat, by which the oxygenating power of the atmosphere becomes impaired 
as a consequence of the expansion created by increased temperature. He 
then goes on to make some observations, the truth of which was illustrated 
in my experience of the disease during tho mutinies. 

It follows, thot the oxygenating power of the atmosphere being diminished, 
the respiration must become accelerated ; the circulation also increases in 
rapidity, and, as a result, the temperature of tho body rises. The imper- 
fect decarbonization of the blood which results from this condition, is in a 
measure illustrated in everyday life in India; giving rise, as it no doubt 
does, to the listlessness, lassitude, want of physical energy and mental vig- 
our, as also to the extraordinary tendency to somnolence, which manifests 
itself to persons newly arrived in that country. 

As the expansibility of tho circumambient air increases, so likewise does 
its capability of receiving other gases, whether in tho shape of malaria, 
miasma, or effluvia, emanating from the earth or disengaged from soils or 
other sources, often under circumstances inexplicable and conditions un- 
known. Moreover, this expanded condition of air favours the more ready 
disengagement of these noxious principles. It f«>llows, that a great quanti- 
ty of pernicious ingredients are inhaled, and are in an unusually concentrated 
form brought in frequent and close proximity to the blood, tho absorbing 
powers of which are increased by the circumstances which give rise to the 
conditions now under notice. 

The skin is nn outlet for pernicious products that are taken into the sys- 
tem. If it perform its functions in a proper manner, they will be quickly 
expelled; but if this conservative function ceases by perspiration being 
checked, or from any other cause, the inhalation of these noxious principles 
continuing, — then, indeed, are induced a succession of evils constituting in 
their integrity an attack of fever or of heat apoplexy, according to tho other 
causes which may be in operation at tho time. 

Diminished evaporation from the skin in a most hot condition of atmos- 
phere thus explains why we then suffer most (in health), and why hot clim- 
ates are most unwholesome. A moist state of atmosphere is also favourable 
to absorption: hence night is the most unhealthy time in mulvLtU^w^ d\«^- 
tricts, because then morhiBo emanations are most rcadWy takew \u\.c\ \.Vv^ vj^- 
tem; and hence also, no doubt, arises tho circumBtanco, a\tO!\<iy fxWwvS^ci^ V^> 
that attacks of tho present disease more frequency occut in \^e»t%o\i% ^>w\Ti% 



76 ^ PRACTICAL MEDICINE. 

the night-time than when they are exposed to the direct rays of the most 
powerful sun. 

Another circumstance of no little importance may also be explained on 
the same supposition — namely, the greater liability of men to be attacked by 
the disease when they are crowded in masses than when they are in parties 
of inconsiderable size, or altogether isolated ; as also the fact, that a body 
of soldiers, marching in close column along a narrow road through dense 
brushwood, where the atmosphere is but little agitated, are far more liable 
to suffer from heat apoplexy than they would be if marching along the open 
country, whore the poisonous emanations arising from their own bodies ure 
instantly carried away by the breeze, even if that breeze be intensely hot, 
as it certainly is in India during May and June. Of tliis we had numerous 
illustrations during the campaign against the Sepoys; and I may h(rre ob- 
serve that our great^proventive was abundance of water, carried by natives, 
by camels and elephants, with which soldiers and officers had continually to 
drench themselves while pursuing the Sepoys through the tracts of jungle,' 
as, for instance, in thfe province of Bahar, where they took shelter. 

Mr. Hill accounts for heat apoplexy thus : — 

1. The lungs are the organs primarily deranged ; becoming surcharged 
with blood, rendered impure by noxious products. The good effects of cold 
affusion may thus be briefly stated : — As stimulating the flagging respira- 
tory functions through excitomotory influence, moistening the surface, by 
which exosmosis and endosmosis are established ; and, from evaporation be- 
ing induced, the temperature of the body is directly reduced. 

2. Nature determines to the skin; and its functions, being already weak- 
ened or deranged, become ultimately stopped. It thus becomes dry : dry 
and highly congested as it is, superficial oxygenation of the blood partially 
goes on, and hence the increase of heat. 

3. The brain is not primarily affected, but becomes so from the derange- 
ment of arterialization of the blood. 

4. The congestion of blood in the vessels of the membranes (and skin 
is apparently due to a loss of tonicity in tho structures, and an inability in 
the heart to overcome this congestive state ; and it may be noted, if this ex- 
planation be correct, that it may account for the benefit of arteriotomy, by 
taking the oppression directly off the heart, which venesection would not do. 

Heretofore it has been found that the abstraction of blood in a case of 
sun-stroke was almost invariably followed by death, — the operation of leeches 
was too slow ; in fact, medical treatment in its more severe ft)rms was al- 
most powerless, and hence the frightful rate of mortality alreody stated. 

It is to bo remarked, however, that the general rule was to abstract blood 
from a vein, usually at the ordinary place of venesection ; and that with this 
view, the patient was made to sit up in bod, or was supported in that posi- 
tion. 

In these cases it frequently happened that death was almost instantane- 
ous ; while, on the other hand, the fatal issue scarcely seemed to be accel- 
erated if venesection was not employed, or, in fact, whatever was the rem- 
edy brought into use. 

[Dr. Gordon then proceeds to relate two cases which were treated by 
freely throwing cold water over the head and upper part of the body ; tlien 
n brisk purge was given of calomel and croton oil. In one case this sufficed ; 
in the other, in which the symptoms wore fully developed, the temporal ar- 
tery was divided and allowed to bleed freely, and vesication on the nape of 
the neck was occasioned by the application of a hot spatula. Dr. Gordon 
sums up the paper thus*:] 

The following, as a rule, are the measures from which advantage is to bo 
chiefly expected in the treatment of heat apoplexy : — 1. Arteriotomy ; 2. 
Cold affusion to the head and epigistrium; M. Kapid counter-irritation, by 
the application of a hot spalula to the nape ; and 4. Internal counter-irrita- 
tion by the administration of croton oil. — Edinburgh Med. Journal^ May, 
1860, jp, OS 6. 



PRACTICAL MEDICINE. 77 

24.— ON THE USE OF LARCH-BARK IX HEMORRHAGES. 

By Dr. J. M. 0*Fkrral, First Medical Adviser to St. Vincent's Hospital, Dublin. 

There is no accident that causes more anxiety to the physician, as well as 
t«) the patient, or his friends, than internal hemorrhngo, and none that 
from its suddenness and danger renders empirical treatment more justifiable. 
In such a case time is everything ; life is ebbing away, and we caimot wait 
fc»r the development of the physiological effects of medicines, the principle 
of whose action we fancy we understand. There is no occasion, therefore, 
in which we require to be provided with so many expedients in the event of 
failure of those wo have already tried. AVhen a new styptic is proposed, it 
becomes the duty of the clinical physician to avail himself of the opportu- 
nities afforded by a large hospital, and to record as early as is consistent 
with accuracy the results of his experience. The larch-bark has been pro- 
posed as a remedy in purpura, and analogy naturally suggested it as a 
means of controlling similar conditions of the mucous membranes, often of 
an alarming nature. The first class of cases in which I directed its employ- 
ment was the intercurrent haemoptysis of phthisis; in some of these, the 
usual remedies — ipecacuanha, lead, tannic or gallic acids, <fec., had been em- 
ployed without effect, when the larch-bark was tried. The hemorhage be- 
came diminished and soon ceased, and the remedy rapidly began to acquire 
an importance in our estimation. As confidence in the drug increased, it 
took an early place in the prescriptions for such cases, and up to the pres- 
ent moment has given such satisfaction, that it is the prevailing remedy in 
my wards for this affection. 

There is another class of cases, often of an exceedingly obstinate nature, 
in which it has proved of signal service — cases of uterine hemorrhage. 
8ome of those cases have depended upon the presence of fibrous tumours 
connected with the uterus ; others upon carcinomatus degeneration of the 
iirgan. In both the use of larch-bark has been followed by a cessation of 
thi.s dangerous accident. In some cases of hacmaturia from various sources 
— renal or vesical — the blood in the urine disappeared under its use. 

In hsematemesis I have not yet ventured to try this medicine, as I have 
not experienced failure from the ordinary remedies — turpentine, gallic acid, 
dec, since its introduction. 

The form in which I am in the habit of exhibiting the larch-bark is that 
of the tincture, in doses of half-a-drachm or a drachm every third hour. — 
Dublin Hospital Gazette, July 2, l^rCO, p. 190.* 



DISEASES OF THE ORGANS OF RESPIRATION. 

25.— ON THE Laryngoscope. 

(By a Berlin Correspondent of the ' Mod. Times and Gazette.') 

[The laryngoscope was an instrument formerly in use by the profession. It 
was originally invented by an English surgeon.] 

In Listen's 'Practical Surgery,* page 417, we read, under the head of 
" Ulcerated Glottis," the following remarks : — " A view of the parts may bo 
sometimes' obtained by means of a speculum— such a glass as is used by 
dentists, — on a long stalk, previously dipped in hot water, introduced with 
its reffeoting surface downwards, and carried well into the fauces." This 
pregnant hint of Listen's remained unnoticed till 1855, when Garcia pub- 
lished a most valuable series of auto-laryngoscopic investigations, instituted 
for the purpose of elucidating the mechanism of the human voice. In these 
ezperimeDts the imago of the larynx was reflected from a mirror placed 
against the soft palate, so as to be received upon a second \mvtv)x ^\\iLQ,^\ vci 
front of the observer (auto-laryngoacopy ,) An clemonlary ^wo\N\<i^^<a ^^ 

* This pnper our be compared with onebyDr, Hardy, of Dublin, * EelT<»vec\; \n>\.XTt.y\v\».^V 



rri PRACTICAL MEDICINE. 

catoptrics will suffice to explain the principles upon which Liston-Garem'A 
method of investigution is lounded. The examination itself is conducted in 
the following manner: — A metallic mirror — varying in size from six to f oar- 
teen lines in diameter, in shape either square with rounded edges, as recom- 
mended by Czermak, or oval, according to Ttlrck's proposal, or, as it has 
been found very convenient by Dr. Levin, of Berlin, semi-circular, with a 
concave inferior margin — soldered to a slightly flexible metallic handle, — 
shown in the drawing half the real size — is to be introduced into the weli- 




opened mouth, and fixed in such an angle against the uvula and soft palati) 
as to throw incident luminous rays upon the larynx, and to reflect an image 
of the parts thus illuminated into the eye of the observer. To prevent the 
mirror from becoming dim by condensation of vapour upon its surface, it in 
necessary to warm it previous to introduction by dipping it into hot water or 
holding the unpolished surface over the flame of a small spirit-lamp. Garcia 
made use of the direct rayn of the sun in his experiments : as this source of 
illumination, however, is not always available, and even, if so, attended with 
obvious inconveniences in practice, Czermak proposes the use of a perfor- 
ated concave mirror of 7—12" focal distance, by which the light of an ordi- 
nary lamp can be concentrated upon the larynx-speculum, the eye of the oh- 
8orver being applied to the perforation. As the distinctness of the image 
will depend upon the brilliancy of the illumination employed, it will be 
found advantageous to concentrate the light of the lamp upon the concave 
mirror, by means of a powerful bi-convex lens. Dr. Levin, of this city, ban 
devised a highly-convenient apparatus for this purpose, consisting of a tin 
tube carrying a convex lens oi two and a half inches focal distance, and of 
about the same diameter, which, by means of a simple contrivance, can be 
flscd horizontally over an Argand lamp after the shade has been removed. 

Tlie perforated concave reflector can either bo held between the teeth of 
the observer, fixed on a suitable ivory handle, as recommended by Czermak, 
or attached to a large spectacle-frame, according to Stell wag's proposal, or 
it can be suspended from a support screwed to the corner of the table on 
which the lamp is placed. The latter contrivance will be found the most 
convenient for practical purposes. I think it was first introduced by Dr. 
Levin.* 

It will be most convenient to place the lamp to the right of the patient, 
who is to bo examined in the sitting posture, his hands resting upon his 
knees, his body slightly advanced, and his head slightly reclining backwards. 
According to Professor Traube's advice, the lamp, concave mirror, and 
larynx-speculum ought to be on the sanfe level, and the angle formed by the 
rays incident upon, and reflected from, the concave mirror as acute as possi- 
ble. On this account it will be wise to place the lamp a little behind the 
patient. The observer supports the head and chin of the patient with his 
left, and introduces the larynx- spec alum with his right hand, looking through 
the perforation of the concave mirror, by means of which he illuminates the 
pharynx. 

By causing the patient to sound alternately the Roman vowels, a, «, the 
velum and uvula will be raised so as to admit of the mirror being introduced 
with greater facility. In pressing the speculum against the soft palate and 
uvula, great care must be taken to avoid touching the posterior wall of the 
pharynx, the palatine arches, and the base of the tongue to prevent the su- 
pervention of vomiting and deglutition. •* In this manner,'* as Czermak 
says, ** it is possible to look into the very depths of the pharynx, to obtain a 
didtinct image of the individual parts of the larynx, and, as I first demon- 

♦ATr. TMnlef bju nqneated UB to state that he hasu&edMt. KTen^ftwwAanvvVxkVW^^tc^ tw 
•rcnl jremn jmst.^KD. of* Med. Tlmea.* 



PRACTICAL MEDICINE. 79 

strated in my own person, to see the bifurcation of tho trnclien, reflected 
tfasoagh the widely-opened glottis, with the tracheal rings, shiniug through 
tiie thin mucous membrane." p. 9. 

Of coarse, considerable practice and a certain amount of dexterity is re- 
quired for successful handling of the laryngoscope, notwithstanding the 
simplicity of the principle upon which the method is founded. 

The difficulties are mainly owing to the groat irritability of tho palate, 
which in some individuals is so considerable as not to tolerate the contact of 
a foreign body ; others are unable to keep their mouths open for any length 
of time, or to command the position of tho tongue, which ought to be well 
flattened and protruded. Same patients, as Professor Traube correctly re- 
marks, suffer from a kind of ** moral nausea," threatening to vomit as soon 
as they are told to open their mouths. Tiiis extreme irritability can be over- 
come by methodically accustoming the parts to the contact of foreign bodies, 
as it is often requisite prior to surgical operations on the palate. I remem- 
ber reading that bromide of potash has the power of lowering the sensibility 
of the pharyngeal mucous membrane ; it might deserve a trial in very re- 
fractory cases. 

In general, however, the irritability of tho uvula and soft palate will be found 
very inconsiderable, so that they can be raised and pressed against the pos- 
terior wall of tho phamyx without any inconvenience to the individual ex- 
perimented upon. In Professor Traube^s clinic I have seen an individual 
sitting for nearly ten minutes with the larynx-speculum applied to the fau- 
ces, so that fifteen medical men who were present could successively exam- 
ine the reflectod image of the glottis without any reflex phenomena super- 
vening to interrupt the observations. 

Intnis case the mouth of tho patient was held open by a very convenient 
Instrument, devised by Dr. Levin. The handle of tho larynx-mirror is at- 
tached by a ball-hinge to tho upper bar of tho mouth-speculum, so as to ad- 
mit of the larynx-mirror being easily adjusted for the purpose of demonstro- 
tion. 

In the fifth chapter, Czcrmak details his method for obtaining a view of 
the posterior surface of the velum, the naso- pharyngeal cavity, dec, and he 
represents the image obtainable by rhinoscopic investigation, tho com- 
mencement of tho Eustachian tubes being also rendered visible. Wilde has 
already investigated tho latter by a similar method. 

To obtain an imago of the&e parts, a speculum must be introduced under 
the velum with its reflecting surface turned obliquely upwards, so as to il- 
luminate the naso-pharyngeal cavity. A speculum is proposed for this 
purpose, to which a sliding wiro-hook is attached, for the purpose of raising 
tho velum. 

Examinations of this kind are, of course, surrounded by numerous diffi- 
culties, and can only bo expected to succeed if a combination of favourubU^ 
circumstances obtains. 

The auto-laryngoscopic observations instituted by Czermak for physio- 
logical purposes are mainly confirmative of tho results obtained by Garcia's 
celebrated investigations, and his work will amply repay perusal to those who 
are interested in the important questions involved in tho study of the me- 
chanism of the human voice. 

The pathological observations which conclude tho work, twenty in number, 
illustrating most varied and interesting forms of laryngeal disease, as revealed 
by the larynx-speculum, are calculated to convince the most sceptical of the 
great advantages which must accrue to the practitioner from the adoption of 
this method of investigation. 

The possibility of the eye serving as a guido for tho hand in tho topical 
treatment of affections of the larynx and deep parts of the pharynx is also 

S roved by some of these observations. You must permit m(^ to reserve my 
etailed statement for a future communication. Two of those cases— tl\e ^x%^. 
and third — during the course of which laryngotomy had to \)ft \\ftTioxm^^^ otL 
hccoaat of stenosis of the larjmx, aro of particular intoteat, \>eviic >iJ[i^ ^iiXVcl 
nr/i/ch bjrm novel adaptation of laryngoscopy the g\ott\« ^a^ va^ft«^^^^«^ 



•80 PRAOTICAL MEDIGINK 

from below, This was effected by introducing a small mirror attached to a 
f»uitubly bent handle, with its rcflfcting surface turned upwards, into a fen- 
estrated tracheotomy tube. By illuminating this speculum with a concave 
ri'flcctor of the mo»t brilliant and accurate images of the lower aspect of the 
glottis, <kc., wore obtained, and the nature of the pathological changes affect- 
ing the parts clearly ascertained. This method promises to be of great im- 
portance for the diagnosis and treatment of deep-seated affections of the 
larynx, particularly in cases of laryngeal tumours which cannot be attacked 
from above. By reversing the reflecting surface of the mirror intn»duccid 
into the tracheotomy tube, the deep parts of the trachea might also be 
explored. 

1 vf ill conclude by stating, that those who wish to occupy themselves with 
laryngo.^copy will do well to follow Turck*s advice, and commence by study- 
ing, with an excised larynx, the outlines of the image reflected from the 
speculum, as the altered position of the parts in the reflected image is at 
first very puzzling to the unpracticcd observer. According to Czerniak, 
auto-laryngoscopic exercises constitute the very best preparations for at- 
taining efliciency in this branch of diagnosis. In plate l,of Czermak's mon- 
ograph an apparatus is figured, by which auto-lory ngoscopy and demon- 
stration can be combined.— A/et^. Times and Gazette, May 5, 1660, p, 455. 



26.— ON DEMONSTRATIONS WITH THE LARYNGOSCOPE. 

By JoNATUAM HoTcniKSOv, Keq., ABBlstnnt-Surflreon to the T^indon Hospital, and Surgeon toth« 
Moiropolitan Freo H>.r8pitaL 

[This instrument seems to be exciting interest just now; we hope its pop- 
ularity may continue, and that its operations may assist us in applyinpr 
proper remedies. Professor Czcrmak has been showing how the interior of 
the glottis may bo exposed to view, in different hospitals. We hope that it 
will not end in being run after, like as was the speculum uteri and potassa 
fusa some years ago.] 

The instruments employed were a round mirror for illumination, in tho 
centre of which is a round hole — as in that of the ophthalmoscope — and a 
small reflv?ctor, mounted on a handle for introduction into the pharynx. 
Tho light must be either full sunlight or that of a moderate lamp in a dark 
room. Nothing is easier than by aid of the mirror to illuminate the pharynx. 
This being done, tho next step is to introduce the small reflector, previously- 
warmed, into the throat, gently pressing it against the uvula and velum. 
The patient must now be told to make slowly a prolonged ah, all, ah. — in 
other words, to expire gently, so as to elevote the epiglottis. If this is done, 
and if tho pharyngeal reflector have been properly placed, a full view of th9 
interior of the glottis, true and false vocal cords, &;c., is at once obtained. 

Dr. Czevmak exhibits the employment of the instrument on himself, and 
has acquired by long training, great dexterity in bringing the parts into view, 
and apparently entire freedom from all sense of irritation while doing so. 
He employs a second reflector, by which he is enabled himself to see exactly 
what ho is showing to tho spectator. Having introduced the mirrort he 
first showed the vocal cords, epiglottis, arytenoid cartilnges, &c., in a state 
of rest, then emitting u variety of notes, made the cords narrow the aper- 
ture, vibrate, and go through their various evolutions with most astonishing 
rapidity and clearness. Having shown the closure of tho orifice by the 
lateral approximation of the cords, he lastly brought the arytenoid cartilages 
and the base of the epiglottis into apposition from behind forwards a ivat 
which evidently required considerable effort to accomplish. Among those 
present at tho London Hospital, were Mr. Luke, Dr. Peacock, Mr. Qowlland, 
and many others, and all expressed themselves as highly satisfied with tho 
clearness of the demonstrations. A like degree of gratification was, I under- 
stood, given to Mr. Paget, Mr. Bowman, &c., who had had private seances, 
and als'j at the other hospitals which the Professor visited. 



PRACTICAL MEDICINE. 



8t 



Having ccmcliideJ Ms illusti'ationa of the etatt^ of the larvni lu rost ttml 
in miitkin. Dr. Ozermnk neit proceeded to sliow us the posttTrior tmrts and 
Eiistaclimn tubes* This was nccoinplii^hed hv holding the soft palate dawn- 
wards aud forwards, while a refl Lector was introduced into the upper part ttf 
the pharynx* In this view the septum mirimn (Its post^^rior edge), the open- 
iug into t!io posterjor narcw, the tt.»rminations of the middle and inferior turbi- 
nated houesi and the orifice 8 of the Eustachian tuheg were clearly seen* 

Nothing could have been more ini^truGtlve or more completely satisfactory 
than ttio ProfefiBor^s denionstrationj^ on himself, and he alao succeeded vury 
well on one of the specators present* When^ however, we came to cat»i-d 
of laryngeal disease, or what might be termed laryngoscopy under diffie allies, 
the rDj^ults were different* I had in attendance two patients on whom trach- 
ootoroy had been performed, and in whom we were exceedingly desirous, fur 
purposes of treatment, to ascertain the exact state of the larynx* In the fir^t 
of thcs<», a man mow under Mr. Ijuke*fl caro, the operation was perfonned 
about four months ago, and ho is as yet quite unahlo to breathe without th*.« 
canuia. The man lias been a sweep, and it was thonght within po-ssibility 
that some growth of epithelial cancer might exist in the laryns* Although 
the man was patient, and did his best to assist the examination, yet his in- 
ability to accomplish a sh*w expiration, defeated the Pr*>fesg<ir^s attemptii to 
obtain a view, since the t^pigh>ttis uovt?rcd the interior partj*. The second 
patient was a woman, the subject of tertiary By phililic disease of the pharynx 
and larynx, for wKonj, about two years ago, 1 performed triicheotomy with 
much temporary benefit. A few weeks after the operation f^he becauie able 
to dispen.se with the eanula, and has not since worn it. ^She has, hnwever^ 
had several attacks since, in which her laryngeal pympt<nns have been 
greatly agj^ravated, and she is permanently aphonic* The probability is that 
her rima ghittis is much narrowed by cleat nces resulting from syphilitic ul- 
ceration. Her pharynx is also very much contracted by cicatrici^s^ and tlri;i 
obstacle sufficed to entirely prevent the snccesa of the FrofeBSor's endeti- 
vours to get a glimpse of her laryngeal structureg. 

It must be admitted that these two ca^ea both presented unusual difficul- 
ties; nevertheless, they arc those in which tho aid of the instrument wua 
most etipecially wanted* It is probable, however, that, after a few morn 
trials, the patients might be so trained as to allow of a satisfaetory exami- 
nation. In Ophthalmoscopy the observer alone requires training; in in- 
specting the larynx, however, it is requisite not oalj' that tho manipulator 
should be dexterous, but that tho patient should be able to assisft him, both by 
tolerance and by accomplishing certain efforts which few at the first trial are 
able b* do. liy a little training the velum palati becomon mucli less irriui- 
hie, and spasm is much less readily oseited ny the proBdure of instruments* 
1 1 is well known that training may do mucli in the way of preparing a pa* 
tlent to assist tho operator in cases of staphyloraphy. Certain remedies, ati, 
for instance, the bromide of potassium^ and, possibly, the local application 
of chloroform vapour, muy be found useful in inducing ana«?ithesia of the 
pharynx. By these it is very posBiblo that the future application of laryn- 
goscopy to practical medicine and surgery maj' bo much facilitated. In 
chronic cases admitting of delay, and in intelligent patients, no doubt soiije- 
thing might be done in instructing them to practice self-examination by the 
aid of the mirrori and thu5 accustom the parts to the contact of the re- 
flector* 

Profo^RC^T Czermak told me that he thought he had not inspected the 
larynx in more than 50tl individuals altogether, moit of these, of cour*4ii, 
l>ring in those snffering from disease of the pnrt* Out of this number, in no 
fewer than fifteen t>r sixteen he had been able to demonstrate the presence 
of polypoid growths upon it, — a fact of very considerable importance as re- 
gnrdstho practieiil uses of the method- He stated that, with patlc-nce and 
lime be did not believe that there would be more than ten per cent* in whom 
he could not succeed in getting the desired view. 

The Professor has already left London on his way home, but it is in pros- 
pect, he informed me, that a pupil of his, Dr. Scm©\edcT, B\iim\(i At^-ttlX^ 
XLII,— tJ 



m PRACTICAL MEDICINE. 

visit us witb tbo intoiitioii of rGnjaming- some timet ftiid opening a class fbr 
iij^trtietioii in tUu m^is uf the laryngoscope. In tbcf rnean timet not a few will 
probably ho anxious to try for tbemselveft, Tbo needful in^lruments (ae- 
cafdiug to Czetmak'a patlern?), if not already in stock, will, I believe* very 
fihortly bo go, botb i\t Mn Weisti^a and Mi'< Ferguaon*a, — Med, 7S.m€s and 
Gazette, :Sep. S, l&ji\ p. 236, 




27 -^THE DIAGNOSIS OF PHTHISIS BY THE MICROSCOPE, 

(Tbis papf?r was read at the Graveaend Meeting of the BritiBb Medical 
Association; and the gpecimena exhibited were prepared by Dr, Andrew 
Clnrk* of London; they showed the preaeaceof the elastic trabeculao of the 
air-vesiclesi atid furnished evidonco of the destruction of the lung- tissue*) 

A fow yearet ago* the pulmonary trabeeuhx) were djacovercd la the aputa 
in phthitfis by l^c breeder van der Kolk and by Dr, Andrew Clark, iudepen- 
dently of one another. The former consider^*, or did consider, the exiiniiua- 
tion of the sputa VHlanble only early in pbtbiaisi whilst Andrew Clark holds 
that tbo examinntion i;; ue^eful at all periodit aa being the only ciHuin meana 
of dot PC ting the dis^intcgratiou of the lung and the increase of the disoai^e. 
It 1!^ a faet that tbo dii*eaBe often increases whilst the patient is getting fat, 
and appears suilicienlly well to deceive himself, hh friends, and his medical 
uttendant- 

The viewa of Dr. Andrew Clark, briefly expressed, are as fallows: — 

L The parietes of the air-veaicles are indivisible; that is, they cannot bo 
separated into lay its. They are made up of membrane with blood vessels. 
Hud yellow elastic tissue arranged as trabecular, 

2. Tbo air- vesicles are Uned by scaly epithelium. The epitlieliam is easily 
demonstrated in the child; it ia more difficult of demonstration in advanced 
life* It plays an important part in all chronic structural lesions of the lungs* 
It la absent in emphysema. The eiistence of an epithelium of the air -vesi- 
cles is denied by Bowman, Eainey, and Beale. Tbey admit the appearance 
of cell-particles in the air- vesicles* but they believe them to be only the 
nuclei of the capilhiries. They admit, also, the presence of nucleated cells 
that cnntfot be af*cribed to the eapillariest but they believe them to be the 
product of morbid action* — Dr. Clark*a reply is, tliat no lung is found with- 
out tbem, 

th Previously to the tuberculosii there is a disorder of the aasimllaljoo, 
which may bo termed pretubercular eacheiia, 

4 Phthisis commences witb the deposit of tubercle, and is a term common 
to all the stages of pulmonary tuberculisation. Phthisis is the name assij^ned 
to a certain auutonncal lesion of the lung, and is to be understood in a differ- 
ent smise to that in which tlic older physicians regard it| fur with them 
ph th i sis is hec ti c f e vc r a ri s ing fro m pulm on a ry tab ere ul i saticn . P h t h i sis, i n 
the language of most practitiimers, consists of hectic fever, due to softened 
tubercle in the proecss of elimination* This is aymptt^mutie phthisis. Ana* 
tomical phthisis, so to sneakj consists in the lesion of the hing, whether at- 
tended or not by lieetic fever* Tbo distinction resembles that made betwixt 
the pneumonia before Laennec*s tiuje and that pulmonary lesion recogmsed 
as pneumonia subsequently to the introduction of auscultation into praetiee. 

5* Elimination of softened tubercle is the third stage of phthisis, and may 
^ on in one part whilst deposition occurs in another; consequently, there 
IS a mingling of the stages of phthisis^regarding this disease in an ana- 
tomical light. 

G, Tubercle is a retrograde motamorpbosis of the s true t oral elements and 

of the tluid secretions (if there be any) of the part in which it may be found* 

Tubercle is not a deposit from tbe bkiod, but Is a product of vitiuted-nutri- 

f/n/i — not a simple <?xadation, but a complex losult of perverted vital action. 

When tubercular matter acciimulatc?8 and ptcisea n-^^nx ^e \ikiMil\t^ii?.A*/\\, 



PRACTICAL JfEDICmE. 



mnj f^imtc irritatbti, in whieb case ctmeestlon la not unfroquRjitly eet up* 
which tf^nni nates in nn cxudntion* which bt'comea mistPil with tl)o tubc?roulaT 
matter, and nftt^rwunls tiiborciulisps. Siieb exucktion in the firHt place is 
just Itko the oxudatum that takes plnon on an hiflamed pleura: but the t^x- 
udutlon being placet! undnr unfavorable cireumiitanoes, aoea not becQme de- 
veloped iatn a tissue^ but degenerates into tubercle. 

7, Tho air-vegicle?* are the seat of tubercle in tbo lung* 

9, When the tubercular matter accuuiulatfift to sueb an axtCDt as to coiii- 
prpss the walls of the air- vesicles, the entiro structure of the wiills disinte- 
*j'rRteeit eicept the elastic trabeculie (which are alone diaradcrkltc of the air- 
ve icicles). 

9- The elastic trabeculie are seen in tho spata, Ijine in disorder amongst 
the disintegrated elements of the tissue, and are readily detected by the aid 
ijf tho microscope, 

10, The elastic trabccuhv are present in the sputa during the elirmn/iUon 
f>f the tubercle, and cfmstituto the diaj:^nostie mark of the el i mi native stag*', 

IL If elimination take placid with only miuute deposit in the lung, the 
niicroioop© will reveal tbo disea.se sooner than the plexiuieter and steth- 
oscope; but where there is a considerable rnuas of tubercle in the lun^r* 
without ell mi n at inn of any portion, percne?sIon and anscultHtioni taken in 
eunncctinn with the general symptonns, will detect the di^eaee, whibt the 
tnicroseoi'e givea negative rcsiults. Again, minnto depoiiit in a quiescent 
state will be overlooked, although both tho oar and tho eye be employed for 
its detection, 

12i The physician can confidently declare that phthisis exists wbeu he 
iinda the ehii^tic trabecular in tho i^puta* 

13, Ph this if* commences with the deposit of tubercle, and tends to one of 
two issues : — {a) to recovery by absorption, by calcification, or by indura- 
tion and pigmentary trausforniatioii ; ib) or to Ji»uppuratii>n and the estab- 
lishment of hpcticjevt'r* 

IJ. It h yet uncertain whether recovery or progressiTe disease be the 
more frequent, 

15, Tho air- vesicles may remain filled with tubercle in a state of complete 
quiescence witlkiut softening or elimination, for 3 ear*- Thit* is a state of 
things that tho microscope will not determine. It muiat be worked oat by 
the study of symptoms, and of auscultate »ry signs, 

16, Tho parietes of tho air-vcsiclea remain intact in phthisis until one or 
other of the following- events happen, (a) The tubercular matter aooumu- 
Intes to such an extent as to compress the walk of tho air- vehicle a with such 
force as to empty or obliterate the capillnritvs, when, nutrition being sus* 
pendt dt di 55 integration ensues, and the tubercular matter in one vesicle comes 
in contact with that in the adjoining vesicle, and so the two masses cohere* 
fb) Tbo tubt?reular matter softens from any cause, (c) The tubercular mat- 
ter sets up pneumonia, which breaks down tho wholo mass* 

17, The elu.^tic trabeeul® of the air-vesicles cannnt bo confounded with 
any other yellow elastic tbsues likclif to be fQUnd in (he sputUt henikMne of 
their character and arrangement 

18, Tubercle is often found iu the tonsils ; and the elon^j^ted ofills of tho 
tonsil- tissue, arranged as they are in nn areolar form, might mislead an in- 
experienced observer- A little attention will obviate this apparent difficulty, 
The quasi -bands seen in sections of lUe tonsils consist of s^^parate pi(*ce», 
easily recognised as being separate, whereas the pulmonary trabeeuUe are 
continuous and wavy. However, the distiiietlon is made certain by chemical 
tej*ts» The pulmonary trabecula? resist the action of both noetic acid and 
liquor potassEc (masmuch as they consist of yellow elastic tissue) Avbereas 
the elongated tonsil-cells resist acetic acid only, and yield to liquor potassce, 
which renders them invisible* 

19- The micmscopic examination of the sputa enables \ir \jn ^ft\fecl %^^\^n- 
ing tubercle in the proems o/e/imf nation, which comVA not o\\\etm%ft \ie ^fe- 
Ucted; it eon firms or conecU tlio diaguusis betweea \AA\Cvi\ft, *iAVt»!w*£^i 



Bi PRACTICAL MEDICINE. 

1)roi]cbii cUronic bronoliitis, &:c. ; and it dctennlDes Ibe actual progress ol 
[^the legion of the luug. 

Thus it IB seen that tbe microscope e on firm a tlie opmlan of tlie Tulgar a#l 
'testpt'Cts *' tUe qnttlng' up of tlie ligbts,** which b uow nJi uu«3oubted fttcU I 
In coDcluaJon^ allow me to state nij coDvlctioti tbot the detection of tbi|i 
yellow chistic tisisue of tbo nir-vcsicles in the sputa U one of ike gr^ai difcov^l 
tries Tendered to patbologj- by the micros cope. Tbo iujportoiice of bein^J 
mware of the truo state of mattcra in any given case, cannot be overrated;! 
ftnd I am «ur© that yoti will allow that when once we can pronounce a majtl 
to be under phthifiii (using the term in the anatomical et^nse) wo are likelr I 
to n^a bygteuiG and therapeutic menus with greater precimon and wUli 
I greater prospect of success th m if we considered the case to bo one of ca- 
tarrb, simple djApepsiat or that tnonslrufn horrendum **debiUty.*^— ^rt£wA 
Mtdif^al Journal t Ajml 21, I960, jj, 002, 





28.— ON THE IMPORTANCE OF THE FUNCTIONS QF THE 

SKIN IN THE PATHOLOGY AND TREATMENT 

OF TUBEBCULAR CONSUMPTION. 

By Dt. Tovtmw. 6t Leonard 'ii 

(Being an abstract of a papor read before the Hanreian Societj.) 
Dr* Toulmin commenced by offering as the proiimate cause of tubercle iii 
all cases, **the breathing of impure air* and air in so small a quantity as to 
render it impure, especially during the night." He observed that wherever 
this was the continued state of exii^tence, the result must be a deficiency in 
tbe red globules of the blood, and as tbe consequence of this, the deposition 
of plastic fibrin in an incomplete state of oxygenation, and, therefore, of or- 
ganization, and thus incapable of being ultimately got rid of by cbange of 
malter. It consequently remained as an ejclraneous adventitious substance 
in the system, offering to tbe observer all the characteristics of tubercle. 
To explain tbe discrepancy which appears in tbo rich (who have no want of 
oxygen in the air they breathe) being equally subject to phthisis as the 
pour, he drew the attention of the Society to the importance of tbo respira- 
tory functionB of the skin, as proved by tbe almost instant death that occurs 
on closing the cutaneous pores by artificial meaus — as in varnisbing and 
gilding the skins of rabbits and other animals; and observed, that in conse- 
quence of the coldness of bur climate, and other causes, the higher classes of 
society were certainly not in the habit of making the washing the whole sur- 
face of the body a part of their daily toilet, and, consi^qnently, that tbo ex- 
uvia? momentavily forming on the surface of the skin, the joint production of 
the sordes from within, combined with the df.bris of the cuticle, soon render 
the skin more or less impervious, although tbo individual might be in the 
habit of changing his linen daily. As an illustration of this state of skin* tho 
author referred to acne, so frequently seen on the face, as being in realitj 
tbe general state of the skin of a large proportion of society, especially in 
tho earlier periods of life, when pbUiisis generally shows itself; and that 
the free entrance of air, as weli as the eitlt of carbonic acid through the skin, 
being thus impedcdt the same imperfect oxj'genation of the blood ensues as 
is produced in tbe poorer classes by breathing mephitic air. He remarked, 
that for the removal of this state of skin tbe only means were to he found in 
instituting a full and free diapboresEs by the aid of artificial heat, the result 
of which, in first softening, and then expelling, large quantities of inspissatt^d 
sebaceous matter, after tbe surface of the body had been washed clean with 
soap and water, was (surprising. The author drew tbo attention of tbe So- 
ciety to the fact, that the use of the hot-air bath, as a therapeutic agent, was 
no innovation on tbe established practice of the profession, as it was the 
mode of bathing practist^d by Hippocrates, Galen, and Celsus, and that the 
uQiversaHty of the practice was shown by tbe fact, that tho remains of such 
imihg had £eei3 found m every colony of the Boman. em'plte. 




PRACTICAL MEDICINE. 

Tbo author enunciated some novd doctrinos, both as to the nature and 
trcfltment af phthisis. For instance : IF tuhorclo he imperfectlj organized 
fihnnf then it should he looked upon as,* a h!uod*disf3ase ; and t^eoing tt In 
found ill other parta b<?sides the lungs without dt'stroymg life, Its deposition 
in tliem should not he considered as disease either of the lungs or air*tubeff| 
but as en aoci dental circumstanee, killing mechanically hv its ulceration ex- 
lending to the i^urrounding lung tissue. Again^ ho ealfed in question the 
propriety of f^ending consumptive patients abroad to a warm climate during 
any stage of thfl disease, as, although iu the later stages of tlie complaint 
the air-tubes sympathtsied with the tubercular irritation, a warm atmosphere 
seemed more congenial to the patient *s feelings, still In the earlier stages, 
when a cure was practicable, the breathing the open air of our winter (at 
least on the sonth side of the island) was most important ; and he in^^tanced 
a« ft proof that breathing cold air did not cause the complaint, the remarka- 
ble fact, that tubercular consumption is not to bo met with iu high northern 
latitudes. 

The treatment of phthiMs was considered under its hyglenio and medical 
aspects. Under the f irmeri and particularly in the earlier Mages, the pa- 
tient was recommended to live in a high, dry, and inarine ittmot^phere, vn. 
the downs, rather than under them; tt* be a« much as possible in tho upen 
air; louse nil ports of athletic eiercises (avoiding such as accelerate tho 
pulmonic circulation) sni table to the sck and strength of tho patient, by 
which a more rapid change of matter is effected, together with absorption of 
already deposited tubercle, a,^ well as the deposition of more healthy — i.e., 
of more highly organized matter* Medically, the treatment was comprised 
in a few short aphorisms, the first and most important being,— Keeping the 
fnnettons of the skin in healthy action by inenna of the hot-air bath. 2ndly, 
Anointing the whole surface of the skiu daily with somo oleaginous matter, 
3rdiy. Keeping a local ulceration always patent by means of an issue or 
setim. 4thly. The exhibition of some one or more of a large variety of 
tonic and antiseptic medicinoB — all admirable adjuvants in improving the 
general health, (if selected in confurniity with the function most sympa- 
thizing with, and reacting on, the disease,) but powerless in arresting the 
specific leaion in (jiiestion, without the previous **Open sesame' ^ of the hot- 
air bath, followed by the aspersion of cold or tepid water* The author e^- 
praised himself as fearful of saying all that might bo advanced iu favour of 
this treatment in phthi>*is, seeing that the diseurie was universally considered 
incurabte.^ — Lancely June 14, I&jO, ^. 37, 



29.^0K DYSPN(EA AS A MECHANICAL CAUSE OF 
CONGEST r ON OF THE LUNGS. 

By Or, Asimnw U, i^Jriixn. 

In the 'American Medical Times' fc^r July '21, Dr Andrew H, Smith has 
published an ingenious essay in explanation of the congestion of the lungs 
which results from severe or protracted dyspnc^a. After referring to the 
theorie5 of Haller* Goodwin, Biehat, Kay, Wintrich, and C. J. B. VVilliamf, 
which chiefly uttrtbute tho intpediment to tho presence of venous blood in 
abnormal sltutUiouB, he says that the degree of congestion capable of being 
explained by any of these theories may he estimated by eiamimng tho lungfl 
of an animal destroyed by section of the medulla oblongatu, Jn numerous 
Instances in which ho has performed this experiment, he has always found 
tJiati while some amount of pulmonary congestion was present, it was insig- 
nlficant in com pari srm with that produced by occlusion of the trachea ; al^ 
though the chomical condition of the blood must ho the same in the one ot so 
as in the other* He therefore argues that there must be another c«s.yL%«i tv^^ 
the production of cnn^estwn hf dji^pnffia— and thattkiB Cdvifets \a to>afeiia^tA 
iD fh& Inrren^od energy of the TBapirwtcwy movemonts. 
iJr. Smith observes that. In the mechanism of respiTft.t\Oi\. lV^t% ««* ^*"«<* 




ma PRACTICAL MEDICiHE, 

aTPtiii^g of if»CT08» into tlio Iuif^— fine hj the nir-pti?«inge« for the air, i 
olLftr hy tbw Bloodve&seU far the hU*Q(\ ; and thtiU In fact, wc respiro bloo _ 
iu precisely the stime wtty und by* the samo uieehauUm a$ wc respire air#t 
The mitmirit of blcHid drnwu into thf^ luiig^ in an ordiu&ry mspiration \& Mnath 
owuig to the faet that the ipace nc qui red within the cWst is readily filled 
out hy air adiniUed tlm^tiglL the truehea. But, ob^truet th^ entrance of air, 
and at the same timtj incvt^ase thts force of the inspiratory effi>rt, and the 
iimount of blood entering the lungs may bt* greatly increased* The atmob- 
pheri^ pressure uprui the vesMels wilhiu thefliorai is* rendered less than thak 
upon the vessels of t ho body gene rally, and a rush of blood from every di^ 
reetioti towards thu tlioracic cavity is the result, Hi-nce in every case of * 
dyi]|na>a depending upon obstruction of the air. passages, there mu^t be n 
CKmge^ted state of the lungs at the terniLuution of every inspiratory effort- 
That the congestion which has thus been produced during inj^pi ration is not 
relieved during eipiratiou, is( due to the following circuuijstances ;—L The 
amount of blood to be expelled l» iu<?reased; 2* The interval between the 
inspirations is diminished, so that let^w tinio is allowed for its eipuldou ; 3. 
The tenacity of the vessels is impaired by their over-distcDsion, «o that the 
expelling force is hereby diminished. 

The following eipcriuient has been performed by Dr. Smith to show the 
di6*erence between the degree of congestion resulting from n on- aC ration af 
the blood, and that produtjed by the additional effect of increased energy of 
tho respiratory movetnent^* A ligature was placed around the trachea of an 
animal, and drawn bo tightly an to prevent completely the entnuice of air 
into tlie lungs- At tlio same instant that the ligature vvas tigbtonedt the 
thorax Wat* freely opened on one &idei so that the air passed without oh- 
atruclion in and out of the pleural cavity. By tbi^ means the influence of 
the respiratory movements upon the lung of that j>ide wfl» entirely sus- 
pended, while with respect to the other lung, it remaim?d comparatively un- 
impaired. On eiamining the lungs after death, the one on the side which 
was opened was found to be but elrghtly congested, while the other was 
gtirged with blood* The chemical cmidition of the blood must have been 
tho same in both lungs »ince both were equally excluded from the atoms- 
phercp The effect of any ehangc taking iduee in the action of the bearti or 
an the pulmonary vessel^i mu*?t al^o bavo been the same in one lung ag in the 
other. 

Dr. Smith infers from the preceding rensoningsj that in every case in 
which the respiratory movementft are increased to any considerable extent 
in force or frequency (the entrance t>f air being obstructed), there mus*t be 
a proportionate degree of congestion of the lungs as a neceaaary mechanical 
result* 

The operation of this principle ie well illustrated in a case of bronchitis. 
At the outset of the di^easei the bronchial mucous membrane h congested, 
its vessels turgid with blood. Thin condition implies a thickening of the 
membrane and a diminution of the calibre of the tubes, and hence an obstruc- 
tion to tho entrance of air into the lujiga. At the eatne time, the accom- 
panying febrile movement quickens the circulation, and produces an in- 
creased demand upon the lauga. The respiratory movements become more 
frequent and forcible; and the expansion of the thorax not being responded 
to by a projiipt and sufficient influx of air into the lungs, a compensatiog iu* 
crease in the amount of blood thiwing in is the eonsequence. The pulmon- 
ary vessels, already ovi^rhiaded, receive a new supply; and their tonicity, 
/il ready impaired by the effect of the di.sea6o, is still further diminii^hed by 
this increased distension* With every increase of congestion, there follows 
an increase of obstruction, and therefore of dyspnoea, which, in its tunj, 
gives rise to a further increase of congestion. And ao the proeoss continued, 
the congestion aggravating the dyspnoea, and the dyspnoea aggravating the 
congestion, until finally the tension within tho vciincls arrives at such u point 
that a serous eflfusion takes place into the bronchial tubes, mingling itself 
with the products of inflammation. By this means the tension is relieved, 
and the actual stasis which would otherwise result is avoided* Hut if^ as is 



PRACTICAL MEDICINE. 

liflen the caio* the ft^ebleness of the pntieiit renrlers a BufScieBt eipoctora- 
**Ti nil possible, or if thc^ bronchial tubesi InboTiriug undor the diiadvatttage 
" having lost their ciliated epitbcliain^ and of having their circular mus- 
^ylur fibres paralysed, cannot relieve themsolvea of the accumulating mm*?, 
~})cn suffocation Ib inevitable, unless the proceeE» can be arrestee] by thD inter- 
iTCntion of art. 

From the above c<>nsiderfltion^, and from the rei^ults of nnmerous ox- 
periincnts on anhnaSs antl of a few upon the human *iul>ject^ Dr. Smith has 
ticeii led to believe that, in cases In which the cause of the obBtruction can- 
Kit ho directly attackod» the most direct and ceiiain mf*ants of relieving the 
rayspncea is by aftbrdin|2i; to the lun^s an ntmospbere which Bhall contain, in 
I'tlve volume which finds access to the air-cells, a quantity of oijgen equal to 
lithat respired in health. By this nieiiris the demand for oiygeu in supplied, 
Jwithcml UiG neoesBity for those viok^nt muficukr efforts which aggravate the 
l^ause of the 4lyKpna?a, while at the same tttne tht\y exhaust the slTcngth ef 
I the patient* — Brkish Medical Journal^ Sep, 15, ISOO, p. 726, 




30.— OBSERVATIONS ON THE TBEATMENT OF ASTHMA, 

By T, L. FKiDBiMf Eaq,^ Bldoford^ N'orth DsTon* 

Much has been written of late on the eymptonis and treatment of asthmii — 
Lperbaps the most painful and apparently alarming disease to which human 
Ifiesh is heir* 

The obaervatioua which I have to make on the dieeaiFe are btiscd on the 
Bsperienco of nearly one liundretl eases which have coxne under my inedicai 
I^C^are. I may not throw much new light on the subject ; yet I am desirous to 
ifecord the result of my experience and mj treatment, as well as my nhserva- 
Itloug on the peculiarities of thii^? most dii^itresi^ing complaint, in the hope that 
Isome Itttl© mnj be added to the stock of information which has already been 
[(Collected on the subject* 

It ia now many yeara sinoe n deep-rooted impresBioa was made on my 
|inind, by that memorable nmu, Abemethy, **that in order to treat disease, 
rh^^ther of a local or cori«lituttonal character, it was absolutely necesaaryto 
&p tbo stomach in that state, so that the food which was taken into it 
ttld he properly digested, in order to secure good blood, and conseijaently 
ft! thy secretions and healthy action of the body generally ; and that in 
I proportion as the surgeon or the physician attended to these particulars, so 
[^jn proportion would the means placed within the reach of the practitioner b© 
► more or less successful.*' 

With these impressions, which I behcve to be most useful to the medical 
Itnan, i started in my profession. I had not been long in practice, when a 
evere case of what was called humid iit^thina presented itself for my treat- 
Ixnent, I found that it had been of mi my yeara standing, and frequently 
Ifieeinod, fmm its violence, to threaten the life of tbe patiuot. The attact. 
Iiowever, would nubsldu after a copious expectoration had been thrown off 
Irom the lungs; the man at the same liuu! becoming almost exhausted for 
i-ant of nourishment, which he wan tiot for a time able to take, except in tbe 
B malic fit liuautitiesj. After the lapse of it fiiw weeks, the mau would rally, 
l<iatand drink largely, and go about hi^ ivork until another paroxysm threat- 
ened, when I was again in attendance. Qu each occa.^ion of an attack, I 
[used to say, *'■ This surely mil be Um hist ;*' so severe and imminent did it 
t appear. 

This state of tbingn went on for some time^ till at last tbe the tight oocur- 
Ixed to me. How ia it that asthmatic patients generally live to a good old 
fciige? They do not die of eonsumptifin ; nor do the lunjt^s undergo any other 
I change except the dilatation of the air-colls*^ which dilatntion of the celU 
ldi>cs not much interfere with their normal action when free fram an attack. 
pThus cousidcriug the ninttert it appeared to me probable that the original 
k cause of disease was in the overworkfd powers of digvstlm\, M\ii\^i^s>^Q^tLV\ 





PRADTICAL MEDICINE. 

<iut in thiA suppoiritioti bj ttio circumstance that the patient had respH 
from tittac.ks as booq as a ccrtmo amoiint of expectoration had been tbiTiwq 
oWi nud his btomach had for a ^easoti rested. Was it ni>t then pr*>bol>le ihal-J^ 
impurities m the blood were formed by impurfect digf^stkmi which wwrft 
thrown off hy meanfi of the lungs ? How far mr ideas were correct, tiie M' 
luwing statement of treatment will, 1 think* get far to proro, 

I speak m>w of what is called di/apepiic mthma — a disease which 1 belieTe 
peculiarly hereditary ; that is to say, when the disease has once made ita 
appcaraiJCCt those who Inherit it will erer he liable to attacks from in^ prudent 
diet ; f^^r I am couvluced thnt an ai^thmattc person can never with impuaity 
eat and drink as other people do* I may here state that, out of the number 
uf cases of which 1 have attended* I found hereditary predispogition in nine 
out of ten. And if it ho true that asthma is an hereditary diseanct I will en- 
deavour, by the evidence of cases wUich I inten^l to publish, to show that 
wherever it has existed in aay member of a fumily for ojjc, two, or even three 
l^onerfttions back, exciting cauiCB, such as imprudent diet, an nttack of # 
hroiiehitiH* un attack of itjfluoiDsa* derangement of the liver, or any other 
functional derangonient, atmospheric influences, peculiar odors, inHuence« 
t»f the mind either for joy or sorrow, may at any time or period of life bring 
ti> light tbis peculiar diseaFCi which has hitherto been latent in the syBtem. 
It ii* fortunate that Etomach-derangemcnt from imprudc-nt diet, <5cc*t is, as 
fiir ns toy osperience goes, the most frequent eiclting cause^CEmsequuntly 
more under tbe centred of medical trt^atment, provided the patient lias re- 
solution enough to second the efforti* of the medical attendant in carrying 
out a strict system of diet and regularity ; in fact, it may be said that the 
scales are thua lie Id with diseasfC and suflering on one etde, aod comparative 
health and comfort un the other. 

Most of the other patients inherited gout, and in some instances both 
diieascB were traced in the family; and in more than one instance where 
this was apparent, I found that there were nlteriiute attacks of asthma and 
gout, which is. I think, ati additional evidence that both disease.^ aro here- 
ditnry, and may bo eouiiidt^rf^d hlood-diseaifo»* What the peculiar element 
in thn blood may ho which produces either asthma or goutr it ta to bo hoped 
scientific researches may one day decide. 

To return to my first case. The man in iiuestion, possessing fiotno good 
Hense* although he gave himself to heer-drinkingand gross eating, r^ he said, 
to get up his strength after an attack, after having heard my views of his 
case, replied, *' Well* sir, your remarks appear rea.sonable enough, and i 
wOl endeavour to fidlow your advice, and not eat and drink so much." I 
wrote down a system of dietary and general management, which for a season 
he followed with advantage ; after this* he hecamo tired of the plaa, and 
again fell into intemperale habits, with an increase, if possible, of all his 
original fearful safferings. Ho at last became reduced in circumstances, 
and was obliged to apply for parochial aid* I thought I had now a gmid op- 
portunity of trying the effects of diet with medical treatment oa this patient, 
and I persuaded bim to go into tho union house. There I took good care 
that he she aid not deviate from my prescribed treatment; for I placed him 
under ^£>cAr and key^ ordering his food to be regularly given him, whiUt he had 
a trustworthy attendant when he left his room for the purpose of air or 
exercise. 

His appearance and symptoms at this time were aa follows ;— His coun- 
tenance bore the signs of great distress- His shoulders were elevated ; the 
eyes protruded: he Imd no appetite; tho stomach was greatly distended 
after eating; puUo 70. feeble* j'ct regular; the timgue was coated* with fis- 
sures in it* riiere was great emaciation* and inability to lio down in bed 
or to walk up an ascent* The secretion:?! from the bowels were dark. The 
urine was loaded, showing an acid deposit* 

After giving the patient an alterative pill and a saline aperient, I ordered 
htm the foljowiug diet, which was to bo regularly weighed out to him, and 
the hours of meals most strictly attended to. Breakfast at eight o^clock — - 
half a pint of green tea or coffee, with a little cream^ two ounces of dry 



PRACTICAL MEDTCTNE. 



^ italc bveitct? (llnnrr af one o'clnck^ — t^o onncp^ of fr*^-*Ti bo^pf rn' mutiny 
witUout ftit or skin, twcujuiices of stale dry bread, or Wiill^bfuled ripe ; thno 
litnirft aft<?r dinner, halfn pint of weak brandy ami water, or toa!*(-wntpr ^li 
libitum ; suppiyr at sex* en o'clock— two oimcfs of meut, with two ounces of 
dry brcnid. Ho was not allownd to drjuk within ono hour of hi& dinner or 
^upper^ or till thrpo hour* after; at oth<?r titiiPft, \w was not limited. Open 
HIT cxerci{*e irns ordered to be taken as poon n^ the office of dif^ej^tmn had 
b<'cri performed, but short of fatigne. In addition to this, I ordered him 
I tliree grains of tlie extract of conhnn fonr times a day, At the honrs of seven, 
twolvt*, fiv^e* and ten ; the dose to be gradual ly incrvii^ed to iive grains four 
I timca a day. Under this treatment, in a few days the whole of bis distress- 
ing Fymptotnn Rnhi^ldi'd. At the end of 7i months he was allowed three ouncea 
cf meat twtco a day. At the end of two months, he had gained flesh and 
► itrongth, so that he was abfe to follow Isi** occupation as a carpenter, which 
lie continued to do witljout intermission for some years, adhering ,<(trictljr 
to the rules laid down for him, which ho hud now the good Bense to 
[ adopt* 

My views with regard to treatment in the caj^e wore simply these: not to 
I give the stoam^h more to do than it could well aocomplii^h ; not to dilute tht« 
igjistric juice* by fluids before or ^oon after eating, but allow tln^nt to pur- 
[iorm alone their proper functions ; and to quiet the nerves of iht* stomach 
[ hy means of a mild sedative, wJiich prepared it for the due performance of 
[the oflfice of digestion. By this plan the stomach soon b**gan to crave for 
I food, and a longing for the hour for taking nourishment appeared — g*"^d evi- 
[dence that the powers of digestion were recovering. 

Is It not reasonable, theni to suppose that a moderate f|Tiaiittty of food, 
[well digested, supplies the system with more pure and nutritiou.'* Idood than 
, large quantity of ill digested food can possibly do ? Tt nppi^ars tit me not 

I iinreajsonable that the poison, as it may bo called, which i?* generuted by 
[food ill aHjjimilatcd, findw its way into the circulation; and hence arises the 
[misery of hertjditary asthma, vt hich nothing but a paroxysm, and generally 

I copious eipoctoration will relit' ^^o. 
I now proceed to the further evidence of cases which have been trofited 
why me under the sedative and strict dietary system ; and in doing so, I think 

II cannot give stronger proof of Us efficacy than by quoting connniinication!! 
[from patients themselves, as evidence of the relief they have ohtained-f and 
Khc life of comparative ease and comfort to them after adopting the fiytitem- 
jlkit, before I go further, I would remark on the ah so! ate neeesfiity of pro- 
[ourin^^ the best prepared eximots, which form of medicine I have invariably 
I Used for the purpose required. I havo more than once been di^^appinnted in 
Imy treatment, when my prcHcriptions have been sent to ordinary druggists, 
Iwith whom sufficient care Imii not been taken in this matter; thertforo I 
[itrongly advise medical men to prooure their extracts from, or send their 

[prescriptions to, some known first-rate practical chemist, whose repntation 

If reatly depends cm the purify of his chemical preparations* Goimine cx- 

racts retain for a long time their distinctive odor, remain moist, and do mit 

Imildew. The sedative extracts whiob I have generally used are those of 

ilienbane, conium, belhidonna, and stramonium, gradually increasing their 

looses and frequently substituting one extract for unotber, ait symptoms ap- 

eared to demand, 

ft is not my intention to enter into the more scientific department as to 

ho supposed causes and effects of this mysterious and capricious disease^ 

l«o ably treated of in the pages of this journal by Dr. Hyde H?tlter, whose 

em arks I have read with much interest ; my object is simply to record my 

Ipnnarks on the history of oases as reported hy my patients, together with 

obsepvations made by myself during my professional attendancen, which 

amy, I trust, lead to the mitigation ot sufferings. My own opinion is, that 

It IS impossible, from the president knowledge wo po^sosSi to come to the real 

fameM of the diseai^e in asthma ; but still I trust practical obsors^ntlons may 

' valuable, inasmuch as they rnay lead to scientific researches, not only as 

^gards the state of the blood tu asthmatic patieutSi bmt tl.Uo aB te^^t^le. ^% 




m PRACTICAL MEDICIXE. 

|iecttll«r r'TcprctrtrntloG which Is thrown oW* fljrough th*^ metliumaf tbo luf)gp*J 
m the (iltft^rt'iil formB of the ilisfusc^ whirh rippeurR to me to bo uaturti^s t*f-J 
fijTt for rolirf ; for (t in my i*troii^ iuTpresi^ioiJt as I Imve before ftttited, thnti 
It 19 in th<3 blood tluit tho searol Vich^ asr ibt^ mure hculthy li^ the state of tfa^ [ 
powers of digestion, so in proportion is the freedom of tlie patient from difi- 
e*ise in dyspfptie a?*thnuv. Then, ai^aiiu ti» re^jards person b heing atFecti*^ 
hi certain locuiities*, whilst perfectly fre« in otherj*, may ntit tho peculiar^ 
i^tate of tho atmosphere add impuritieB to the blood in so rat? districts, whMsl 
in others a more congenial atnuiftphere m]\ Uiss^-n, and in some in8taiico«<^ 
entirely ri?inov0, the impurity which exists In the cireulatirig' fluid in iKosai 
pijcdlsposud to the dis^eaae by hereditary can see t 1 have apparently, see^ 
ieverftl inj^tances of this kind, wbitdi I will hereafter name. 

I will now prficeed to record the his^tory of eases of dvijj peptic asthma, 
Ca»e 2. — In the year iSi>5, 1 was requested to visftit a elerjryman* upwards 
of 70 years f»f age* from the nortlj of England, who liad been residing In 
this town for mnnvi weeks, for the benefit of liis heailh* I had frequenUj 
remark I'd him in the streets: and tiot knowing the exact history of his cn^e^ 
1 Ci>neidered tie wai* in the last Btngo of ennKumptiou, po emaciated, so fee- 
ble ami diatresficdT d\d he appear I think 1 never saw any one walking at 
largo so eniaeiatedi I learned from him, that he had been afilieted with 
asthma for ten years, that during that time his cloricai duties had been isuff- 
paudedf and that, in fact, he was quite a martyr. In this time of his afflic- 
tion* he had nought every possible advice, both in London and in the coun- 
try, but without any material benefit or relief? the general opinion given 
hlin was, that he would never recover, and that he must bear his affliction as 
best he couhl. Ho was not able to lie dovvn ia bed; and, fi*r yoarsi overy^ 
night be had anticipated dofith before the morning camei when, however, iv 
copious heavy expectoratton would with difficulty be thrown off from tbo 
lungs, and as the day advanced be beeamo somewhat relieved, was then 
dressed, and passed the remainder of the day In great discomfort. Having 
Inquired into bis mode of living, 1 was told pretty nearly as follows ;— At 
six in the morning ho had a cup of strong coffee ; at nine he had ten or cof- 
fee, t<iast, eggs, or a chop ; bo bmched at one, generally im bread, clieese, 
and porter; ho had a suWtantial dinner, with porter and wine, and a ftiir 
quantity of ptort wino after dinner; ho had tea or coffee in the evening, a» 
well as supper afterwards. My remark was, *^And for uU this amount of 
nourishment, yon are as thin as any human being can well be/' lie replied, 
*''I have been Invfiriably told that, without puch support, I cannot live a 
month ; and I take it to nuike up for the largo amount I expectorate in the 
monung." I examined bis che^t nnd found neither tubercular deposit nor 
any lesion of the langs; but evidently, from the very clear sound emitted 
on percussion, the lungs were enqdiysemntous, particularly under the right 
ehivicle, whilst lower dovvn a dull hOund was emitted. In the morning, the 
pulse was seventy in a miuute, but as night came on it rose to ninety or a 
himdred. His tongue had a very morbid coot — large* with fissures in it; hia 
Momach wa*i generally di intended, and, though he ale so much, he had navet 
any great dcf^ire for food; his bowels were irregular; the secretiom^ dark; 
the urine was loaded with a pink depo&it. At the conclusion of my first 
visit, I surprised him by saying, ** You will considerably imprtjve in health 
nnder the treatment whicn 1 intend to adopt, and, although your age In 
such, 1 shoald not be surprised at your one day being in harness again.'* 
His reply was, *'Tbat is utterly impossible; my disease has taken such hold 
on van for so many years/* He farther said, '' he looked forward to nothing 
but death, and lie often prayed to be released from his huflferings/' I went 
on to remai'k, that if my treatment was to benefit him, seeing it was an ex- 
treme case of dyspei^tic aslhmaT he must make np his mind to one thing, 
and unless it was fully carried out, he must not expect to derive any g^»od 
result; thul was, he must eat jast one fi>urth what he was <laily in the Uabjt 
i>f taking, and, in addition, his food must be weighed, aiid taken as regu- 
J/irJr n^ the clock struck. His reply was, *' If that he your plan, you will 
Maon shorlvn my day 8. " I begged him to try \t for oiie ir^^V, \^V\^i\l \3kft vX 





I 



PEACTICAL MEDICINE, 

leng^th accp<led to, I common cod my troafinent on the 23*1 of April, by 
giving nn alimntiye doso of hluo-uili» nni] a valine aperient, I llicn urdoroJ 
three grains of the oxtract of beuonne four times a' day, and tlio sanjo sys- 
tem of du*tary aa prescribed in my fir^t ca^e, alluvvirifj bim^ in tbe form of 
auiffaal fuoti, only two ounces of it twice a- day. The result was^ tliat iit tlut 
©ml of a week he wos able to lie down in bed and ah'v^ several hoiirif ; hii* 
raorniug eipectoratioti had lessened considerably ; bis appetite improved: 
his tone^ue cbaTod ; tho distension at his fc^toriuich Icst^ened ; the urino was 
clear; hi a spirits lightened; and ho could cj^eit biini^itif with much more 
ease. He was noir fully satisfied that the plan hud so fur tfucceoded ; but 
his great fear was that be should be starved, by reason of so small ^ 
quantity of food being alh»wed him. At the end of ten days, I substituted 
tiie extract of eonium for that of henbane^ ordering him four grains four 
timei a duy. From thi^ time, he improved rapidly until he left tbe town to 
return hornet on the 14th of May* On tbe lOfh of June, bo wrote me from 
London, where be wn^j staying with tome friends; **1 cannot be suflieiently 
thankful for tho comparative case and comfort whieli, tbraugh tTod's biess- 
ing, and your skilful management, I bavo now enjoyed fi*r the last ftix weeks. 
Tho weather has been most uupropitious, notwitbiitanding which, 1 have not 
entirely avoided tbe cold ; my nose is rather * stuffy * from its effects, but no 
j^ymptom.^ of asthma have yet appeared, and I trust, by my strictly adher- 
ing to your regtmeu^ I may be spared any return." Od the iiOtb of Juue^ 
he wrote, frotn bis home in the north of England — *' I find the air hero 
much keener than lu Biddeford or London, and it bus cotoe ebiefly from tho 
eit£t, I congb a little in tbe morning, on first waking; but I have f(^lt noth- 
ing like aslhnm, I bnvo adhered very generally to your rules, with only 
the addition of more bread to my breakfast mid tea, which you have allowed 
in©. My secretions appear all right- I am, as you saw me, almost a skelc* 
ton ; but 1 am in hopes, however, that the wholesome food which I get here 
will be beueticiai/' I may remark here that the months of May and Juno, 
in 1855, were unusually cold, the east winds generally prevailing. On tho 
l^th of J jlyt my patient wrote; ** I am perfectly free from asthma ; my ap- 
petite is very g<xid, and I greatly desire that my dnUy allowance nmy be in- 
creased; and thi} number of my pills, I think, nrny be reduced." 1 now or- 
dered five gi^ains of the extract of eonium tbreo ttujos a- day, and increased 
bis daily atlownnee of food a little, keeping strictly to the hours of taking 
it. On tho 7th of December, my patient informed me : ** Notwitbslunding 
tho seventy of tbe cold, and tho dampness of the atmosphere, I am quite 
free from asthma^ I now tiike my medicine only twice a-day ; it appears to 
have a wonderful efFeet. ) am able tf* Ho down in bed all night; and I sleep 
six or s<?ven hours at a time, and feel no difficulty in breathing, and I trui^t 
thiii winter I i^fiaU he able to remain at home witliout a return of my fearful 
disease," On the 17th of Dee,, bo wrote to say be was still going on well — 
*• Sonte days since, 1 imprndently exposed myself too mticb to the eold and 
damp, and was consequently seiaed with a shivering fiti and afterwards fe* 
ver. I was confined to my bwd for forty-eiglit hours; but no asthma nuidtJ 
its appearance, I weighed myself lo?;t week; and notwithstHnding my Into 
tttt&ek, I found I bad gained seven pounds in weight since tbe previ4ms 
weighing,'* 

Since tbe date of the last letter, I have occasionally heard from my pa- 
tient, who stili applies to me for advice whenever bis complaint, from any 
imprydence in diet or irreguhirityj threatens an attack ; and, to make my 
prediction true, I hear be has occasionally resumed h'm parochial duties &s 
rector of his fiarish. 

Cmc 3, — Tbe third case of dyspeptic asthma was also in a clergyman, 
whose appmruneo was very different from that of the lai^t, he being stout 
Rod lethargic* lie catne to be under my care from tbe county of Sussex ju 
lBo*Jp Hy hud Iwi'u uftliett d for seven years, and bis difficulty of breathing 
was constantly on hirn whilst awake, parliculavly nfteialuW m^;uX. '0\\ vis- 
aininatjonr 1 ^hiatd his lungs greatly oppressed, aud duU oiv \i^TCUfes\oTi% \vv* 
heAtt's action wn^ rerjr fevliJe and slow; his tongini coated tiii^V V-^to^U \ ^^ 



UCTTCAI. HEDTCmE. 

stomach greatly tliHteTi^uil with flutiia, which nppenred to distress him grpaM 
ly; th« wrjnc! was ItHuled; hn wa.^ unable tn Iid down in bed^ and hud K(*avj 
I expect orii turn in the mnrninp:. Fie MjU perfunned hta parcicbial duties 
I though with the grrittr^j^t difiiculty. Having clcnred out tho bcpwtls 
Imenns of an aporii?nt* I plftced him on the ^edativo end strict dietnTv pya 
I tern t giving three grulns of thi> c^itmot of couium f*iur times a-day, with an 
rpiH evt!ry other night of two grains of each of tho o^ttracts of taraxacum i 
I limple aloitic piU. 

Jle came nndrr my mpdical care on Ihe l&t September, On the 9th of th#l 
[Bftme monthi I had the following bultetin from him* *^My htmlth improT©»9 
rti>pidly undor your mode of treatmcntt and I was able yesterday to repeat' 
I the responHei at chnrch with ca?o to myself; and 1 took a wdk wlthotit 
l!l«liiig the least oppressod in my breathing or fatigues to myself. I have beco 
uBioted with a^thnni. for inoro than Eleven yearSi and have consulted saevernl 
^Iftftient physicians without rtny thing like the relief which I even now enjoy. 
A week only has elapsed since 1 consulted you; and yet, 1 am thankful to 
say, my chest i* so mnch relieved, that t am able to walk several mile^ with- 
out being obliged to rest in order to fetch breath," On the 1 8th Sept., ha 
wrote T — ** By this time you will be anxious to know how I am going on- 
The weather has certainly been very fine and clear eince I commeucod your 
mode of treatment ; but many a year has elapsed since I have had such free- 
dom from pain. On Thuri^day lasti I walked up a steep hill of half a mile 
without stopping once; and on the following day* 1 bore tbo fatigue of a 
long joarney into Sussex* without finding my chest at all oppressea. Ijaet 
Banday wag the grand criterion ; and 1 can assure you my voice was re- 
markably clear, and my chest but scarcely influenced by the enemy." Ott 
the 2nd October, he wrote :— My health, on the whole* is very satitrfaetory, 
Since I last wrote to you, the weather has been x^Tf cold and stormy ; not- 
withstanding which, 1 have breathed more freely than I have for many a 
year, and I now go about the active duties of my calling with confidence.** 

Another letter, a month after wards^ tells me be is quite well: since which 
time I have had no communication with my patient, but 1 learn from bis 
friends that, thinking that ho had remained so long free from complaint, ho 
might with impunity return to bis former way of eating and drinking what- 
ever came in hii^ way, Iw hail consequently since experienced returns of his 
complaint, as might natunUly be expected; for, as J have before staled, an 
asthmatic patient, who inherits iistbma, oan never with impunity eat and 
drink as other people ; and although I gradually increased tlie amount of sup- 
port taken in this ca^e, yet tbe patient was not fttttiiified, but allowed his in- 
clination to overrule hit* better judgment. 

Tbe above case must be admitted to be strong proof how much tbe dis- 
ease is influenced by the manner in which the oflice of digestion is peifortned, 
and how much the patient has it in his own power to live a life of comparative 
ease and comfort, — JBrUish Med. Journal t June 9 and Julv 28, 18ti0, pp. 
434, 670, 






* 31.— On the Esgsntial Nature of Asthma, By Dr, H. Hyde Sai*teR| 
F.R.S. — There are two ways (which I have not mentioned in my work), am 
indicated to me hy my friend Dr. Brown -R^quardi in which bronchial spasm, 
when once establi!*hed, may be kept up by the very conditions which tt gen- 
crates ; one is^ tbe power which carbonic acvd gas possesses of producing 
oontractlon in amooth muscles. Tn asthma, tho deficient standard at which 
respiration is carried on, and the diminii^hed interchange of the gases, pro- 
duces an accumulation, in the air locked up in the air passages, of carbonic 
acid to iin unusual defjree. This, by the action to which 1 have just re- 
ferred, sets the bronchial mnseles still further contracting, and thus increases 
the very condition which at first caused tb« accumulation of tho effete gas. 
In this way, asthma keeps up asthma. The other way Is hy tbe broncbial 



(ipasm stimulating i\w afForcnt or perceptive T\eTVO\^^ ^Vt^mftuts^ and tliua 
fivia^ iiso to re Bex nm.-fouIar contraction; ^ust Tx%t\io %t\x£va\ft?L\iiTi ol \Va 



i/L*..^ ^ , -- - . v.^ 



PKACTICAL MEDICINE. 



lensJtive roots of the spinal neTvcu produces reflex muacakr pbonotnctiii in 
the parU to whloh tho correti ponding niutor riervH^^ ^re ili^tnbuted* iu lUU 
way, tnui$cukr spasm becoineii a fitimuluid to m macular a pas in. 

But ill b<jth these, as in the otli<;r ways 1 have indscatcsd tn my bookt 
the brc>uchial epasm h secouclary to an aaUcodeut nervous ooDditlon« — 
Briiuh Med. JoumaUJuly 2i?, 1800, p, 581). 



I 



33* — On die Prober ux6 of Stramonium in Hay* Asthma. By Dr* EuwAUU 
LAWFOitDt Lcigbtou Buzzard*— [Tbo thorii-applQ or striiuionium was first 
intro^3uced to our notice from the idhiud of Coylon. Auth<jr« diffur re^umrk- 
ably ill thftir teatiraoiiy as to its use — aome reporting favourably, otiiers con- 
BideFiug It well nigli valuoless*] 

Smoking the herb is tho plan generally rccomanjndedt and in thnse who are 
e&sily brougbt under its influoaoe thiji plan ist doubtli^esi occotsiouany of 
coasidcrable eervice ; but with tho majority little or no effect is produced by 
this mode of procedure. Truet smoking, if long contiauedi may produoo 
nausea and alight narcotism ; but the paroxysm is urgent, and immediate re- 
lief is required. Under tUo^e circumstanced, I have been in the habit of 
dlrcctiag the patient to introduce portions of tho stem a»d leaf of the plant into 
hia pipi^t as before, to smoko it, and inject tho smoke thus obtaini'd from tho 
month into an inverted ale glass; to continue this procedure until the glass 
ia filled with the stramonium fumes, and then to place the gla^s(stm inverted) 
over the mouth, and take one long and deep inspiration, The effect im in- 
stantaneous, a sense of sufiTocattou for the moment, tlien copious expectora- 
tion of rQpy mucus, and immediate relief. 

Stramonium, in addition to its antipasmodio and narcotic properties. Is a 
dirscti jmttter/uU <ind instaniancQus cj^pectorant, If pri>porly applied, and ia 
this consifltg its peculiar value iu this distreBsin^ complaint; hut in order to 
effect this object, it must be brought into tibioluie cmimi with tho air-cells 
of the lung; simple inibibitiou through the mucous roembrauo of the mouth 
will not bring' out its powerful eipectoriiut properties, and hence tboso who 
have looked tor benent from smoking the drug dimply, have ho en grievously 
disappointed, and have prououncjd It valueloiis- — Bnlish Muiimi Jourtttd^ 
Aug. 18» 1860» p. 657. 

33.— OH THE VALUE OF TONICS IN ASTHENIC DliOPSY* 

By Dr. B. 3» SiSDosr, CliettenliCim. 

(It has been shown by Dr* HandBeld Jones, that some eases of usthenie 
dropsy are curable by tonics alone, and are unaOfected by diuretics* In the 
following paper Dr. Blsson shows that other casctf, though beneiited hy 
drugs of the latter description, require the former to complete a cure*) 

Mrs* , aged forty-five, has been ailing more or less for the la^t ton years, 

during which time she has been frequently under trt'atmeut with only tem- 
porary benefit. For the last threo years she baa bad swelling of tho faoei 
abdomen, and legs* Catamenia have appeared only oneo iu that time, and 
then in excess. Has had an erupticm on the skin, unaffu'oicd by treatment* 
For the last two years or more siie has Jived on slops, forced down without 
appetite. Has had frequent Tomitings, with diarrh<ea, blood being oft^n 
poAsed with the stooLi. 

Mmy 16th* Found her in bed* presenting the following symptoms :— Face 
muok hloatod; abdomen very protuberant; body goner&lly auasarcous, with 
large dropstool swellings in Spending parts i much euiaeii^ted in parts nnt 
conBealed by effusioa ; patches of eczema on hack of haadsi feet< und front 
of legs ; greai dyapnom i bortJEoutal poftiticm intolerable ; iucessaot tjouga* 
expect<»rataoii tmn and frothy ; comj^lainta of groat pam \xi IVw ^V^%\.v Wk. 
percuAsioD, tnarif^J daUuesM on ihe right aide, aver \owQt \i\k\i ot Wuv?^ V^" 
Uinorijr mad miteriorlf; hud crej*j"tations ; mucous tdXm \ ^'Q^m V:^S^m 



I 




L 



01 PEACTICAL MEDICINE. 

iirmo turbitl* Bonntj, tif dark -brown colour, not ooap^iilablo bylioat and nitric 
aaUI; stnoU liquiil, Oark, and ofTensive. To apply turpentine stitpes tu 
che^l ; cbloL'ide of mc^rcurj, three grains ; powdered rhubarbt ten i^ratus* 
To be fill Ui wed by an aperient draaght. 

17tb. Ordered bitartrate of iiotass* one scrapie; vinegar of si]ui]1^f spirit 
of nitrous etber^ of eiich ten niininii^ ; compound dL^crK?tion of scoparhim, 
two ouuoei, thrice a day; beef- tea, and half an ounce of brandy every four 

The patient improved most natisfactanly up to tlieS^th^ when her husband 
itiimintmed me in ha9t;e, stating that hH wife was dy'mg, I found bt^r gapping 
for breHtk ; pulse at tlie \rriat scarcely perceptible ; had complained of great 
pain in tho cheat. Apply turpentine stupes to the chest; hot bottles to tli« 
fi*pt, and give one drachm of brandy. Ntitrients more fre<|Uenlly; eontintio 
diuretic nurture and bntndy, 

2ytb* Tho patient was delirioua laat night; got out of bed, and went into 
the adjoin hig room. This morning i^lie h nervous and fidgi*ty* Pulse 120, 
weak. Hidf an ounce of brandy every two houra ; continue diuretlo; twenty 
minims of tincture of opium at bedtirno* 

30th. Slept well hist night; much improved; dropsy diflappearingT e:ic©pt 
in face and legs; urine mticb IncreamHl^ clear. She ealled my attention to 
a swelling in the right iliac region, for wlilch pho bad been previously under 
treuttJient* Now that the ascites was removed* I perceived a tumour in this 
pituatinn, of the size of a large fii^t ; painful; movable; outline distinct; 
ilucluation perceptible. As vaginal examinati*rn was objected to> I did not 
prosB it in her present statCt in tendings howeveri to do so at a future time. 
To apply fitx k^eche^, and fomentation* 

Juno 1st* pHin in iliuc region removed. Apply six more leeches. 

6th. At this time nil the more urgent symptom sit bad disappeared, but tho 
legs became euormouHly distended* and covered with one ma-^s of pcteohiae* 
The cutamenia reappeared; execftisivo and pule. Discontinuo the diuretio 
mixture. The legs to be band aged t Ten minims of tincture of muriate of 
iron thrice a day* 

From tbi^ time the patient reeovered most rapidly, the bloated cheeks, 
however, remained unchanged, fihowing that the cure was not yet complete- 
Ordered to bandage the fuce tightly with handkerchief a, and to continue the 
iron. In a few days my patient had the satisjfaction of seeing her face re- 
duced to its nornuil proportions. Th-? eczema entirely disappearedt and bj 
the end of June sfie had not only regained her strength, but stated that ?he 
never felt better in her lifw. I now pressed for an eiamination of the Bwel* 
ling in the nlde, when ^lie assured me, that after a minute eiumt nation, not 
a vestige remained. 

Here was a case of acute pulmonary cede ma, i^upervening en chronic 
ascites and general anatisurea, in a patient debilitated by long disease and in- 
ability tij take subsitnntia! food. Her history was most unpromising, her 
brother having died of dropsy, her mother dropsical, and a sister, abuut 
whom T have s^ince been consulted, in the same state. To a young practi- 
tioner like myself, tt may bo supposed that the case was one of uo little 
anxietyp But still, after a most miuute cxaminaHon, being satisfied that no 
organic diseujjc existed, and believing in the wonderful power of drug-^ when 
properly employed, 1 predicted a perfect recovery. Hut when the ascites 
had disapeared, and my attention was called to the tumour in the iliac region, 
my favourable prognosis was shaken* Had I continued the routine practice 
with diuretics^ not only should I buvo failed in effecting a cure, but t anti- 
cipated a return of all the symptoms which bad disappeared. What diure- 
lies failed iiu iron accomplished, and hafi I believe, rendered permanent 
cure, which would otherwise have been of short duration* AVhat would na- 
ture — what would the much-vaunted homceopathy have done in such a ease T 
Allowed disease to have its sway, and hurry the poor patient with rapid and 
tmerrhiff Htntim to a premature and unnecessary death* Upon what pat ho - 
It^^wal eondition did the dropsical effusion in tVia case ^e^eiitll \>Q\i.l\Ueas 
iifo more h'qmd port torn o£ this greatly impQ^^ma^^^ \>\oo4 limTlii \)* tcti^-^ 



PRACTICAL MEDICTNE. 



exit through tho wall^ ♦*£ tb© capillario*?, r(*hi:^otl fvom want of their proper 
stlmuluii — a hi'ahliy l>h>n(l. The action of the iron \fi then ohvhmj*. 

And now comf*?* Uio iim^t import fint question, Whnt was th*' tumor in 
thtt W'rne n^'^ion i Con Id it hti ovanan dropsy t t>ncb Tras my diagno»iji , 
But wo nru lohi that the contents of an ovarian cyst nre never abijnrhod* 
The vnf^inal wails, ho^'evtr, may give wrtVT and the contents be disch argued 
hy thiit elnajiu'f, Wiis the supposed reliirn» tltcn* of thi^ catmneiiia on tlu* 
0th of Juno s-nch a discharge '.' I think it pussibltt; but as a viiglnul e^eiiun- 
uiitton wft« m>t made, a duabt may oxis^t whether the tumor was ovarian nt 
all. Hero is a tunior dating from a mij?e'irriago ten years ago, gradually 
rising out of the pelvic cavity towards the abdomen, increasing ra it pm- 
eeedi* ; at tinioa piiinful ; movable; with defined outline and perceptible 
tlnct nation. I ask, if not an ovarian tumon what was it? 

Thu extractrt I tiave made of thin case sopmed to me as f*3w as were com- 
ppitible with the right under&tunding of ao important a Bub^ecL— Lance I, 
Aug. IK lHt;0, p. IM. 



34.— ON PAJJALYSIS OF THE BRONCHIAL MUSCLES, 

Tty Dr. JiKEfl F, Dtiacjjf, T. C. D,, Fhyiieiiiii to the Aclelnido iijid @^rapion''ft EToflpJtal. 



The morbid changes occurriag in the muscular tissue of the pulmonary 
a?stem do not nppear to me to have attmcted that attention from pathohi- 
gtatH which has bet-n 1*0 readily ext<*ndiad to every other structure in tho 
body. It ii* quite true, that wo havo for a very long period been accustomed 
to recognise ^spitstie contraction of these tihres as a frequent cauKe of some 
fiirma of dy^pna^a; and various appropriate remedies have been resorted 
to f<*r the relief uf those dij*cases, suggested by the idea of their convulsivo 
nrtture. But the oppofiito condition of impaired contractile power, if it ban 
not been totally' overlooked, has at least been greatly di?* regarded. No at- 
temptt that I am aivare c>f, has becu made to ascertain the peculiar s^ymp- 
tom« atid signs arising from such r state, or to determine the treatment suit- 
able for its reniovol ot relief. And yet, judging from an ah >gy, no reason 
cnn bo assigned why such n condition ns thtit of paralysis, or impaired vital 
energy, should not o ecus ion ally oecur here, as well wa in otlier muscles; or 
why. when such a condition does occur, its existence ahonld not be disco v- 
erablo by a careful ohsurvation of its attending phenomena. 

i^overal circumstances naturally suggest themselvos ns serving to account 
fin- this omission. In the first place, the small size and obscure develop- 
ment of these muscles give us the idea that they are to ho regarded rather 
as a rudimentary structure, preserving the analogy of form with the same 
partH in other animab, than as an apparatus designed for any iipecial use in 
ilie ecouojuy of man. Very f«w practical physicians, I bolieve, look upon 
these muscles as performing any efficient part in healthy respiration; and 
henco they are not prepared t« e3f[>ect any tnaterial inconvenience to Uc 
produced as the result of their impaired action. In the second place, the 
tact that care has been taken, by the very oreanization of the parts, to j*re- 
veni tho respiratory process being materially interfered with by ninrbid 
changes in the vital action of thes*w fibres, renders the occorrence\if the&e 
changes, when they <lo take place, JesH obviou» to tho general observer, 
Not being voluntary muscles, neither the patient nor tho physician is pkced 
hi a positkm to dli^cover the loss of their contractile energy, while the man- 
ner in which they are associated with the elastic structures uf the lungs is 
calculntcd to counteraefc the injtirlous eft'ects that would bo sure to follow, 
were eoUapse of the air-passages a necessary result of their paralysis* In 
tba la%t place, morbid changes in tho muscular structure generally are not 
of a n»turi* to bo recognised by microscopic exumtnatton. Chang(?s in utlwi^ 
tissues lire toci obvious to be overlooked. The inucQixft mewft^'tttw^ \\\vv3 \i^ 
conge^hil or ihhkiHiodf or stripped of its epitbeWatn. 'Y\i© ^iitou% \^t^v^\' 
hmne mnj lose it^ tran.spnrency, OT ha covered \\\l\\ m yiiitVfeQXitmwf^ V^^"^ 



I 




m PKACTICAL WEDICIKE. 

of lymph* The tiir-collg mny bo rupture*!* ealnrgetl, or othertPise ultered^ 
The pun ricbymu i>f the lungi may bo hepatized, iiifiltraU-tl with purulent 
uiiitter, or a?tlt'iimtoiJi, all <*{ whieh ciiu be t*a*:ily refogni^ed by the senses* 
But tlie nmi^oultir structure eeems to defy ;dlke th<.^ gcalpel of the anatotDist 
aud Uio li'iis of tbo microsco[>iAL Evon atrophy, a condition* with the oo- 
currencc uf wldcb iti rrtlier muscles overy pathologist is ftuniliatf hecotnes* 
in tb^ instance before as* an uitccu'laiu pht^noinenoni to be discovered with 
difliicuUy, bi'cau^e the ixoraml isiru€ture itself ig »o dc'licata that it seems 
(icar^ely possible to decide whether the appearance, m any particular caea 
uuder oiiAminationT U really u. morbid coud Umiu «r not. 

[ bavii Haid tbat analogy would lead uit to expect that occasionally, at 
loustf tbese fibres >iUotild exhibit the c^indttion of diniinished vital energy, or 
paraly,*§is. To Dr. ^tokeb the nnifession is iuiltbted for having* mauy yeitra 
ago* enunciated a pathological law as regards mu^cidur structure, t^'bich ban 
beeu uuiversatly recognij^ed sinco a^ a well-estabU.shed principle* Tbo 
principle i^ thi^* that wiieu muscular fibres have beeii long exposed to ii 
ctmtiuucd irritation from the esistence of luflamDititiou in m» iiJjaceut struc- 
ture* thone fibroa which at first are thrown into a Ht^vto of umiatural oontrac- 
tiou, by contact with tlie inflauied parts, at last become paralyzed from 
over-Btiniulution. It wai> in this way he explained the bulging out of the 
intercostal muscles* wbicb is univert^ally observed in the advanced ^tage of 
empyema. But tbls principlet wbicb is universally aduutted* when applit'd 
to mu;icular fibres in contact with serous memhrauei 1^ e(]uuily applicable 
to miiftculor fibres in contact with mucous membranes. In fact* Jt has been 
ao applied to explain appearances die^covert d in the duad bodies of persons 
who have died of ileus. Now, If tlus bo true, and tbt^rc seems no reason to 
doubt its accuracyi it foilovvs as a matter of course, that long-continued in- 
fiamuiatory action in the bronchial mucous meml*miio ought frequently to 
impair, or even destroy altogether the coutractility of tht* muscular fibres 
wbicb lie in clogo contact with the undc^r surfuoo of the intiatncd brouchi. 

This idea was strongly impressed upon my mind by a case which I had 
recently under my care in tbc Adelaide Hojipitab which presented some fila- 
tures of a peculiar character* tbat appeared to me to tally with what might 
be es|vected to follow from impaired energy of tbet^e fibres* and which de- 
rived immediate and obvious benefit from a plan of treatment odapted to 
such an hypotbosis. Under the imprestrion tbat this idea niay be well 
founded, I venture to lay the particulars before the Asi^ociatloa* in tliii hopo 
that more extended observations may confirm the condusionft at which I 
have arrived, or, at all events, that the hints which I now throw out may 
lead to some practical improvements in the treatment of purlieular fonns of 
chronic bronehitli, 

Eliza Simpson, a married woman, forty yeari of age, the mother of nin« 
children* was admitted into the Adelaide Hoj?pitali December 12, !8fii.>, labour- 
ing uuder a bard cough, with frothy and scanty expectoration, and suftering, 
fjfonj intense dywpncea. Iter history was thi« i she was a laundress by occu- 
pation ; twelve months previous to her adniiission* when in a state of per* 
Expiration, she bad gone out of her wasblng-room into the open air to gather 
in some ciotbcs^ when the weather was vary severe, and snowing. In this 
way she got cold* which affected her breathing, and from which she had 
never recovered; within the last four or fivo weeks ber condition bad got 
very much worse* ber sufferings being greatest at night ; for several weeks 
she had been totally unable to lie down. 

At the period of bf*r admission she was a picture of suffering ; she was 
worn out from want of rpst ; looked pale and emaciated ; her lips wei-e livid, 
and ber res pi ratio Ut though only 18 In a minute, was forcible and labourer]. 
On esaminiug the chest, it was of a rounded form, by per- re sonant ou per* 
cusslun* with a feeling of increased resistance under the pleximetcr, and 
with loud* sonorous, and cooing 'rales, audible in every direction. There 
was no lateral or nntero-posterlor enlargement of the thorax during respira- 
tiou : ii movedt as a whoh^ as if the rfiiii and caTt\\w|r©a itstm^d *3no firmly 
uiilied and usioItQruble piece, and the only lucreaio its capiv^Aty Ti4\ftv\X.fta. ^l 



_j 



PRAOnOAL TffEDIOnm 



was by thd eler&tton of its upper margiiit and the dtpression of tha dfa- 

The tnAnnef irt which the respiration wa& carried on sufficiently accounted 
for the puin and difficulty she folt at night. Tho iavoluntarj inuscloa not 
being able, without assiatanco, to maintain the acceasary eacpanaion of the 
cbest to carry on respiration, each act of rcapiratioa waa* to eotite oitent at 
least, an olfbrt of volition % and as tho condition of steep Iraplioit the abey*- 
ftnce of seusation, ^he was obliged to remain awake, to keep herself all re. 
But there was one feature in her dyspna^a which could not fail to etnke the 
most ordinary ob:*erver, and whioh appeared to me to give it a peculiar char- 
acter, and that was* the great diaproportion which existed between tho dura- 
tion of inspiration and that of expiration. In health, so far as I have been 
able to obi^erve, tho act of inapiration is really longer than that of expiration ; 
at all event^f 1 am satisfied that it do os exceed in duration the 2>ertod of time 
occupied by expiration. But in Simpson's case, this ratio was reversed, the 
duration of expiration beinc^ fully three times as long as tliut of iuapLratlon, 
This eould ho seen by the eye, as well as felt by the hand, and heard by the 
utethoscopo. I am well aware, that in chronic bronchitis^ a proloncred cje* 
ptratory murmur, attended by sonorous and sibilous rillesi is one of tlko com- 
motiftst and best known signs of the disease. But even in cases where the 
itethoscop© reveals this sign, it is rare to see the difFetenco manifested in a 
marked manner to the other senses, as it was in this Instance, 

How is this* prolonged effort of expiration to be accounted for ? I believe 
the usual way of explaining it is, by referring it to tho diminished force with 
which the air is expelled frona the lunge, ai$ contracted witli that with which 
it enters ; hence, when any mechanical ImpodimentH exit^t to the free exit of 
the air, owing to congestion of the muo<iuii membrane, or the exitttenea of the 
products of inflammation on its surface, it must take a longor time than usual 
for the aceoaiplishment of tho effort. But if this wore true, how doei! it 
happen that such a phenomenon is never observed in acute bronchitis, where 
such congestion undoubtedly occurs, as woll as in the chronic att'ection 7 
Kejoctirig tor this reason the explanation iu^t given, I attribute the prolonged 
expiratory murmur to impaired action of the muscular fibr*?*, 80 long as 
they retain their healthy vigour and contractility, weak as they are, they 
materially assi.'*! the act of expiration by simultaneously diminishing tho vol- 
ume of the lungrf; but when their vital power is impaired, by reason of tho 
Inng-continued irritation to which proximity to an intiamed mucous membrane 
subjects them, thoy no longer assist, or umUt but very feebly and imperfectly 
the other agents, whose office It is to diminish the capacity of the chest. 

This, thc*o, is what I would consider as the distinctive f^ign of paralysis, 
mure or less perfect, of the muscular fibres of the bronchial tubes. 

But to return to our case* She was treated on her admission with stimu- 
lating expectorants, and turpentine stupes at nighti but with very littlo 
relief* A variety nf expectorants were tried in succession, but without 
advantage. On December 24, *he was put upon a mixture coutaining nitric 
acid, which agreed rather better witli her than any she had previously used. 

On the 26th the galvanic coil was usedi and a current of electricity di- 
Teeted through the chest from the side of the neck to tho pit of the atom* 
ach* This gave her no annoy ance* but was productive of no benefit. On 
the 27th the report was :^** Looks a little better, but there is no material 
change ; sleeps very little (all her sleep had to be tnknn in the fcitting pos- 
ture, or sleeping in bed with her bead raised up); hur bn^athing is very diffi- 
cult J* On that ihiy she was ordered pills, containing iialf a grain of extract 
of nui vomica, and one grain of ipocaouatihar one to be taken three 
times a day, and her nitric acid mixture to be continued. The eflVct of 
this treatment was most surprising, and, T nuist confess, most unexpected* 
lliat night she was able to lie down and sleep all night ; her breathing 
was much easier^ and her expectoration free. She looked obeotful; e.wi 
her appetite, which had been very deficient during t\\Q w\vu\i£5 ^^xw^ ol V'cx 
illness, was improveil Ttmi was the first nij^ht, aa ft\i© fstAted.^ l\\«tt ft\\fe\^a^ 
been Me for seven weekM to lie down and sleep all night* \\im\«i«ivl o1\jxqY^^ 



I 



i 



96 PBACmOAL MEDICINE. 

snatches of rest in an uneasy posture, she was ahle, without inoonrenieiioo, 
to rcBumo the natural recumbent posture, and to enjoy the refreshment 
that none can appreciate so well as those who have been long deprired of it. 
This treatment was continued with the happiest effects during the remain- 
der of her stay in the hospital; with the exception that, on the 31st of Do* 
cember, the quantity of the extract of nux vomica was increased firom bnlf a 
grain to a grain for a dose ; not because the former quantity had in a meas- 
ure lost its effect, but under the idea that it might the sooner enable her 
to return to her employment. The effect of the pills, as she described them 
herself, was to relieve her breathing, promote expectoration, increase her 
appetite, and keep her bowels open. I certainly was not prepared to find 
nux vomica a promoter of sleep, believing, as I do, that it is in many of its 
properties an antagonist to medicines of the] narcotic class. Yet so it 
was : the poor creature, who before was almost unable to close an eye* be- 
gan to sleep in the day-time, to her own infinite relief. It is scarcely neoes- 
sary to say, that I do not regard this result as contradictory in any measoie 
to the physiological properties of nux vomica. It was the consequence, not 
of its direct, but of its indirect action. It did not narcotize the sensorionit 
but it stimulated the muscular apparatus of the pulmonary system, and by 
so doing, removed a mechanical impediment to the proper performance of 
the respiratory functions. On applymg the stethoscope to the chest, it was 
found that the bronchitic rAles ha!d lost much of their intensity ; they were 
shorter and looser, and the expiratory murmur, as .contrasted with the in- 
spiratory, was less prolonged. Corresponding to this change in the phe- 
nomena of auscultation, there was a corresponding change perceptible to 
the eye and hand in the relative duration of inspiration and expiration. 
The former having lost somewhat of its voluntary character, was neither 
so forcible nor so short, whilst the latter, though still pretematurally longer, 
scarcely exceeded the former in duration. At the period of her discharge from 
the hospital, January 6, i860, the two effects were very nearly equal in 
length of time. — Dublin Quarterly Journal ; May, 1860, p. 299. 



35. — The Successful Treatment of Hooping Cough, by Increasing Do$es of 
Sulphate of Zinc and Extract of Bdladonna. By Dr. Fuller, Physician to 
St. George's Hospital. — [In the last volume of the ' Medico-Chirugical 
Transactions,' Dr. Fuller publishes a paper on the tolerance of belladonna 
by children. The following abstract of a paper read before the Harveion 
Society of London, contains a sufficient epitome of that aricle.] 

Dr. Fuller commenced his paper by calling attention to the commonly- 
received opinion, as stated in most books on the subject, that, ** Hooping^ 
cough must run a certain course." He combatted this opinion by reference 
to £e results of his own experience, and then proceeded to point out the oaoees 
which had led to its general adoption. Among these he mentioned the ineffi- 
ciency of the treatment ordinarily employed, and the neglect of all measures 
likely to subdue the tendency to spasm on which the continuance of the 
whoop depends. Dr. Fuller regarded the complaint as consisting essentially 
of bronchitic irritation, usually not very severe, accompanied by reflex spasm 
of the air-passages, and expressed his opinion that in most cases the spasmodic 
STmptoms|are those which demand our most serious attention. Not only is 
the spasm a most painful symptom, but it is one which may give rise to life- 
long mischief. His object, therefore, had always been to subdue the spasm 
as speedily as possible, and the practice which, until the last twelve-months, 
he had found most successful for the purpose, was the administration of sal- 

Shate of zinc in rapidly increasing doses. Dr. Fuller then referred to the 
iscovery he had made as to the tolerance of belladonna by children, which 
is recorded in a paper published in the ' Medico-Chirurgical Transaotionef' 
and he briefly stated the facts which are there detailed in extenso, as to the 
mmount of belladonna which may be given wilVi saC^ty^ and the oonditioBe 
wJiIob should be observed in its aamimstratlou. T\ie coTwQL\^Qiii%>ia v^ma&mIl 



:raACTICAL MEDicira- m 

irere* firsti Che remedy shoal*! ha given at least faiir times dailj, and should 
he 4!idiiiiiii8tered at first in small doeesi, whicb mtiy be incrfiased day bj day 
nr on alternate days* by acorrefipondmg amautit. He pointed out that maro 
dtlatutii^n iif the pupil need not be regarded as a bar to its admmistratitjti, 
1 stated tliat tf tho precautions iiiat referred to are observedr the daily dote 
fche extract of belladonna may be safely inoreaa<?d up ton hc tuple, or half* 
a-dmcbm without the production of any unplettstint ayrnpt<jms- He then 
proce cycled to state that be had brought these facts to bear on the ti-eatment 
of hotjping-coug^b, and from the conjoint use of sulphate of sino and eitraet 
of belUidoima* in rapidly increasing doses, had obtained res^ults exceeding 
his most sanguine e^cpectations. Karely had he found the whoop to last abovt? 
twenty -one days, and in some instances it had subsided in ten day?. Tha 
fuode in which Dr. Fn Her proceeds is to give the zinc and belladonna a-^ anon 
as the whoop declares itself. If the attack is accompanied by much febrile 
eicitement, and bronchitis irritation, he prescrilie^i a cough-drop con- 
taining' a drachm of antimonial wine and a drachm of Ipecacuanha wine to 
two ounces of water, and, if necessary, applies a blister to the chest. Of 
the cough-drop, a larger or smaller amount is given according to circum- 
stances. In a\i case^<, however^ the zinc and belladonna are perseveringly 
sdminlstered. To children under three years of oge lie usually begins by 
giving one-si ith of a grain of extract of belladonna, and half-a-grain of sul- 
phate of zinc four times daily ; and to children above that age one-quarter 
of a grain of extract of belladonna and a grain of sulphate of zinc. Those 
remedies are given in aolutioTi in water, and tlie dose of eaoh subs tan co is in- 
creased by a corresponding dose daily, or on alternate days ^ so that the child 
who began by taking one -quarter of a grain of the extract and one grain of 
j^lnc, at a dosef would be taking one grain of the extract and four grain a of the 
line at a dosoi either on the fourth, the sixth, or the eighth day, according to the 
rapidity with which the dose is increased, Dr* Fuller concluded by oitmg 
cases illustrative of the value of this treatment ; asiured the members of its 
safety, and urged its general adoption* — Med* Times and GazetU^ May 26, 
1860, p, 539. 



5^— Ore Chronic Bronchitis and Empkysema^^Of the number and variety 
affections of the pulmonary organs which constantly present themselves 
for treatment at our hospital?^, perhaps there is none so distressing and so 
difficult to relieve effectually, as the above complication* Chronic bronchi* 
tta alone requires much attention and oaro, but when interlobular emphysema 
is combined with it the disease is quite incurable, and our efforts can be at 
br^st but pailiatlve. Although this double form of chest disease is one of 
pecaliaritiea of the aged who are subject to constant exposure, it is 
Ity commoniy witnessed also in tniddle*nged and even younger persons ; 
in many instances wherein it is seen in apparently strong and vigorous 
' iudrviduals, the emphysema has beeti the primary affection, originating pro- 
trnbly In rupture of the air-cells during foroible bodily efforts. To take a 
siiuglo example out of a number in illnstratlon:— A hitherto itn>ng and 
robust man i Nalban N.), aged forty -four years, a gaa-stoker, was lately ad- 
initted into 8t. Bartholomew's Hospital, under Dr, Farrc's caro, with ei- 
tensive euiphysema and chronic bronchitis, which he has had for nineteen 
years* The suffering from dispnfra and shortness of breath during that 
lim|if period, in a strong man, may be readily imagined. Now, he was suf* 
f'^rtug from the consequences of this double malady; there wai anasarca of 
the legs, body, and face ; the prominent parts ot bis rounded back were 
Hwollen like puddings; the face was dusky, the lips bine, and the breathing 
very distressing. He was subject to epistaxis ; the urine contained no al* 
bumeo^ In the treatment, attention was paid to the bowels ; siimpismfl 
were applied to the chest ; cupping was resorted to between the Btv^wVi<M* 
blade i ; ho was ordered a mixtif re of decoction of senega, ca.t\>'^\i^lB kA wx^- 
roonla, tincture of sqatUsj and uitrous othor ; and was \3^M^e.^ ^vU vo^n^x 
AmoJr. The improtem^Rt hj treatment was but tmiiBVtorj^ iot Vkia \ift<s^^«* 



i 



100 PBAOnOAL MEDICINE. 

moribund in the fourth week, and died shortly afterwards. As we learnt 
from Mr. Sprague, clinical clerk, there was strong pulsation in the ex- 
ternal jugulars* and a systolic murmar of the heart, some days before 
death. 

We might give many more illustrations of this malady eren in St. Bar- 
tholomew's Hospital alone, but the present is sufficient for our purpose. 
Sometimes powerful medicinal treatment will do much in removing the nr* 
gency of the symptoms, but it never cures. And this leads us to ask the 

Suestion, whether some relief might not be afforded by. tapping the lung 
irough the parietes of the chest (as we do in cases of thoracic fluid effos- 
ions), for the purpose of letting a certain amount of air escape, and so re- 
duce the great pressure constantly exerted by the distended lungs upon the 
heart and its bloodvessels. At any rate the suggestion is worthy of remem- 
brance in desperate cases. — Lancet, July 7, 18w, p. 8. 



37. — Pills of CarbonaU of Ammonia in Chronic Bronchitis. — By Dr. John 
Williams, of Cork. — Dr. Williams recommends the following formula for 
administering carbonate of ammonia in pills, which, he says, are of great 
service in chronic bronchitis, and especially in those cases where the bron- 
chial secretion is viscid and expectorated with difficulty ; 

Q . Ammoniac!, gr. ij ; pulv. ipecac, gr. i ; morphise mur. gr. « ; am- 
monia carb. gr. ij ; mucilaginis acacise, q. s. Misce. Fiat pilula. 

The pills should be at once coated with a varnish of balsam of tolu, dis- 
solved in chloroform, and they should afterwards be kept in a bottle. — JPAar- 
maceutical Journal. — British American Journal, June, 1860, p, 266. 



DISEASES OF THE ORGANS OF DIGESTION. 

38.— ON THE DIETETIC INVENTIVENESS OF HUNGER. 

[Captain Marcy, in his interesting work ' The Prairie Traveller,' relates 
that when his party were yet eighteen days from the settlements of New 
Mexico, their supply of provisions, including tobacco, were entirely ex- 
hausted, and this when undergoing the severest labour.] 

In this destitute condition we found a substitute for tobacco in the bark of 
the red willow, which grows upon many of the mountain streams in that vi- 
cinity. The outer bark is first removed with a knife, after which the inner 
bark is scraped up into ridges around the sticks, and held in the fire until it 
is thoroughly roasted, when it is taken off the stick, pulverized in the hand, 
and is ready for smoking. It has the narcotic properties of tobacco, and is 

2uito agreeable to the taste and smell. The sumach leaf is also used by the 
udians in the same way, and has a similar taste to the wiUow bark. A de- 
coction of the dried wild or horse mint, which we found abundant under the 
snow, was quite palatable, and answered instead of coffee. It dries up in 
that climate, but does not lose its flavour. We suffered greatly from the 
want of salt; but by burning the outside of our mule-steaks, and sprinkling 
a little gun-powder upon them, it did not require a very extensive stretch of 
the imagination to fancy the presence of both salt and pepper. (There can 
be no doubt that the nitre and charcoal would to a great extent supply the 
want of salt. Soldiers and huntsmen have Ion? resorted to this use of gun- 
powder under emergencies.) We tried the flesh of horse, colt, and mule, all 
of which were in a starved condition, and of course not very tender, juicy, 
or nutritious. We consumed the enormous amount of from five to six 
pounds of this meat per man daily ; but continued to grow wetJc and thin, 
until, at the end of twelve days, we were able to perform but little labour, 
mid were continually craving for fat meat. — iMncetf April 28, I860, p. 435. 



3D.^On the Ahsorplion of Suhitances at the Stomachy and thfit Excretion in 
the Urine^ Hy Dr. Lionel Bealis, Pliy**ictan to King's CoH(>ge HoapitriL— 
Tho rapidity with which weak solutloas aro abf orbed from the digestive or- 
gaDs* and secreted by the kidney. Is marvellous. In Mr. Erich sen's well- 
known expeiimentg^ it was aho^vn that ferrocyanide of potaBsliiin could be 
detected in the urine withm a minute after it had entered tho empty stom- 
ach* These interesting conclusions were derived from eiperimenta mad** on 
a case In which, from the dolicieney of the anterior wall of the hlatlder and 
abdomem the orifice of the ureters could be seen, and the urine coll eo ted ii» 
it trickled from thorn. A German Buffering from this terrible mftl formation 
was in London two years ago, and I think many of you had an opportunity 
of seeing him, and obsornng how very soon after a large quantity of water 
had been swallowed, tho rate of the flow of nrina from the ureters in crease il. 

Anything interfering with tho absorption of fluid from the stomach or in- 
testinal canal will necessarily affect the score ti on of urine. In various cases 
where the contents of the alimentary canal are in a condition unfavourable 
for absorptiont but a Tery small quantity of urine is formed, Dr* Barlow 
has gone so fur as to say that the seat of an obstruction in the intestine coii 
be ascertained by noticing the quantity of water eioreted in the form of 
urine* When close to the pylorus, it is stated that scarcely any uriue is 
separated. Tn ordmary cases of what is known as sick headache, where, 
from temporary stomach derangement, little absorption occurs fur some 
hours, no urine is secreted perhaps for twelve hours or longer. The ter- 
mination of the attack is marked by the very free and rapid action of tlio 
Mdmjs*— British M^d, Journal, Jul^ 28^ 1860, p. 576. 



N 

b 



40,^ON THE USE OF CREASOTE IN THE TREATJIENT OF 

DYSENTERY, 

By Dr. W, T. G-JHtP^rfn, Pbjfflclwi Ui the Kdlnbtuif h Eoyml InHrmajy. 

[Of the four ca^es of dysentery which occurred at the Edinburgh Boyul 
luhrmary, under Dr. Gairdner^s care, during a period of three months, thret* 
recovered quickly under the use of large injeotiona of warm water, and 
moderate doses of opium, chiefiy administered by injection.] 

One case (James A., ssL 56) was exceedingly severe^ and required a prt*- 
tracted treatment. The patient had been ill for several months before ad- 
mission ; he was very much reduced, and extremely pallid. The st*>ols, no 
longer bloody to any conaiderable extent, were passed in small quantities at 
ft time, with great suffering, and were extremely fcetld. I had great appre- 
hensions as to the result in this case ; for, from the slight effect produced by 
opiatRS and injectitms, and the severe tenesmus, with tenderness on pressure 
along the di^sc ending colon, I formed the opinion that considerable dieor- 
ganiaation of the lower bowel existed. J determined, under these circum- 
stances, to try a remedy which I have frequently found useful in subacute 
and chronic dysentery » — viz., the addition of creasote to the large emolient 
and d©tt*rgent enenmta, which 1 employ in all ca^es of dysentery whatevert 
tind which I believe to be by far the most important element in the treat- 
ment of that disease in all its forms. As I am not aware that creasote is in 
general use In the treatment of dysentery, I may state that I was led to its 
employment some years ago, by the statements of Dr. Wilmot as to Ha ef- 
£eacy in an epidemic prevailing in the Union Workhouse of Pembury. I 
have employed it, however, somewhat diflFerently from Dr* Wilmot, who ad- 
OTinistered it in large doses { 3 iO merely suspended in grueh It appeared to 
mo more likely to do cood, and with less risk, if employed in smaller doses 
in solution, so as to be applied uniformly and certainly to the whole sur- 
face tjf the diseased mucous membrane* 1 have, therefore, usually employed 
the mistura crease ti of the PharmacopoDfa, and have added one to %\\. 
ounces of this, according to e Ire am stances, to eaclft Wg(i \tv\«i(il\ciw. \^ 



3 



102 FRACnCAL MEDICIKE. 

has been followed in seyend cases by the best possible effects; and 
I can safely recommend it as a ralnable addition to the resooroes of 
the physician, in cases of dysentery attended by great irritation and 
foetor of the evacuations. In the present instance, I employed a so- 
lution of creasote in glycerine,* which was prepared lor me by the 
Messrs. Smith of Duke Street, to whom I had applied to find a neutral 
solvent for creasote, for another purpose. The relief afforded in the 
case of James A. was very remarkable. The injections were repeated twice 
or thrice a day, the dose of creasote in each being from Hi ▼. to nix., and 
the patient experienced so much benefit from them, that he proposed of his 
own accord to take the remedy by mouth also. The intense irritation sub- 
sided, and the stools became much less offensive. It is right, however, to 
remark, that the remedy appeared to lose some of its power after a time, 
and that this man was finally restored to greatly improved health under 
considerable doses of ipecacuanha, which was well borne by the stomach, 
find seemed to have a very decided effect in removing the remains of a Tery 
dangerous and exhaustinc^ disease. 

In a case of obstinate diarrhoea from Bright's disease, and also in the case 
of John W., alluded to above, creasote was also tried as a dernier report ; 
hut only with the effect of showing that its good effM^ts are probably limited 
Ui oases of genuine dysentery, accompanied by ulceration of the great in- 
tostino. It failed, in the others, to afford even temporary relief. — J5(ita* 
hurgh Medical JoumaU May 1800, p. 994. 



41. — On the Use of Santoninc in the IWatment of Lumbrici. By Dr. S. 
Bkihiiank, (iiiliishiols. — (In the treatment of ascarides, santonine is of little 
or no uso, but Dr. B. Hays:) 

1 nuiy montion, however, that I have used it in the lumbricoldes with the 
most surprising, or I hud almost said, specific effects. Much depends on the 
method of administration. Before using santonine I had tried Dr. Watson's 
method of treatment by stetl and purnitivos alternately, with only trivial 
benefit. I also tried santonine by itsclt, and found it scarcely more effica- 
cious than the former, the only advantage being that from its small bulk, it 
could easily be administered to children. 

On resorting to the method suggested by Kuchenmeister of administering 
it with castor-oil, the effect was most gratifying. The first patient to whom 
I administered it in this way, a child fifteen months old (ana who had been 
treated by the two former methods without benefit), passed no fewer than 
thirty-six worms, varying in size from a few inches to nearly eighteen inches. 
On repeating the dose several more were expelled. The effect on the child's 
appearance was really wonderful, from beinc a tiny emaciated creature, with 
a ravenous appetite, &;c., it in the course of a short time assumed a plump, 
healthy aspect. 

Since that time I have used it very extensively, and know many instances 
where from twelve to forty and even in one instance fifty-nine worms have 
been voided, and that, too, where Dr. Watsou*s method and the santonine 
per se had signally failed. Indeed I may say, where children have previously 
passed worms (which is considered the only unequivi>cal evidence of theSr 
existence), that I have never known the santonine and castor-oil together 
fail to eject more of them when administered. 

I usually order from two to oi^ht grains of santonine, stirred in from a 
tea to a table spoonful of castor-oil, according to age, to be administered at 
night and a dose of senna the following morning. — Medical l^mes and Oa- 
% June 9, 1860, p. 580. 

pmortioDs vsed wen omuote 90 rolnlmt, to glyctrlne one ox. The materfale nqntn t»to 
to be well rubbed op together in a inortAr. TUa rMult U what appeitn to me a perfect 
Itoagh Mr. Smf th doabu iu being to. Tho tuVyMX duMTv«a xW vccv.«d\^oql q!C Um beoMn 
wNktlooml PiianiMeop«Bla. 



PRACTIOAL MEDlCmE. 



103 



42,— ON HYDATID TUMOUE OF THE LIVER. 

(The liver is perbapi^ of all other orgaui^ tlie most lifible to bo infustod hy 
liydatidti; luckUy eojnethlng cran eometlmisii b© douo in theee caaca, whereas 
wben ID most otber organs little or ncitbing whatever cou be done.) 

Assuming that au hydatid tumour of the liver haa been satisfactorily made 
outf the (juestLon naturally arii^es in the Diindof the physleiani whether there 
i^ a single hydatid or a number of the m present ; for, uu fortunately, it often 
happeu:i thai they exist in couutless numbers^ disseminated throughout the 
hepatic tissue. Dr. VVatgon in hi» leeturos, mentions the case of a girl who 
died in the Middlesex Hospital, who is u liver contained thousands of these 
globular bodies, tlje enlarged gland having, by its pressure, completely 
sealed up a portion of the inferior cava* 

Experience provoij, bowuver, that it li seldom that more than three or 

\ I four are developing in various parts of the organ at one lime ; but it is this 

circumstance which constitutes the difficulty, and we may say the danger 

of interference ; for jf one ta collapsed through evacuation of it ^ c jntentSt 

f ll^ othertj enlarge, and the patient die^ at last from eschaustiun, 

J^r. Oudd has affarded some useful hints on the treatment of hydatid tu 
mora of the liver, which are of great practical importance. It is well known 
that hydatids some time a spontaneously lose their vitality ; the sac shrinks up, 
its inner surface secretes a peculiar motter compared to glaaiers* putty from 
it* appearance, and the tumor ceascB to he of any further danger or Inconven- 
ience beyond that vrhich arises from it^f mere preseuce. Now I>r. 11 Lidd proposes 
to imitate this state of things by art, if practicable, and he thinks it probable 
that it may be attained by medicine ; but so far, the latter, except in a very 
ftiw instances, has proved wholly unsatisfactory. He advises the tapping 
of the hydatid cyst through fk fine ts^hring Ifonar^ by means of an exhaust- 
ing pump, drawing off all the water, and taking the precaution that not a 
partJclo of air shall enter the cist— the danger of putrefaction of the dead 
hydatids being thus completely obviated. An instrument of the kind ii* pre- 
pared by Weiss, according to the plan recom mended by Dr, Bowditch of 
IJostoa, U.S. Dr, Budd further advi^-^es the precaution of inserting the tro- 
car downwards, with the outer extremity of the instrument at a higher level 
than the bady, so that as the liquid rises in the canula it will expel the air 
from it If the vitality of the hydatid is completely destroyed in this way, 
should others enlarge and become prtimiueot, they may be submitted to the 
same plan of treatment if suppurative action dues not sponUvneously occur; 
f^houla this take plq.cc, however, the nature of the case becomes changed to 
one of a more serious character* If there be but a single cyst In the liver, 
and no fresh growth make itu appearance, a cure may be considered to huve 
Uiken place. 

The three examples of thia aflTcctiuu which we record to-day were all tap- 
pad, but not with the precautions recommended by Dr, Budd \ hence* in 
two, auppuration ensued; whilst in a third, at St Thomas' HoapitaU the 
Stto bad already undergone that process, and it was treated like a large ub- 
aooas. Ill the following example tlie tumor was remarkably prominetjt just 
b«low the ensiforra cartilage; it waa tapped by a very line trocar, and ib ur 
ounces of atiueons and colorless fluid were withdrawn. This wa^* followed 
by local peritonitis and rigorst which ushered in the suppurative crisis; and 
in throe weeks from the first puncture an evacuation of pus was effected by 
a trocar. Afterwards matter with f<etid gaa escaped from the old opening, 
and at the present time the former continues to flow to the extent of a few 
ounces daily. The general bulk of the liver has become diminished and the 
diiiease is now chronic ; but it is moat probable that there is only a single 
hydatid in this instance, although at first it was suspected that tbtit^ m\^U\ 
hi more. 

jMrteJ,,aged nm&teen^ adinhted March 2^M, 18tiO. Has ^w^o^^^ ^^^ 
ijte^ih up to two j-oars ago ; tho catameoia ftppented at M\jG^ti^ ^vuil X^.'a.N^ 



i 



104 FBACTIOAL MEDIOIHE. 

always been regular until six months back, when they became irregu- 
lar. Two years ago she had an attack of jaundice, which continued for 
four months, but did not confine her to bed. She states there was no tumor 
in the hepatic region at that time. After the attack of jaundice her health 
remained perfectly good again until last November, when she felt shootinff 
pains in the back, under the right scapula, not extending down the arm, and 
at the same time discovered a swelling in front near the lower end of the 
sternum. This tumor gradually increased in size, and she soon felt an ach- 
ing pain in it of a continuous nature. The patient thinks it was about two 
months after the discovery of the first that she noticed another small swell- 
ing beneath this. The swellings gradually enlarged, and became more pain- 
ful, and at the same time her appetite began to l&iL A month ago she was 
admitted into the hospital under Dr. Murphy's care, and the tumors have 
been painted over with compound tincture of iodine every day, without, 
however, diminishing them, or giving much relief. Since her second ad- 
mission, another small swelling has made its appearance, external to the 
other two. Bowels have always been regular. 

March 27. — ^Present state : Patient is thin and somewhat emaciated ; 
muscles ;nther irritable; but in a better condition than on admission a 
month since. Hepatic dulness extends as high as the level of the right nip- 
ple, and below to horizontal line through umbilicus. From about three 
inches below the right nipple considerable bulging is observed, extending to 
the left, two or three inches beyond the median line. This bulging seems to 
be composed of two protuberances, the larger occupying the epigastrium 
and part of the right hypochondriac region, me smaller below and somewhat 
to the left No tenderness felt over prominent parts, but much below 
them. On pressure over the large central protuberance some sensation of 
elasticity is experienced, and sudden pressure on one side is propagated to 
the otiier. Conjunctivae not turgid. On examining the back, some distinct 
but slight bulging is seen in hepatic region, and dulness on percussion ex- 
tends about an inch higher on tho right than on the left side. Slight curva- 
ture of the spine is noticed, the concavity towards the right side. She was 
put upon sarsaparilla, three grains of iodide of potassium, and decoction of 
cinchona, thrice a day. 

28. A fine trocar was passed into the center of the larger mass in the epi- 
gastrium by Mr. Erichsen, when the suspicion of the hydatid nature of the 
tumour was confirmed ; for a clear fluid (four ounces) was drawn off, which 
was found to contain minute flakes, each consisting of a collection of well- 
formed echinococci. After the tapping a compress was applied, and, with 
the exception of slight vomiting, no bad symptoms appeared. 

dO. Some pain and tenderness in the region of the puncture. 

31. Much relieved from pain; tumour not much diminished in size, but tho 
note over it is quite tympanitic. 

April 1. Had an attack last night of rather severe rigors, with the return 
of pain over the swelling. To-day the pulse is 130, very weak; cheeks 
flushed ; suffering great pain over the region of the liver on the slightest 
movement, deep inspiration, &c. Slight tympanitis of the abdomen. 

3. Has less pain to-day ; no return of rigors ; still much tenderness over 
the hepatic region. 

10. Pain has varied since the 3rd, but she feels much better ; the central 
tumour appears larger and more tense. 

19. Yesterday about six or eight ounces of thick foetid pus were obtained 
by tapping the centre of the tumour. The tumour became flaccid for a 
time, but to-day is again distended. Tho complexion and the eyes are less 
yellow than they were. 

24. On the night of the 22nd the tumour gave way from the old opening, 

apparently discharging air at first, then watery fluid, and afterwards thin 

foetid pus. Yesterday the discharge of matter continued ; but to-day it has 

ceased. The patient remains comfortable as before. 

Afajr 1, Since the last report the tumour Viaa \>e€^ii ^\%c\iaT^Ti^ «b inixtnrQ 

lipma aad blood. The skin nearly natural m ooVot, 



PE ACTIO AL MEDICINE, 105 

22. For tbo Inst foir dnjs the tumour has bomi ogajii plugged up and 
irerj piiinful ; patient much exhausted; J>ulse 130. Ordered a miitu re uf 
quinine. 

24, The abscess discharged two or three teaoupfuls of pus^ after wliicb 
&he beeame better. 

June 5. The tnmour much diminiihed in size, and dij&charges pretty 
freely . 

July 5. She remains much the same ; very weak ; unable to get up, Two 
grulnH ef sulphate of iron to be adde<I Co her quinine mixture* 

Aug. 2. She suffer a leas pain ; discharge still continues^ and amounts to 
about four ounces in the twentj-four hours ; has not bst more Hesh ; the 
tongue is clean ; and she is free from pain* She is picking up her strength « 
and ii doily gaining flesh. — LunceU Bept, I, I66O1 p* 310. 



I 



Ik 



^a-^N SOME CKEMIGAL QUESTIONS IN CONNEXION WITH 
DISEASES OF THE LIVER, AND THEHl TBEATMENT. 

[There arc many points in this paper respecting practice^ which we ought 
to attend to. Hithertoi affections of the Hvor have been treated very en»- 
pirieally* Calomel and blue plU, with some aperient, liave often been the 
sole remedies employed without any scientific object in view* In a former 
paper Dr. Thudichum referred to gall-stones, in the centre of whieh he had 
detected cc^rtain peculiar formations, whieh he thought were casts of the 
biliary ductSf This opinion has since been confirmed. Dr. Thudichimi 
goei on to say i] 

As matters now stand t essential oonstjtuentii of gall-stones seem to be 
chotochrome, cholio aoid, and earthy salts. In man, gall-stones contain a 
large amount of cholesterine in most caaess ; hut that is a secondary and ac- 
cidental ingredient, and le nioi^tiy cry stall issed around the other matters 
forming the nucleus* There are human gtill-stonea which, like those from 
the ox, contain no cholesterine. 0th era are iaid to consist entirely of chol- 
eitefine— -a fttntement which requires to be verified by fresh analyses, which 
prove the absence of choUc acid. Stearnto and palmitate of lime are 
My present in human gall-stones. The idea of oji inspijigation of mucus 
the ftjrmation of gall-stones was shown by the author to be untenable % 
the binding material of the concretions is cholio acid. 

The process of the formation of ^all-stones was explained by Dr. Thu- 
dichum to be perfectly analogous to that which produces phosphatic calculi 
in the urinary bladder* The compound ami do acids (taurocholic and gly- 
coohoUc) spht up under the influence of a cauao of which the nature remains 
t4i bo ascertaiued — probably a ferment from the intestinal canaL They de- 
posit chtikwhrome and a portion of cholic acid, some salts, and a little fat, 
under the influence of acetic acid derived from glycDColL In man, gall- 
atones contain cholesterine; this has, in the healthy bile, been held in solu* 
tion in taurocholate of soda ; but when the taurocholic acid is decomposed, 
the cholesterine h set free, and h deposited on any particles which may ho 
at hand. In other words, the process of formation or gall*itones is the fol- 
lowing: — 

Hi^althy bile contains taurocholic and glycocholio acids, in combination 
probably with aoda. Under tbo putrefactive change, these two acids split 
np^ the taurocholic acid yii-lding taurine; and the glycocholic acid, glyoo* 
eoll. Chotate of soda is left; the glycocoU is destroyed, and is tran!*formed 
into acetate of ammonia. Valerianic acid is also formed* and combitien with 
the ammonia from the glycocolL Some free acetic acid then sets free thi"* 
cholic acid from the cholate of soda, and the cholic acid is then ^jreot^tUited 
in comi>ination with cholochrome, so as to form casta ot 1\^b XmW*. 'WiV*^ 
inkpft phf^e in the ox r in imiii, cholostnrine i& nUo d^pi^Mled \u M^^t\^(?,tvakfcwc>^ 
0/ tk& breakmg up of uurocholaU of sodft* which bti4 held \t v\i ftoVx\ivQ\v. 



I 

formi 
K theo 
^H eiter 

I 



106 PBAOTIOAL MEDICINE. 

Within the last fow weeks, Dr. Thudiohum had examined the prodacts of 
decomposition of fibrine, and had-f4>nnd amongst them oholesterine ; whicht 
with a gritty matter and an oil-like body, were left when all the naatten 
soluble in water were remored. The presence of oholesterine and gritty 
matter in atheroma led to the question whether this condition was not a sim- 
ple result of the decomposition of fibrine or of albuminous matter from which 
the earthly particles had been washed out. It was further a question whether 
the cholesterine in gall-stones might not in part arise from the deoomposition 
of cholic acid. 

Dr. Thudiohum then noticed that the healthy action of the liTer-oells oon- 
sists ill the absorption of certain albuminous, fatty, starchy, and saccharine 
matters, and their transformation into the ingredients of bile. When this 
becomes impaired, the cells assume a fermentative tendency, leading to the 
same description of decay in the albuminous matter as that which is induced 
by putrefaction or by treatment by acids or alkalies. He then proceeded to 
point out that the general principles elucidated in his paper could be applied 
m the treatment of all liver diseases. In jaundice with obstruction of the 
biliary ducts, we should make early use of nitric acid or nitro-hydroohloric 
acid. He had with great benefit given a watery solution of nitrous acid. It 
is easily made, and may be drunk as a pleasant lemonade. It is less apt to 
produce griping, which, during courses of nitric acid and aqua regia, is not 
rarely complained of. This acid not only destroys and lixiviates the deposits 
of cholochrome and other amido-acids, but it also tones the digestive organs, 
and acts autiseptically. Nevertheless, a remedy to stay the abnormu ac- 
tion of the liver-cells we are yet in want of. Creasote is beneficial. In all 
oases where the disorder of the liver proceeds from the intestinal canal par- 
ticularly, creasote, charcoal, astringents like gallic acid, and preparations of 
iron, particularly the tincture of the sesquichloride given together with some 
nitric acid, are highly beneficial. In a case of desquamation of the epithe- 
lium of the kidneys consequent upon chronic jaundice, he had exhibited this 
latter mixture with the most decided benefit 

Nitric acid was introduced into the treatment of these diseases by Annes- 
ley. Many have used it since with variable success. Dr. Thudiohum be- 
lieved that it is frequently not borne because it is not sufficiently diluted. 
The more it is diluted, the quicker it is assimilated, and the more certain are 
its effects. 

It might appear paradoxical that a free acid should travel through the 
blitod, and act upon certain parts through tissues. We are, nevertheless, 
obliged to admit the possibility of that occurrence. Thus oxalic acid and 
many other acids have been proved to have passed through the blood un- 
combined, and have been found in the urine in a free state. Even allowing 
that blood so mixed with nitric acid might show a precipitate, there is no 
reason why a molecular precipitate in the blood, which is full of molecules 
of its own, should not again dissolve. 

All liver diseases require the greatest attention to the intestinal canal. 
Mild purgatives, of salts or fruit, PuUna water, Seidlitz powders, waters con- 
taining one per cent, of ordinary chloride of sodium and a little sulphate, are 
the best remedies. If stronger purgatives are required, the vegetable ones 
deserve preference. The fatal error of treating with mercurials the various 
disorders of the liver, he could not sufficiently deprecate. 

The diet should be juicy, include fruit and vegetables, and eggs and meat. 
Starch and fat are always badly digested. 

The skin must be well attended to. Baths, with some aqua regia, stimu- 
late the skin and open the epidermis. 

In true bilious attacks, with indigestion, a furred, sometimes yellow 
tongue, constipation, sickness and vomiting, headache, yellow appearance 
of face, and albuginea, he had found the use of blue pills mostly hurtful. 
Whenever he had been called upon to treat such an attack, his treatment 
Lad to deal with the effects of the biliosity and blue pills combined. In cases 
where guoh attacks, without previoas excesses, beocnne hahituaU gall-stones 
Are not mroljr devolopod, 1 have known two casern «Ti^\ix\^\i^\«Mu ^^Vi 



PRACTICAL MI^^^P 107 

that of a gentleman, married, about forty years of agio, is yet undar obsfr^ 
valiiin. lit many oases of pKtliUiST in which g-ull-f^tone^ are found after death* 
this habitual biliosUy did not rarely precede the disease of the lungs, Bui 
phtbisii^ may also produee gall-stoue disease. 

Ljtstly, he adverted to the use of soluble pliosphates. He had made the 
observution that bile contains no f^niall amount of phosphate of soda. With- 
nut thi^ mlIU the ai^similntinn of the fats must needs be imperfect. Consid- 
ering, therefore, that the absence of the phos^phate may be hurtful, and that 
its presence never has been found to be so, he was juolitted ti> pive it a fur- 
ther trlah It should be gh'im in the food, together with chloride of indium, 
or iu a dilute solution in water. Hinco he eibiblted before this Society the 
action of phosphates upon fatly aeid^, with which they produce an emulmon 
ready for transition mto the blood, ho bad thought of cotnbltiuig the acids of 
cod-oil with phosphatesi in order to make this eubstance more genevally di- 
gestible. 

Lie big has long since shown that the moat pleasant manner of giving Bol- 
ublo phosphates consists in the administration of beef-tea; but where this* 
oitract cannot bo had in a quite reliable form, a weiglied quantity of the i>r* 
dinary phosphote of sodai say to the amount of half a drachm or a drnchm 
per day, or more where it is liked and well borne, is preferable. 

In bile, soda preponderates over potasf^a. In the substance of the liver 
the proportions arc reversed. The relations of these two bases require fur- 
ther study. It is not probable that the one may substituto the other, aud 
citff versa ; and hence the want of potussa may become a source of disease. 
It is known that this base prevails in the musclof!, soda in the blootL 

By thus attacking the liver froiu all sides, we slmll soon sutjceed in oh- 
tatnUig a surrender of its secrets. This organ can in this way only be stim- 
ulatedi wliile it m out of the reach of so-called medicinal stimulants. Tor- 
pid liver, sluggish fever, and the likPt may be us^iful practical denomina- 
tions; but they are not baaed upon any positive evidence. We want much 
lt*ss cholagogues than we require romedles to appease, subdue and change 
the activity of the liver. The organ is accused of much of which it is nut 
guilty. It is by the mouth that most diseases enter ; and it is from the in- 
Bults received from the direction of the intestinal cavity that this patient and 
enduring organ mostly derives its detriment. — Lancet, OeL 20, 1 860, ^. 3B9* 



DISEASES OF THE URIXARV ORGANS, 
44.— ON THE TESTS FOR ALBUMEN IN THE URINE. 

By Dr, Liojisl Bbjuje, F.lt.S., Pbi'McUn to King'a Ctillcge HoBpltaJ, &o. 

Tbe most important soluble substances present in the urine in diiieaaeT but 
absent in the healthy secretion^ are albumcnt biliartf constiturnts, and suffar. 
The clinicfil importance of these is so great, that they deserve special at- 
tention, 

Alhumen^ — The occurrence of albumen in the urine has been regarded as 
a most important pathological fact ever since the connexion between dropsy 
and disease of the kidneys was ostablj,ibed by Dr. Bright* Albumein at 
need scarcely be iaidi is absent from the urine of healthy persons, although 
now and then it may be detected for a short period of time m the urine nf 
individuals who are not suffering from any i^eriouH or permanent derange- 
ment of health. The presence of albumen must always bo regarded by the 
physician as a point of serious importance^ although at the same time, per 
wsy it cannot bo t4iken as evidence of the existence of any orgauie lesion, un- 
less it has been clearly detected frtmi day to day for a iTertiin time. Many 
of the cases which give rise to the escape of senmi from the vof^seb in 
other parts of the bodyi independent of disease, wlU detettn'mti \\a \t^\i.¥i\s&5^' 
tion ihTouffh the wails of the renal capillaries, and, aa a matlttx qI ^qui^^^W 
wIJi he found in the urine. 



108 PRAOnOAL MEDICINE. 

To recognise with certainty the presence of a substance in the urine hav- 
ing so important a bearing in the discovery and interpretation of certain 
morbid processes, as albumen, is obviouslv a point of the utmost importance 
to the practitioner. In the examination of the urine of patients, simple tests 
are at once applied, in order to determine if this substance be present or ab- 
sent. In a majority of cases, such information is easily obt^ned ; but oc- 
casionally an instance occurs in which, without great care, an erroneous 
conclusion is likely to be arrived at after the ordinary tests have been ap- 
plied. As this question is one of very great practical importance, and of 
much interest, I propose to consider it at somewhat greater length than is 
usual in works devoted to the clinical examination of urine. The reactions 
to which I shall refer are not imaginary, but have actually occurred ; and I 
have known instances in which albumen was stated to be absent when the 
urine contained a large quantity ; and other specimens have fallen under my 
notice, which, although they really contained none, yielded a precipitate 
having many of the characters of albumen. Let us then investigate the 
phenomena seriatim, 

1. Albumen is usually f*recipitated from its solution upon the addition of 
a few drops of nitric acid. Heller recommended that acid should be allowed 
to flow to the bottom of the tube containing the urine. In this manner, three 
strata are formed, the lowest stratum consisting of the pure acid, above which 
is the precipitated albumen, while the upper stratum consists of the fluid 
containing the albumen uncoagulated. 

2. — Albumen is also generally coagulated by the application of heat (140* 
to 167° Fahr.). If very dilute, a higher temperature is required. The best 
way of testing urine by heat is the foliowiue : — An ordinary test-tube is 
about half filled with the urine, and is to be held by the lower part. Heat 
is applied to a point near the surface of the fluid ; the tube being shaken a 
little at the time, to prevent the glass bein^ cracked. The slightest precip- 
itate cannot fail to be observed, as the fluid below remains perfectly on- 
changed. When urates are present, this plan is very useful, as we get three 
distinct strata ; the upper one formed of coagulated albumen ; the next clear, 
in consequence of the solution of the urates at a temperature somewhat be- 
low that necessary for the coagulation of the albumen ; and lastly, the un- 
changed urates. 

3. If the solution of albumen be alkaline, no precipitate will be produced by 
heat. We are, therefore, generally directed to neutralise the alkali by an acta 
before heat is appLiea. If excess of acid be added, the albumen is, of course, 
precipitated in the insoluble form, without the application of heat. 

Freauently specimens of urine are met with which exhibit one or more of 
the following peculiarities, which tend either to make us believe that albu- 
men is present when it is not, or cause us to conclude that it is absent when 
the urine contains it. 

1. Upon the application of heat, the specimen may become turbid in con- 
sequence of the precipitation of phosphate. The reaction of the urine in 
this case would generally be neutral or feebly alkaline; but sometimes 
urine depositing phosphate on the application of heat is of a decidedly acid 
reaction. 

2. Upon the addition of nitric acid, the specimen becomes turbid, in conse- 
auence of the decomposition of the urates held in solution in the urine, and 
the decomposition of uric acid in a granular state. If the acidified urine be 
boiled, it usually becomes clear with the development of a pinkish or brown 
colour, consequent upon the decomposition of the uric acid. 

3. Upon adding nitric acid to some specimens of urine of high specific 
gravity, an abundant precipitate of a crystalline character is produced. 
This consists of nitrate of urea, and is easily recognised by its crystalline 
character. It seldom appears immediately, and is hardly likely to be mis- 
taken for albumen, except by a most superficial observer. 

4. After adding a drop or two of nitric acid to urine suspected to contain 
a/baiaen, in order to render it distinctly acid, no precipitate i» i^oductd upon 

doiling^, although a large quantity of albumen ma-y-be present. 1>Kkft Sa wSdb* 



PILiOnOAL MEBICIHE. 



^fetant in all Bpeclm(?TiB of albuminous urine, anti shows thn importanct* of 
mover boiling urine ^uspoct^d to oontain albumen in a tube wlijch uiay duu- 
l tain, by accidunti a drop or tvro of nitrie acid. 

5, CubebSf Copaiba, and Bome other resinous substaaceB, taken intemallj, 
^ mre said to give rise to preoi pita ten in the urine which are liable to be mis- 
taken for albumen. 

A Precipitate pToduced in Urine amtaining no Albumen,^ — PJmsphaie re- ( 
scmhiing Albumen. The precipitate of phosphates is vorj readily dUtm- 
puisbed from albumen by Its solubility in a little acid. Upou the addition 
of a few drops of nitric acid, the turbidity instantly disappears, and the so- 
lution becomes perfectly clear. 

Uric Actd rmemhiing Albumen* When a precipitate of uric acid in fi 
minute state of division is caused in consequence of the decomposition of i 
the urates by nitric acid» its nature may be ascertained by altomug the 
miiture to stand for sometime, when the minute granules gradually increase 
in ai)se, and at length become crystalst the nature of which is at once reco^f- 
niscd upon microscopical examination. In some cases the crystals may be \ 
seen to form under the microscope, Tbis precipitation of uno acid on add^ 
f ng nitric acid often leads to mistakes, and albumen ii stated to be present , 
in urine which really does not contain a trace. Several cases of tbis pre- 
olpitate have occurred to myself* and I have heard of many others in th© j 
practice of friends. It has happened in the wards of our hospital, that Ibt] 
precipitate produced by nitric acid has been inferred by the clinical clerk lo i 
consist of albumen, when subsequently no precipitate could be obtainf^d. 
The fallacy was esplalaed by careful eiamination afterwards. 

Dr. (r. 0. Hecs has met with urine adbrding tbis precipitate of uric acid 
on the addition of nitric acid in oases of typhoid fever. Most of the in-^ 
stances which I have met with occurTed in cases of liver ad'eotion. I ex-j 
troct twu or three tts examples. 

Urine from a Patient suffering from large Hifdaiid Tumours of the Liver ^i 
A small quantity of urine vvas filtered, and, upon the addition of a little ni-- 
trie acid, a precipitate wan produced. After standing a little while, this was 
examined by the microscopo, and found to consist of minute crystals of uric 
acid- These were dissolved upon the application of heat ; but, a** the sidu- 
tlon cooled, they were deposited again in the form of much larger crystals. 

A specimen of urine exhibiting the same peculiarity contained exceija of 
urea. Upon the addition of half its bulk of nitric acid, thomiiture became 
i Tieuffly solid, from the formation of crystals of nitrate of urea» The deposit 
in this instance consisted partly of urnte of soda. 

Another example of which I have kept notesi occurred in n man aged 
?, suffering from Theutnatic fectr. The urine was acid, specific giiavlty 
' 1027, and containiuf? much urnte of soda. The prnctitioner who fir?*t saw 
the case boiled a portion of the urine. It remained clear; and he said, there- 
fore» that it contained no albumen. A physician afterwards tested a portion 
of the same urine with nitric acid ^ nndt finding that an abundant precipi- 
tate was produced, a^rmed that much albumen was present. The deposit 
produced by nitric acid was found, by subsequont examination, to be dis- 
solved by heat; and. when a portion was examined in the microscope, its 
true nature was decided by the presence of numerous uric acid crystals. 

No PrcciptiaU produced in Urine contnining Albumen* — Albumen notcoag' 
alated bif heat when a little nitric axid is presenL—\J}^n the careful addition 
of a drop of nitric acid, the precipitate at first formed when the acid comes 

t contact with the urine, slowly dissolves as it descends toward the bottom, 

bon boiling this acidified solution^ no precipitate of albumen will take place* 
ypon the farther addition, however, of nitric acid, the albumen i« precipi- 
tated. 

This reaction has often led to mistakes. Not un frequently album bous 
urine has been pcmrcd into a teet4ube which contained a trace of the nitric 
acid remaining from aomo previous experiment; and, upon boUm^ i\\ii \v\i;- 
ture under these clrcuwetntwe$, no precipitate of albmtv&\i \\ii% citiCi'att^iA. V^ 
^3 hw dmpB of a dilute aolution of nitric acid be added W e^ \HVtt;vni ^l \^^- 



! 

i 

1 

I 

I 



110 PRACTICAL MEDICINK 

miiHMis urino in a tost- tube, and the mixture boiled, no precipitate will take 
place. In fact, the addition of a little dilute nitric acid will prevent the oo- 
Hgulation of ulbumou by heat. Dr. Bence Jones was, I believe, the first to 
explain this fact, in a communication to the editor of the 'Medical Gazette * 
(vol. xxvii, p. 289); and, so far as I can ascertain, no other explanation for 
the circumstance than that offered by him has been given. Dr. Jones thinks 
that the solution of albumen is owing to the formation of a nitrate of albu- 
men which is soluble in a weak solution of nitric acid, even although boiling, 
but insoluble in a mixture of acid of moderate strength. Dr. Benoe Jones 
has also shown that albumen is not always precipitated from very acid urine 
upon the application of heat. From some experiments I have made, how- 
ever, I have been led to conclude that the above result depends upon the 
decomposition of the phosphates by the nitric acid, and the consequent de- 
velopment of free phosphoric acid in which acid albumen is freely soluble. 
This view has been confirmed by some experiments which I made sometime 
since on the subject, and which have since been many times repeated. A 
weak solution of albumen was treated with a few drops of chloride of oml- 
cium, and afterwards with a little ammonia. After hav.ng stood for twenty- 
four hours, it was filtered. In this manner, any soluble phosphates present 
wore removed. The solution was then tested as follows : — 

1. Albumen was precipitated by the application of heat, or by the addition 
of nitric acid, as usually occurs. 

2. A very small quantity of dilute nitric acid did not prevent the coagula- 
tion of the albumen by heat 

3. After the addition of a few drops of phosphoric acid, the fluid so longer 
coagulated upon being boiled. 

Some of the same solution as the above, which had not been treated with 
chloride of calcium and ammonia, afforded the same results upon the appli- 
cation of the tests as other albuminous solutions. A few drops of a weak 
solution of nitric acid, or a little phosphoric acid, prevented the precipitation 
of the albumen by heat. The addition of phosphoric acid to an albuminoos 
solution, or a soluble phosphate and a little nitric acid, prevented the pre- 
cipitation of the albumen by heat. 

These results, tlierefore, led me f o conclude that a truce of nitric acid pre- 
vents the coagulation of a moderately strong solution of albumen by heat, in 
consequence of decomposing the phosphates and setting free phosphoric 
acid, in which the albumen is soluble. When, however, excess of'^nitric 
acid is added, its action predominates over that of the phosphoric acid, and 
the albumen is precipitated. 

At the same time, it must be admitted that there are several facts con- 
nected with the behaviour of weak solutions of albumen with acid, and under 
the influence of heat, which are not satinfactorily explained ; and forms of 
albumen having different reactions are from time to time met with. The 
whole subject requires further careful investigation. 

Soberer descrioes a variety of albumen which is only imperfectly ooaga- 
lilted by heat. It is probable, however, that many of the peculiar reactions 
met with from time to time depend upcn the presence of other substances 
dissolved with the albumen, rather than upon any peculiar properties of the 
albumen itself, or the existence of a variety of this substance. 

Other Testa for Albumen. — Albumen is precipitated from its solutions bj 
alcohol, alum, and many metallic salts, as those of lead, mercury, copper, 
and silver. Hichlorido of mercury is employed as a test,andferrocTanM&of 
potassium precipitates a solution (»f albumen to which acetic acid has been 
added. These salts will, however, produce precipitates in solutions of other 
substances allied to albumen. 

()n EBtimatirifi the (Quantity of Alhumrn in Urine, — The quantity of albv- 
men varies tnuiii \n different tmnnn, luimetiinos amounting to a mere trace ; 
while, in other InstttiiceN, a proportion not much inferior to that preeent in 
s<trum has been met with, in <»riler to estimate the quantity of albuiBeii, it 
U only ncceisarv to mU\ acelln lu^lil, and hent the urine in a water-bath to a 

nperature of 194^, or until U IniIIs. I^he prvolpltato is to be oolleeled 



PRACTICAL MEDICINE- 111 

veighed filter, well washed, driodt and weighed. The ftlbumcn nlwAjs oon- 
tBJns a umtiW quantity of oiirthy SfftHji^ wliich are obtained by ijiciuertttbn, 
Th© residue must be deducted frotn the weight of the dried preeipitute, 

Alhuminous Urine, from a patumt with acute inflammation of the kidney. 
The deposit contained numerous granulur catsts* but no fat-celU wero pres- 
ent ; specific gravity, 11)15; acid. Tho albumen oottgulated by hoat and 
nitric acid. 

New Substance allied to Alhtimcn. Dr. Bence Jones obtained a new suh- 
etunce allied to albumen from the urine of a patient (under tho care of Dr, 
Watson and Dr* Maclntyre) suffering from raollities osaium. The urine was 
slightly acid ; specific gravity, lfl*M'2 {PkiL Trans, for iSAB, p. 55,) The 
deposit couHisted of phosphate of lim«, and cylinders of fi brine* Phosphates 
were precipitated hy bf^at ; but the urine was cleared by adding a drop of 
acid. No precipitate was produced by nitric acid ; but, after being heated 
and left to cool, it became solid. The fiolid material was redisaolrcd by 
heat, and precipitated again when the mixture became cool. On some days, 
the tirine coagiuated by boiling; on others, prolonged boiling produced d4^ 
ohange. A specimen, wbicb did not coagulate by boiling, was carefully 
axaniined. It was acid ; specific gravity, 1039'6, It contained much urate 
of ammonia, pho^pbato of lime, and oxalate of lime. 

The new **ubi?itanoo was precipitated from the urine by alcohol, well 
washed, and ultimate analyecB were made* It contained 1*09 per cent of 
salphur, and "20 per cent, of phos(>horus» This substance is the hydrattd 
deutoridt of album fn. It was soluble in boiling water, and the precipitate 
produced by nitric acid was redissolved by heat, and it formed again as the 
mixture cooled. A similar substance occurs in small quantity in pusr and in 
the secretion from the vesica lie seminaies. The urine contained Gti 117 parts 
per 1000 of this substance— an amount equal to the quantity of albumen in 
the blciod. The patient was passing about 35 ounces of urine daily, which 
would contain upwards of 1000 grains, or more than two aiinces of this new 
material, 

Pr. Uence Jones recommends that this flubstanco should he looked for 
again in acute cat^es of niolliticfi oasium. He suggests that the reddening of 
the urine upon the addition of nitric aotd might lead to its detection. — 
Brit Med, Journal, Apnt 21, IStiO, j>. 207. 



45.~ON THE IMPORTANCE OP ALBUMEN IN THE URINE IN 
A CLINICAL POINT OF VIEW- 

BjBr, LioNML Ukaul, F.RA, FbjAi^jlui to the Ktiig> CoUego Ho&pltAl. 

In the mnjority of ca^^es, in which the urine crmtains a very large quantity 
i>f albumen* and eapeeially if the urine be of specific gravity of 1020 or higher, 
the inference will be that tbe case is an acute one, and that this largo quan- 
tity of albumen has not been passing from the kidney for any length of time. 
By far the majority of these acute cases recover if the patients are placed 
under favourable circumstances* In eome instances, however, the circula- 
tion through the kidney becomes more and more obstructed ; tbe urinary 
constituents accumulate in the blood and seriously impair the various actions 
going on in the body, and ewpecially affect the nervous system ? and death 
results, probably preceded by coma and sometimes by convulj:<inna* Occa- 
sionally pus is found in considerable qimntity in the uriniferoua tubes, 
Sometimes tho acute stage passes off, and the albumen, although it dimimshes 
In qaantity, does not entirely disappear from the urine, and tee acute attack 
afterwards proves to have been the commencement of chronic kidney- 
disease* 

If the quantity of albumen bo small^ amounting nearly to milkinesa or op- 
alescence when heat is applied, or nitric acid adJed to tho urine, and especi- 
ally tf the urine bo pale and of specific gravity 10J2 or lower, we should sub* 
pect that the lesion giving rise to the escape of the albumen was Cpkcom^^ 



I 



112 PBAOnOAL MEDICINE. 

and would ultimately destroy life. If the proportion of area to the other 
constituents of the solid matter were large, we should form a more favorable 
opinion than if the percentage in the sohd matter were very much less than 
in health. In the latter case, a great part of the renal structure would pro- 
bably be involved; but, in the former, there would be reason to think the 
disease hud only affected a certain number of the secreting tubules. There 
are, however, some exceptions to these general statements. Patients have 
passed small quantities of albumen m the urine for many months, and it has 
afterwards disappeared. In other patients the progress of the disease is ex- 
ceedingly slow. I have known a man pass urine of the character above men- 
tioned for upwards of twelve years ; and I believe that this might go on for 
twenty years, or even longer, the patient perhaps dying at last of some other 
malady. Under favorable circumstances, the life of patients suffering from 
certain forms of chronic kidney-disease may undoubtedly be prolonged for 
years ; but it must always be borne in mind that such persons are more likely 
to suffer from exhausting influences, cold, fatigue, dec., than others ; and an 
attack which would cause no alarm for the safety of a man pi;pviously in good 
health, might be rapidly fatal to them. 

It is very important that the medical officers of Life Insurances should be 
aware that there are many instances of persons having chronic disease of the 
kidney, who are not themselves aware of it. Neither is there in many of 
these cases anything in the appearance or history of the person that would 
cause the physician to suspect the true nature of the case. The discovery 
of albumen in the urine, or of casts in the deposit, is sometimes the only 
point which leads the practitioner to a correct knowledge of the doubtful 
nature of the life. Now, if one of these persons experienced a severe attack 
of catarrh, his life might be endangered ; and any exposure to cold would be 
very likely to set up acute inflammation of the kidneys, already impaired by 
disease, and thus prove fatal. The only way to discover such a condition, is 
to institute a careful examination of the urine in every case ; but to carry 
this out practically, it must be confessed there are many difficulties and ob- 
jections. A microscopic examination of the deposit in the urine will proba- 
bly throw much light upon the case, and enable us to diagnose the condition 
with much greater precision than is possible from a mere chemical examina- 
tion. Wc cannot be too cautious in arriving at a prognosis in these cases. 
Every circumstance connected with the individual case must be carefully 
considered, and the state of nutrition, the progress the disease has made in 
a given time, the state of other organs, the constitution of the patient, his 
circumstances, temperament, &c., must be passed in review. Even with 
the greatest care, we shall seldom feel justified in expressing any but a very 
guarded opinion as to the probable duration of life. 

Albumen is always found in small quantity in urine containing pus. We 
shall therefore meet with it in cases of inflammation of the pelvis of the kid- 
ney (pyelitis^, and in cases of inflammation of the bladder and of the mucous 
membrane ot the urinary organs generally. Whenever blood is present in 
the urine albumen is detected; for, if blood-corpuscles escape from ruptured 
capillaries, a certain quantity of serum must at the same time pass through 
the same apertures. The coloring-matter of the blood is sometimes passed 
in urine in a state of solution ; but in this case also, a certain quantity of 
albumen is present. 

Dr. Bence Jones detected albumen in the urine of a patient who passed 
spermatozoa. The urine passed in the morning contained spermatozoa and 
albumen. The evening specimen contained neither. On a subsequent ex- 
amination, no albumen could be detected. 

I have detected albumen in many cases of pneumonia during the period of 
hepatisation of the lungs. It is present, also, in the specimens of urine first 
passed after the period of suppression in cholera. In some cases of acute 
rheumatism with pericarditis it is observed ; and it has been occasionally 
detected in continued fever. In puerperal fever it is often met with, and in 
puerperal c^mvulsions it is almost constantly present. Dr. Lever found 
that it was absent in only one case out of fifty. The pressure of the gravid 



PRACTICAL MEDICINE. 113 

uterus is probably a cause of the albuminous uriuo mot with in some cases 
<if pregnancy, but it cannot always bo referred to tho same cause, for it occurs 
at an early period of pregnancy, when the uterus is too small to exert much 
pressure. Dr. Tyler Smith considers that it is to be accounted for by an influ- 
ence exerted upon the nerves, in those cases in which it is not connected with 
'irganio disease. After intermittent fevers albumen frequently escapes in 
the urine. In cases in which any physical impediment to the return of blood 
in the emulgent veins or inferior cava exists, and in some cases of obstructed 
portal circulation, as in cirrhosis of the liver, traces of albumen may be de- 
tected in the urine. In amomia, and in cases of dropsy dei^ending upon an 
impoverished state of tho blood, albumen is often i)assed. Sometimes a 
large quantity of blood extractive matter is also present. After long con- 
tinued hemorrhages, when dropsy occurs, we not unfrequently find albumen 
in the urine. In these cases it does not depend upon kidney-disease, but 
upon the state of the blood. Just as serum escapes from the capillaries of 
various tissues of the body, it is prone to transude through the renal vessels. 
Lastly, in persons who have suffered for many years from affections which 
produce alterations in tho capillary walls, albumen may pass off in tho 
urine ; and towards tho termination of exhausting diseases it is frequently 
present. 

In those cases in which its presence depends upon obstruction to tho cir- 
culation in tho kidney, the impediment may be functional or temporary^ or it 
may be organic and permanent. As examples of tho presence of albumen 
depending upon temporary congestion, may bo adduciid certain cases of 
pneumonia and cholera, cases of acute dropsy, and of dropsy consequent 
upon scarlatina, with many others. Fatty degenera.ion and chronic neph- 
ritis may be brought forward as instances of structural disease, giving rise 
to such impediment to the circulation of the blood as to cause albumen to 
transude througli tho capillary vessels. 

In the majority of cases, tho vessels of tho Malpighian tuft doubtless form 
the precise seat of the escape of albumen ; but there are reasons for believ- 
ing that albumen sometimes passes from tho capillaries surrounding tho con- 
voluted portion of the uriniferous tubes, and in some instances uom those 
in contact with tho straight portion. (* Archives of Medicine,* vol i., p. 

aoo.) 

In most cases in which albumen occurs in tho urine, casts of the urinifer- 
ous tubes are also found ; for with the serum a certain quantity of coagulu- 
blo material transudes, and this becomes solid while it lies in the tube, of 
which it thus takes a mould, and entangles in its meshes any looso bodies, as 
particles of epithelium, &c., which may happen to be in tho tube at the 
time. In the first series of cases alluded to, casts are often absent, or, if 
formed, they are perfectly transparent On the other hand, where the struc- 
ture of the kidney is altered, the casts often afford evidence of tho nature 
of the lesion. We shall consider this part of tho subject in the next lec- 
ture. Albumen is, however, often present without any deposit, sj) that for 
its detection we must rely solely on chemical icaiii, — British Med, Journal^ 
April 28, I860, p, 315. 

46.— ON RENAL CASTS. 

By Dr. Lionel Bials, F.R.S., ^. 

In many cases of congestion, and in inflammation of tho kidney, a spon- 
taneously coagulable material is effused into the tubes, and coagulates there, 
forming a east or mould of the tube, which is gradually washed out by the 
flaid which is secreted behind it, and thus it finds its way into the urine, from 
which it may be easily separated for examination. 

A oast 18 composed of a coagulable material which is effused into the urin- 
iferous tobe; and, becoming solid there, it entangles in its meshes any struc- 
tnies which may be in the tube at the time, and forms a mould of tho urin- 
Iforons tube. Tho characters rary very much in different cosea, ik^Gox^tk% 
XLU.— 8 



114 PRACTICAL MEDICIKE. 

to the state of the tubes and the part in which the effusion of the matter takes 
place. Various substances are often entans^led in the cast ; and, by observ- 
ing the character of these, we are often enabled to asc-ertain the nature of 
morbid changes going on in tubes at the time the cast was being formed. Gre«t 
difference of opinion has been expressed with reference to the nature of the 
material of which the cast is composed. By some it has been termed 
fibrine ; but the striated appearance always present in coagula of this sub- 
stance is not found in the cast. Others have considered the cast was com- 
posed of albumen ; but it is not rendered opaque by means of those reugents 
which produce precipitates in albuminous solutions. Not more than ^re 
years since, it was stated by two observers in Franco and Germany of high 
reputation, at least in other branches of scientific inquiry, that the cast really 
consisted of the basement membrane of the uriniferous tube. How such a 
statement could be made by any one possessing even a slight knowledge of 
the anatomy of tissues, it is difficult to conceive. 

The transparent material probably consists of a peculiar modification of 
an albuminous matter possessing somewhat the same character as the walls 
of some epithelial cells, the elastic lamina; of the cornea, the walls of hyda- 
tid cysts, &c. I think it not improbable that these casts of the uriniferous 
tubes may really be composed of Ihe material which, in health, becomes 
converted into epithelial cells. In disease, this substance, perhaps some- 
what altered , passes into the uriniferous tubes, and coagulates there. If this 
be so, the formation of the cast must result from depraved nutrition, and 
the material must pass into the tubofromtheintertubular capillaries — an idea 
which receives some support from the fact that occasionally casts are formed 
although no albumen passes into the urine. According to this notion, it is 
possible that a cast might bo formed quite independently of any congestion 
or morbid condition of the Malpighian tuft ; but, as a general rule, there can 
be no doubt that serum escapes as well as the coagulable matter, and albu- 
men is found in the urine. 

The diameter and general character of the cast will be determined by the 
state of the uriniferous tube at the time of its formation, as the researches of 
Dr. Johnson have indisputably proved. If the epithelium be abnormally 
adherent, the cast will be very narrow ; if, on the other hand, the epithelium 
be removed, it will be of the width of the tube. Should the epithelium be 
disintegrating, the cast will afford evidence of tho change. If in a state of 
fatty degeneration, fat-cells will be entangled in it. In hemorrhage from 
any part of the secreting structure, blood-corpuscles are present ; and when 
suppuration occurs, the cast contains pus-corpuscles. When the transuda- 
tion of the coagulable material occurs in a tube to which the epithelium is in- 
timately adherent, or in a tube whose walls are smooth, the cast will bo clear 
and perfectly transparent. The import of all these different characters is fully 
discussed in the works of Dr. Johnson ; and several interesting cases, un- 
der observation for a considerable period of time, will be found reported in 
Dr. Basham's work,— British Med, Journal^ July 21, 1860, p. 556. 



47.— OX MORBID CHANGES AFFECTING THE STRUCTURE OP 

THE KIDNEY. 

By Dr. Liokil Bbalb, F.R.8., Physician to King's College Hospital 

In cases where the blood which passes through the kidnej is unhealthy, 
and especially when it is loaded with noxious matter, as takes place in the 
majority of cases of long-continued beer or spirit drinking, the secreting 
power of the renal cells is gradually impaired. They lose their healthy ap- 
pearance, and become much shrivelled, and at last suffer disintegration; 
while, in consequence of the germs having been destroyed at an early period 
of growth, their place is not occupied by a new generation. A complicated 
series of morbid changes in other structures of the kidney gradually ensues ; 
and, in consequence of the blood being rendered still more deprared by ^e 



PRACTICAL MEDICINE. 115 

accumulation in it of matters whicli ought to be removed by the kidnoj, 
other organs are gradually involved. 

In the kidney, it will be observed that the coats of the smaller arterie.H 
become much thickened, the capillaries shrink, white their walls becomo 
thicker and often granular. The quantity of blood distributed to the organ 
diminishes ; and many of the capillaries, being no longer required, shrink 
and cease to transmit blood. The diameter of the secreting tubes decreases, 
while the basement membrane is thickened and more impervious. The whole 
organ becomes hard, and at the same time small and shrunken. This de- 
crease in size takes place principally at tlie expense of the cortical or secret- 
ing portion of the kidney, as would be supposed. Such serious changes in 
the structure of an organ so important as the kidney necessarily affect the 
system generally, but these we must not now stop to consider. The Mal- 
pighian bodies also waste. The remains of many may be seen without a capil- 
lary in them being pervious ; and not a few of those which Ftill exist are 
found to be so altered that they can hardly be recognized as Mulpigbian bo- 
dies at all. The greater part of the blood sent to the kidney passes into the 
pyramids by the vasa recta, and soon re-enters the veins, a small quantity 
being distributed to those tubes and Malpighian bodies nearest the pyramids. 
The diminished amount of urea, &:c., present in the urine, is probably sep- 
arated in this latter situation; while a certain quantity of water, with a 
little albumen and the material of which the casts are formed, also escape in 
this situation, as well as from the straight part of the tubes. 

Long before the disease has arrived at this stage, the urine will bo found 
to contain a very small amount of solid matter, which consists principally of 
salts and extractives, with a very little urea. 

By many pathologists these changes are explained by the effusion of in- 
flammatory lymph, and subsequent thickening, condensation and ccmtraction 
of the so-called matrix ; but it seems to me that all the appearances observed 
may bo much more simply accounted for on the view that they depend upon 
depraved nutrition and wasting, than by resorting to the hypothesis of the 
iutlummation of u structure whose existence has not been satisfactorily de- 
monstrated, and which, if it does exist, according to its warmest advocates, 
only serves as a supporting tissue to the more essential elements of the 
gland-structure. It is very hard to see why such a tissue, which takes no 
active part in the changes going on in the gland, should be the starting-point 
of all the serious morbid alterations which occur. The idea, I believe, has 
arisen from a supposed analogy between cirrhosis of the liver and the so- 
oalied chronic inflammatory disease of the kidney. Cirrhosis was considered 
to depend upon inflammation, thickening, and subsequent contraction of an- 
other supporting fibrous tissue (Glisson's capsule), which was supposed t<» 
surround the lobules of the liver, and by its contraction to press upon the 
vessels (** On Cirrhosis of the Liver," * Archives of Medicine, vol. i., p. 118). 
For the origin of these morbid changes, we must look to the altered actions 
going on in the secreting structure, and not to inflammation of tissues of 
doubtful existence, whijh take no part in the nutritive operations or gland- 
functions. The conclusions to which I have arrived from my own observa- 
tions, with reference to the nature of the so-called matrix in the healthy 
kidney, and the changes taking place in disease, are at variance with those 
usually entertained both in this country and on the continent. The discus- 
sion of this question involves the whole subject of areolar tissue and its cor- 
puscles, and I therefore propose to defer it until this has been fully entered 
into in another place. For an admirable statement of the opinions generally 
heldt with many original observations, I must refer you to a work by Arnold 
Beer, just published in Berlin (*Die Binde-Substanz der Menschlichen 
Niere*). The drawings accompanying this work appear to me rather rough. 
The engraver perhaps has misinterpreted some of the author*s represen- 
tatioiu. 

In other oases, the epithelium undergoes a very peculiar change, to whioh 
maoh attention has been given of late years. Fatty matter accumulatA% Vn 
tlie oelli oi the uriniferous tubes. The intertubulai oapxUamB «a^ VXio^^ ^i 



116 PRACTICAL MEDICINE. 

the Malpighian bodies arc also affbcted in a similar manner, and little collec- 
tions of minute oil-globules may often be seen at intervals in their walls. 
This change often commences in a few of the tuben, and gradually extends 
until tlio whole organ is affected. The kidney is in many instances much 
enlarged, while its colour has become very pale. Fatty degeneration, in 
many instances, is not confined to a single tissue or organ, but almost every 
part of the body is more or less involved. 

BrighVs Disease, — This term has been applied to all morbid conditions of 
the kidney associated icith albuminous urine. Of late years many important 
characters have been made out, by which we are enabled to distinguish se- 
veral diseases of the kidney essentially different from each other — different 
in their origin, in their progress, and often in the rosults to which they lead. 
Dr. Johnson has accurately described several <»f these morbid changes, and 
his researches have been confirmed by other putliologists. However, some 
physicians still insist that the different conditions above alluded to are merely 
different stages of one and the same morbid process. Let me ask you to examine 
carefully the small contracted kidney so commonly found in the bodies of old 
drunkards, with its rough puckered surface and diminished cortical portion, 
and contrast it with the large, smooth, and pale kidney, in a state of fatty 
degeneration, which is not unfrequently met with in young people not more 
than twenty years of age. The causes of these diseases are different ; the 
conditions under which they occur are different ; and, although the result is 
fatal in both, death occurs in a very different way. Their chemical charac- 
ters are different; their microscopical characters indicate the occurrence of 
changes which are totally distinct. Again, the treatment required in the 
early stages of these diseases, when alone any benefit is likely to be derived 
from treatment, is different. 

The divisions and nomenclature adopted by Dr. Johnson are the follow- 
ing : Acute desquamative nephritis ; Chronic desquamative nephritis ; Waxy 
degeneration of the kidney ; Non- desquamative disease of the kidney ; Fatty 
degeneration (f the kidney ; Suppurative nephritis. Dr. Johnson still sup- 
ports the same classification, and opposes the theory held by some patholo- 
gists with reference to the oneness of Bright's disease. He has recently writ- 
ten a paper on this subject, which will be found in vol. xlii. of the * Medico- 
Chirurgical Transactions.* Dr. Johnson says, with regard to the oft debated 
question, if large kidneys, at a subsequent stage of the morbid changes, 
contract, ** The rule is that a large Bright's kidney remains large to the end 
and does not become a small one ; and on the other hand, a contracted 
Bright's kidney docs not pass through a previous stage of enlargement. — 
British Med, Journal, July 28, 1860, p. 576. 



48.— ON THE TREATMENT OP ACUTE AND CHRONIC ALBlJMI- 

NUIilA. 

By Dr. Gborok Corfb. 

During the last outbreak of cholera in London — namely, in 1854 — many of 
its victims who recovered from the direful scourge were left the subjects of 
more or less permanent uraemia. Some of these cases proved fatal, and the 
mode of death differed but little from iira^mic poisoning in the ordinary forms 
of morbus Brightii or albuminuria. The pn^gressive and fatal steps of the 
disease were, insidious coma, total and permanent suppression of urine, a 
small pupil and a hazy cornea, a peculiar fiabbiness on handling the fleshy 
parts of the body, and well-marked fumes of muriate of ammonia were formed, 
as a mirror, moistened with hydrochloric acid, was made to receive the ex- 
haled breath of the patient. This latter pathological feature is induced by 
the non-eliminated urea becoming converted in its elements to ammonia 
when it arrives at the pulmonary cells for exhalation, and is oftentimes a 
most valuable indication of the existence of uraBmic poisoning. The frequent 
occurrence of albuminuria in hospital practice since 1854 has induced me to 



PHACTICAL MEDICINE. 



m 



keep a record of many of tbtj mnst interpEsting forms of tins diseasi? ; niul in 
wtttcliirig tlio profrre^ss af tbo affiH^tion, I Imve been lt>dtn gmup ctnluin diss- 
tinct pbonorncna, wbieU will onnblo ua to firm tin tiocumte bosis*, *md servo 
ns a dingnoBtic mark bctwceu tho acuta ntul chrmnc stagcji tif tbis in tract* 
«blp malady. Such a do s idem turn appears the morf n"co§j5iiry" wbotj wc* rp* 
tlect \\o\y diftVrpnttbo trea tin en t should necesBarily bo in cachf*>rm, and that 
by ajndicifais nianugem6nt of the acute, tho direful mvagfis of a chronic? 
stage urn thort'by obviated, 

U may bt* gtiited^ thrm, as a pretty p^oneral rul*?* that ivliere tbf^ arine ia 
RCflnty, the Bpe?ific gnwity rariablo from lOlU to U}'2(h thy morniug secre- 
tion (urina sanguinis) Ugh tor than that of llie afternoon (urlna cbyli)*thc al- 
bumen copious both by nitric aeid and by heat, the lube casts abundanti the 
urine smoky and frothy, with or without oil -corpuscles, thoagh th(* amount 
of dropsy l>e small, yet tbo disease iS| under these elrcumstajices, in its early 
and aciite f*)rm. 

On the otht^r hand* a chrouio stage may bo readily diagnosed by the fol- 
lowing physical signs : — The countenance lias already become more or less 
cacbt*ctic: there is frequent nocturnal micturition ; tho albumen is i=canty, 
perhaps ultogethor absent; the specific gravity rarel)- osceeds 1010, and i-* 
persistent In weight; its acidity is so faint that it can scarcely be exhibited, 
iind there is a strong tendency In it to pass into an alkalest^ent state under 
tlie sm;dlest doses of alkaline^ remedies: the oolonr is of the palest straw. 
The skin assumes a faint but distinct shining appearanecT as though a thin 
layer of Cidlodion or gam had been painted over its surfuce* There are fre- 
quent attacks c»f frontal headache; tinnitus auriuin, lum!>ago, and general 
' ttrostration of the system are also sequences of the acute form of the disett^v. 
_ltis by no means a rule that dropsy should supervene in such a change of 
itructtire as that which tho kidneys undergo in the chronic form of aibumi- 
iiuria; indeed, this sympti^ni is more frequently absent, but usually preaen 
in the majority of acute eases of the disease. 

The pathological appearances of the twoformSitbe tendency to inflamnia- 

nfion of the serous membranes, tbo fretjuent fatal attacks of renal epilepsy, 

&ther cerebral di3:turbanees from ura»mic poisoning, have been pointed out 

kj Dthcrsn^ so that I need not dwell upon these phases of the disease, ^ly 

Special object is to give to tho profession some of tho results of a succeFsfnl 

'treatment of the acute and of the chronic form. Amongst sevpral hundred 

cases which have ptissed under mj notice in hospital prncticct I eanuot tmd 

from the notes on tbem that there was any connexion between this disease 

and scrofula. Dr. Bright considers the occurrence of tuberculosis with 

ilbuminuria to be '-^ decidedly rare ;" and on this account, perhaps, one may 

prefer the more frequent adoption of an antiphlogistic and powei'ful drastio i 

reatment in tli* early stages, which would be inadmissible if experience ' 

iud pathology led us to suspect a compUoalion of tuberculosis with the diji- 1 

' '^nse. 

In treating the acute stage, my experience justiftos mo in urgiiig strongly I 
the adoption of one of tho two following lines of practice : — If the patient 
libas had no previous attack, and has bved temperately, and was otherwise in 
^good condition before the invasion uf the disease, then I would recommend u 
iomlt bleeding, so as to affect the pulso under the finger; and, after twi* i 
bours^ the exhibition of half an ounce of frosb-mado infusion of digitalis evory 
" "boor for three doses. Both the bleeding and the diuretic should be admin- 
litered early in the day- After a pause of tweuty-fitur or thirty-six hours, 
according to the condition of the vascular system, the same dose should J 
be repeated, ard even to a third and fourth repetition, falhiwed on each oo* j 
• casion by copious draughts of ** nitre-drink," tlie form for making which ii j 
flimply to di solve a drachm of the nitrate of potash in a quart of thin barley- 
fwatert and a little " foots " sugar may be added to remove the mawkish taste. 1 
11 have witnessed the most extraordiDary results from this line of treatment* | 
If the dl-oase docs not yield^ — that is to say, if the invasion of dropsy in- 
creases, the albumen is yet copious, the ^peciilc gravity high, tUe IwW ^a»\* 
numerous, and the urine scanty, instead of reaotlmg to l\\ta iras^i^vv^sCiXiA 



118 PRACTICAL MEDICINE. 

and unscieniific mode of attacking the enemy by stimulating congested kid- 
neys, already semi-inflamed, with saline diuretics (the evils of which prac- 
tice by-the-by 1 have too frequently seen displayed in a few days in the 
pathological theatre,) then a most valuable agent is to be found in the de- 
termined exhibition of elaterium, accompanied with daily dry-cupping to the 
loins, and a sudatorium at night. The form for exhibiting this drastic is the 
following: — Fresh extract of elaterium, half a grain; powdered capsicum, 
two grains ; gamboge, three grains ; soft extract of jalap, four grains ; 
make two pills. One of these pills should bo taken at six o'clock in the 
morning; the second at eight ; and if no powerful drastic effect follows by 
nine a. m., a third dose may be given. The intense vomiting and purgation 
which ensue, it must be acknowledged, are very trying to the patient ; but 
he is amply rewarded for his suffering by a subsequent relief to all his dis- 
tress, so that he has oftentimes begged for a repetition of the pills before it 
was thought advisable to put him to a second trial, even when such an heroic 
treatment has been met by heroic suffering. I am convinced thatthe value of 
this drug is only appreciated by a few physicians ; and even where it has been 
employed, the exhaustion consequent upon its action has deterred many 
practitioners from persevering in its use. But it ought to be borne, that 
under such treatment the patient should be a'llowed a lioeral quantity of ani- 
mal food in the form chiefly of strong broths, with chops and steak together 
with a pint, at least, of stout or good ale, and vegetables, &c., daily. 

I remember on© instance amongst many which Dr. Watson was in the 
habit of mentioning to his class when speaking of the use of this drug in 
albuminuria. He was summoned to attend in consultation a case of the above 
disease. ** When I arrived there,*' he would observe, ** I found the man over- 
whelmed with anasnrcous swelling, his dyspnoea was most urgent, and 
there appeared to be no prospect of relief. However, I ascertained from the 
practitioner that he had tried everything but elaterium. I urged its use, and 
prescribed some to be given immediately. Four or five years after this oc- 
currence I was again in consultation with the same practitioner, when he 
asked me if I recollected the cns^ of albuminuria, and what I gave him, adding 
that it made a complete cure of the man. I referred to my private notes, 
feeling assured that the chief drug wns elaterium, and so it proved, and this 
was the form I administered it in : — One grain of extract of elaterium, dis- 
solved in an ounce of spirit of nitric ether; a small spoonful to be taken 
every hour until tlie bowels have been well opened." 

I have frequently used the same form with excellent benefit in children 
affected with the disease after scarlatina. As soon as the system has been 
thoroughly brought under the influence of the above remedy, immediate re- 
course should be had to another equally valuable agent — namely, the tinc- 
ture of the sesquichloride of iron in half-drachm doses, and the most elegant 
and efficacious mode of exhibiting it is in a glassful of seltzer water. Allu- 
sion has already been made to the injudicious practice of giving stimulating 
saline diuretics in this stage of the disease, and it has repeatedly happened 
that hsematine and red corpuscles have been voided, and finally suppression 
of urine has followed the use of such drugs, whereas a nearly and a discreet 
use of the remedies alluded to has been attended by a complete alleviation 
of the worst form of the disease. As the attack becomes more chronic in its 
nature, I have seen marked benefit follow the use of the syrup of iodide of 
iron in half-drachm and drachm doses, together with a generous animal 
diet, and a moderate use of good beer or porter, to the exclusion of all spirits. 
Drachm doses of cod-liver oil after each meal has proved a valuable ad- 
juvant in the treatment of many severe cases. — Lancet^ May 19, I860, «. 
489. 



49.— ON THE TESTS FOR DIABETIC SUGAR. 

By Dr. Lionsl Bbalk, F. B. S., Physician to King's College HoepitaL 

The presence of grape sugar in urine is readily ascertained by the appli* 



PRACTICAL MEDICINE. 119 

cation of oertain tests, and if modorato caro bo taken in the examination, the 
detection of this substance is not open to many fallacies. 

Mooters test for grape-sugar consists in adding, to the urine suspected 
to contain it, about half its bulk of liquor potassae. If sugar be present, 
the mixture becomes of a rich brown colour upon boiliug, which increases 
in intensity if the boiling be prolonged. The brown colour of the solution 
is owing to the formation of mellassicor sacchulmic acid ; glucic acid is aLK> 
produced in the decomposition. Thi.s test, however, cannot bo depended 
upon for detecting the presence of small quantities of sugar, because there 
are some other substances besides sugar which will cause the development 
of the colour in a slight degree. 

Trommer's test. — Of all the tests which have yet been proposed, that orig- 
inally suggested by Trommer, or some slight modification of it, will be found 
of the greatest practical value for showing the presence of sugar in diabetic 
urine, in clinical investigations. Trommer's test is applied as follows: — A 
fimall quantity of the urine, placed in a test tube, is to be treated with so- 
lution of potash, and a drop or two of a solution of sulphate of copper is to 
be dropped into the mixture. If sugar be present in any quantity, the pre- 
cipitate at first formed will be redissolvod, and the solution will be of a aark 
blue colour. If only traces of sugar are suspected to be present, one drop 
of the sulphate of copper solution will be sufficient. The dark blue solu- 
tion is now to be heated to the boiling point, and if sugar be present, a pale 
reddish brown precipitate of suboxide of copper is immediately thrown down. 
Instead of boiling the mixture, it may be allowed to stand for some time, 
when a similar deposit will gradually subside. If the suboxide is only re- 
duced after prolonged boiling, this cannot be taken as good evidence of the 
presence of sugar, for under these circumstances there are some other sub- 
stances which will cause the reduction of the oxide of copper. Again, if 
the solution simply change colour by boiling, without the occurrence of a dis- 
tinct precipitate, we must not infer that the change is necessarily due to the 
presence of sugar, for almost all specimens of urine exhibit this change. A 
flocculent precipitate of earthy phosphate, which always takes place, can- 
not be mistaken for the suboxide, as it is quite colourless, or of a pale 
greenish tinge. Tbe reaction alone characteristic is the production of a 
brown or yellowish precipitate (varying in quantity according to the amount 
of sugar the urine contains), either after the mixture has stood for some 
time, or upon boiling it not longer than tor a minute. 

Modifications of Trommer^s test have been proposed by Barreswil, and 
others, the most applicable, however, according to Lehmann, being that of 
Fehlin^ (Lehman's * Physiological Chemistry,' by Day, vol. i., p. 288. 
Cavendish Society). As this test is more easily applied than the sul- 
phate of copper and potash, it may bo well to mention its composition, — 69 
grains of sulphate of copper are to be dissolved in 345 grains of distilled 
water ; to this solution a concentrated solution of 268 grains of tartrate of 
potash, and then a solution composed of 80 grains of carbonate of soda in 
an ounce of distilled water are to be idded ; the mixture may be poured into 
a 1000 grain measure and filled up with water. 

Barreswil's solution is composed of the following constituents : — 

Cream of Tartar . . .96 grains 

Crystalised carbonate of soda . . 96 „ 

Sulphate of copper . . . 32 „ 

Caustic potash . . . 64 „ 

Water . . . .2 fluid ounces. 

In using these tests, it is only necessary to add about an equal bulk to the 
urine in a test tube, and then to boil the mixture. If sugar be present, the 
precipitate of suboxide occurs immediately. The application of this solu- 
tion to the quantitative determination of sugar, will be considered under 
volumetric analysis, Trommer's, or one of the above mentioned modifica- 
tionSf will be found the most delicate test which can be used, when only 
small qoantities of sugar are suspected to be present, tmd Wi^ \».t\x«Xa ^1 



120 PRACTICAL MEDICINE. 

copper solution is applied as easily as the liquor potassse test, while the re- 
sults obtained from it are far more to be depended upon. If aibomen be 
present, the reduction of the oxide of copper does not take place, so that in 
using the copper test we must ascertain that this substance is absent. Am- 
monia also dissolves suboxide of copper. 

It has been shown that allantoin, creatine, and creatinine, have the power 
of producing a precipitate of suboxide of copper, like grape-sugar, and 
more recently, M. Berlin has proved that uric acid possesses to some extent 
the same property. 

Some time since I endeavoured to ascertain the cause of certain anoma- 
lous results, which were sometimes met with in employing this test ; and as 
these to some extent explain the discrepancies of different authorities with 
reference to the presence or absence of sugar in the urine in certain cases, 
it is well to allude to them here. The following results were obtained. 

1. The precipitate of suboxide of copper was readily dissolved by acetic, 
hydrochloric, and nitric acids. It was also dissolved by ammonia. 

2. The precipitate was insoluble in a solution of chloride of sodium, but 
was readily dissolved by a weak solution of chloride of ammonium. 

3. The addition of a few drops of chloride of ammonium previous to 
boiling, entirely prevented the precipitation of the suboxide, the mixture re- 
taining its greenish colour. Upon adding some soluticm of potash, however, 
the preci[)itate of suboxide was produced, and ammoniacal fumes were given 
off at the same time. If a moderate quantity of solution of chloride of am- 
monium was present, the precipitate did not occur upon the addition of pot- 
ash, even after very prolonged boiling. 

4. If a drop of a very dilute solution of the chloride of ammonium was 
added to a pretty strong solution of sugar, and, after the addition of the tar- 
trate, the mixture was boiled, no precipitate took place, but the solution be- 
came of a pale brown tint ; the suboxide being immediately thrown down 
upon the addition of a few drops of a solution of potash, with the develop- 
ment of ammoniacal fumes. In the above cases in which no precipitate took 
place, it w^as ascertained that there was the usual excess of alkali present in 
the test solution. 

5. A solution of oxalate of ammonia also prevented the precipitation of 
the suboxide, but a greater quantity of this salt than of the chloride of am- 
monia was required. 

6. A neutral solution of urate of ammonia (artificially prepared) also pre- 
vented the reduction of the suboxide, and dissolved the precipitate if added 
to it. On carrying out this experiment further, it was found that the precip- 
itate of suhoodde of copper wcls dissolved by urine containing an excess of urate 
of ammonia, 

7. A solution of grape-sugar in water was prepared, and by a preliminary 
experiment it was ascertained that, upon being boiled with the tartrate test, 
au abundant precipitation of suboxide took place. 

To a portion of the precipitate of suboxide produced in this way, about a 
drachm of healthy urine, immediately after it was passed, and while yet 
warm, was added, and the reddish precipitate was instantly dissolved, form- 
ing a perfectly clear solution. Upon further boiling, a slight precipitate of 
phosphate took place. The suboxide, however, could not be precipitated by 
the further addition of potash and prolonged boiling. 

8. Upon mixing a small quantity of grape-sugar with the same specimen 
of healthy urine, and boiling the mixture with the tartrate te^U no precipitate, 
except a little phosphate, was produced. About half an onnce of the same 
mixture of urine and grape-sugar was 'placed in a test tube, mixed with six 
drops of yeast, and inverted over mercury. The whole was then placed in 
a temperature from 70° to 100° for about twelve hours, at the end of which 
time tne tube was found quite filled with gas, and all the liquid was expelled 
into the vessel in which it had been placed. The specimen of urine with 
which the above experiments were tried, was allowed to stand in a still place ; 
and when it had become quite cold, an abundant precipitate of urate of am- 
moDja woB found to be present. 



PRACTICAL MEDICINE. 121 

9. A portion of the aqueous solution of grape-sugar was mixed with a strong 
solution of urate of ammonia (artificially prepared), and then a certain quan- 
tity of the tartrate solution was added, and the mixture hoiled. The cbarao- 
teristic precipitate, or opalescence, was not produced, but the mixture be- 
came of a pale fawn colour. In a weak solntion of urate of ammonia, the 
characteristic precipitate appeared after boiling the mixture for some 
minutes. So thaU although much sugar is presevU tlie colour of the mix- 
ture may he merely changed to hrown^ and no precipitate whatever may take 
place, 

10. A solution of grape-sugar was treated with a drop of a dilute solution 
of chloride of ammonium, and boiled with the tartrate solution. The mixture 
became of a brown colour, but no precipitate occurred. Upon the addition 
of a few drops of solution of potash, the precipitate of suboxide was 
produced. 

A solution of grape-sugar, treated with Trommer*s tost, according to the 
usual method, behaved in the same way, in the presence of chloride of am- 
monium, as when treated with the tartrate of copper solution ; but in this 
case a greater quantity of the chloride was necessary, for when only tracen 
were present, ammoniacal vapours were given off, and the precipitate of sub- 
oxide subsided, as before remarked. 

From the results of the above experiments, the following conclusions 
with reference to the practical application of Trommer's test, and Fehling 
and BarreswiPg solutions, and other modifications of the copper test, may 
be drawn : — 

1. That if the urine contain chloride of ammonium (even in very small 
quantity), urate of ammonia, or other ammoniacal salts, tlio suboxide of cop- 
per would not be precipitatated if only a small quantity of sugar were 
present. 

2. That unless there be a considerable quantity of one of the above salts 
present (in which case the blue colour will remain), the mixture will change 
to a brownish hue upon boiling, but no opalescence or precipitate of sub- 
oxide of copper will occur. VVhen only a moderate amount of sugar is 
present, I have been unable to obtain a precipitate, under these circum- 
stances, by the addition of potash to the solution, and prolonged boiling. 
By observation 8, it appears that a specimen of urine exhibiting this 
reaction may contain a large quantity of sugar, as ascertained by the 
yeast test. 

3. That in many cases in which the precipitation of the suboxide is pre- 
vented by the presence of ammoniacal salts, the addition of potash to the 
solution, and subsequent boiling, will cause the production of a precipitate 
with the evolution of ammoniacal fumes. Hence care should always bo 
taken that there is a considerable excess of free alkali present. 

4. When only small quantities of sugar are present in the urine, and the 
precipitate of suboxide of copper is not decided, the fermentation test should 
oe resorted to. 

Upon treating different specimens of diabetic urine with Trommer's test, 
or its modifications, it has often been noticed that in one case the precipitate 
is produced as soon as the mixture reaches the boiling point, or even before; 
while in other instances it is necessary to keep it in active ebullition for 
some minutes, before any precipitate is produced. This circumstance re- 
ceives explanation from the facts above detailed with reference to the pres- 
ence of ammoniacal salts; and other anomalous results, which must have 
occurred to many in the habit of employing this test, become explained. 

As a test for diabetic or grape-sugar, if proper precautions be observed, 
mncb greater dependence can be placed on this test than by simply boiling 
with liquor potassro. Specimens of urine in which sugar is suspected to be 
present* and no decided precipitate of suboxide (which must be carefully 
distinguished from phosphate) occurs, should be carefully fermented with 
yeast oefore any conclusion is arrived at. 

On Testing for Sugar when only Traces are Present. — In fluids \«l\\c\i vc^ 
tiiBpected to contain only mere traces of sugar, it \a ncec^^aty \.o ^b^'^oct^XA 



122 PRACTICAL MEDICINE. 

some of the other constituents before applying the test. The plan recom- 
mended by M. Leconte is the following : — Excess of acetate of lead is added, 
and the precipitate separated by filtration. The solution is concentratr^d by 
evaporation, treated with ammonia, and again filtered. The copper test is 
then applied. The objections to applying the reduction tost to solutions 
containing ammonia has been already discussed. It is better to employ 
carbonate of potash, or soda, instead of ammonia. The excess of lead salt 
may also be remored from the filtered solution by passing sulphuretted 
hydrogen. The precipitate of sulphurct of lead is removed by filtration, 
and the liquid, after evaporation to a small bulk, may be tested. 

Another plan recommended by M. Leconte is to treat the urine with 
acetic acid, and evaporat^it to about the fifth of its bulk : it is then treated 
with alcohol, and after filtration fro > the salts, 6cc., the alcoholic s(ilution is 
evaporated and tested. This plan is free from the objection that ammonia 
may cause the destruction of the sugar where only truces are present. 

ilie Yeast Test. — This is one of the most satisfactory tests for the pres- 
ence of sugar, and if employed with proper care can hardly fail in its results. 
Two test tubes, of the same form, and of equal size, are to be taken. Ono 
is nearly filled with water, and into the other a corresponding quantity of 
the urine is to be poured. An equal amount of yeast is now to be added to 
the liquids in the tubes, and after pouring in just sufficient fiuid to fill the 
tubes, the thumb is to be carefully placed over the opening, and the tube 
inverted in a small cup of mercury. The best plan, however, is to cut out 
a little india-rubber pad, slightly larger than the upper extremity of tho 
tube. When the tubes have been filled up to the brim with a little water, 
the pad is allowed to float on the surface, next a little cup or beaker is in- 
verted, and carefully placed over the end of the tube. The india-rubber 
being pressed against the open end, the fluid is prevented from escaping. 
The whole may be inverted, and a little mercury having been poured into 
the beaker, the india-rubber may be removed, with forceps, without any 
escape of the fluid. The tubes may be supported in position by a wire 
stand. Both tubes are then to be exposed, for a few hours, to a temperature 
of from 80° to 90°, and the comparative size of the bubble of gas in the up- 
per part of each may then be noted. If an appreciable quantity of sugar 
be present, the bubble of gas in the tube containing the urine will be many 
times larger than in the tube which contains the yeast and water. In the 
latter tube the bubble of gas merely arises from the small quantities of air 
previously mixed with the yeast, becoming disengaged, and floating to the 
surface. Fermentation, when carefully performed, is positive evidence of 
the presence of sugar, although it does not indicate the kind of sugar present. 

Maumene^s Test. — A little woolen rag, as merino, is cut into strips, and 
soaked for four or five minutes in a solution of perchloride of tin (one part 
of the perchloride to two parts of water.) The slips are then dried over 
the water bath. A drop of the urine suspected to contain sugar is allowed 
to fall on a small slip of the prepared merino, which is then dried, and ex- 
posed to the dull red heat of a spirit lamp. If a trace of sugar be present, 
a black spot is produced. 

Bismuth Test. — Bottger has lately proposed a new test for sugar. This 
consists in adding first of all potash, then a small quantity of subnitrate of 
bismuth ; lastly the mixture is boiled. If sugar be present, the oxide is re- 
duced to metallic bismuth, which is precipitated in the form of a black 
powder. It has been asserted that sulphuret of bismuth is formed, but this 
seems not to be the case. Brdcke shows that this test is more delicate than 
Trommer*s (or the modification of it by Fehling) ; and he finds that the 
black precipitate is produced to some extent in specimens of healthy urine. 
The bismuth test may also be applied thus — A solution of carbonate of soda 
(crystallised carbonate 1 part, water S parts) is prepared, and a certain quantity 
added to an equal amount of the urine. A little basic nitrate of bismuth ia 
then added, and the mixture heated to the boiling point. If sugar be pres- 
ent, a black precipitate is produced. — British Med. Journal^ May 19, I860, 
p^ 874. 



PRACTICAL MEDICINE. 123 



50.-^)N THE METHOD OF DETECTING AND ESTIMATING THE 
QUANTITY OF SUGAR IN DIABETIC URINE. 

By Dr. Jamks M'Ghir, Glasgow. 

A considerable variety of methods have been given by different writors 
on urinary diseases, for testing diabetic urine, and estimating the quantity 
of sugar contained in any given specimen. The sense of taste is perhaps 
the readiest means of ascertaining that saccharine matter is present in 
urine, and evaporation gives an approximate estimation of the quantity. 
Trommer's test is now most commonly employed, and the improvements 
made upon it by Barreswil and Fehling, enable us to employ it not merely 
for the qualitative, but also for the quantitative determination of sugar in 
the urine. The fermentation test, also, is one fitted to give satisfactory re- 
sults. 

Havins been engaged in 1849 in the examination of diabetic urine, I had 
frequenth'^ tried all the tests usually employed, and among others that of 
Pittenkofer, with bile and sulphuric acid. At that time there was no notice 
of Runge's test in Dr. Golding Bird's work, though it appeared in a subse- 
quent edition. Runge only contemplated the production of a blackish colour 
by applying dilute sulphuric acid to diabetic urine : while Pittenkofer em- 
ployea it along with bile to produce a violet colour. Neither of these meth- 
ods afford satisfactory results. ** Grape sugar," says Thudichum, ** is not 
influenced by dilute acids, and not blackened by concentrated sulphuric acid. 
If grape sugar dried at a temperature of 100°, is mixed with one and a half 
times its weight of concentrated sulphuric acid, it dissolves, and forms with 
the acid a combination which is an acid itself, and has been called sulplio- 
saocharic acid." However just this observation may bo in reference to dried 
grape sugar, it does not apply to that form of sugar found in diabetic urine. 
When concentrated sulphuric acid is added to an equal volume of diabetic 
urine, and heat applied to ebullition of the mixture, the following changes 
occur : First, the fluid becomes blackish, and soon passes into a state of inky 
blackness. As soon as ebullition commences the mixture begins to froth 
up, and continues to be covered with a layer of froth so long as the boiling 
continues. This layer of froth also remains after the mixture is cooled. In 
no other kind of urine except the diabetic, are these appearances manifest- 
ed. After the boiling has been continued for a short time, besides thein- 
tense black colour, when the fluid is closely examined there will bo found a 
copious evolution of carbonaceous particles. The high specific gravity of 
the fluid in which these fine black particles are suspended, prevents their 
being deposited as a precipitate till it is largely diluted with water. In or- 
dinary samples of diabetic urine a copious precipitate is speedily deposited 
on the addition of water. The precipitate should now be thoroughly washed 
on a weighed filter, till all the acid is removed, and nothing but the pure car- 
bon remains on the filter. After being carefully dried and weighed, the ex- 
cess of weight of the filter containing the carbon over the weight of the 
filter without the carbon, will give the amount of carbon contained in the 
sugar; and when this quantity is found it is ea&y to calculate the weight of 
the sugar. The dried precipitate on the filter will be found in the form of 
numerous small pieces of jet-black carbon, which may be collected, and, by 
combustion, will be dissipated in the form of gas, without leaving any solid 
residue. 

It may be objected to this test, that there are other kinds of urine which, 
when boiled wiih sulphuric acid, develop appearances somewhat analogous* 
if not altogether identical with those produced by diabetic urine. It is true 
tiiat nlbuo^ons urine, when boiled with strong sulphuric acid, gives a deep 
rich brown colour, approaching to black ; but it presents none of the pecu- 
liar phenomena which we have noticed as accompanying diabetic urine when 
treated in a similar manner. The colour is different; it does not froth ; and 
when dfluted with water, there is no deposit of black carbonaceous matter, 
but the deep brown colour merely become less deep in shade. 



124 PRACTICAL MEDICINE. 

Any probable fallacy as between albuminous and diabetic urino, will, if 
the following method is adopted, be completely dissipated. Let the urino 
bo first acidulated with N0», and then boiled, when, it albumen is present, 
it will become coagulated, and may be removed by filtration, then proceed 
with the test as described above. 

I have seen this test fail to develop the characteristic phenomena when 
applied after the urine has been kept a sufficient length of time to admit of 
decomposition taking place. A sample of urine which has already been found 
by Trommer's or some other test, to contain sugar, may, after it has stood 
some time, be tested by sulphuric acid, and will probably fail to produce any 
of the characteristic reactions. It will be found in all such cases that de- 
composition has begun, and not only this, but every other test will fail. 
The precaution ought to bo taken to have the urine operated upon as fresh 
and recent as possible, when embarrassing failures of this kind will be 
avoided. 

The modus operandi of the sulphuric acid in its action on grape sugar is 
extremely simple and well defined. The sugar consists of Ci, 0,a Hj,; that 
is, twelve atoms of carbon are combined with twelve atoms of HO or water. 
Strong sulphuric acid has sufficiently strong affinity for water to decompose 
the sugar, and remove from it all the elements of HO. and leave the insoluble 
carbon disft-eminated in fine particles through the mixture ; and whatever ac- 
tion it may have upon the other constituents of the urine, it does not give 
rise to any other insoluble compound, if the necessary precautions have been 
taken at the outset, to remove the mucus by filtration, and the albumen, if 
there is any present, in the manner indicated above. In some specimens of 
high-coloured and concentrated urine, when there is a considerable quantity 
of animal extractive and colouring matter, the action of the sulphuric acid 
may develop a small amount of blackish particles, which, when treated in 
the same way as the carbon of diabetic sugar, are readily distinguished from 
it. It may be affirmed, without fear of contradiction, that there is no other 
kind of urino which comports itself in the presence of sulphuric acid in a 
manner analogous to diabetic urine. Grape sugar in the solid state is dis- 
solved in SOs, but in solution in the urine is decomposed by it. When 
treated with caustic potash and heat, the smell of burnt sugar is evolved, the 
solution becomes brown in colour, and glucic and molassic acids are pro- 
duced. In the crystallized state it contains, besides the constitutional ele- 
ments of water, two equivalents of water of crystallization, which are dis- 
pelled by a temperature of 212°. When the temperature is raised to 284°, 
three equivalents of constitutional water are dispelled, and caramel is pro- 
duced; but it is only when in a state of solution that sulphuric acid I'emoves 
all tho constitutional elements of HO. Of the ordinary tests Prommer*8 is 
preferred by some, Cappezuoli's and the fermentation test by others. The 
sulphuriomcid test is one which, if deemed worthy of a trial, will, in point of 
simplicity in manipulation and certainty in its results, be found second to 
none. — Glasgow Med, Journal^ April 1860, p, 42. 



51.— ON THE DETERMINATION OF THE PROPORTION OP 
SOLIDS IN THE URINE OF HEALTH AND DISEASE. 

Dj Dr. William Sbllbb, F.I1.5.E., Edinbargb. 

Of late, my attention has been drawn to the modes of estimating the pro- 
portion of solid matter in the urine. There are still attendant on the reduc- 
tion of the urine to dryness, great practical difficulties; and, respecting the 
proper rule for solving tho problem by reference to the density of the urine, 
there are conflicting views among the best authorities. 

I propose to offer a few observations bearing on each of these two methods ; 
and first, of that which rests on the density. 

It will be remembered that the three best-known proposals for finding the 
projyoTtion of solids in the urine from the density are, to multiply the nam- 



PRACTICAL MEDICINE. 




bf'r tlcTioting tlie exccFs of the density above iO(10» l^t. by t!io nunibrr 2 ; 
^illy, by a uumber legs than 2 (L65) ; 3diy, bj a nuiiibor greutor tban ;S 

This mode of proceeding rests on tbe circumstance, that when soluble 
matte I' b added t4i watery thu aolvent coitiiDouljf yet not always* undergi>eii 
(Ian ex^>aimion< 

If Ih^ro be no expftnslon, there is no need of n Tnultiplbr— the excess of" 
he density above 1000 sigoijioti tho nmount of the s^oluldo mutter preseiit. 
^f tbo expansion expressed in wfiter-gmin ment^ures be found to be equal to 
Iho expfss of tbo densily above 1000, reprf^i^i^oted by weight in grnina, thun 
Eiltti tnu]tip!ter2 will glvt^ tbe amount of Bolubte matter eon ttiiued in tho eolu* 
It ion, FL»r e ram pie T in tbe 1000 grain epeci fie- gravity bottle, let 50 grainii | 
l^of fcjoluhle matteri tho mean expansion caused l>y winch is 25 water-grahi 
[tnensiireSi be dijasolved in U73 grains of distilled water, the bottle will be ex- 
Hctly filled, and the s'peciHc gravity » which here correMponds with the actnul 
'gbt, will be 10*^5* But 25^ the excess of tbe density or specific gravity 
ve lOOO, multiplied by 2, gives tho whole amount of solid matte r* viz.^ .lO 
|min.s. I'urallel to Una iii every ca^^e in which tbe expanse ion is equal to the 
excess of deiistty ftb<»ve 1000* And thiJS» lliat form of the rule undi-r con- , 
Ifideratiun wiiich makia 2 tbe multiplier, proceeds on the assminption that J 
Ithe number denotiug, in water-grain mt'asures, the mean eispau^ion caulked i 
] in water by tbe solid matter of tiie uriue is equal to half the amount of that 
rmatter expressed by weight in grains. 

'Vhen, again* 1,65 is used aa the multiplier, the method proceeds on the 
^, (itnption that the expansion is to tbe excess of density ahuve 1000, very j 
Beady as 2 to 3, or is e<joal to two-fifths of tbe numbor denotiug tbe weight | 
[^ f t h e !*ol u b 1 e nmt t er p r ea en t * 

Lastly, when the multiplier in made 2,3?}. the nB^umption exists that thai 
expansion la to the exceMS of the density above 1000, nearly na 4 to 3, or i«| 
.ttlmoftt equal to four-sevuntha of tho numbiU' denoting Uuj whole atnount of * 
iBoitd matter present- 

Tbe whole of these stntements is Indisputablet provided it bo mlmttted that 
I fixed weight of soluble matter of one kind e rentes tho same amount of ex-j 
f Jjansion during solution, whatever be the proportion of water. Ami though 
Nhis proposition cannot be a.'fsujned as true without exception, yet tt i» cer- 
rtain that exceptions take place only to a small extent, chiefly when the point 
[4»f:sat unit ion is apj»roachod. 

It should be observed, as flowing from what baa been aflirmed abovei that 

I tbe number expre^«iug the weight in grainji of a salt present in solution, iiiJ 

rinade up of the excess of density above 1000, together wjtti tho number dii*l 

FBoltng the expansion in water- grain meaauros. Tbus^, when the specifiu-j 

[gravity bottle ia filled with a Bolution weighing 1020 gniiuK, tho quantity of* 

I wutfr preseot, ff there has been any expansion at all, must be less than 1000 

[grains by the number of woter-gmin miusurcs denoting the expansion; that 

IK, The whole quantity, 10:20 gmiu.s is mado up of the quantity of soluble 

matter, together with 1000 grains of water minus tbe number expressive of 

tbe expansion. 

It should bo remarked a!»0| that, owing to the expansion being so uni- 

ffirmly constant for the same weight of a salt, whatever be tbe pn^iortion of 

I watei, we reduce the specific gravity of a aoiutiou^for example^ troui 1050 

to 1025^ — not by bidding a volume of water equal to that which the solution is 

estimated to coutuin, but by adding a volume of water equiil to that of the 

jeolution itself. Thus, 1000 grain'mensures of urine of fiipeeitic gravity 1030 

^miiy bo found to coutajo no more than D70 grains of waiter; yet its speciiio 

.gravity i^ reduced to 1015, not liy ad{liijg other 070 grains of water, but by 

. tidding to it an equul volume, or 1000 grains, of water* 

It t^honld also be remarked, as flowing similarly from what has been 
I iiflirmed above, thiit, for example, if four wateri* be poured upon a sultt and 
.then four waters more, and bo on in sncecfiHon for a numbor of times, tbe 
S trjluiUm obtained will not present such a uoiformly dooreasini^ specific grav- 
ity ,^th at sucb a scale of decroaso is obtained only wken tW tMa^ifcWN^ 



126 PRACTICAL MEDICDiE. 

quantities of water added are each equal to the lirat quantity, together with 
tne expansion which took place while in the first instance the salt was taken 
up. Thus, if 250 grains of nitrate of potansa are dissolved in 1000 grains of 
water, the expansion amounts to nearly 90 water-grain measures ; so that 
the quantities of water to be added in succession to produce such a uniformly 
decreasing scale of density are, not 1000 grains, but 1090 grains each. 

So much, then, for the principles on which the necessity for a multiplier 
rests. 

We have next to consider the practical application of these principles to 
the case of the urine. 

Of the practical rules before referred to, that most in favour in this coun- 
try at present is the one proposed by Dr. Christison, not for the urine in 
general, but for the special highly dense urine of diabetes — that, namely, by 
which 2*38 is made the multiplier. While many adopt this rule implicitly, 
like Dr. G. Bird, who has founded two extensive tables upon it, others qual- 
ify it by the rule wherein the number 2 is made the multiplier, which they 
recommend when the density of tho urine is lower in the scale, while they 
take Dr. Christison*s rule only when the specimen of urine under examina- 
tion is of high density. The third rule, that in which 1*65 is made the mul- 
tiplier, was proposed by the eminent French observer, Becquerel. This 
last rule, however, has, of late years, thrown entirely out of English books 
on the authority of Dr. Day, who, in an elaborate paper, has laid down Dr. 
Christison's rule as that most applicable to all kiuds of cases. 

The evidence on which each of these rules has been supported by their 
respective partisans, is the actual amount of solid matter obtained from nu- 
merous specimens of urine of known density. The objection to this evidence 
is the discrepancy in the results described by different observers, — which 
discrepancy is manifestly dependent on the difficulty of getting the solid 
residue perfectly free from water. 

I am not aware that any one has hitherto attempted to try the merits of 
these several rules by the particular properties of the known constituents of 
the urine. This kind of inquiry, however, does not appear unworthy of at- 
tention. The plan of such an investigation I shall endeavour to suggest and 
follow out, as far as materials exist for the purpose. 

The solid matter of the urine in health admits of a threefold division, 
namely, into — 1, urea; 2, organic matters other than urea ; and 3, inorganic 
saline substances. The proportions under these several heads, in many 
standard analyses of the urine in health, approach to an equality. Thus, in 
the analysis given by Miller in his Chemistry^ the proportion of urea in 1000 
parts of urine of specific gravity 1020, is 14'23; that of organic matters other 
than urea is 15*56; and that of inorganic saline substances is J 3*35; while 
the proportion of water amounts to 956*80. Thus it may ha allowed to us 
to assume, as a convenient diagram of the constitution of the urine, that the 
proportion in each of these divisions is equal, say 15 of each in the thousand 
parts. Such a diagram will stand thus ; — Urea, 15; organic matters other 
than urea, 15; saline substances, 15; water, 1000, less the amount of ex- 
pansion ; while the specific gravity will hardly exceed 1020. It is obvious 
that, were the medium expansion created in water by such a proportion of 
each of those divisions ascertained, a considerable step would be gained 
towards determining which of the multipliers before referred to should in 
general be preferred. 

It is only in the case of the saline substances commonly believed to be 
present in the urine, that any evidence has hitherto existed with regard to 
the amount of expansion produced during their solution. When a substance 
can be obtained in a stAte of purity, nothing is easier than, within moderate 
limits of accuracy, to determine its property in this respect ; for no more is 
necessary than to put a certain quantity of the substance into the thousand- 
grain specific-gravity bottle, and to fill it up with distilled water, then weigh 
the whole. It is manifest that the difference between the entire weight and 
the weight of the soluble substance put in is equal to the quantity of water 



PRACTICAL MEDICINE. 127 

presont, and that the difference between the quantity of water and 1000 is 
the amount of expansion in water-grain measures. In this way I find that 
30 grains of pure urea cause an expansion equal to 22 water-grain measures. 

With respect to the organic substances other than urea, the small propor- 
tion of each, together with the difficulty of procuring most of them in a stato 
of purity, has prevented me from making any direct observations as to their 
effect on the expansion of the solvent during solution. But it is evident 
that, in an exact analysis of the urine supplying the means of determining 
the effect of the urea and of the several inorganic saline substances on the 
expansion of the s«>lvent, the means are furnished of inferring the expansion 
created by these organic substances in the aggregate. 

Unfortunately, few recent analyses of the urine are of a kind to assist the 
mode of investigation here sugj^ested ; because it is not common, of late, to 
attempt to ^x the exact proportions in which the several saline substances 
are present. The well-known analysis of Berzelius, now so time-honoured, 
is almost the only one I can find suitable to my present purpose. It is cer- 
tain that no analysis has yet appeared fit to take the place which it has held 
so long. The only considerable defect in it is, that the specific gravity of 
the specimen of urine from which it was taken is not stated. It is less ma- 
terial that the organic substances other than urea and uric acid are not 
named in accordance with present views. 

The proportion of solids to the water in this analysis is remarkably high, 
being 67 to 933 on 1000 parts by weight, or, in round numbers, 70 grains in 
1000 water-grain measures of urine. If the specific gravity be sought by 
the converse of the rule so often referred to — that is, by dividing the quan- 
tity of solids present in 1000 water-grain measures by one of the three num- 
bers, 1*65, 2, or 3*33 — the answers will be respectively 1043, 1035, and 1030. 
The first number, 1043, is certainly considerably above any specific gravity 
which we are accustomed to meet with during health in this country. Nev- 
ertheless the case may be different in Sweden. As to 10.30 and 1035, they 
are by no means uncommon as characterizing the urine of particular parts of 
the day, chiefly when the urine is very slowly secrot*^d. The chief pecu- 
liarity, besides, in this analysis is the large proportion of urea. It has, 
however, been remarked, that the slow secretion of the urine with a small 
proportion of water is the circumstance most favourable to the elimination 
of an unusually large proportion of urea. And it is probably this same cir - 
cumstance which has given rise to the prevailing idea, that it is the large 
proportion of urea which principally contributes to a high specific gravity of 
the urine. The truth, however, is, that when the urine has a high specifio 
gravity, in health, there is an abundance of urea ; but it is not the abundance 
of urea which chiefly contributes to that high density, for even 70 grains of 
urea, contained in 1000 grain measures of its simple solution, give rise to a 
density no higher than 1019. There is thus no reason to doubt that this 
analysis correctly represents a genuine specimen of healthy urine. 

First, then, of the inorganic saline substances in this analysis. These 
salts are the sulphate of potassa, the sulphate of soda, the phosphate of soda, 
the phosphate of ammonia, the chloride of sodium, the hydrochlorate of am- 
monia,' earthy matters with a trace of fluoride of calcium and siliceous earth. 
The two last particulars being omitted, the sum of these salts in the analysis 
is 17*41, and the sum of the expansion which they create in water during 
their solution, calculated from data obtained, for the most part, from authen- 
tic chemical sources, is 7*26 water-grain measures. Thus, a solution of these 
salts in 992*74 grains of water would yield 1000 water-grain measures of a 
fluid having a specific gravity of 1009*15. If this fluid were a true type of 
the arine, the two lower multipliers would give a more correct indication of 
the amount of solids present than the highest ; for 9*15 multiplied into 2*33 
gire 21*31 — an excess of nearly 4 grains above the quantity of salts present, 
vi«.. 17*41. 

Bat area, which in the analysis under consideration is present in large pro- 
portion, prodaces a very different effect on the urine from these salts. It 
was itateid above, that 30 grains of urea create an expansion dantv^ !^q\\x>\^u 



138 PRACTICAL MEDICINE. 

equal to 22 water-grain meaAures. Thirty grains of urea being the ouantity 
stated in tlie analysis in 1000 grains of uriuo : there is more than <k) grains 
in 1000 water-grain measures of urine ; and, therefore, the expansion due to 
it is correspondingly greater than 22 water-grain measures ; but that small, 
difforonco may he left out of view. If, then, the fixed salts (17*45 grains) 
and the urea (30 grains), together 47*45 grains, are dissolved in water, the 
sum of their expansion is (22x7-26) 20-2G; so that 970*74 grains of water 
will suffice to produce a solution 1000 water-grain measures in volume. The 
specific gravity of this solution is 1018*19; and even the highest multiplier, 
2*33 fails to bring out so large a quantity as the solids present are equal to; 
for 2*3iJ X 18*19 arc only equal to 42*38, the multiplier required being 2*6, 
since 18*]9x 2-6=47*29. 

Wo have next to conj*idor the effect of the organic matters other than urea. 
Here the uncertainty of the specific gravity creates a great difficulty. Thus, 
were wo sure that the specific gravity is 1030, the aggregate of the expan- 
sion produced by the three divisions of the solids would be known, since it 
is the whole amount of the solids diminished by the excess of the density 
above 1000; or it is 70 — 30 = 40. Hence it would at once appear that 
the expansion created by 18*46 organic substances other than urea amounts 
to 10*74, or the difference between 40 and the expansion already seen to be- 
* long to the sum of the urea and the inorganic salts, namely, 29*26. 

Since, however, this uncertainty as to the specific gravity of the specimen 
of urine under consideration prevents any trustworthy inference as to the 
effect of the organic matters of the urine other than urea in the expansion 
of the solvent, recourse may be had to some other analysis in quest of such 
information. 

In Miller's analysis, the amount of fixed salts, 23*35 gives rise to an ex- 
pansion of no more than one-third *%", or 4*45, while 14*23 parts of urea cre- 
ate an expansion of 10*43, — the joint expansion, therefore, effected by the 
fixed salts and the urea is 14*88. The Avhole quantity of solid matter in this 
specimen of urine is 43*2, and the specific gravity is 1020. The total expan- 
sion is discovered by taking the excess of the density above 1000, namely 
20, from the whole quantity of the solids, 43*2, when there remains 2^3*20. 
But this last number being diminished by that denoting the joint expansion 
produced by the fixed salts and the urea, namely 14*88, there remain 8*32 as 
indicating the expansion attributable to the organic substances other than 
urea, which amount to 15*56. But 15*56 : 8*32 : : 18*46 : 9*86. Thus there 
is deduced from Miller's analysis a number, 9*86, expressive of the expan- 
sion due to the 18*46 of organic substances other than urea contained in the 
analysis of Berzelius, — a number differing in a very slight degree from that, 
namely 10*74, inferred from the assumption of 1030 as the specific gravity 
of that specimen of urine. 

We may regard it as proved, then, that the true specific gravity of tho 
specimen of urine to which the analysis of Berzelius applies is 1030. And it 
should be observed, also, that the highest multiplier, namely 2*33, gives a 
nearly exact result as to the whole quantity of solids present; for 30x2**33 
= 69-90, or, as nearly as possible, 70, — the round number assumed above us 
denoting the quantity of solids present in 1000 water-grain measures of this 
. specimen of urine. 

It must be confessed, however, that little progress can be made towards 
determining by this method which multiplier deserves the preference, until 
many trustworthy analyses of the urine, as it exists under different circum- 
stances compatible with health, can be procured on the exact plan adopted 
by Berzelius. In the meantime, some progress might be made, at no groat 
cost <if trouble, if those who have leisure were to accumulate information b}' 
determining the exact proportion of urea and of inorganic salts in a number 
of specimens of urine. It is easy to determine the proportion of urea by tho 
method of Liebig. to which I endeavored to draw attention in a recent num- 
ber of this journal ; and it is a work of no great difficulty, to those who have 
time on their hands, to determine the amount of inorganic salts. Thus, if 
the urine be reduced by heat to the consistence of syrup, and pure nitric 




PR ACTIO AX MEDIOINE. 

acid ba added to the extent of 4 or 5 per cent, an the original quantity of 
tbe unnu ; if the ovapamtion be ceutiiuied till tbe wbole will solidify ou 
eooliDg ; nndi InBtly^ if portions of the mass he projt^cti'd Into it red- hot pln- 
t inn in capsule, the fixed galt# will bo obtained hi tlie furru of u. white mass* 
It Is true tbnt, after we have ascertained lli« proptirtioa-i of urea and of tlie 
fi^ed Bait:?! we cuiinot discover the proportion of the organic matters other 
than urea unless we know the whida utaount of »aljd mattflr present* But 
lif^aD easy method for this purpose I am goiug to spenk before closing thlit 
paper. 

Before leaving this subject I will only add a single illussfrutionT by way of 
showing the point from which any further iiivetitigntkm mu^l set ouL Let 
^» recur, then, to the diagram of the ctmstitutiou of the urine in which the 
solid matter was regarded a:^ falling under three divi.sious, in each of which 
the proportion was held to bo 15, while the amount of the scdveiit waa taken 
at 1000^ legs the total expansion. Of the amount of eipmision produced by 
these several divisionSi there is no cert4iioty except in the case of that oon- 
i4|5tingof urea. With respect to the expansion produced by the other two 
divisions, though a figure can be produced by calcuhiliou for each, yet, ow- 
ing to the insuiiieiency of the datoi these numbers must ho regarded as merely 
provisionah For every 15 parts of urea dissolved, it is certain that the ex- 
paoMon is nearly 11 ; for every 15 parts of organic substances other than 
urea, the provisional number denoting the eipanjtion is 1>; and for every 
15 parts of inorganic saltSi the provisional number denoting the expansion 

X»et us ilrst attend to the result when the formula is used without change 
on the^e numbers. If 13 parts of each of the three divisions of constituents 
be together dissolved in 975 parts of water, the aggregate of the expansions 
is 25, so that the solution occupies ItlOG water-gruin measurefi. The total 
amount of solid matter is 45i from which the spi^oific gravity may be de- 
duced by subtracthig from it the number denoting tho entire expansion, 
45 — J25 = 20, which is th*! excels of the density above 10tM3, Or the specific 
gravity in this case is dit^covorod by estimating the total weight of the bcIu- 
tion, thus ;-* Water, U7 5; t^olids, 45 — sum of both, 1020, Here the excess 
of the density above 1000 is 20; which number, with the higheet multiplier, 
gives a product somewhat in exoesa of the amount of the solid matter prei* 
ent, tiO X 2-;iy = 45^(i<j, 

If 6 parts of urea and 15 parts of each of the other two divisions be dis- 
solvedv the aggregiite of the expansioust \lz.y 40, 9* and 5, amounts to IB^*S\ 
which number, taken from the entire sum oi the solid matter, namely, 30, 
gives 17-7 for the specific gravity* Here, then, the number 2, as multiplier, 
gives very nearly the actual quantity of solid matter present. Again, if tl4 
parL-^ of inorganic salts, 8 parts of urea, and 4 parts of organic matter other than 
the urea» be dissolved, the total expansion is nearly lt3 (nearly 11, 4*7, and 3), 
which taken from the whole anmuut, 46, leaves 28 for the specific gravity, 
But2dgive«, with the iGn^itaiultiplier, 1 't>5, very nearly the exact amount of 
Dsltds present, vias, ; 4ti*48. If, then, the above diagram of the general con- 
atitutton of the uriue he found to come neat the truth, and if ihe numbers 
adt*[ited be discovered, on further investigation, to express nearly the aver- 
age expanse ion created by the organic matters other than urea and the inor- 
giknic saltsu, thci hig!le^t multiplier, 2*33^ proposed by Dr, Christtson and 
i^xtonded by Dr» Day, is that which decidedly deserves the preference. 

The conclusion to which many wil! be disposed to come, from what has 
been advanced in thit* paper, will probably be, that the settlement of the 
point at issue is not of sufficient utility to deserve so much trouble. It may 
be so ; but the inquiry itself, independently of the result, cannot but lead 
to the aceumuJation of useful dutailjf on a subject of growing importanGO in 
practice* 

For example, I do not find that attention has been anywhere dmwn to the 
remarkable effect of urea in creating expansion of the solvent during its so- 
lution* The sngur of grapes, commonly regarded as identical with the sugar 
of diabetes, has, I find, a aimilur proporty^-the augar of grapest disaahtdU'^ 



130 PBAOnOAL MEDIOINE. 

the extent of 50 g^ins, giyes an expansion equal to 30 water-grain meaaores. 
Cane-sugar has nearly the same effect. 

With regard to the mode of determining the specific gravity, it appears to 
me that an urinometer with a properly constituted scale, the requisite atten- 
tion bein^ given to variations of temperature, is sufiicient for all purposes 
eonnectea with practical medicine. It should be seen to that the scale is 
properly graduated. I observe a very singular reason, given most unac- 
oountebly both by Golding Bird and Thudichum, for the inequality of the 
degrees of the scale, namely, that ** the density of each stratum of fluid in 
which the instrument is immersed, of necessity increases with the depth 
from the surface." The degrees of the scale are necessarily unequal, oe- 
cause each is a sign of a new proportion ; since the volume of the portion of 
the instrument immersed is in.the inverse ratio of the density of the fluid 
into which it has been plunged. If any further reason be required* I should 
venture to say that the hi^er the urmometor stands out of the fluid, the 
greater is the pressure owing to the difference of weight in water and in air, 
with which it resists the buoyancy of the part immersed, so as to render the 
degrees shorter in proportion as these approach the lowest part of the stem. 

I lately extemporised an urinometer, on the plan of which a convenient 
instrument might, I think, be made. I took a small pipette, and, having 
closed the lower aperture by the gas flame, I put a sufficient quantity of 
mercury into the interior to cause the instrument to sink perpendicularly 
below the level of the bulb. The pipette now floated, in pure water, per- 
pendicularly with the water line, nearly midway between the bulb and the 
upper extremity. I then fixed a thin slice of common cork on the upper 
end, so as to form a small teble on which weights might be laid. I also 
passed a wire with a slender point perpendicularly through the cork till it 
touched the surface of the water, to serve for an exact index to the height 
at which the instrument stood in the water. When this rude instrument 
was placed in a fluid denser than water, it rose, of course, throwing even a 
portion of the bulb above water; but, by placing weights on the little cork 
table, it was made to sink to the level at which tne point of the wire grazed 
the surface of the water. Since by this means the same bulk of fluid is 
evidently always displaced, whatever be the density and whatever the tem- 
perature at the time, provided the weights on the little cork teble are ad- 
justed to keeping the point of the perpendicular wire just grazing the sur- 
fftce of the fluid, those weights will exactly indicate the difference between 
a given bulk of distilled water and the same bulk of any denser fluid. 
Whatever be the temperature at the time, the index for distilled water is 
shifted to answer for that temperature. If the bulk of fluid displaced by 
such an apparatus be not known, all that is requisite, for example, in the 
case of the urine, is to immerse the instrument in a fluid known to have a 
density of 1060, and to ascertain how many grains suffice to sink the point 
of the wire to the surface ; and the product of this number divided by 60 
will answer to the weight required for each degree between 1000 and 1060. 
Here there is no inequality of degrees. The sixtieth part of the difference 
between the weight of the volume of distilled water displaced, and the same 
volume of the stendard fluid at 1060 equally displaced, corresponds to a 
degree. I find it convenient to use pieces of thin lead-wire in such experi- 
ments, owing to the facility with which these can be adjusted to any weight. 
Such an instrument, of course, is better suited to the study than to the sick- 
chamber. 

With respect to the determination of the proportion of solid matter in 
the urine by evaporation to dryness, it has long been manifest that the diffi- 
culty of the ordinary methods place them entirely beyond the reach of med- 
ical men for practical use. A mode, however, occurred to me some time 
affo, which I have repeatedly put to trial. This mode is, I think, susceptible 
of very great accuracy, and at very little cost of time. It must be confessed, 
nevertheless, that without due precautions, it may lead into very considera- 
ble errors. It is founded on so simple an observation as that common filter- 
ing paper readily takes up a large proportion of urine, and, under favonap 



PKACTIOAL KEDICTmi, 

We cfrettTnsrtnTieeB, dries in no long time, Tho only considerable source of 
error ia the difficulty of hringiii^ back the p£ij>er to eiactly the same hjrgro- 
mptrie state in which it was at the beginninrj of the eiperiuient. Tlie papftr 
ie to be carefull}* weighed before heiD^ nwlstened^ and weighed ngrtin with 
the same care after it has become dvy — the difference in weight 13 the 
amount of tlie solid matter in the quatitity of urine employed* For 1000 
grains of urine, or mther for 1000 wivter-gram measuroe of urine, I have 
commonly uaed throe *theets of filtering paper, cut each into four pieces* 
The urine is poured into a woil-dned tmsiut ami oncli piece is moi^ttsued in 
ftiiccei^rtion, us far as it will bear wilhont drippiuff ; enough being left un- 
wottod at its upper part to allow of a fold, hj which it niaj be hung on a 
Btriug or wireti> drj* For this effi*ct a few hourtt suffice* If the tempera- 
ture uud hygrouictHc state of the npnrtment can be kept uniform durini^' the 
whole procosH, tlicre is plaiidy no difflcuUy; if ilie drylug be earned too 
fun there m an error of deficiency m the amount of flolids infurred ; if the 
drying be insufficient, or if the apartment baa declined in temperature, oritfl 
hygi'ometric state has become greater, there is an error of eiceea». It should 
be remembered that the paper, thoun^h apparently dry^ readi y absorbs 
moisture, owing not only to its original tendency, but to the deliquescent 
oharaeter of the #olid matters contained in the uriue* — Edinburgh Med^ 
Journalf Aug. lljfiO, jf* 105. 

52.— ON THE FREQrENT OCCUHKKNCE OF PHOBPHATE OF 
LIME, IN THECKVSTALLINE FORM, IN HUMAN UK1NE» AND 
ON ITH PATHULUUICAL IMFOKTAXCE. 

By Br. Aktuoh riiLt Hig^j^tt^ Lgriflon, Rend bLTart" ih« lloyal Buciety (CoiumaQLcatod by 

Dr. Sharpcy, Slvs. U>±) 

In 1854 I submitted to tho Rf^yal Society a paper, * On the Frequent Oo- 
currence of Iudigi> in Hufnim Urine,' The commuuieation, which was pub- 
Muhed in the * Philosophical Trau^uctiona/ attracted considerable attentioa 
Imtb at home and abroad. The singular fact of the frequent presence of in- 
digo in the urine, first announced by me, has since been amply confirmed by 
ft variety of observer*. I have now to place before tho Society some hives- 
ttgationis in relation to the not unoommon occurrence in human urine of 
phosphate of lime^ as a dfpmiU In a welUmarked cryslalline fonn. 

When tho earthy phog[diates aro treated of by writeri*, in crmnexion with 
the urine, they are usually described collectively, and it is seldom that each 
kiud of phosphate in particularizcdi and yet there are scYcral which may 
occur either separately or together. The phosphate of ammonia and mag- 
nesia, or triple jihoaphate, U often specified, but rarely ig phosphate of liiue 
*^i*par«tely mentionedi and phosphate c»f nmgnesita scarcely ever; and yet 
phosphate of lime is very frequently present as a di'pu5*it in urine, mucli 
^ore so, indeed, according to my experience, than the triple phosphate, ex- 
Ksludin^ those cases of the occurrence of that ammoniaeal phosphate ariiing 
Irom the decomposition of the uriue subsequent to its escape from the kid- 
neyi. Even in these few cnses in which phosphate of lime is specially men- 
tioned » it is described u&ualbj as miied up with the other phosphatoH, and 
alwaifM as occurring in the amoqih/ms or gmjiuluTf and nevor in tho oryatal- 
k line state ; further/ no peculiar importance is attached to it, as contracted 
llrhh the magnesiun phosjdiate. 

1 Even one of tlie most recent writers on the urine givoa the following de- 

tBcription of the physical characters of deposits of phospliate of lime in 

iltriuei — '^'Deposits of phonphute of Kme," he states, *'aa usually occurring 

In the urine, and mixed with magnesia» are always white and amorphouj*^ 

Indcr the microscope appearing in granules, sometimes of a greenish tLngCi 

irhich exert a refracting action upon light. Cr^stallhtd dtpo^iU of this sub- 

.tiiuncchave not been observed*'^ 

I now propose to show, first, that there is a crystalUue dopositt the crys- 
tals composing which will be descriW**! hereafter^ which does re ally cc)Tiii\a\ ' 



132 PRAOnOAL MEDICINE. 

of pbosphate of lime ; socond, that it is of frequent occarrence In human 
urine ; and third, that it is of greater pathological importance than the de- 
posits of triple phosphate. 

I would first remark that I have for years been acquainted with the fact of 
the occurrence of crystalline phosphate of lime in the urine, and I have 
referred to it in the Lancet of 1853, and also elsewhere. I should now re- 
mark, however, that the statement made by me as to the composition of the 
crystals, has hitherto been based upon their guulitative analysis only, and 
therefore was not so completely conclusive ana satisfactory as could be de- 
sired. Until recently I had not made any quantitative analyses : these I have 
since been enabled to perform, and I now furnish the results of the chemical 
examination of four samples of the deposit. 

First Sample. — Filtered from the urine of twenty-four hours ; mixed, as 
ascertained in the first instance by means of the microscope, with a very 
minute quantity of triple phosphate, 

Bibasio phosphate of magnesia . • .0*15 

Bibasio phosphate of lime . .1*85 

2*00 

Second Sample. — Filtered from urine after the lapse of a day or two ; 
mixed with a small quantity of triple phosphate. 

Bibasic phosphate of magnesia . . . 0*47 

Bibasic phosphate of lime . . .6*18 

6-65 

Third Sample. — From urine of twenty-four hours after the lapse of sev- 
eral days. Admixed with much triple phosphate, as shown first by the mi- 
croscope, and afterwards by the chemical analysis. 

Bibasic phosphate of magnesia . 
Bibasic phosphate of lime 

9*71 

Fourth Sample. — Separated from, six ounces of fresh urine. Deposit very 
pure. 

Bibasic phosphate of lime . . .1*96 

No phosphate of magnesia. 

Now the admixture of the phosphate of magnesia in the first three sam- 
ples, was due solely to the fact, that the phospnate of lime deposited at first 
in the pure state, was allowed to remain in the urine until decomposition 
had commenced, and the phosphate of magnesia and ammonia had, in con- 
sequence, become formed. Deposits of pbosphate of lime are sometimes 
contaminated from the same cause with carbonate and oxalate of lime. 

These analyses are therefore conclusive as to the composition of this 
earthy phosphate. In order to show that no error has been committed in 
them, I here append the process adopted. That the deposit in question re- 
ally consisted of a phosphate^ was first repeatedly determined by the action 
of a solution of nitrate of silver ; the crystals, when touched with this re- 
agent, assumed a bright golden-yellow colour. After having been sepa- 
rated and washed in distilled water, the phosphate was ignited to free it 
from animal matter, urea, &c., and weighed. It was then dissolved in hy- 
drochloric acid ; ammonia was added until a permanent precipitate fonneci ; 
this was re-dissolved by the addition of acetic acid. First the lime was pre- 
cipitated from the solution by oxalate of ammonia, and afterwards the 
magnesia as follows : — Chloride of ammonium was added, then ammonia In 
slight excess, and lastly, phosphate of soda. The oxalate of lime formed 
was converted into carbonate of lime in the ordinary manner, and the phoa- 
"phate of ammonia and magnesia into the pyro-phosphate of magnesia ; tfiese 



PRACTICAL MEC 

I'wert then weighed separately, and tlio amouats of tlie Ijibasjio pliosphato of , 
» lime were determined hy the usual calculations. Tito rei^ults obtnincd cor* [ 
feBpouded very closely with the origiiml weights of the Ignited phusphatei | 
^ subjected to analysis. The analyse:*, thei-efore» show that the crystallized 
jlh^to of lime Is a tiiba^iiiic pbosphata, containing two atoniji of lim^, 
_ .jil99st probably, one of water* 1 

Mrm 0/ the CrysiaL — The sue, farm, and arrangement of tho crystals o( I 
pbot^phftto of lime, as tbey occur m buttiuu urhie^ vary greallj^ but the po- T 
Giiliantiea arc in alt case^ sufficiently character] fitic to allow of tho readj 1 
identification of this phosphate by means of the microscope. The crystali 
are either single or aggregated, most frequently the lattori forming glom* [ 
eruli, or rosettes* more or less perfect. Sometimes they are small and needle* I 
Hko, and then thcjy frequently form, by their crossing and union at righil 
angles, glomeruli or spherali3H. So me time £3 the crystals ore thin and mit, | 
having oblique or pointed torminutions. Ycty frequently, however, thoy j 
aro thick, nud more or less wedged- Bhapod» and united hy their narrow cj£*| 
t re ml ties so as to form more or less couipUito portions of tt circle ; the fre# f 
larger ends of the crystals are usually somewhat oblique, and tho more per* I 
feet crystals present a sis-sided facette, I iiavo never yet mot with tlies^ j 
crystals having both ends perfect, owing* I beliove^ to the tendency which j 
thoy have to crystal lijso from a centre in rosettes. When these crystals art j 
^t in the dry state for a long time, they not uafreqaeutty break down and I 

able into powder* 
The late Dr. Golding Bird, in bis work on *' Urinary Doposits," ha* given! 
representation of soni€ crystals which ho has denominated *^ penniformn^' 
orihiu^ them as con^istuig of a variety of the magnofiiau phosphate; tho 1 
StaU figured do, however, undoubtedly represent a modib cation of those I 
' pko^phaU qflime. Although I have olsew^here pointed out this error, moat j 
recent writorej on the urine still persist in dejicribing these crystals as 
variety of the phosphate of ammunia and mognesia. 

Oil the frequency of their oecurrence. — I find, as already stated, that pho8-] 
pbate of lime, in tiie fonn of crystals, is of much more frequent occurrenoi I 
in human urine than the triple phosphate, excluding those cases of iho pre- [ 
ftence of the latter phosphate which are due to tlia, decomposition of the ureft 
of tho urine subsequent to itjs emission. I have met with deposits of cryn* 
tallized phosphate of lime m some hundreds of unnos, and in many diftbretit 
ca«es; It is therefore not a little remarkable, from the frequency of its 
occurrence, and the peculiarities presented by the crystals, that it ahoulil 
have been so long ovt^rhiokod. The microscope, therefore, furnishes uj«, im 
most eases, with the ready means of detecting the presence of deposiU of 
I phdsphAte of lime, as of fto many other urinary deposits. 

€naTa£tt€T$ of Urine depofiting CrysiaUUrd Pfiosphute of Lm€, — Tho urino 
from which phosphate of lime is deposited in usuuUy pale, hut occasionally 



it is high*coIoured ; the quantity passed is largo, and the oalls to void it fre- 
quent* more or less uneasiness and smarting biding occasioned by its passaj^e, 
al the neok of the bladder and along the course tif the urethra ; its speOLfic 
gravit}? varies greatly. Taking tho whole quuntily passed in twenty-four 
hours, it is usually below the average, nevertheless the animal matter and 
nrea are absolutely in excess* It is generally feebly ucid, oftttn decidedly so 
when first voided, tho greater part of the phoiphate of lime becoming de* 
posited while the urine still retains some degree of acidity; it, however* 
epeedlly becomes alkaline, owing probably to the e^tcess of mucus containtjd 
in it* Sometimes the crystals ot phosphate of lime are thrown doivu frt*m 
tho urine before its escape from the bladder ; ordinarily, however, tho urino 
is bright and clear when passed, and the crystals are not formed until soma 
time after it ha« heen voided. In collecting this phosphate for analysis, th© 
object being to procure it in a^ pure a state a^^ possible, and a* free from 
iDhospfaate of ammonia and magnesia, oxalate and carbonate of lim«, it wbould 
00 separated from die urine very soon after it has become deposited, and b(?- 
jfore deeomposition has had time to set in, 

Qj* i/« Fathological Importance 1^ I}tpQiiU of Pko^haUGf Limtxx^ Hu.iaxLiv 



^ 



1S4 PRAOnOAL ICEDIOINK 

Urine, — Of the patholo^oal importance of excess of phosphate of lime in the 
urine not a doubt can ne entertained, but certain reasons and facts maj bo 
advanced to show that deposits of that phosphate have a deeper pathological 
■ignifioance than those of the phosphate or ammonia and magnesia. The 

Sroof of this is the more necessary, since writers on the nrine are in tiie 
abit of describing, as well as of treating, deposits of the earthy phosphates 
collectively, and without distinguishing between them: this course was na- 
tural enough so long as they were unacquainted with the fact that deposits 
of phosphate of lime, in the state of crystals, are of frequent occurrence, or 
so long as they mistook them for a variety of the ammonio-magnesian phos- 
phate. One reason why we should be disposed to attach greater importance 
to the excess of the calcareous than the magnesian phosphate, is that most 
of the phosphoric acid of this last phosphate, and all the magnesia, are de- 
rived from without, being contained in the various articles consumed as food ; 
while for the phosphate of lime, we have in the system — ^in the teeth and 
bones, and al80 in the nitrogenous tissues — sources containing some pounds 
weight of this phosphate. 

That the osseous system is subject to disintegration is certain, and that 
the extent and rapidity of this differ remarkably in different cases is equally 
so. This is shown by the simple fact alone, of the early and rapid decay of 
the teeth in many persons. For this general reason therefore only, we 
should, d priori, be disposed to attach greater importance to the occurrence 
of deposits of phosphate of lime than those of phosphate of magnesia. 

Other facts tending to confirm this view are, — first, that while deposits of 
phosphate of lime are frequently met with, those of phosphate of magnesia 
(not the ammonio-magnesian phosphate) are exceedingly rare ; and seemed, 
that the calcareous is of more difficult solubility than the magnesian phos- 
phate. This last circumstance explains probably why phosphate of lime 
falls as a deposit from acid urine, while phosphate of magnesia remains in 
solution. 

The particular or special reasons for regarding deposits of phosphate of 
lime as of more moment than those of the triple phosphate, are derived from 
direct pathological observation. I have observed that when this deposit 
occurs, it is very apt to be persistent ; and when it has disappeared, to re- 
turn whenever the health is reduced from any cause. I have also noticed, 
that when it is persistent, it is usually associated with marked impairment of 
the health, and this often where organic disease does not exist. The promi- 
nent symptoms in one case of calcareous phosphatic deposit which I have 
,had under observation for some years, were, — great disorder of the digestive 
organs, fretjuent and distressinj? headaches, occasional vomiting, debility, 
emaciation, great irritability of the nervous system, sexual powers weak, 
pulse slow and feeble, skin cold, urine in excess, of rather low specific grav- 
ity, acid when passed, but soon becoming alkaline, micturition frequent, 
with irritation at neck of bladder and in the course of the urethra ; teeth 
much decayed. It should be stated that there is in this case a very slight 
tendency to paralysis of the right leg, as shown by an occasional sensa- 
tion of coldness in the limb, and slight deficiency of power in it at times 
only. This symptom is, however, by no means a constant or necessary one 
in such cases. 

If these views of the pathology of phosphate of lime be correct, we should 
expect to find an excess of that phosphate in the urine in great and rapid 
waste of tissue, during the rapid decay of the teeth, and in cases of mollities 
ossium. That there is an excess of the calcareous phosphate in the urine in 
these cases, is shown alike by observation and analysis. 

It is obvious from this imperfect sketch, that much remains to be effected 
in regard to the pathology of phosphate of lime ; but now that the frequency 
of its occurrence in human urine as a crystallized deposit is made known, its 
pathology, apart from that of the triple phosphate, will no doubt be specially 
considered. 

It will be apparent from the following quotation, that the late Dr. Golding^ 
"Bird regarded deposits of phosphate of lime of more consequence than those 



PRAOTIOAL MEDICINE. 135 

of the triple phosphate : — *' The pathological state of the system accom- 
panying the appearance of deposits of phosphate of lime is analogous to 
that occurring with the triple phosphate ; indeed, as has been already oh* 
senred, they often, and in alkaline urine always, occur simultaneously. So 
far as my own experience has extended, when the deposit has consisted 
chiefly of the calcareous salt, the patients have appeared to present more 
marked evidence of exhaustion, and of the previous existence of some drain 
on the nervous system, than when the triple salt alone existed, unless its 
source is strictly local. 

It should be remembered that these remarks of Dr. Bird refer to deposits 
of phosphate of lime in the granular slate, and not to the crystalline depo- 
sits, with the occurrence of which he was unacquainted. I have alrea«ly 
stated that, according to my experience, the granular calcareous phosphatio 
deposits are much more rare than the crystalline. 

It follows from these observations and investigations : — 

Ist. That deposits of crystallized phosphate of lime are of frequent oocnr* 
renoe in human urine, much more so, indeed, than those of the amorphous 
or granular form of that phosphate. 

£id. That the crystals present well-marked and highly characteristic forms 
whereby the identification of this phosphate, by means of the microscope, is 
rendered easy an4 certain. 

3rd, That there is good reason to believe that deposits of phosphate of 
lime are of mater pathological importance than those of the phosphate of 
ammonia and magnesia. — Lancet^ Aug, 4, 1860, p. 111. 



SURGERY. 



AFFECTIONS OF THE BONES AND JOINTS, ETC. 
53.— CASES OF EXCISION OF THE KNEE-JOINT. 

I The following nine cases appear in the * Lancet,* in its *' Mirror of the 
Practice of Medicine and Surgery in the Hospitals of London." Probably 
statistics would now show a very fair amount of success in cases of excision 
of the knee-joint. The operation is undertaken with more confidence than 
formerly, and, in suitable cases, is gradually superseding amputation. The 
editor observes :] 

To speak of pai*tioular points in connexion with excision of the knee, it 
seems to be questionable whether the operation should be resorted to in the 
young, because the affected limb, after the loss of its main joint, does not 
ffrow proportionately with other parts of the body. This has been found to 
be true in some cases ; nevertheless, the shortened limb with a high-heeled 
shoe is preferred by the patients themselves to going about with a single leg. 
It would appear that there is scarcely a disease of the articulation, excluding 
of course anything in the shape of malignancy, for which excision may not 
be practised. It may be done for even extensive necrosis ; indeed, we can 
call to mind other instances besides the subjoined wherein Mr. Fergusson 
adopted this mode of treatment with decided advantage ; and we have the 
recent experiments of M. Oilier, of Lyons, to prove that if the periosteum be 
left entire in the vicinity of joints, it will reproduce bone. 

At one time the patella was allowed to remain, because it added support 
and strengh to the knee ; but subsequent experience has tended to show 
the advantage of its removal. Its retention is still a subject for considera- 
tion. 

The great inducement to perform excision of the knee-joint at the present 
day is me fact that the per-centage of deaths consequent on this operation 
is much less than that attending amputation ; a reference to the memoir of 
Mr. Butcher and Mr. Price will satisfactorily prove the truth of this. At 
Guy's Hospital, Mr. Bryant has shown, the per-centage of deaths in patho' 
logical amputation is 1 in 5 '5, the same as in excision of the knee ; whilst 
that in chronic disease is 1 in 7, being somewhat more favourable. The sta- 
tistics of amputations elsewhere, taken generally, will not give such favoura- 
ble results as these. 

Removal of Necrosed Bone, with subsequent Excision of the Knee- Joint in a 
lad aged 14 ; Recovery. Under the care of Prof. Fergusson, at King's 
CoUge Hospital. 

£. H., aged fourteen, was admitted Dec. 27th, 1859. He stated that in 
May, 1858, he was bein^ carried down some steps, when his knee came in 
contact with the iron railing ; the joint was slightly painful at the time, but 
he thought little of it, and it improved by fomentations and rest. About six 
weeks after the accident, however, he experienced a good deal of sharp, 
shooting pain in the joint, with considerable swelling. He sought mediimi 
advice, but no remedies appeared to have a beneficial effect upon it. This 
state of things continued three months, when an abscess was discovered to 
exist in the joint, which was opened, and an immense quantity of matter 
evacuated. This gave him some temporary relief, but the knee had now 
become considerably flexed, obliging him to adopt crutches to enable him 




k 



to giet about. He continued much in tlib state up to the time of ad~ 
mlgBiou. 

The patiQut h a pal^, delicate, Htrumous-lookiug' boy* He lies ou his lefit 
side : tup thigli being flexed on tlte truukt the leg on the thigh i There are 
fteveral sin uses in the region of the joint leading to bone; one, on the inner 
and lower part of the thigh leads to an extensive bare surface of tbe femur- 
The patient has no brotbera or sisters ; father and mother healthy* No luug 
affection ; other functions of the bodj natural. 

Jan* 7, The patient having been narcotized, Mr. Fergus son proceeded to 
remove a piece of the shaft of the femur about six Inches in length, by an 
incision of two inches, made at the lower end of the thigh. The removed 
portion was easily detached, and found to be necrosed. 

6ttu Has had a good nrght ; oom plains of slight thirst. Limb rather un^ 
comfortable ; pulse 1(X?* 

10th. Wound suppurating healthily ; the patient says the limb is not bo 
painfal a3 before the openitiou; appetite good. 

Feb. 2nd. Has gone on well since last report ; eatsi drinks^ and sleeps 
well ; is uniious to have his leg put straight* 

March* 3rdp To dny the operation of excision of the knee-joint was per- 
formed by Mr- Fergus sou, the patient being under the influence of chloro- 
form. The H inci^Jfn having been made in the integuments, sufficient of the 
onda of the femur and tibia was cut off to briug the limb in the straight po- 
sition. Tlie patella wa^ removed. There wi^s very little hemitrrhiige during 
the operation, no vessel requiriug a ligature. A splint having been ap- 
plied, the patient was sent to hod. 

4th. Has had a restlo^it night» the limb liaving been very painful; but the 
pain has been much mitigated by an opiatu draught; pulse V20, 

5th* Is much better to-day iu health* but the leg continues to give great 
pain at intervals. To have three grains of se^qui carbonate of ammonia iu 
an ounce of decoction of oiuchonu every four hours. 

10th. Wound dischargi ng healthy ; no bad symptom; appetite good ; bowels 
reguliir; all pain has disappeared, 

20th, Is still g*>inj5 oij well, the wound di&^chrtrging a thin, serous fluid* 
mixed with pua ; splint removed; the joint seems firm i eplint reapplied. 

May l^t. Gutta-percha spBrtt applied to the back of the leg. 

Utb, Discharged to go hi to the country* 

Sir Cases of Ertmofi of the Knee-Joint performed at St. Thomas -s Hos- 
pilal during 1859** Eeeovery in Fii^e. Under the care of Mr. South, Mr, 
Solly, Mrl^LE Gros Clark, and Mr. Simon. 

The operation in the following cases was performed much in the same 
manner. Chloroform was given, and the joint was opened by an elliptical 
incision, which included the patella in the flap* The end^ of the bones and 
the joint surface of the patella wore removed by Butcher's saw, and the 
limb was put up in a slightly -bout iron back splint. Liberal diet aud 
stimulants were given, and all the patients had cod-Hver oil and Bome pra- 
paralion of iron, 

Cetse L— A strumous, delicate man, aged thirty-seven ; had disease of the 
steniuoj and uloeration of the cartilages of the left knee-joint. He suffered 
much pain, hia rest waa disturbed, appetite bad, and his health generally 
broken. Two sinuses, connected wttb the joint, discharged a watery pus. 
Excision was performed by Mr. South, Nov. 5th, 1859. The cartilages were 
found extensively eroded, and the head of the tibia secondarily affected to a 
f«light extent. At first, after the operation, his health improved ; the wound 
united in part, and healthy suppuration was e^tablii^hed r but towards the 
end of February diarrhma of a very obstinate character set in, with night* 
sweats. By the end of March his conditioii was by no means stttlFifaetory ; 
there Wrts no apparent union of the bones, his diarrhoia continued despite the 
a*e of VRrioUH astringents, he was sick at times, and his appetite was capri- 
cious. The wound did not discharge excessively, and it looked hmltby. 
From this time there was but little alteration in his condition, and certuAtd^' 
none for the better, and be wont out, at hia own panle\i\tit tet\u<i^\^ oix ^t 



138 8UBGEBY. 

2nd of June. There was then no amount of bony union, the wound was 
discharging a tolerably healthy pus, and he did not suffer pain. He died a 
short time after leaving the hospital. 

Case 2. — A Tery strumous-looking boy, aged six, with chronic ulceration 
of the cartilages of the right knee-joint, the tibia being dislocated back- 
wards. He was hectic ; suffered much pain ; and there was a discharging 
sinus connected with the joint. Excision was performed by Mr. Solly on 
the 9th of November, 1859. iThe cartilages were extensively eroded and 
the ligaments destroyed. After the operation he improved at once, never 
having a bad symptom. The wonnd healed ; he gained health and strengtli, 
and left the hospital with scarcely any perceptible shortening of the Umb, 
being able to walk with ease and comfort. 

Case 3. — A delicate, scrofulous boy, aeed eight, with chronic ulceration of 
the cartilages of the knee-joint; free discharge from three sinuses. He 
was hectic, and suffered much pain. Excision was performed on the 5th 
of March, 1859, by Mr. Solly. There was a considerable erosion of the 
oartilagos, and false membrane in large quantities ; but no disease of 
bone. The wound united in great part by first intention ; his health im* 
proved; he slept well; and his appetite was excellent. He left the hospital 
quite stout and well ; the limb was only half an inch shorter than its fellow, 
and he could walk with ease and rapidity. 

Ceue 4. — A strumous boy, aged twelve, with long-standing suppuration in 
the knee-joint and several discharging sinuses. He was much out of health, 
and suffered ereatly. Excision was performed by Mr. Le Gros Clark on the 
12th of Marcn, 18^. The cartilages were found to be in great part re- 
moved, and there was some secondary disease of the head of the tioia. A 
considerable portion of the wound united by primary intention. He slept 
well, and took his food with relish. During the progress of the case he had 
a slight attack of erysipelas, and an abscess formed over the ankle. Despite 
these drawbacks, the result of the case was favorable ; and when he left 
the hospital there was firm bony union, and only a small portion of the 
wound uncicatrized. The limb was but slightly shortened. 

Case 5. — An emaciated, sickly cirl, aged six, with scrofulous disease of 
the knee-joint. She had suffered much ; slept badly ; and had but little 
appetite. Excision performed Nov. 12di, 1859, by Mr. Simon. The cartil- 
ages were eroded, and there was softening of the end of the femur. For a 
few days after the operation her condition was very critical, but when sup- 
puration was established she improved, slept better, and was more cheerfoL 
She was sent from the hospital to the Margate Infirmary. There was firm 
bony union, and only a slight amount of ulceration in the line of the incision 
when she left St. Thomas's. 

Case 6. — An unhealthy, pasty-looking man, aged twenty-three, with long- 
standing disease of the knee-joint. After his admission two incisions were 
made, and considerable quantities of pus escaped. He did not improve 
much, and excision was performed Nov. 19th, 1859, by Mr. Simon. There 
was extensive ulceration of the cartilages, and superficial caries, dependent 
upon a small sequestrum in the head of the tibia. He improved in health 
after the operation, and a good deal of the wound united by first intention. 
A counter opening was required, when suppuration occurred, to grive exit to 
some retained pus. When he left the hospital there was firm union of the 
bones, he was able to get about, and was in very fair health. 

Two Cases of Excision of the Knee-joint performed at the Royal Free Hotpi- 
ttd ; Recovery > Under the care of Mr. Gant. 

Case 1.— John P., aged eighteen, was admitted on Oct. 19th, 1859. The 
patient is a strumous, unhealthy looking subject ; a coal-porter. While fol- 
lowing his occupation about four years and a half ago, a large piece of coal 
fell on his right knee, and occasioned pain for some days, after which he re- 
sumed his work, although the joint was much swollen, and still painful. He 
continued to work durmg the ensuing three months, the joint remaining 
swollen, and latterly the hamstring muscles contracted so as to draw the 
limb backwards to nearly a right angle with the femur. He then went under 



sTTSGiaBrf^ 



139 



^ 
P 



treatment ftt t!ie Westminster Dlsponsniyfor four montlis, dtirlug whioh pe- 
riod th<? mnsGles gradually drew the liefll tip to the butt4>ok. He ultonraT^ 
resorted to St. George's Hospitfl,l, whi^ro he eiperieticefl ^oDie relief, under 
the care of Mr. Hawkin,s and wa« discharged at the end of throe months. 
Thonco he went to 8t- Mary*?? Hospital, nnd was a patient for more than 
eight wpeks, uiidflr the care of Mr* Lane. Suhsequently, at the Westminster 
Hospital, ho remained for ton nionths, under the earo of Mr. Guthrie* when 
he was discharged. After six months' sufferhig, he w«s again admit fod into 
the same hospital » and Cimtinued under treatment for tvro montha more. 
At length ho sought relU+f at the Middlesex Hospital ; hut having* remained 
for three raon thsu, without any improrement, he left the ho&pital, EFontually 
he came to the Royal Fr^e Hospital, and wa» placed under the caro of Mr* 
Gont on the I9tb oY October lanU 

The joint was found to be uniformly flwollen, but not so much as to ob- 
scure Hs outline, A thin unhealthy diaDharge issued from two or three 
sinuses which led into the joint, and the patient was much emaciated* His 
general heiUth having been renovated so JFar as the loonl disease and length- 
ened illness allowtnh Mr. Gant excised the joint under chloroform on October 
3 J St. By a transverse and slightly curved incision below the patella^ and 
extending from one condyle of tlio femur to the othcft the joint was fairly 
laid ope a. The patc41a was thL*n removed, althouch In a sound condition, 
and a slice of the femur and tibia, both of whicTi were partially bare of 
cartilage, were sawn ofl:\ The femur was moat diseasedt and a sectmd slice 
was taken from it, until the rose-coloured bleeding bone waa reached, AH 
the diseased bone having been thus got rid of* the surface of the femur and 
tibia were seen to be well adjusted to each other, and the edges of the inoi- 
fion brought together with sutures of fine silver wire. No vessel required 
ligature. The limb wag at once placed upon an extended Maclntyre splinti 
of such a length as to allow of the femur and tibia to bo in easy apposition 
without being much pressed together by the foot-board. Broad slipa of ad* 
be^i\*e plaster were then drawn around the limb, a splint applied above and 
below the knee, and a bandage from the foot upwards, and from the thigh 
downwards, leaving the knee uncovered, around which were placed strips of 
wot lint* No side splint was used. 

No unfrivourable or unusual symptom followed the operation. On the 
eighth day some hemorrhage occurred, which was arrested by the application 
of iee. 

Dec. 1 7th- The splint was removed, and union found to have taken place ; 
the limb was replaced; general health much improved* 

Jan. 2nd. Union was more firm ; health continues to improve ; and his 
trembling agitation has subsided. 

27tb. tlnion more firm ; limb replaced ou a short posterior splint. 

From this time the patient sat up in bed daily, but it was deemed ad vis* 
able not to allow him to try the log much* When the weather became 
warmer, he took gentle exercise, with" his leg saspended in a sling* He left 
the hospital with a sound and useful limb, having been alli>wed to remain an 
in-patieut until he CfHiId bo admitted into the Margate Infirmary to thoroughly 
fe-establish hii health. 

Case 2.— Elizabeth D*, aged thirty-three, married, on September 29th* 
185:J, while walking down a gentle pescentt slipped over some rotten pears, 
and caught the heel of her boot in a grating, whereby the knee was wrenched 
Inwards, causing aevf»rc pain. Considerable swelling ensued, which never 
aitbsided; but the articulation continued movable for three months, at which 
titiie, the patient having scrubbed two or three roorn^, more Intense pain at- 
tacked the joint which soon became fixed. This crippled rtate continued 
without any improvement, although leeches and blisters were used frnrn time 
to time after the injury. The general health remained unimpaired up to 
October, 1858, when she experienced severe pain, apparently rheumatic, ex- 
tending throughout the whole limb. This subsided under treatment, but 
the practitioner to whom she had last applied candidly told her that th^ 



140 SURGERY. 

case was incurable otherwise than by ampaation ; and by bis recommendar 
tion she came to the Royal Free Hospital on September ]2th, 1859. 

The joint was considerably and uniformly swollen. Three sinuses, one 
in the popliteal space, discharged a thin ichorous matter, and the limb was 
bent towards the buttock, but was movable with a grating noise, such as 
plainly bespoke destruction of the articular surfaces. The constitutional 
urritation was proportionate to the six years' suffering the patient had en- 
dured. She was not so much emaciated, bul passed sleepless nights, trembled, 
and was always in tears. 

On October 19th, chloroform having been administered, Mr. Gant excised 
the joint by making the same incision as in the preceding case. The head 
of tne;tibia was sawn off to the depth of half an inch ; a thicker portion of 
the femur was taken away, and the cancellated structure scooped out for 
more than an inch, so as entirely to remove all diseased bone. The patella 
was also removed. The subsequent steps of the operation and adjustment 
of the splint were precisely similar to those iidopted in the other case. 

The general health improved rapidly after this operation. The patient 
gained nesh and spirits, and progressed without a single unfavorable symp- 
tom. At the end of eight weeks the splint was finally removed, and so firm 
was the anchylosis that no other was applied, the limb being merely band- 
aged from the toes upward to prevent any tendency to swelling on first 
moving about. 

The patient could rest her whole weight on the operated limb, and she left 
the hospital in time to eat her Christmas dinner at home. — Lancet^ '^^g* 4, 
1860,1?. 107. 



54.— ON EXCISION OP THE IIIP JOINT. 

By JoBK EmOBBBy, Esq., Professor of Sargery and of Clinical Bargery in University College. 

Under the term **coxalgia*' a great variety of diseases of the bones in the 
vicinity of the hip -joint are included. And perhaps the advance of conserv- 
ative surgery has produced no greater improvement in the treatment of dis- 
ease than by inducing surgeons to make a more careful and exact diagnosis 
in cases of hip-joint disease than was formerly the case, when no distinc- 
tion was drawn between the varieties depending upon the tissues affected. 
Now surgeons are, for the purposes of operation, in the habit of diagnosing 
between cases of disease affecting the soft parts only or the bones only; 
and further, of distinguishing which bone is primarily or principally at- 
tacked. 

Under the one term ** hip-joint disease" are included several forms, com- 
mencing in one or other of three primary pathological conditions. 

First, in the arthritic form, the soft structures — viz., the ligaments, the 
synovial membranes, cartilages, &c., — are alone primarily affected, usually 
with acute infiammation, presenting the symptoms of arthritis elsewhere, the 
disease usually continuing limited to these structures throughout. Its course 
frequently tends to abscess. Sometimes, however, the joint recovers with- 
out suppuration, but with more or less stiffness, or even complete anchylosis 
by fibrous adhesions of the opposing surfaces. 

The second form — the femoral — ^is that in which the morbid action com- 
mences in the upper epiphysis of the femur. The progress of this variety of 
coxalgia is very insidious ; its symptoms are by no means prominent ; it gen- 
erally occurs in young children, and is usually, I believe, of tubercular orig- 
in. In it you find the yellow, somewhat soft, friable matter filling up the 
cancelli of the head and neck of the femur, resembling, and indeed being 
identical with, tubercular deposit in other organs. This form of coxalgia is 
accompanied inevitably by the formation of abscess in the soft parts around 
the joint, commonly on the outside of the thigh, and in the gluteal region ; 
and destruction eventually of the articular surfaces, with caries of the head 
of the bone, followed by its displacement, and leading to shortening and dis- 



SUBGERT* 



141 



tmiton of the limb, torratnating very gcnernHj in tliQ death of the patient 

from exhaustlrm Riid hectic. 

The third form \s the atclabulur. Here the disc^ase originates in the pel- 
vic Imnes, When this* the pelvic aspect of the joint, i& the part first affect- 
ei], abscess iQ^nriably formsi sametime^ inside the hone» in the pelvic cav- 
itj, but occfi^ii>iiallj presents ezternallj among the muscles, and points 
most commonly near the pubes al>ove Po a part's ligament. In these 
cases, difilocaticm, though it is met with now and then, rarely takefl place. 
Sometime?, however, the destruction nf the acetahulnm is lo extensive that 
the hend of the femur penetrates it, and passes into the pelvic cavity. Dislo- 
cation is most frequent when the disease has arisen in and has destroyed the 
hpad nf the femur ; so that the head being no longer present, no impediment 
is offered tcj the action of the mui^clee around the joint, and the bone at length 
slips from its position in the cavity of the acetabulum* 

It is on that fortn of di.^ea^e of the hip-joint which originates ini and 
is chiefly confined to, the bead and neck of the fenmrt ana to the root of 
the great trochanter, the conservative surgery has most influence. It is* 
therefore, of great importance to he able to diagnose this form from the 
other two. 

Distinctive CharacierE of the Three F&rms of Hip-Uisease. — Now, before 
any question of operating can be entertained, and in onJy the worst forms 
and most advanced cases of hip-joint disease can such question be discussedt 
It is necessary to ascertain to which of the three forms of disi?ase doe* the 
case under consideration belong — whether, in other words, it be acelahulatt 
and, if so, wlmt is the eiact state of the pelvic bones, ajid which are affected ; 
nrjemorai. and how far the destruction of the head and neck of the femur 
has proceeded ; or whether it be arthritic, when operation is seldom allowable* 
►The determination of this question, which is by no means alw^iya easy or 
pen possible, is often much facilitated when we are enabled to watch the 

sp, or have a clear history of its progress previous to any examination. 
But when we have to ilt-al with an advanced case, of which the account is 
not clear, and the patient, especially if he be a child, possibly unable to 
gire a succinct history, we niay geneniUy, by attention to the following 
points, arrive at a pretty aceurato opinitm of the precise extent and scat of 
the osseous disease. In doing thi^, the points to be iittejidcd to nta three in 
number t 1. The absence or presence of didorathn ; 2. The existence, posi- 
tion^ and extent of sinuses ; *1, The cnndition of the exposed hone at the bot- 
tom of sinuses, as the pelvic bones usually undergo necrosis, not caries; 
the contrary being the ca?e with the femur. It is by attention to those points! 
that we may generally arrive at a pretty accurate diaguosis as to the precise 
state of the hip. 

L Dislocatmn.—l\i the arthritic form, this rarely ocoura. Anchylosis, 
fibre us generally, mm and then u>«!i;eous, is the u^ual termination. 

In the acetabular form^ al^o, it is an nufrequent result, the head of the fe- 
mur usually remaiuing ini absorbed ; and, thuugh the cartilaginous surfaces 
disappear, the bono remains in its cavity. 

But in the ft moral variety dislocation is common, the head of the femur 
being getir mlly disintegrated ; that is, the cancellous structure becomes soft, 
cariousi and breaks up into small frngnientjri, whieh gradually come away in 
the discharge ; and tlie ligaments being at the same time destroyed, the re- 
mainder of the upper end <^f tJie bone slips oat of the socket, and lies on the 
dorsum of the iliam, being dit^located backwards and upwards. The limb is 
thus shortened to the eilcnt of two or three inches* adducted, and crossed in 
front of the other, its abduction being impossible. This is the usual course 
in the femoral variety of hip-joint diseases, 

t2. Sinuses. — An attentive examination of tho position and direction of 
these is of great importance in forming an opinion as to the seat of the os- 
teons disease. Hy passing down them a long probe, we may often ascertain 
the nature and position of the osseous mrsehlef; but still tho amount may be 
concealed by tho fact that sound hone may intervene between tho surface 
and the diseased bone, as whon the inner aspect of the great tttjcWxAet \ft 



142 SURGEBT. 

affected, or sometimes the diseased or dead bone is covered in bj a thick de* 
posit of dense plastic matter ; and so the real extent of tlie mischief in the 
bone remains obscure. 

Situation of Sinuses, — There are three situations in which sinoses are met 
with, which vary according to their point of origin from the abscess, and 
the position of the diseased bone ; hence it is of importance to note their 
nite and direction. I. When the sinus opens two or three inches below and 
a little in front of the great trochanter, about the insertion of the tensor 
va^inaB femoris muscle, the disease is almost invariably /«moraZ in its origin. 
2. Wlien in the gluteal region, the sinus may indicate /amoral, but not un- 
frequently is dependent on pelvic disease ; tiie acetabulum, or a portion of 
the dorsum ilii, being the part involved. 3. The sinus may open in the pu- 
bic region, either above or below Poupart's ligament. A sinus in this situ- 
ation is almost certainly diagnostic of disease of the pelvic bones, especially 
the pubic aspect of the acetabulum. When it appears above the ligament, 
it probably leads to intrapelvic abscess. On the other hand, when the ab- 
scess opens below Poui)art*s ligament, there is generally disease of the rami 
of the pubes or ischium. 

The situation of the sinuses, as well as their direction, will thus be found 
to lead the surgeon to a more accurate diagnosis of the seat and extent of 
the osseous disase than he could otherwise form. And, indeed, it is only by 
attention to these circumstances that he is enabled in many cases to form 
an approximative opinion on those points ; for the diseased bone is often so 
covered in by healthy osseous structure, and by plastic matter, that the probe 
cannot touch it ; or the sinus may bo so tortuous that a straight probe can- 
not follow its sinuosities. 

3. But there is other important information obtainable from an attentive 
consideration of the situation of the sinuses. It is with reference to the 
probable nature of the osseous disease. In femoral ooxalgia, this is almost 
invariably caries : hence those sinuses that indicate the existence of primary 
disease of the upper epiphysis of the femur proves this to be of a carious 
nature ; whilst, on the other hand, sinuses occurring in the pubic region and 
by Pou part's ligament are almost invariably dependent on the presence of 
necrosed bone ; necrosis being the form of disease that affects the acetabu- 
lum and pelvic bones. 

Cases requiring Operation, — Diseases of the hip-joint may, so far as the 
question of operation is concerned, be divided into two great classes — those 
in which no suppuration takes place, however acute the inflammation may 
have been ; and those in which abscess forms. 

To the first class belongs the arthritic variety of the disease. In this form 
of coxalgia, the patient commonly recovers with a stiffened or oven com- 
pletely anchylosed, though useful and straight limb. In such ca^es, I be- 
lieve that excision is never needed ; at least, 1 have never had occasion to do 
it, nor have I ever seen a case that seemed to me to justify such a pro- 
cedure. 

The second class of cases — those in which abscess forms — are by far the 
most numerous. In the great majority of these, however, recovery will take 
place eventually, under properly conducted medico-surgical treatment. 
But the recovery in such cases is always so far incomplete that the limb is 
left much crippled, and often of but little utility. In such cases as these, 
after years of suffering and of confiucment to bed, and after a hard struggle 
for existence, we find the unfortunate patient left eventually with a limb 
that is shortened to the extent of fn)m two to four inches, wasted and ad- 
ducted, with a projecting deformed hip seamed with cicatrices ; the remains 
of the upper epiphysis of the femur being dislocated from the acetabulum, 
and adherent to the dorsum ilii by firm anchylosis. The limb is unable to 
support the body, and cannot be extended or the sole of the foot firmly 
planted on the ground ; but it is to a certain extent useful in progression, 
the patient using it as a kind of paddle to push himself on with, as he limps 
on the point of the toes. In these cases, it is interesting to observe how 
Nature compensates for the loss of all abduction and rotary power in the hip 



SURGERi, 

hj gi^iTig «o titremety increased degree of mobility t o th e la mbar rertebraei 
so that the pfttjeot, in walking, swings the pelvic* from tlics*^, and thna in a 
great degree makes up for the loea of the natural move meats m tlie go.£0- 
femoral articuhilloEi. 

But, though recovery taltos place eventually in the great majority of eases 
of coxiilgia that have advanced to auppuratlou, yet m some, and uot a few 
inataticei*, the patitnt^s constitution tiecomeB unequal to the drain imposed 
upon it, and falul hectic will eventually supervene* This fatal result is the 
direct consequouce uf i\w waiting and exhausting influence of llie long con- 
tmued discharge of pas? from masses of C4triaua or necrosed Iwne too oxten- 
sivo or too deeply aeated to be elinunated hy the natural actions of the part. 
It is in Hucii cases as these that conservative surgery steps in^ and endeavours 
to ^ave the patient^s life by the removal of tho morbid causo that keeps up 
the discharge which is wasting it awnj, Tho object here is simply to save 
life hy the removal of diseased bone. For tho same reason — the preserva- 
tion of life from hectic— that the surgeon amputates in an eitreme case of 
suppurating disorganisation of the kneegoint, be excises in an eitretno ease 
of disorgaiiisntton of tlitj osseous structures that enter into the forinntion of 
the hip joint, amp a tat ion he tag here too formidable a proceeding to he nn* 
dortaken ; and yet the removal of the diseased bone, the irritation and sup- 
puration from which is rapidly destroying the patient, being an Imperative 
necessity* 

TUi^ femoral coxalgia i» that form of the disease that is most amenable to 
operation* In severe and oxtretae oases of this variety of hip-joint disease, 
the upper epiphysis of the fenmr will bo fouml lying in a state of caries on 
the dorsum ilji, in a suppurating cavity ^ with sinui?es leading d*"wn to it. 
The pelvic bones are sound; the acetabulum tilled by fibroplnRtie mat tor of 
a reparative character, though possibly slightly roughened and necrosed at 
one lip. The soft structures in the gluteal region are thinned and wutstod, 
the limb inevitably shortened and adducted. In such cases as these, tho pa- 
tient will probably pt^rish, if left to the unauli.jd efforts of nutur*^ ; Of if ho 
recover^ after years of sufferiug, it will bo with a limb shortened, deformed, 
and but littlo uaefnl. Whilst resection, being limited to the upper end of 
the femur, or at moat to the roughened lip of the acetabulum, as well, is an 
easy oporationi removt*s the cause of the wasting discbarges and bectic^ and 
in no way increasea the already existing shortening, as it is limited to thai 
portion of diseased bone which is already lying above and behind the aeeta- 
bulum, and which, being earioas*, must disintegrate and crumble away in the 
discharges before a natural cure without operation could take place. 

In the acetahuiur form of coialgia, the ultimate result i.s, I belie\'e, liievi- 
tably fatal, if tiie disease is allowed to run its own course unchecked hy 
operation* Large portions of the pelvic bonea in and around the neetabulum 
fall into a state of necrosis; that cavity becomes oerforated; and the bead 
of the femur, still lying in it, becomes denuded or ils cartihiginons invest- 
ment, rough etied, and carious. Large abscesses, intra^ as well as extra- 
pelvie, form, and the patient dies worn out by hectic, tho natural ctforts of 
the part being entirely unavailing to separate and to eliminate such large 
masses of necrosed bone* deeply lying and covered in as they are by the up- 
per end of the femur. 

Until a very recent period, surgeons feared to undertake the removal of 
targe necrosed portions of the pelvic bones, and acetabular disease of the 
hip-joint was accordingly allowed to run its fiital course unchecked, Mr. 
Ifancock was the first surgeon who undertook tho removal of largo piirtions 
of these bonesi and since then the operation has been done several times by- 
others. In no case has, I believe, more extensive. disease been removed with 
a good result than in a girl of the name of Fallowfield, who was sent to me 
three years ago by my friend Mr. Tweed, and from whom I removed tlio 
apper end of the femur, tho acetabulum, the ramus of the pubes and of the 
Jichium, a portion of the tuber isclni, and part of tht? dorsum ilii. This pa- 
L»nt, when admitted, was in the last stage of disease, exhausted by the con* 

at dieohaTge,and must inevitably have speedily sunk under the ^Mstx^X^ xA 



144 SURGERY. 

the disease, bad no effort been made to remove the cause of the prostration. 
At the operation, she was so exhausted that it was necessary to have her on 
the operating-table for some hours before she was sufficiently restored to 
bear moving into bed. Nevertheless, by free use of stimulants and nourish- 
ing food, she made a rapid recovery : and a few months ago, the limb was 
straight, shortened about two inches ; good movement existed at the hip ; 
and she could walk with much ease. Constitutionally, she was in perfect 
health. In cases such as this, the result, if they are left to themselves, most 
inevitably be fataL There is no danger of laying open the pelvic cavity 
during the removal of these masses of pelvic bone ; for, as Mr. Hancock has 
shown, during the progress of the disease, the fascisd. muscles, &c., lining 
the pelvis, become so thickened and infiltrated with plastic matter, that they 
form an effectual barrier which protects the pelvic cavity. 

Method of Operating, — The patient lies on the sound side. If the disease 
is femoral, the gluteal region perforated with sinuses, and the soft parts 
thinned, the head of the bone lyin? dislocated on to the dorsum ilii, it suf- 
fices to pass a director down one of the chief sinupes leading to the carious 
bone, and to slit this up. If, however, the bone be more thickly covered, 
and is not easily reached with the probe, and if the sinuses open on the thigh 
at some considerable distance from the seat of disease, then a T-shaped in- 
cision should be made over the upper end of the femur, so as to einpose it. 
The limb should now be forcibly adducted, rotated inwards and pushed up- 
wards by an assistant, the son structures separated by a probe-pointed 
knife from around the upper end of the bone, so that the whole amount of 
disease may come into view. The carious epiphysis is then cut off with a 
saw, the soft parts around being protected, if necessary, by means of re- 
tractors. 

There is one practical question with regard to the amount of the nppor 
end of tlie femur to be removed, which requires consideration; and that isv 
Should the bone be sawed through below the great trochanter ; or through 
the neck only, leaving the trochanter ? The practice should, I think, differ 
according to the nature of the disease- If this is femoral, it is best to take 
away the great trochanter, as the caries has generally reached its cancellous 
Htructure, or it may be infiltrated with tubercle. But if the disease be ace- 
tabular, it will suffice to remove the head only, leaving the trochanter, which 
is not affected in these cases. After removing the head of the femur, the up- 
per end should be examined, and any carious parts gouged out. After the 
epiphysis of the femur has been removed, the acetabulum must be exam- 
ined, and any rough or necrosed bone lying at its edge should be gouged 
away. 

In the acetabular form of the disease, the early stages of the operation re 
quire to be conducted in the way just described ; the incisions, however, be 
ing made more freely, but not carried so far forwards as to endanger the> 
anterior crural, or so far back as to wound the sciatic nerve. After the 
removal of the head of the femur, all loose pieces of necrosed bone are to 
be taken out, and then, by means of ordinary cutting or gouge forceps, the 
acetabulum and other diseased osseous structures cut away piecemeal. In 
doing this, it will be found that the necrosed bone readily separates by 
means of the finger, or by the hand of a scalpel, from the subjacent soft 
structures ; and the muscles and fascisD lining the pelvic bones, being thick- 
ened and infiltrated with lymph, effectually protect the contained parts from 
all injury. 

The result of excision of the hip-joint has to be considered from two 
points of view : 1. So far as the mortality immediately referrible to the ope- 
ration is concerned ; and 2. As to the utility of the limb that is left after 
its performance. 

] . As to the fatality directly referrible to the operation itself. On this 
point it is difficult to sneak with absolute accuracy at present, the statistics 
of all the operations not being before the profession ; but, so far as my own 
experience is concerned, it is as follows. I have operated in seven cases. 
Of these, not one has proved fatal ; three are now well and going about; two 



SUEGERY. 



143 



^ 



r bare lost Biglit of, after their recovery and dii$c1iarge from the hospltnl ; 
and two havo dtud, one eloven months and the <ither two years after the ope- 
ratloD, frara cousjUtutionul diseuse uncoiiuected with it* When wo coDsidtT 
that all th£tsi> cas^ea wore iugtauccs of udvEinoed fi'mor**! or acetabular coial- 
gia, whtcli would speed tly have provc<l fatnl if not subjectoti to operation, wo 
may with justice look upon them aa success^ful so far aa the preservation of 
life was concerned. And, in this re spec t^ excision of the hend of the femur* 
or of the hip'J4>intt stamU in a different po:silion to siuular operations prac- 
tised on other joints. The surgeon excises the elhow, shoulder^ or ankle, in 
order to reiitt)ro a useful limb to tho i)atitmt, Escisiou of these jointa Is n 
Bubstituto fur tho loss of tho limb by amputation — not* as in tiio case of the 
hipT for the loss of tho life of the patient by a eontinuaneo of the hectic. 

2. An tu the utility of the limb left after oxolaton of tho head of the femur 
or the hip'juint. In esiimating tho utility of tho limb left after eicision of 
the hip-joint, we raust compare it with the kind of member that would he 
left in tho event of the pntient surviving suflicjently Jojig for a nutural euro 
to re.Hult. It would be manifestly absurd to compare a limb which had be- 
come «eriou«ly crippleti* diseased, and shi>rtenedt before imy operation was 
undertaken, with one in which no tourbid action had ever taken place. So 
aUo would it be unjust to compare it with tho state of a limb left after a 
slight attack of coxalgia in which an operntioa could never have become 
neeea^ary or been contemplated. But, on comparing the result of operated 
ca^s with that of those which recover spun tan oousTy, after caries and des- 
tructive disintegrotion of the uppor epiphysis of tho femur has existed for 
years, wo ^hall find that the balance is by no means against thoie in which 
excision has been done*^As I do not consider tho operation necessary, iti 
cases of arthritic coxulgltv, I do nut compare tho result of these casen with 
that of those operated on, hat confine myself entirely to those in which 
there has been deatructivo bone-Lh.^ease, In such cases as these, wheni af- 
ter years of prolonged suftcring, recovery is at last accomplished by natu^ 
ral means, what is the conditi<m of tho limb that is left T Why, more or 
less completoly anehylosed at the hip, wasted* shortened to the extent of two 
or three inches, partially ilexed upon the pelvis, adducted-, with the knco 
po^^slbly stiffened, semiflexed and advanced, the patient just able to put the 
toes to the ground, without the power of bearing upon or rotating tho limb ; 
but when he wishes to turn, twisting the whole pelvis by tlio aid of the 
greatly increased mobility of the lumbar spine. 

After fiuccesafui excision, the result is much more satisfactory, as you had 
an oppurtanity of witnessing in tho hoy on wliom I had operated three years 
ago, Tho principal morbid appearance in the limb is its shortening to the 
extent usually of from two to three inches — to the extent, indeed, to which 
the preexiiting disorganisation and dislocation of the head of the bone bad 
previously reduced it. It is well nourished, straight, firm, and admits of 
easy and rapid progression. The anchylu^ls is fibrous, not osseous. The 
patient is tlien enabled to flox the thigh on the pelvis, and to adduct it ; but, 
just as in the cases that have undergoue a natural cure, the power of exter- 
ual rotation and of abduction are lost, the mobility of tlje lumbar spine com- 
pensating for the loss of these movements* — British Mcd^ JoutnaU Maii IS, 
1800, p. aoL 



55,— ON THE PATHOLOGY AXD TREATMENT OF SCROFULOUS 
1>I8EASE8 OF THE SYNOVIAL MEMBRANE OF JOINTS, 

Bj EicfTAUi BiJtTiLl, Eftq , F» E, G. &, Aulftuit SaTyeoa to Cbuliig Croat Uotpilol. 

There is no doubt that even the most chronic, Insidious, and paiule»sfonn 
of this complaint, is at least in tho fir^^t stages, an inflammation ; and hence, 
the joint must at once be placed at absolute rest. Some form of counter- 
irritant should be employed, and proper internal remedies to ameliorate the 
constitutional condition. This is not the place to enter into the reasons that 
would cause the choice of one counter-irritant more than anotlier, but it is 
XLIL— 10 



146 SUBGEBT. 

desirable to point out the disadvantages attending a certain p.an too much 
in vogue. A patient applying with this disease is gcneralljr ordered a splint 
— perhaps leeches or a blister ; and after a time an issue is made, which ia 
kept poulticed for a month or two, discharging all the while. Now it is evi- 
dent that nothing can more conduce to the spread of the new tissue, whose 
encroaching growth constitutes the disease, than warmth and moisture, unless 
it be an indolent suppurating and granulating sore, such as an issue becomes 
a week or ten days after its application. If issues are tliought desirable, 
they should be either kept open only for a short time after the separation of 
the slough, and another be made, or they should bo touched again with the 
caustic potash, and so kept irritable. The former method has its disadvan- 
tage in the breadth of suiface destroyed, the latter in the depth to which the 
sore penetrates, and both in the very great pain produced by the treatment. 
Some persons have believed, and do still bolievc, that the amount of benefit 
is proportionate to the pain. This is a mischievous idea, (i^ince it leads to a 
cruel line of practice. The notion, no doubt, was obtained from the obser- 
vation, that issues benefit mostly at first, and that in a short time their ac- 
tion becomes null, or absolutely injurious, since the constant discharge 
weakens the tissues, and tends to produce cell generation all around. 

A much better, and a much less painful plan than an issue, is the actual 
cautery ; it is one which I would wish to see much more generally used; but 
its application requires some practice, skill, and knowledge, since an unskil- 
ful use is apt to produce too great a destruction of skin, too deep a furrow, 
or other evils instead of benefits. If the means be judiciously employed iu 
properly chosen cases, its action is marvellous, and now that chloroform 
prevents the immediate pain, the objections which caused it to be disused in 
England have disappeared. 

The iron which I employ for this purpose is known as Rusts : it is simplj 
a tliree-sided prism, mounted by one of its oblong facets to a curved handle. 
The edges are slightly blunted. An iron of this shape has bulk enough to 
retain the heat a sufiicient length of time, and yi^t presents a small edge. 
Two irons ought to be used, as a white, not merely a dull-red, heat is desir- 
able, and thus a change of instruments is necessary. While the patient is 
being placed under the infiuonce of chloroform, the joint to be cauterised 
should be protected by strips of plaster, or of moistened lint, a good inch, 
or an inch and a half broad, leaving narrow intervals between each, where the 
lines of firing are to run. When anaesthesia is fully established, a white- 
hot iron is to be slowly, and with gentle pressure, pass^ed three or four times 
along each space, until the skin be turned into a yellow-brown horny sub- 
stance. Let it 1)0 particularly observed that the rays ought not to he 
nearer than an inch ; the skin must not bo divided by the iron ; the heat 
mu)s be sufiicient to char the hkin. This mode of using the iron was called 
by Percy (* Pyrotechnic Chirurgicole,*) ** cauterization transcurrento." Wo 
might name it linear cauterization. Kust, of Vienna, and Bonnet, of Lyons* 
emploved it with great success. My own experience warrants me in speak- 
ing of it very highly. In the first place, it gives no pain whatever at the 
time of application, and when the efiect of the chloroform has disappeared* 
still no pain from the cautery can be felt. Compare this with the torture 
produced by the potassa fusa, under which the patient will writhe for hours 
after the application. But not merely is the hot iron painless; it absolutelj 
relieves pain. I applied it in a case of hip-joint disease, in which the 
patient was suffering so much that he dared not move, his face was anxious, 
and his nights all but sleepless. After he had recovered from the chloro- 
form, he was laughing, talking, moving about in his bed, and wanting to get 
up. In a case of knee-joint affection, the same change from pain to pain- 
lessness followed the use of the iron, and the patient is now able to walk. 
The narrow charred lines made by the cautery begin to separate in from five 
days to a week, and come away between the fourteenth and twenty-first day. 
They should then be healed as quickly as possible. 

The value of pressure in strumous synovitis cannot be too highlj esti- 
mated, if the proper oases be chosen for its use ; such, for instance, as those 



SUBGERT 



Uf 



In trhieh the tWpllm^Ts snlt ami sluggish, in which a bursting* pa?n i* foil, and 
in winch a seDS&tion nf coI<3 h oiperionceiL Dp. Scott of Bromley, first uaod 
this plan with consldorablo guccp«*; ho applied morcuriaU to tho j*>tnts, and 
over thorn etrappiug pLi?itcr. The value af ttio treatment I ioi* in tlio pre8- 
aiire. Mercurials art* of littlo or no help; in strumous cases 1 belicvo thoy 
are even injurion??. The modus operand i of this ti|]jent I believe to be» .simply 
preveuting the oells^ through want of room* from generating ivfresilu ana, 
thertfore, cons training thi^ir organ ijsing force to aot in the pmilm-tlon of 
tlsiiuo from tho ci>lU alieady forineti, or in the ubaorption ef thotsc unfit for 
this purpose. I know no means at all compnrnhlo in their povver of resolv- 
ing strumous synovitis to the use uf the actual cautery folio weJ by press urOi 
1ft for instance, on the knee-joint the lines have been drawn parallel to tha 
11X19 of the limb, they wilU on hf^alingt contract very considerably like all 
Bcara of bums ; and if to the prensur^ thus produced, be added that of j^trap* 
ping plaster, an almost irrortistiblo pow^r of rei*ohiti*m]wlll havo been gainedp 
Indeed, unlcfts tht* case be too far advanced, or too much supporteil by n 
vitiated constitution, it wilt yield to this treatment in a few wecka. The fol* 
lowing case shows the vtibjo of this method : — 

Jane S.* aged six, a pale, strumous girl, hoa hmn infFerlng for twenty 
months from pain uni! swelling of the left knee, and was admitted into Char- 
ing Hospital undin' my care, (through the klndnosfi of Mr, Hancock,) Dec* 
Othi 1830. The knee U a good deal bent, the joint hoing round mid shapii- 
less; the child criea when it ii touched, and when any attempt h made to 
move it. 

Dee 21 st. I drew four tttrioa of linear oanterization, one on either sid^ of 
the patella, and one an inch beyond each of these, and got the limb into 
& straight position. On recovering from the chloroform the child oxproi^scd 
no sense of pain, but sat up, and began to play with toyts and other children 
itt the ward. 

On the third day thft skin belween the cauterized lines looked red and in^ 
flamed. On the fifth, i*ome reparation at the edge of the slongh had occurred. 
The horny portion gradually tseparated, and on the li*t January, IHfjO, th*s 
lines left were aim ply ch^ar llnca of ulcer, which were drot^sed with zinc 
ointment, discharged very little, and gradually healed. The knee wa*t much 
diminished in size; morcver, it could he pressed without producing f^ymp- 
toms of pain. It wa^. however, still swollen, and on the 23rd January, when 
the »dar was quite .sudieiently healed, the knee was tightly strappodi and 
a roller applied frojn the foot 

3^Jth. Strapping applied again, and towards the end of the week the child 
was dressed, and allowed to get about by aid of the sides of the bed and 
of a chair. 

March 6th. The child is able to go about so well that the mother in.^!st« 
on taking her out; promises to bring her to uie amongst my out-patients. 
This she has hitherto not done. 

Other cases showing the value of pressure might easily be given, 1 ro- 
corded three in the Lancet for Dee, 20Lh, 1851), Several others proving the 
extreme value of this combination have ficcurred to me. 

We now* however, come to a much-neglected questions-one which ]s« 
perhapa, scarcely comprehended in regard to the treatment of strurnoua 
synovitis — ^viz., h the principle of perfect rest to be exchanged for tb.it of 
limited motion at any period of the disease T If so, at what period ! I say 
that this quojfUon is either not undcTitood, or is ignomd in England al- 
together ; while, in Lyons, M. Bonnet applied eome practical suggestions 
to the answor. 

1 rnnat, at the riak even of occupying much space, explain the principle 
whereon the value of passive motion, shampooing, &o„ is basyd, Wlmn 
th& ceils, which have formed s*j abundantly in and around the synovial 
membrane, cease their generative activity, thoy remain for an indefSnila 
period more or less passive. We know that the gelatinous eorjdilion thus 
produced mnv las^t for years without change, and that, being left undisttirbfid^ 
^bs maaa will, after a time, become the seat of abseeast o^u^e d^ftlTm&XJvimKu 



3 



148 ^^H SURGERY. 

eurroandinpf pflrt»» prodtiee caries* Ace, ; fir, itt more foroi 
bc^gui to aasuine a tibroid, ttjul ultimtLtely utuUi the two hoiiaii If 
Now, I Imve no he&ilatjon in saying tbat, in the krge majitrltj of insttttioeii, 
the pa^^ivc condition nmy bo tiikeii advantage of to induce n much more por- 
feat, froquontty an alnioj^t cotnplct^i cure ot the malady ; and that« bj allow- 
ing it to couiinue, a much larger mass of disease 1^ fonnedi rnuob more tln- 
eue (periarticular, cartilaginous, or osi^eooi*) is irnpUeated, and, therefore, 
even if the joint ultinuitelj heal over, the cure is far from being as perfect 
n» it might be* tnad^j ; and if degene ration »et in, the ravages are unnecea- 
SBxily wid^-tiprend* Moreover, bo it r«*inembercd, tliat if even a healthy 
joint h^ kept very long immovable, fatty degeneration of the cartilages ii 
ftpt to come on, and even a flluggiBh infiammation of the synovia] tnetn- 
branc. It mual not be, however, for one moment imagiuedt that 1 woold 
advcKiate movement of the joint at all stages of the disease. On the con- 
trary, sach treatmi^nt can only be beneficial during the above-named passive 
oonditjon, and wheji all influmnmtory signs have disappeared. Hence it ii 
important to form a correct judgment as to this condition. It ia well known 
|.^mt each joint, when InHamed, presents a certain Bpot in which pain and 
It&nderne^s are much more marked than elsewhere ; this \» in every joint a 
l£xed point— on the hip, behind the great trochanti^r; in the knee, the edgfr 
I pi thti inner condyle, inside the ligamentum patella ; in the elbow, at tno 
I back, over tbo head of the radius, and so on. Now, if the surgeon find that 
[pressure upon these points produces no pain, he may begin to move ibd 
I limb with perfect conbdenco and s^afcly ; and, as far as my experience goei 
*%B this treatment (already pretty considerable)^ with Terj great benefit. 
The movement must not, at the beginning, be violent or long continued i m 
iligbt passive motion* and that rigidly in the normal direction, a oertaia 
amount of rubbing and kneading with the band, and then reappli cation of 
tbo splint, aro all that can ho undertaken; and it may be a long time befor«i 
it wiil be safe to abandon the patient*a limb lb his own management. I bav^ 
also found it a u»efui plan when it can be managed, slightly to change tbo 
angle of the »iplint at e^ch reupplicatiom 

The subject of angle at which the joint would ho fleied, would naturally 
lead ns to consider another subject— vii,, the value, as an actual remedy 
for inflammation, of changing any vicious position in which the joint may 
lie. There is no room for doubting the diminution of the inflninmation and 
of the pain after this has been done ; and amongst my cases are one or two 
which were clearly benefitted by t]ii» means. But this subject ia too wide, 
and space too limited, for its discusRion here. 

The three methods more particularly named in tJsia communication — tLk,, 
actual cauteryt pressure, and passive motion, are neither original nor new; 
but the first and last more particularly are not used so frequently, nor with 
such discrimination and power as they might be. Much benefit would result 
from substituting these means for the negative, If not injurious, treatment 
to which these strumous cases are too often subject, — Lancets June 30, ISOWt 
p. 640. 

56,— LOOSE CARTILAGE IN THE KNEE-JOINT— REMOVAL. 

By W. FKiicu8s«?f, Esq., F.RB , Baripfloti to Klng^a College Hospital. 

There is some difiference of opinion amongst surgeons as to the means to 
be adopted for getting rid of these bodies. Some prefer to remove them at 
once J whilst others leave them in the areolar tisi^ues. Eiperience goes to 
prove that succe^ss more nsually attends the latter proceeding, and that 
sometimes most serious consequences have ensued from the former, involv- 
ing loss of both life and limb, Wtt recollect seeing an hospital patient sub* 
raitt*?d to Syme's operation for the passage of a loose body from the knee to 
the subcutaneous areolar tissue, but the surgeon could n^it reslit the desire 
of removing it altogether. The consequence was that the most violent in- 
flAmmation set in, in a healthy constitution and robust frame. It went on 



^ 





SURGERY, 



14d 



I 



to Piippuratlon» and tho leg hi%d to be removod at the tKIgh* the patient 
barely f sen ping with hiw Ufc. Thts Is by iir> nutans a (iolitiiry jniaitnnc.e of 
the bad j<?&ults of direct removal f>f tho loose cartilagp, arid hRnce that pro- 
ceeding has invested almost every case with uncertainty and feEir as to the 
reiult of any operative mea surest for rt.diof. Mr, Syme*s and Dr. floyTand's 
operatroo* together with various modifications of it, taking the precaution to 
leave the loo^e body burneath the skiiii at any rate for a time, wo have now 
fieen performed on several occasiouSf without any bad consequence}* what- 
ever, Some suf ^eona endeavour to obtain adhesion at the spot recottitn ended 
for it« detruBiou by eiciting some inflammation by puncturing the synovial 
membrane Rubeutaneously with a lithotome* An example of euro by thiji 
method, under Mr, Birkett'« care at Gity*sHnfipital, is recorded in a i(>rmer 
'* Mirror/- (^Lancet/ vol* i., 18rj(j, p, 7d,} We have heard Mr. Hilton re- 
mark at the same hospital that lie has treated one case by subcutaneous sec- 
tion with Buccesp, and two without any operation, the bodies being kept «ta* 
tlonnry, and ultiraately, ho believes* absorbed. 

We bad the opportunity of seeing another case treated during tbo pai*t 
eummer at King's College Hospital, in which the loose cartilage had been 
present probably for ten years, but most certainly for three. Mr. Fergus- 
son preferred cutting it out direct from the joint by means of a valvular in- 
cision. In some observatiann made on the occa^^ien, he stated that be bail 
cut a loose body directly from the knee-joint several times, and tbe result 
hadalwaysbeensucces sf u I, HendvertedtoMr.Syme'ssubentaneouso pe ra- 
tio n, but preferred his oivn method. Fortunately, the present ease has 
turned out tolerably well, but the patient run very great risks from the ex- 
treme severity of the inflammation which foUoived* synovial fluid and pu;? 
flowing from tbe joint for some days ; recovery has ensued with n stiff limb. 
We have ween recovery tnkt> place under precisely similar circumstances* 
but with firm anchyloj^ls t*f thi^ jnjut after a long and tedious illness* 

We are indebted to Mr, W\ Wlckhaui, hoase-aurgoon of the hospital, for 
tbe notes of the following case : — 

Thomas H., agod thirty-four, admitted into the above hospital on April 
2'itUt with a loose cartilage iu tbe knee-joiut. He stated, on adtnlssiun, that 
ten years ago, whilst walking, he was suddenly seized with severe pain in 
the left knee-joint* It lasted for a few minutes, and then as suddenly left 
him. This occurred on several occasions for a month or two, when it disap- 
]>eared. He was not troubled again with It till three years ago. Ho could 
now feel the loo^e cartilage at tbo Inner aide of tbe joint. About s.1% monthi 
ago the joint l»ecame intlained, for which leeches and bli^tters were employed. 
And he was obliged to keep bis bed fur a fortuififbt ; Qud> on getting up. ho 
found great difficulty in v?alklngt and the joint was very sJlltT. He had 
another similar attack of intl am motion in the joint three inonths since. On 
admission, the man's general health was very good; tbe b^ft kiieo was rather 
larger than the right* On maoipuliition, tbe b^ose cartilage could reiidlly bo 
felt on the inner side of tbe puttdla. The patient walked with a H\W knee 
to avoid pnin consequent on the hioae cartilage getting between the ends of 
tbe bones. 

May 13th. Tho patient being placed under the influence of chloroform, 
Mr. Fergu^son removed the Itnise cartilage, whieh was about the size and 
whape of a broad bean, Tbe cartilage having been iir^t brought to the inner 
side of tbe patella, and the leg atraigliteiicu, a valvular Incijiion wasi made 
over it, and, after some difliculty, it was removed by means of a scoop. 
Some Mynfivlal lluid escaped during the opera tit m* Tbe wound in the skin 
was cbjsed, and the limb placed in a M*Intyre splint The patient was tbeo 
removed to bed, and the limb swung, 

13th. The patient passed a very bad night ; complains of great pain in 
the joint, which is much swollen and intlamed. Ordered sixteen leeches to 
the joint and a pill containing three grains of calomel and half a grain of 
opium every four hours* 

15lb. He Is greatly relieved since tbe application of tbe leeches. Or- 



tflO SUBGBBT; 

dered poppy fbmentationB to the joint, aod a saline draught with the pills 
erery tour hours. 

17th. The pain in the joint has returned, and the swelling increased. 
Twelve more leeches were applied, with much hene6t. 

18th. He is much hotter ; the wound is now discharging a thin fluid, con- 
sisting partly of synovia and partly of pus ; the pain is much less, and the 
swelling has diminished. Poultices were applied to the ioint 

29th. The splint was this morning re-npplied, with very little inconvenience 
to the patient, and he did not complain of any pain on applying firm pres- 
aure over the joint. 

June 21st. The splint was left off to-day, and the whole limh firmly hand- 
aged. The wound in the joint is healed. The swelling in the knee-joint 
has greatly subsided ; manipulation causes no pain. With the assistance of 
crutches he is able to walk about the ward. 

He was discharged to go into the country on July 12th. At this time 
there was still some swelling of the joint, with very little motion ; he could, 
however, slightly bend the knee without causing pain. — Lancet, Oct. 13» 
1860, p. a58. 

57.— CASE OP DISLOCATION OP THE ULNA FORWARDS AT 
THE ELBOW, WITHOUT FRACTURE OF THE OLECRANON 
PROCESS. 

Bj Edwih Cantoit, Esq., F.B.C.S., Sargcon to the Charing Cross HospitaL 

[The occurrence of dislocation of the ulna forwards at the elbow-jointt 
without a simultaneous fracture of the olecranon process, is so rare, that most 
authors have denied the possibility of its occurrence ; others make no men- 
tion of this form of injury. One case of this accident is related by Colson 
in 1835. Mr. Canton says:] 

The following case came under my care in the Charing Cross Hospital : — 
P. P., aged 40, a somewhat short, slim-built, but muscular man, while driv- 
ing in a light cart at the rate of seven or eight miles an hour, was thrown 
out, and instinctively extended his right hand to prevent injury to his head. 
The weight of the body, however, caused sudden and forcible flexion of the 
elbow, and at the same time the forearm became twisted in under the chest. 
On rising, it was found that the elbow was considerably swollen, and the 
power of moving it entirely lost. When admitted into hospital, the forearm 
was forcibly flexed, and the hand supinated. The swelling, ecchymosis, and 
tension around the elbow were so great that it was with difficulty any of the 
more salient anatomical peculiarities of this part could be recognised, — 
everything appeared, in every way, so disarranged. The skin covering the 
inner condyle was stretched to the utmost, and here, over a space about the 
size of a sixpence, it was to such a degree injured, that a compound state 
seemed to be momentarily threatened. The antero-postcrior and lateral 
diameters of the joint were increased in extent, and the general swelling was 
so great as to present a circumference far beyond the normal size of this 
region. Externally and somewhat anteriorly the cup-like cavity of the ra- 
dius could be indistinctly distinguished : internally, the condyle was unduly 
prominent; anteriorly no particular point for diagnosis could be determined 
on, on account of the state of forcible flexion and great tumefaction there ; 
posteriorly also the swelling was very considerable, but, below it, there ex- 
isted a depression favouring the view that the ulna was broken immediately 
below its olecranon process. No median gutter, with lateral elevations to 
bound it, could be felt. 

Attempts were made to ratify the mal-adjustment, but without success ; 
the efforts, however, could not be longer continued, for, it was obvious that 
the injury already sustained by the soft parts was so extensive, — the obsta- 
cles to be overcome so resistent, and the great likelihood incurred of render- 
ing the case one of the compound kind, forbade further trial, and it was 
agreed, in consultation, to place the limb at rest on a splint, and to keep 



SUBGERY, 



151 



tTie parts cool with an arnicsft lotion. Witliin tbe courae, howevert of fortj' 
eiglit lifmrs th& tumefiietion became still grenter ; a large Blough was form- 
iiifj on tli(* iunor ^\de of the joititT and high ccinstitutionftl irritfttion having 
got in. I wa« obliged to amputate the limb at a sufficient distauee above i\w 
articulatlou* 

JJissedion* — A v<*ry carf'ful o3tnmjntttit>n of the elbow was mad*?* nndor 
my siiperiiitendence, by my pupil, Mr, Edgar Brown* with the foUowiug 
results : — ' 

Bones. — The ulna was dislocnted forwards, so that the upper surface of itfl 
olecranon procnss be<?anie placed in front of thy capitellum hu merit and had 
thus n3«?umed the postilion naturallj occupied by the head of the radius dur* 
ing fleiion of the forearm. The radiufi wtvB supinated and maintained in 
situ mifurale—as regards the ulua— by the coronaiy atjd interosaeoui liga^ 
merit!^ being iiitarit. 

Ligaments. — Of the anterior ligament, the only part remaining at all per- 
fect was* a f^lireddy portion aboat thii centre; all tho rest of it had beijn torn 
through. The pf*sterior, and both lateral ligaments were oompletoly divided. 
The coroimry and oblicjuo ligaments were injured* 

Musdts. —Thi}. tricepK eitensior was detached from all its pointa of inser- 
tion. The supinator radii Inugus* wn^ unintorfered with at it-^ origin ; but 
the two radial extenBorw of the earpii« bcmoath it were ti>rn away from the 
Btirfnces whence they spring. All the muscle** w hich ad 3*3 from tbo escti^rnal 
condyle— with the exception of the siipiinitor radii brovis, and anconajus — 
were detached from this process. The only muscle that was torn through 
at its orfgm from the internal condyle was the flexor carpi ulnarisT — the ole- 
cranon and ulnar portions of it^ boweverT continued Intact. Notniachief 
whatever had happened to any other of the pronatorft and flexors. The 
bicfpa and bracbinlis antlcus wore put greatly on the stretch. 

Bioiid'VcssHs. — Though much ihlfting of their position had necessarily 
titken placet no vessel of large size had boon injured; the sacrifice, however, 
of #mallf»r ones must have been great — jndging from the large amount of 
blood with which ull the ^rtft textures were inflitratod. 

iVi?rrfji»— ^The ulnar nerve was torn across where it jiaased behind the inner 
condyle. The sheath of t\\{i median was di?3tendedi and its substance per- 
meated with blood* The other nerve a uuinjured.— i>afc/m Quarterli/ Jour- 
nal, Aug. imO, p. 27. 



I 



56.— ON THE TREATMENT OF LATERAL CURVATURE OF 

THE SPINE. 

By Hout^ Co&n^ E^q.^ F.fi,aB„ A««i4t.%rit giirj^i^an %9 tha R{>ya1 UoapLti^l of Bt Bmholom^w iiiit 
lo the Itojiil tff llitifHuitlc nocpItiiL 

[After considering the causes and pathology of lateral curvature, ahowiug 
that after a certain period important chrmges take place in the bodies and 
arlicubtiug processes of the vertebrn?, Mr. Coo to proceed* to consider the 
treatment of the disease, lie observes first that for the cure tu be effectual 
it must be dotie be fort? these changes have tttken place.] 

The dlsoaso comujence* as one of general weukwo^s of ligamoutii, Just as 
U seen id cases of knock 'knee; but iu a brief space of time tho oppo.^ed os* 
(*eou5 surfaces become adapted* &ud cannot clmtjgo their form, Of what 
use then can be cold ablutions, the shower bath, salt and water sponging, 
or the intenml administration of tonics. All tho salt and water in the uni- 
verse will not spt Btriught a distorted back i nor will steel, ^^r other tonic 
remedies, replace a twisted vertebrae. By mechanical means alone can we 
hope to check and correct this serioua and progresmve deformity ♦ This 
- jnethod should be resorted to, not only in the more severe, but in the earlier 
se»f when hopes may still be held uut of even complete and permanent re- 
>very. 



152 



SURGEBY. 



Tavernier's belt has been aupersedcfl 
by Tamplin'8 apparatust of which a repre* 
scntation ia nven in the acoompanying 
wood- cut. ^ter many alterations, it it 
the iDstrument now commonly used, at 
the Ortbopoedic Hospital. It consists of 
a steel padded pelvic belt ; of two orutoh* 
es capable of elevation to reach the azilhet 
and to take off the weight of the head and 
upper extremities; of a webbing band to 
pass in front of the abdomen, where, 
moderately tightly laced, it holds the in- 
strument forwards, and of one or two pads 
on steel supports, worked with cog-wheels* 
to pass the displaced vertebrsQ steadily, but 
slowly back. Patience on the part of the 
patient, care and skill on the part of the 
surgeon are necessary, that the apparatus 
may fit without rubbing, and the weight, 
which is considerable, may be so equally 
diffused as to bo borne without inconve- 
nience. 

It acts under the management of the surgeon, by slow, steady, gradually 
increasing, yet unremitting pressure, before which the strongest ligaments 
will yield. The pressure should therefore never be so great as t<» cause pain« 
nor to irritate the skin ; it must be continued night as well as day, for what 
progressive improvement could be expected, if an extension of twelve hours 
were succeeded by a relaxation of a similar space of time ; some oases re- 
quire to be seen twice, others three times a week or oftener ; for constant 
adaptation of the pads, or readjustment of the entire apparatus is necessary 
during the treatment. These points, however, may be readily learnt by the 
surgeon, who hears in mind the fundamental rule of patience, steadiness, and 
gentleness. When the spine has been brought again to the straight line, it 
can be so held by stays not differing in appearances materially from those 
usually worn. 

The constitutional treatment must be guided by general principles. The 
patient may take exercise as usual, but should rest on an easy sofa, when 
tired. She may also with prudence, continue her education, so that the du- 
ration of the treatment becomes a matter of less regret to the parents. — lath" 
don Med, Review^ July, 1868, p. 13. 




59.—ON THE DRESSING OF STUMPS AFTER AMPUTATION. 

ByJF. Stmonds E8q,4F.R.C.S.,^nrgeon to the Radcliffe Infirmary, Oxford. 

The chances of quick union and a good stump undoubtedly depend, in a 
great measure, upon attention to a number of minute details in the dressing. 
Though the importance of such details have been generally acknowledged, 
they are too minute and various to have had much space allotted to their 
oonsideration in works on surgery. The following observations on certain 
points connected with the dressing of stumps have no pretension whatever 
to originality. They are simply a statement of views, which l>oth reason 
and experience have induced myself, and I believe many others, to adopt. 

Sutures. — If we divide sutures into two great classes, viz.. Metallic and 
non-Metallic, the majority of surgeons of the present day — in amputation 
wounds, and most others where sutures are applicable — will probably be found 
to give preference to the former. In perfectly healthy tissues, union will 
generally take place so readily that the kind of suture to be used is not so 
much a matter for consideration ; but when from any cause union is likely 
tn be tardy, then it is a great desideratum to have one which may be kept in 



SUEGEHY. 



%{i wouiifl for R oompavfttiTply lon^ period, at the same lime cnnBing thft 
mimmuin of irritatioQ and lesiem of the tissues through which it is puBaed, 
This see in s to be the very advantage which the metallic suture poaseaseii 
OTPr one of auy organic metiil* 

I muBt beg to acknowledge the experiments — so conclusiTe as to the rela- 
iive merits of these two classes of suture — ^niado sometime ago under the di- 
r<*ct[on of Professor Simpson, of Edinburgh (vide * Medical Times and 
Craze tte / J nn u arj J , 1 859 . ) 

Asstuuiing, therefore, tlie general inferiority of the organic suture, I beg 
to offer some observations on the relative merits of the two chief kinds of 
metallio tiuture^ — via., the common wire and the noedle (or twisted) suture^ 

With a view to tost their relative value, repoatod eiperiments were made 
by myself and Mr. Gray our house-surgeon. In different patients, with 
different descriptifms of wounds the twisted suture was used side by side 
with the wire sature» and the result in almost every case wa^ this — that, at 
Ihe end of a given time, anion was more advanced and more satii^fictory at 
tbe points where tlip twisted suture was employed, than at the other pointu* 
These experiments appear to me to carry some weight ; fur, when two kindn 
of Jiuiure, inserted simultaneously^ are left side hy ^ide in the game wound 
for an equal length of time, there oao be little room for fallacy iu one^n esti- 
rante n{ their relative efficiency. 

The superiority of the needle to the ^ire is probably due to its greflter 
firmness, enabling it to hold the edges ofa wound in more exact apposition* 
The superiority of wire to thread on the other hand, must bo attributed to 
its iourtness from u on *ab sorption of surrounding fluids. 

An objection sometimes urged against the twisted suture is this — that 
often {hi consequence of blood and lymph drying around the points of en* 
trance and exit) its removal require;! an amount of force which cau^^ps pam 
to the patient, as well as injury to the newly -formed adhesions. This evil 
may be prevented by a very simple precaution — well oiling the thread before 
it is twisted over the needle, and oiling it again (with a eamePs*hair brush) 
once a day an long as the needle remains in. The ueudie may then be re- 
moved without any pain, or any injurious traction on the tissuej* recently 
uniied. 

A very exeelleut kind of needle for the twisted autnre is the common 
lance -pointed hare- lip needle, made by Weiss. It does not ojtidieo; it cuts 
easily, and is easHy cut. I have suggestt^d to Messrs. Weiss, as a matter of 
economy, to have them made at least double their present length, since about 
B fjnarter of each one (the flattened extremity) has t<* be wasted. 

Bandaging, — In ordmnry case^i is it advisable to bandage the stump 1 I 
think not. The praotlco of bandaging the stump immediately after ampu- 
tatinn scemH to bo grounded on the following suppositions: That It prevents re- 
traction and involuntary twitching of the divided musoles* and (according to 
eonie; tlie entrance of air or duleterioua j!uid$ into the veins. Now let us 
examine what truth there is in each ot these hypotheseB, 

1. As a matter of fact does bandaging prevent muscular retraction? My 
own observation convinces me that it' does not* I doubt whether it can even 
retard retraction. Consider the case of an amputation of the leg or thigh. 
The immediate and primary retraction of the divided moscles takes placo 
probably in the course of a very few hours. In the operation the whole 
thieknoss of tbe m uncles has been cut across, therefore ttic whole substance 
of the remaining muscle contracts. Now any one, who knows any thing of 
the enormous strength of a single bunch of muscular fibrcN, will bear in mind 
how great must be the coUeotive retractile foree of the several mui^oks of a 
limb acting simultaneouftfy* I am strongly inclined in think it is fur too 
powerful to bo counteracted by any amount of bandaging. 

Again, even if It were pogi^iide to effect this retraction, would it be desim* 
hie ? Surely not ; for until the retraction has taken place, and the muscles 
have become quiescent, I do not see how Nature* s process of repair can 
commence, 

I have spoken of the immediate, primary retraction of U\t mua<iVb%. T^«t^ ' 



154 SUBGEBY. 

in a Bubsoquent, secondary retraction, which begins generally about the seo- 
ond or third week after the amputation, and lasts a considerable time. It 
shows itself by an alteration to a variable extent, of the position of the cica- 
trix. In a thigh, for instance, the undue action of the flexors gradually pulls 
backwards the line of the cicatrix. Now, according to my experience, band- 
aging will no more prevent this secondary, than it will the primary retrac- 
tion. The truth seems to be this, — that if a surgeon- has left flap enough to 
allow for retraction, its occurence will be no mishap ; if he has not left 
enough, no amount of bandaging will remedy his error. 

2, As to the involuntary muscular twitching, causing the stump to start, 
this I have observed to occur just as much with a bandage as without one. 

t). There is one more hypothesis to bo considered, viz., that bandaging the 
stump may prevent the entrance of air or deleterious fluids into the veins 
from the wound. 

This theory ignores the first principles of hydraulics and all that we know 
of the physiology of the veins, and the circulation. It assumes, first, that 
notwithstanding an atmospheric pressure of fifteen pounds to the square 
inch, the cut extremity of a vein may remain open, like a hollow tube, op 
to the nearest point where the current of blood begins. (We know that in 
certain localities a cut vein urt^ remain open, its connexions being such as to 
prevent its collapse ; but of these wo are not now speaking.) Secondly, it 
assumes that ^he vein aforesaid has a marvellous power of suction, whereby 
it is able to imbibe fluid from the wound, through this tubular portion, into 
the current of blood beyond. 

Now, if bandaging cannot answer any one of these ends, and has, further, 
the disadvantage of complicating the dressing, or concealing the stump from 
view, of getting constantly fouled by the discharge, of diminishing (wnen at 
all tight) the afflux of blood to a part which needs a very rich supply, — ^why 
bandage at all, unless oedema of the stump or some other complication ren- 
der it necessary to do so ? 

In my own practice, and that of my colleague Mr. Hester, there haye 
been at this Infirmary a considerable number of cases of amputation, in 
which primary union took place at all points, except those which gave exit 
t«> the ligatures, and good stumps resulted. In these the mode of dressing 
was as follows : — The wound having been secured with twisted sutures, a 
single layer of wet lint was placed loosely over the end of the stump, and 
kept constantly wetted for about a week ; no other covering was applied. 
Then, as each suture was removed, a narrow strip of adhesive plaster was 
put to support the parts it had held in apposition, and changed as seldom as 
possible. No bandage or compress was used from first to last. 

Plaster. — When it is desirable to support the edges of the wound with ad- 
hesive plaster, whatever may be the width of the strips towards their ends« I 
have found it better not to cut them more than half-an-inch broad at the 
part which is to be in contact with the wound. The advantages are ( I), That 
the condition of the wound in the intervals between the strips is thereby con- 
stantly open to inspection ; (2) There is the smallest possible area of contact 
between wound and plaster — a great advantage when the former happens to 
be irritable ; (3) Free vent is left for discharge. 

The position of the strips of plaster should be changed occasionally, 
otherwise the intervening parts from the unequal distribution of pressure, 
have a tendency to become unduly prominent. Attention to this will secure 
an evenly- rounded contour to the stump ; neglect of it will do the reverse, 
however well the stump may have been cut. This leads me, lastly, to notice 
how much it is in the power of the dresser to mould a stump, by making con- 
stant, steady pressure (whether by plaster or other means) on any point. 
If in any case, to use Mr. Paget's torse language, unremitting pressure will 
cause unr paired absorption, more especially has it a tendency to do this 
in a part where new tissue is in process of formation. — Medical Twines and 
Gazette, Sept. 8, 1860, p. 230. 



STJRGEET, 



tm 



^ 



eik^O^ TALIPES EQumus, 

f BtcB^fts W»« T^MJ-LLi, Eik|,, F* B. C. S^ eurgeon to tha Boy id Orihopffidla llaiplbkL 

[Tn tiie first pnrt of his paper Mr, TatnpUn makes tho sturtUng remark that 
out of the 2O»D00 cnsr^s of tiilipeij equinus wbioh have* pa.sj^ed under hH ob- 
servation, tujt inje \va^ congenitaL The mast Uiiual causes are irritation 
with dii^turhatico of the nervous aystem, as from dentition* worms, and febrile 
affections; also froni woundst rheuniatic aifeetions, Berofiiloua (iisuase of the 
bonefl of the leg. It also sometimes auUes (itpoutaneoufilj, without any ap- 
parent cau^e,] 

When talipes eqninus arises from either of the three first- named causes^ 
It b o<;raj?!Onally aBsociatod with paraljsii or spasmodic contraction of tho 
corresfKinding upper extremity* as shown in the etatistical report. The 
majority of the case^i however, are those in which the muscles of the calf 
alone suffer bj contraction. There are sonuf in which the uuterHir tibial 
muscle is the only one paralysed* The balanee of power being> under thane 
circumstances^ destroyed* the extensors appear to contract upun tbemselveSv 
and thus pvotlucc the deformity. 

Not unfrcquently the firat cause has been an attack of hydrooephalua, 
upon recovery from which the flexor muscles of the foot and toes arc found 
to be perfectly paralysed or interrupted in their functions. I have in some 
cases had opportunities of witncBaing the origin of the deformity. The his- 
tory is as follows: — Tlie parents of the child notice the frequent tripping 
and falling of the child from any slight impediment or irregularity on thu 
surface trodden upon. They also notice a divergence of the toes, or, m 
they term it, increasing breadth of the front of the ftiot. If you request 
them to lead the child across the room in these eai^eH, you will notice that 
the moment the opjmslte extremity to the one affected is carried fori^vard be- 
yond the perpcndicuhir position of the hodyi the heel of the affected foot ii 
perceptibfy raised fnuu the grtjund* and the toes unduly diverge from each 
other* by the increased presauro thrown upon the front pnit of the foot, and 
the inability to flei it, owing to the incipient contraction of the giistroone* 
mius musole. If the leg be kept exteaded, it will he found, upon ejtmnlna- 
tiou, that the foot can be forcibly Hexed to its full extent; but* upon with- 
drawing the hand and setting the foot free, the gastrocnemius will itnmedi- 
wtely contract upon itself and draw up the heel* Upon UMikiug inquiry* you 
will generally thid that the child is sutfuriug froto irritation coui^equeut upon 
dentition* or from the presence of the soiull thread- worms. 

In these eases, L have had the gums freely lanced ; calomel, seam m on y, 
and jalap* administered for relief from the worms; stimulant embrocation 
applied throughout the whole length of the spinal column, and attention paid 
to the general health ; applying to tlie foot tin spliut^, bent somewhat be- 
yond a right an^le, to counteract the tendency of the gastrocnemius to con- 
tract upon its^lt. I have in many cashes fidlovved up this plan of treatment 
for months i but, although the contraction was at its commencement the re* 
■ults have been unsatisfactory, except in a very few instances. Division 
of the tendo AchiUis must be had recourse to* and then all tendency to con- 
traction ceases, if propor precaution be used. 

8tnne years since, Dr* Strom eye r, to whom wo ar^ indebted for the intro- 
duction of this new mode of treatoicnt, visited this hospital, when a slight 
ease of the kind just alluded to was placed on the table for operation. I 
consulted him upon It. lie advised the use of the hot bath night and morn- 
ing, together with general trcutment, stating that he believed that would 
cure the child. This advice was followed, out of respect to so distinguished 
%n authority, hut with no satisfactory result. 1 afterwards divided the tendon, 
proceeded cautiously with tho after treatment and &«cceedod in perfecting 
the cure. 

These cases are instructive and important; for it appears that* although 
there is not decided and permanent contracticm* yet the tendency to coTitract 
IS permanent J and will inevitably produce complete ct^uUm^, \1 Tt(i c^t\A 



IM SURGERY. 

are used to prerent it ; and also that, as a rule, general means are insuffici- 
ent. Within the last few weeks, I found it necessar}' to operate upon a child 
with this slight form of contraction, after having for six months tried general 
means without success. The temporary increased length given to the ten- 
don by the operation in these oases, and the consequently weakened state of 
the gastrocnemius, although only continuing for a time— t. e., until the ten- 
don has resolved itself into the permanent condition — appears to admit of the 
anterior tibia exercising its full functions, thus restoring the balance of power 
between the flexors and extensors of the foot ; at least, this is the only satis- 
faotory inference I can draw. 

Irritation consequent upon a Puncture or other Wound in the Ca(/* produces 
at times an active and continuous contraction of the gastrocnemius muscle, 
which terminates in this deformity, without any apparent loss of power in 
the flexors of the foot, or any interference with the efforts of the will, so far 
as can be discovered. This does not show itself at the time the injury is in- 
flicted, nor until the patient has to all appearance recovered from the imme- 
diate effects of the wound, attention being then drawn to it by the inability 
experienced to flex the foot. This also, if neglected, slowly and certainly 
terminates in complete talipes equinus, the inherent motion of the ankle- 
joint remaining unimpaired. 

Rheumatism is the next of the causes mentioned as producing this defor- 
mity, as well as many other non-congenital deformities, as I shall have to 
mention. Contraction, when arising from this cause, is found to commence 
during the active stage of the disease, and seems to be produced by the in- 
stinctive efforts of the patient to keep the joint at rest. The gastrocnemios 
muscles are thus kept in a state of constant contraction, and the flexors of the 
feet, by the same efforts, are kept constantly relaxed, by which all motion is pre- 
▼ented, and the pain attending this affection is of course thereby mitigated or 
greatly relieved. The extensors become, therefore, permanently contracted, 
which is not discovered until the patient is able to stand or take exercise, 
when the heel or heels are found to be elevated, with total inability to flox 
the ankle-joint. In these cases, the integrity of the joint suffers by thicken- 
ing of the synovial membrane, or greater or less alteration in structure, of- 
fering an obstinate resistance to the restoration of the natural position of the 
foot, even after the resistance of the contraction of the muscle has been over- 
come by the operation ; and even after the foot is restored to its normal po- 
rtion, great difficulty is met with in the endeavour to restore motion, requir- 
ing the most unremitting perseverance and attention. The muscles or nerves 
themselves do not appear to suffer beyond the contracted state of the gas- 
trocnemius, neither during^ the attack, nor at any period subsequent to it ; 
for, after the removal of the contraction by operation, the voluntary powers 
over the muscles remain unimpaired. In fact, the deformity may be said to 
be produced by the exercise of those very powers, as we know the less a 
joint attacked with rheumatism is subjected to pressure, the less painful it 
is, and it is only by preserving the extended position of this articulation that 
this object can be attained, inasmuch as the astragalus is kept very nearly 
out of the articular cavity. 

The next cause is Scrofulous Disease in the Joint or its neighhourkood^ or in 
the Muscles of the Calf or Tendons of the Leg. Here, again, the instinctive 
efforts of the will are the remote cause, and the cicatrix or cicatrices the 
immediate cause. Many patients have applied with disease in the neighbor- 
hood of the ankle-joint, producing effusion into the joint by irritation or in- 
flammation of the synovial membrane. The joint is kept by the patient per- 
fectly passive in the extended position, hence, again, arises contraction. 

In some instances, all the muscles surrounding the joint are kept in a state 
of active contraction, even with the very slight symptoms of disease : so 
much so, that upon examination you would be led to suppose that they were 
all permanently contracted, for you can neither flex nor extend the foot, 
which disguises the real nature of the case. This is also occasioned by the 
efforts of the patient to prevent motion of the joint in walking. A person re- 
cently consulted me respecting his son, a boy aged eight years, in whom 



SURGERY. 

' iht5 ccm^Hioa of the muiacles existed, Tvith verj h light «*r©ilinpf d? the joint* 
Upon examination, no truce of motion eould be discovoreilt from the es- 
Irenie rigidity of all the inusoleH .iiurmundiug the joint, I ordered iib^oluto 
rest, tiio li?g Uy be kt^pl in ft horizontal posture on n conch — poullicos and 
warm covorin^a to bo applied to the Hmb* In five weoka, the mnacles re* 
iumed tiieir pniisivo contlition, rendering the cauae perfectly evident, viz., dis" 
Lthe joint. 

important that this peculiaritj in connection with the diseaBC ihonM 
Ofae in mind, as at first aigbt jou might bo indnced to divide the ten- 
I dons, which would remore the rigidity of tbe muscles undonbtedlyr but that 
I effect would be but temporary ; for as soon as the patient used the foot, the 
diiease would again become a source of pain and irritation, and a second 
eon traction inevitably result. It illuet rates, however, one mode bj which 
contraction of the muscles takes place, yi;^,, that these constant instinctive 
efforts of the will, if not relieved early in the attack by local and general 
treatmenti terminate in pennanent contraction. Buob a case occurred to me 
tnnny years since, in a patient nged twenty years, who had suffered horn 
cbildbimd; and in this case I was compelled tn divide every tendon eur* 
rounding the joint, with tho exception of the flexorii tif the toes. 

When scrofulous disease affects the joint itself, a pernianently stiSTened 
condition of the joint must be the result. You can, however, keep the foot 
«t right angles during the time the restorative prueess is going on, and 
thus semiTO the position mont favourable to the patientt I have bad many 
eases (young patients) in which the most fri|;hlfal di&ease existed, affecting^ 
the articulation, and in some the metacarpal bones, in which amputation haa 
been recommended* all of which have yielded to treatments and have been 
cured of the disease by rest, warmth, attention to the diet and general healthy 
occupying, it is true, from two to three, and even four years* I mentloti 
this, in order that you may be indnced to hesitate before you condemn the 
limbs of youug patients to arnpntntion^ us is too commonly done ; for, from 
nn exppTience of years, I am ccmvinced that it is an unnecessary step* — 
Brkish Med. Jourfial^ Jul^ 7, 1800, j^* 515» 



61.—^ New Trephine.— Dt, G* A. D. Galt* of Virginia, United States, 
has devised a new trephhie, with the object of avoiding injury of the mem- 
branes or subj^tance of the hrain. Tbe instrument consists of a truncated 
cone* with peripheral tooth arranged in a spiral direction, and oblique crown 
teeth* When it is applied, tho peripheral teeth act as a cutting wedge, so 
long as counteractbig pressure acts on the crown teeth ; on removal of that 
pressure by the division of the cranial walls, its tendency is to act on the 
principle of a screw, but, owing to its conical form and the spiral direction 
of the peripheral teeth, tbe action ceuses* Dr. Gait says that be has ope- 
rated fin the dead subject with it twenty times, and has never succeeded in 
wounding the membrane, although he mideavonred to do so* The editor of 
tbe *New York Journal of Medicine,' in noticing tbe instriunent, says that 
it has been examined by the members of the surgical section of tbe New 
York Academy of Medicine, and has, after repeated trials, been found fully 
to answer the design of the inventor. The instant the crown teeth cut 
through the internal table, all action ceases, and it is impossible to turn the 
erowm,— British Med* Journal, June 16, 1&60, j?* 458, 



flBGASS OF CIBCULATION. 

e2.-KEW MODE OF MAKING PRESSURE IN POPLITEAL AN- 
EURISM. 

By Dr. MavfiTT. 
Dr, Moffatt thus describes an apparatus for making CompreBsion in a po- 
pliteal uueuriam, which Is a modification of one already employed b^ \>x 



156 SUBGEBT. 

Foantain. ** In a few mintiteB, with the aid of a carpenter, we erected a 
structure consisting of a stick of timber about four inches in thickness bj 
eight in width, one end of which was secured to the top bj an upright post 
of the same dimensions. This post was fastened firmlj to the floor, and 
lashed to the iron cross-bar at the head of the bed. It was about six feet in 
height, and bevilled at the top to receive the stick first-named, these being 
firmly nailed together. The largo piece of timber, about twelve feet in 
length, rested at the lower end upon a strong table placed at the foot of the 
bed, thus forming an inclined plane over the bedstead placed lengthwise be- 
neath it. The patient was then placed upon the bed in the supine position, 
with his le^ slightly flexed, somewhat everted, wrapped in thick layers of 
cotton, and placed in a long fracture box. A compress mado of adhesire 
plaster wound tightly into a roll about an inch in length and three-eighths of 
an inch in diameter, was then placed over the femoral at the inferior ancle 
of Scarpa's space. Upon this rested the lower end of a perpendicular 
piece of wood, about an inch square, the upper end of which was bevilled to 
meet the inclined plane before described. The pressure was commenced at 
eight in the morning. Its degree was regulated by drawing the upper end 
of the perpendicular down the inclined plane, to a greater or less extent as 
might be required. The hand of the operator was kept upon the stick, and 
thus secured an equable pressure, even though the patient moved his limb, 
as he sometimes did a very little. A second compress and upright were 
placed over the artery as it crosses the horizontal ramus of the pubes, and 
when the pain from pressure on ono was too great to be home comfortably, 
the other was used ; and thus alternately pressure was kept up until ^ve in 
the evening, when pulsation could no longer be felt in the tumour. Mode- 
rate compression was kept up for eight hours longer, after which the pa- 
tient was kept for several days quietly on his bed. The gpreat simplicity of 
this plan of compression, which is always available must be palpable to 
every one. That it is far easier for the patient, and unspeakably more bo 
for the operator, cannot be questioned. It would also seem reasonable to 
infer, that the compression itself, made but at one point, is more uniform and 
certain than has yet been secured by any other method." — American Med. 
Times. — Brit, and Foreign Med.-Chir, Review^ Oct,, i8G0,p, 547. 



63.— ON THE TREATMENT OF ANEURISM FROM ANASTO- 
MOSIS BY EXCISION. 

By Olivbb Pbhbibtos, Esq., Surgeon to the General Iloepital, Birmingham. 

[The means of treatment selected in the hope of curing ** aneurism by an- 
astomosis" may be resolved into three well-marked divisions. These are:] 

1. Endeavours to alter the intimate structures of the tumours, so as te 
render the further development of the arterial network well nigh impossible, 
and at the same time to promote its destruction and absorption. 

2. The deligation of the principal arterial branches that are distributed 
within the tumour itself, or of those main trunks that immediately give off 
the branches that nourish it and pass about its locality. 

3. The excision of the disease. 

The first division comprehends pressure, the use of refrigerants, of cans- 
tic pastes, the injection of astringent fluids, and the introduction of setons 
and of needles with the view of exciting suppuration. Without, here, more 
particularly inquiring as to the value of compression, refrigerants, caustics, 
and the injection of astringent fluids, it may he oflirmed that each one of 
these methods will prove of great utility in certain cases; these will, how- 
ever, be found to be characterized generally by their comparative insigniii- 
cance in size, and by their situation on the more solid textures of the frame. 
They appear to me altogether inadmissible in a case like that which I am 
about to relate, as their exhibition could only delay the attainment of the end 
in view. On the other hand, the introduction of setong, of nomeroos ju&gle 



SURGERY. 



tbronds, of neodles* and ligatures, with the view of pxeitiug gyppuration, or 
other means i.>f trentmont liiivhig sitnilwr iibjc^cta tt> uitain — nil thftsu will lie 
eiiimentij useful, cvoa should iht^y full fclmrt of effVctrng a comploto t3ure of 
tjj*^ JiseiLse* The exuiti^jnent nf suppuration lu all parts of one c^f tUuse 
vascular growths canuul fail In chaugiiig cmiipletelj the nature of its struc- 
ture ; so that sliould iLhsorption of the now alttjred tissues bt% from its size, a 
tntittor of ioiprohalnlitj, at least one great danger— that of hemorrhage — 
k absent, &ud other steps t^i Insure iti removal can now bo udoptt'd in 
siifi?f.y* 

Ot' all the tmnle* of treatment devised for the relief of this foroiidahl© 
dtsea^e, perhaps noni) have jrei^uUed in so great disuppointrnent as that in 
which thi^ ligature of either the main arterial trunks, or their brnneheg snp* 
pljing tho tufoour, has been accomplished. The return of blood into the 
disease in nmny instances occurred ai certainly as the fiow through the main 
channel was cut off, and where the only branch yielJing a ssiipply was ap- 
parently arrested, a now one, ere loDgi was found to have arisen near the 
same place. An exception, however, to this result, as will be aoeo, must be 
made iu favour of those tumours situated in or near the orbit. 

Of forty-five cases, in which the ligature was applied, either on the 
branches or the principal trunk, the following results were obtained? — 

In ten of these cti^eg the bmncbes were ligatured* Of the patients who 
were submit ed to this treytmei*t not one was cured! 

In tin rty -five the prlucipal trunk was tied. Of this number, fourteen 
were curedi ten dieil, niuc were u unsuccessful, and in two the rf*sult was im- 
perfcotly given. Furthei^ in reference to situation, of these thirty -five* six 
oa^ee were tujnours in the orbit ; of these, five were cured, and the sixth wtia 
reported as being imperfectly so. 

It woulJ appear^ then, from these observations* that the ligature on tho 
brunches hasaltogelher fiiiled, and that where the principal trunks were tied, 
»! access was only remarkable when tho tumours were within tho orbit. 

With such evidence of the danger aiid uncc rtfiiuty attending this practice 
in the treatment of these diseat?e,s under wlmt cireumitances, iet us inquire, 
are wo justilied in resorting to it! In the first place, tho tumour must be 
fiufficiently fonnidabic as to endanger the life of the patient, should its fur* 
tb(tr increase be unavredted. Secondly, to check liemorrhage. Lastly, with 
the view of preparing the tumour to undergo, in comparative safety, the 
most certain of all remedies, (where its situation renders it practicable,) the 
excision of all the parts entering into its foravation. 

The excision of tlie structures constituting aneurism by anaRtomosia, teema 
to have irnpret^aed, in a very strcmg degree, the minds of those snrgeouii 
who first directf'd their attention to its relief, "You must not cut into it, 
but cut it out." This was the opinion held by John Beil, and be vigorously 
and succe.^s fully illustrated its value, J. L. Petit held the ^auje doctrine, 
expressing it in the important caution that the incisions should be made in 
tbe sound tissues, where the bloodvessels were unaffected- 

George Freer, who pubtished his "Observations on Aneurism," in IB07, 
Jind who added a lustre to his connexion with the General Hospital in this 
town that has never been surpassed, by being the first to succeB^ftiily tie the 
extt^rnal iliac artery for the ^ure of femoral ancurii^m, also was impressed 
with the importance of the total removal of these growths with the knife. 
He records two casesT in which the disease was situated in tho cheek, where- 
in the treatment by excif*ion was attended by complete Biiccess. 

More recently i^urgeons have been content to regard tho operation by ©x- 
tjrpalioo as the means uf treatment that should be adopted whun all others 
have failed. There are no records of late years, that 1 am aware of, of 
cases where this mode baa been resorted to in the first instance ; and yet 
there arc many instances where such a course would have induced far loia 
suffering, and would have placed even life itself in mnullor perlL Thus Ne- 
kton relates, that M. Musscy, for a relief of tho fungus of the head, tied 
both common carotids, but was after all obliged to havo recourse to excision, 
and euced his patient. 



109 SUBGEBT. 

Dr. Warren's case also (American Joamal of Medical Science, 1846) may 
be perused with advantage, as it shows that however necessary preliminary 
treatment may be ere incision can be ventured on in safety, it yet must coma 
to it at last. The tumour, in this instance, was situated on the forehead, 
and was three inches in diameter : after repeated applications of needles and 
compressing ligatures to the arteries in the ncigbourhood of the disease, to- 
gether with the use of caustics, the cure hod to be completed by excision. 

This excision, or complete extirpation of the diseased structure, need not 
of necessity be carried out by the knife. Sir Benjamin (then Mr.) Brodie 
e£Pectually accomplished it in the case of a tumor similarly situated, and 
which had resisted all previous efforts at cure, by means of ligatures so ap- 
plied around steel needles, that complete strangulation was produced at its 
base. (Medico-Chirurgical Transactions, vol. xv., p. 177.) The situation, 
however, of the disease, must be the main guide to the selection of the mode 
by which it shall be thus entirely removed. 

We are justified, then, in arriving at the following conclusions which may 
regulate our surgical treatment of these cases : 

a. To cut out the parts containing the vascular structure as speedily as 
possible. 

When the lips are the seat of the disease, this proceeding may, in some 
instances, be adopted, to the exclusion of all other modes. 

h. If this excision cannot with safety be accomplished in the first instance, 
when the disease is otherwise situated, owing to the dangers of hemorrhage, 
or the prospect of too great disfigurement, the branches of arteries leading 
into the growth should be tied subcutaneously by needles and ligaturesf 
whilst the intimate structure of the disease may be further altered by the in- 
troduction of numerous double threads, in the way I have described. 

Should the situation be altogether unfavorable for the use of the knife. 
Sir Benjamin Brodie's plan of strangulation at the base should be adopted. 

By whatever mode, however, the vascular character of the growth is mo- 
dified, let this change only be desired in the hope that one or other of the 
means of extirpation I have mentioned may be carried out. — Lancet^ May 
26, 1860, p. 516. 

64.— CLINICAL REMARKS ON VARICES, &c., AND THE BAR- 
NEEDLE AND CLASP. 

By Jamxs Stabtiv, Esq., F.B.C.B., Senior Sargeon to the Hospital for DlaeaMs of the SUn. 
Shortly before Professor Simpson published his papers on acupressure, 
fr. Startin, was expeiimenting as to the treatment of varicose veins. He 
used a tubular needle, through which, having passed it around and behind 
the vein, ho introduced a strong wire ligature, and then, withdrawing the 
needle, left the wire in situ. Over this, a piece of gutta percha or metal 
was twisted so as to compress the vein and cause its obliteration. On the 
introduction of acupressure, Mr. Startin says,] 
I immediately saw its adaptation to the end I was endeavoring to aocom- 

flish by the tubular needle, and forthwith constructed a needle from a No. 
9 knitting- pin,* which I employed with such marked success as induced 
me to get the instruments which are before you, made by Messrs. Savigny 
&Co. 

They consist of six or eight inches of No. 19, 20, and 21 steel wire, prop- 
ly tempered, so as to bend and yet break short when required; one end be- 
ing ground to a triangular point, and bent into a curved form of different 
sizes, to the extent of two or more inches of its pointed extiemity, so that 
the needle represents a sickle with a long handle, the curved part being con- 
structed to pass under and around the veins, the other straight portion or 
stem to form three or more bars. The point of this needle should project 
the sixth of an inch above the wire of the stem, and, as before said, the tern- 

'Aajr ordinMry wcxrlrmaii eaa oonvert them needles into the baiHseedle, the nnmhen to be em- 
ployed being Not, 18, 19f 20, Aod 2L They will aflerwudA ie<\olre to be proptrlyltemperefL 



SUEGEEY, 




BAR NEEDLE 



pi^r of tiiD atcel rcquiFcs to be regulated so as to permit it to bond, and yet 
Ureak short if pressed against any solid rdslstuig body, as tbo pair of furcepir 
aho iibown in tbo diagmni, I JmvQ found aome difficulty in obtaining the 
eiact tempered steel required, bo that were it not better to avoid a multt- 
plicity of instruinent^t it niigbt be preferable to diri^et tbo needle to be made 
aoft (»naugb to be divid**d at the required place by cutting nippera ; if tiuch 
cuttmg portiiin oould aot bo added to tbo present foreops. Those forcepfl, 
yon will observe by the diiigrumt somewhat resemble the ordiuriry tootb-for- 
cepa, save that their descending blades are made to fit accuratcdy by plain 
aurfaces, excepting where two grooves cross them at acute angles, one of 
which grooves is to hold tlxe needle for inaertion beneath the vein — the other 
fur withdrawing it when its point has passed the skin. 

By reflecting on tbo i^bape of this needle* it will be seen that when its 
cnrvQture ha^ passed the voin» that iti* straight portion will coxMpreii th« 
pajrt to which it is applied with considerable forces which I have practically 
found quite suffieient to tutercept the flow of blood through the vein and 
iecuro the obstruction of the vessel iti all cases where much adipose tia- 
sue is not preeeut, or where the vein is of medium sbo only ; but, in the 
#vent of either of these occurrence*! or indeed, in many instances, for ad- 
ditional security during the first ten or twelve hours* I have latterly used tbo 
second part of the contrivance* which I have called the Clasp. This ct^nsists 
of a piece of tinned iron*wire, varying in length and strength to suit thu 
carvature of the needle and consequent length of tlio bar employed and left 
beneuth the vein. One end of this clasp, as seen In the drawing, c^iOKistN 
of a ainall circular ring or eye, and the other of a hook of corresponding 

1 have now, I fear not too intelligibly , described the Bar- needle and Clasp, 
a aimple, yet, 1 believe, moat efficient apparatus* which, if I mistuke not, ir 
destined to occupy as wide a sphere of utility in surgary as glycerine— ivn 
iotraduction of mine sixteen years ago — has held in therapeutics \ ^^^^i ^\» 
-^^^le 18 doubtless applicable to ranous other p\iipOi%% t\!kAXk ^<i:i%«t vz^- 

XLIL—II 



I 



laS 8UBGEBT. 

It mar be mentioned that this instrament seems to be adapted to the treat- 
ment of aneurism by arterial compression ; to the operation of the radical 
cure of homia for closing the ring; to the treatment of many forms of 
Dsevus; and as a readily applied tourniquet, cither before operations or after 
arterial wounds, or hemorrhage. In the latter instance I have once success- 
fully employed it, — viz., in the case of a schoolmistress residing at Peck- 
ham, who is suffering from fungoid tumour of the breast, from which she lost 
a large amount of blood daily, reducing her to a hopeless condition ; three 
bar-needles, introduced at different parts of the base of the breast, and the 
clasp applied, have not only arrested the bleeding, but have produced a 
sloughing of the diseased mass, thus conveying a hint which, when a more 
favourable case offers, I shall not fail to turn to account. I have also used 
the bar and clasp with success, instead of Professor Simpson's wire seton, 
in hydrocele. 

Little more than a month has elapsed since I substituted this apparatus 
for the tubular needle and wire ligature in the treatment of varices, and I 
have already employed it in nearly thirty cases in public or private practice 
with a degree of success which has followed no other treatment with which 
I am acquainted, as the examples about to be cited will testify ; but, to pro- 
vent disappointment, let me earnestly request those who adopt my sugges- 
tions, to take especial carathat no complications exist in the cases selected; 
but that varicose ulcers and eruptions, and varicose veins, pure and simple, 
are alone to be considered amenable to the treatment recommended, and that 
any specific or other cachexy will render the procedure worse than useless. 
I must also beg it will be remembered that as yet I cannot decidedly pro- 
nounce on the effects of the bar and clasp upon very deep or chronic indurated 
ulcers, such as run the round of the London hospitals, and nearly environ 
the limb; nor has sufficient time yet elapsed, nor have my applications of 
the instrument been numerous enough to enable me to speak with much 
certainty, upon its ultimate effect upon varices, and very chronic varicose 
isruptions, with much cutaneous hypertrophy; such cases, however, will 
claim my early attention, and a record of the result in future clinical re- 
marks. 

The following is the method employed in operating with the apparatus 
above described: — The patient being placed in a good light, with his limb 
upon a chair, the bar-needle is to be seized by the forceps, near its curva- 
ture, taking care that its stem rests in the horizontal «:oove of their blades, 
its spare portion passing between the handles of the forceps so as to bo 
grasped with them by the hand of the operator, as seen in the diagram. The 
point of the needle is then to be raised with the hand until it becomes nearly 
perpendicular to the spot at which it is to be inserted, when the needle is to 
be depressed so to occasion its curve to pass deeply behind the varicose veins 
and the smaller dilated plexus behind it, when a little pressure with the left 
hand on the place where the needle projects on the opposite side of the vein, 
will occasion its point to pass through the skin, when it is to be grasped by 
the forceps, and a little pushing with one hand and traction with the other, 
will bring the stem of the needle into the position it is to occupy, t. «., within 
two inches or thereabouts of its blunt extremity, so as to allow half-an-inoh 
or more to project on each side of the vein, as shown in the diagram. This 
portion of the needle now requires to be broken off, which is readily done if 
the steel be properly tempered, by taking the needle's stem between the 
blades of the forceps, half-an-lnch or so from the point at which it first pene- 
trated the skin, when pressure from the left to the right or from above down- 
wards, made by moving the curved end of the needle, will break off the stem 
at the desired point, and leave the bar behind the vein with about half-an- 
inch projecting out of the skin on either side. The clasp is now to be ap- 
plied, if required, (see diagram,) by passing its ringed extremity over (me 
projecting side of the bar, carrying its middle portion, previously bent to fit, 
and yet gently compress the parts across the vein, when its hooked extremi^ 
may bo passed behind the other projection of the bar, and the whole appan- 



SUBGEEY- m 

ttts becomes firmlj fixed like the pin in a broods Bj tins procoJure, of 
courseT all .'irculn-tifm in the vein ia arrested^ and a eon^ulum forma on both 
sides of the haXr witich may be rendered more or less peimzinent by retaimn^ 
the bar a bniger or shorter time. 

In my fir&t essays witb tho ttibukr tiaodle* four* five, or six dnys were the 
periodtt adopted for ket^iitiig tho Ugiiture hisfirtod; but Interally I hava 
found fifty to siity liours t^uite safficicnt, whotltor in the? ca&o of an ulcor^ 
eruption, or simpio Tnriji, though ttie laat roquiroa tho Umgos^t insurtion of 
the needltj, 

■ A^ the modus operandi uf tho bar-needlo upon an ulcer, is to check tery 
materially all secretion from it* surface, f^ that it may he said to dry up, I 
have founil the most suitahle dressing^, us ita^sitsts in tfiia drying process, to 
be hiottiug-paper» which I fold into a thick compress and wet with water, 
and apply directly to tho fi(*re, the pad heinc Iftrge enough to cover all sur- 
rounding inflammation; this \h secured by the dt>mott bandage before men- 
tkmed, tiie bar-needle being covered with a piece of lint or adhesive plaster, 
and left between two of tho turns of tho bandage, winch enables tho clasp to 
be taken off the bar, without disturbing tho dressings, should it cause puln 
ttfCer ten or twelve hours; and it is perhaps prudent, as a rule, always to 
ftltend to Ihi^ point* as otherwise the wire may cut the skin, and make* 
while It curo», a wound, tlitkUgh this may be obviated by a pad or plaster 
under the claap. 

The h lotting- paper drensmg and tho bar may remain forty, fifty, or si^fey 
hours, when the needle must ho taken out, and the tdcer dressed ngaln aa 
before described, taking care not to remove any portion of the paper which 
may adhere to the uleer, as this forms an arUncial £Cab, which favours tUo 
healing proccj^i. 

If the ciiao bo a varis or varicose eruplion only, all that will be necessary 
wil! bo to apply the wet pad of blatting'paper over the site of the needle, 
and afterwrrds roll the limb with the domett bandage, which alr^n may be put 
OD wet with warm water, if pain or inflammf^tion be present : and the erap* 
lion itself may bo painted with the calajnino and zinc lotion of the Hoapital 
Fharmacopteia* 

Any subsequent uneasiness in the limb or parts affected, may be moder- 
ated by passing a compress wet with tepid water around the banda|»-ei and in 
YHij irritable patient:^ the clasp may bo required to be removed after a few 
hoitri. My own experience of this matter leads me to believe that as far wa 
have yet (*one, the treatmejit of varicose ulcer, pure and simple, is reduced 
from weeks into days by this operation. — Mcdkai Times and GazeiUf Mm 
m, J8G0, IK 517, 



ALIMENTARY CANIL 
65.— A NEW METHOD OF OPERATING FOR HARE-LIP. 

r Bfiv^nD WolKKi, jaa. Ecq, Laton. (Read befDn the South MidJiind Hmncli BrilUh MeillotI 

[There are some inconvenjenee attending the ordinary operation for hare* 
jp ; thuF, the pins are iiable to cau^o ulceration, and additional support i< 
"requently requtredn, to keep the edges of the wound together.] 

1 he following plan has arisen out of a consideration of the desiderata whielt 
1 iuccessful operation for hare- lip demands. Briefly stated, these are — 1, ta 
■upport the opposed surfaces <^f the wound so thoroughly that any amount of 
eoBtortion on the part of the patient will not interfere with the adhesive 
process: and 2, at the same time to secure so accurate an adjustment of the 
Bkin that when the cure is completed, there shall remain a minimum amount 
of oicittrtic* 

In tho operation now proposed, these objects are aooomp\\s\3t«4 Vu ^ t«iTf 





IR BUEGERT. 

ginipletr>niiiier,hy substituting silver 
wirf?s nud splints for the steel pinn 
tod silk in ordinary nac^ The wirvs 
buing introduced, u f^plint of the 
ftijse and «hapR of that rejirc^^onted 
ki the drnwing, is ftlippod along tUeir 
projecting ends on each side by 
fneans of hides just I urge enough to 
iidmit the Tvire5, and cnrricd liome 
to the cheek, at the s]>ot where the 
irirei* were inserted, Tho ends of 
the two wire» on each side are now 
twi^todo utside the splinti wliich thus 
serves as a point d'appuu from which, 
at every additional twiati the ap- 
proximation of tho edges of tlio 
wound ia made more perfect. The 
chief point to he observed is to in- ^~ 

■ert the wires ftufficiently far Imck to form a firm support to the wound; and tbii 
can he done far more safdy with metallic wire than with (iteel pins, as the 
Ibrmer, by adapting itself to tho shape of tho mouth, causes no painful ten- 
8ion# as do tho pins when very deeply inserted* At the samo time, so 
•Seetual ia the support afforded by traction on the spliutj?, that no additional 
aid for this purpose, such as adhesive straps, spring 'trusses, Arc, is requi- 
site, even in the most formidable eases. By this immunity from tension* 
the tissue! are enabled to display their well known tolerance of metallic sub- 
fttancep, in consequeiico of which the wires may be retained for an itlmoat 
indefinite period; whereoB, from the oftentimes early commencement of 
ulceration when the less yielding y>lns are employedi these may have to be 
removed before union is complete. 

The cut surfuces having been approximated as closely ns maybe considered 
advisable by twisting the wires, the line of incision remains still uncovered ; and 
the second condition of the operation may now be accomplishedby theinser* 
tion of three or more delicate silk sutures very superficially. By this means, 
the most perfect appoBition of the edges is obtained, and in consequenee, aa 
regards the final result, a very slight scar^in some eases all but impercep* 
tible— remains. These suturen should be removed within twenty-four hours* 

When the operation is complete, the appearance is much thnt represented in 
the accompanying drawing, where the actuiilsijse and shape of the splints are in- 
dicated. The followiagcase may illustrate some undefined points in the opera- 
tion. 

Casr.. — W» M., aged 19 months, was the subject of congenital hare-lip; 
the cleft, which extended to just within the nasal orifice, being to the left of 
the median line. The usual incisions having been made while under chloro- 
form, the wires were introduced about two- thirds of an inch from the line of 
incision, and made to pass out at a similar distance on the opposite side. 
This wna done by attaching each wire to a piece of silk connected with a 
straight needle, sufficiently large to admit of the silk, with the wire attached, 
being drawn throu^b after it, (This mode of introdncing metallic wire an- 
swers perfectly well when the hollow needle for tho purpose is not at hand, 
care being taken that, where tho wire Is bent down for the attachment of the 
silk, it ia ^queejsed together with pincers that it may present as small an ob- 
stacle as posKiblo to the passage of the wire at this its bulkiest part.) The 
ends of tho wires to which the silk was united were then removed with scis- 
sors, and a splint passed aiorg them, a twist being given to secure it. The 
other two were then similarly treated ; and by alternately twisting the wires 
of opposite sides with a pair of ordinary pincers, the splints were first 
brought to lie upon the cheek, and then to approximate tho edges of the 
wound. Three superficial sutures were now introduced, and the integument 

us accurately adjusted. Adhesion took place rapidly, and in the course of 
nty- four hours one of the superficial sutures was removed. The child, 



^ 



SURGERY, 



l^which hnd not bopn weaned, sucked well, and appeared perfectly free from 
*. pajB QT \iXk&a.sluess* 

nThe following inj^ tlie other superficial sutures wort 
tukeft a\v4iy. On the fifth dny, uiikm apjioared perfect. 
mid the apparatus was removed; Uy snipping the wires of 
one side* and takiDji; off the splint, that of tbo other with 
the wires attached was readily withdrawn. 
The resultji of thii^ luid subsequent eases, as seen sotne 
months iiftor the operation— tho traces of the original de- 
forrnltj being less than in the niOi»t euecessful instances of 
the ordinary mode of operating — may I vonturo to thinly 
claim for it the attention of lliose who are inte rested m 
plastic surgery. — British Mfd. Jmtrnah Aug, 25, J 860, 
p. tilMI, 



CiG, — Chia Convenient Needle for the Eeady Application 
qfMeluliic futures in ike Operations t^ Clef t Palate, f^tsi* 
eo' Vaginal Fistul^^ ^t. By P. 0, Tjuce, Esq., Surgeon 
to the Great Northern Hospital. — Those surgeons ivho ar« 
engaged in the renovation of deformities arising from 
arrest of development — such, for instance* as the de- 
ficiency of the soft portions of the roof of the mouth In 
what l^ conHnonly known as cleft or split palate ; or in the 
reparation ot* breaches of structure, as those resulting m 
permanent lesions of the female bladder* vagina, and reo- 
lum* — linve often doubtless experienced the necessity of 
*tuch mechanical instrument!* as would enable an easy per* 
foruianee of an operation^ Improvetnents Id such necessi- 
tous instruments have by degrees been added to the opera^ 
tor's iirmunienlanum; but still every addition seems to 
show the further nccesfiity that exists for yet more useful 
mechnnical aids. Since the introduction of metallic sutures 
(so ably and forcibly recommended by Dr. Marion Sims) 
for the more efficient closure of the structures of the blad- 
der, vagina, A:c., the want of a suitiiblo means of appliance 
has been more than over needed. 

The ordumry curved needle set in a handle, and drilled 
with a single hole near its potntt is found inconvenient, for 
great difficulty is ejcperienced In disengaging the mctalllo 

Ui tliread with which it is armed. To obviate this inconveni- 
1 ence, among other contrivances, a needle was invented by, 
1 I believe, a <|erman, with a movable point, but still further 
perfection and simplicity was needed. A short while sincet 
Mr. Sf^irtin, in the oolumns of this Journal, suggested the 
use of a tubular needle, which waij a decided improvement, 
ad one that was quickly recognised* Stilh however, there eeemed room 
or Q more complete instrument to enable a free and ready application of the 
rire gat ure ia cases rendered unusually difficult of managuuiont by reason 
»f the positron of the lesion, &c. 

While lately witnessing one of Mr, Baker Brown's skilful operations for 
teslco- vagina I Rstula, I w^s struck with the inconvenience that resulted from 
the method of applying the metallic suture ( winch, iu this instance, required 
an extra pair of hands to arm the needle after its insertion through the solt 
tissues) by means of the ordinary grooved or tubular needle, lo dispeneo 
vith what I consid*^red an impediment in these usually scientific and clever 
operations, I have devised the needle as shown above. 

It consists of a tubular needle, PUch as at first suggested, I believe, bj 
Mr. Startin, set in a wooden handh:?, but immediately connected therewith by 
ii rod of metal, which is out of tlie plane common to both tUe uftc4V*i ^\A\\a 



]« SUBGIBT. 

hmndle. Working on the upper sorface of ihe handle is a steel slide with a 
forward and backward movement. At the front end of the slide is a oatch- 
spring, regulated by a small screw-button. The arming of the needle is 
thus accomplished. The slide, having a moving range of an inch or an inch 
and a-quartcr, is to be drawn as far on to the handle as it will go ; one end of 
the metallic thread to be used is then inserted into the needle at what may be 
termed its breech, and pushed along the tube till it nearly roaches the point; 
the portion of the wire that projects at the breech is then placed in the 
catch-spring, and the needle is ready for use. 

Having inserted the point, and as much of the needle as is necessary, 
through the lips of the structure to be closed, the wire is made to project 
beyond the point of the instrument (as shown by the dotted line in the en- 
graving) by pushing forward with the thumb or forefinger the slide. The 
projected wire is now caught with a pair of forceps, and disengaged by 
pressing with the forefinger the button-head which regulates the catch- 
spring, so that it can be readily and quickly drawn from the needle, or the 
needle from it. 

The instrument is depicted about two thirds its proper size, and was made 
for me by the well-known surgical mechanician, Mr. Matthews, of Portugal- 
street, Lincoln's-inn, and has been much approved of by Mr. Spencer Wells, 
and other surgeons who are in the habit of performing certain plastic opera- 
tions on the perineum, 6cc. In clcft-pAlato, as woU as in operations about 
the geni to- urinary partp, this needle will bo found very advantageous, and 
will at once render the passing of metallic threads through the curtains of 
the soft palate a less complicated proceeding. It has been my good fortune 
to have assisted for many years my friend Air. Fergusson in nearly all his 
numerous operations for split palate ; and although his master hand makes 
perfect in utility incomplete surgical instruments, still I have occasionally 
met with instances in which a more ready appliance for the application of 
the wire suture (which this distinguished surgeon now usually employs in 
his palate operations) would have been of much advantage. — Med. Times 
and Gazette, June 9, 1860, ;?. 574. 



67.— ON THE REDUCTION OF STRANGULATED HERNIA. 

By Walter Jissop, Esq., Surgeon to the General Hospital and Dispensary, Cheltenham. 

flMr. Jessop publishes what he thinks a new method of reducing hernia. It 
8 a good yfity^ but not a new waj. The case seemed almost hopeless : an 
operation was refused, and Mr. Jessop then adopted the following plan :] 

Calling a male attendant into the room, I directed my patient still Iving 
on his buck, to the edge of the bed, and, with assistance, separated his legs, 
placing one over each shoulder of the attendant, who, facing the bed, 
stooped to receive them ; and, in this position, by passing his hands round 
to the fore part of the thighs, was enabled to obtain a sufficient purchase to 
permit of his raising him on to his head and shoulders on the bed, thus 
throwing the intestines back upon the diaphragm, and to some extent neces- 
sarily making traction behind and directly from the seat of strangulation. 
After two or three minutes* manipulation of the abdominal parietes, I found 
the tumour become less tense, ana drawing forwards the integuments round 
the point of rupture, I made lateral, upward and downward movements — 
jerking, as it were, occasionally the parts immediately contiguous to the 
stricture. This seemed to excite but little suffering ; in fact, me patient, so 
fisr from uttering complaint^ declared himself, after the first two or three 
minutes, decidedly relieved — that ** the dead sickening weight that killed his 
ffroin," as he termed it, was better. Continuing these efforts, and varying 
Uiem as they seemed to occasion distress, I presently felt a slight gurgling 
under my hand, and almost immediately had the satisfaction of finding the 
hernia reduced, and my patient comparatively in a state of safety. 

The whole proceeding certainly did not occupy ten minutes. Slight peri- 
toneal tenderness ezist^ for some days, but the man eventually did welL . 



StJEGEUT* HI 

The rafitmale of th« prrffnis(*d pUn is simple. A mnns* largo or small of 
iifiplnced jiiteBtinG or omentum mue^t n^s^iiredly be more readily withdrawn 
[ft-om iti? point of iiionrc(*raUon or »tranR:ulatimi hy trtxction from bphhid than 
Ifcy tlio be^t-diroctpd efforts of thp tuxi^* Any one, for ill ti^tratioti^ taking 
[tlje trotiblo to put a fold or two of hU lmndk*>r(']ii(*f m t% ring formod bv Itii 
J fioijer nod thunvk and li^litlj Btran^uluting it. will* on niUnnpitng trt return 
lit by pushing or kneadinj^ from before buckwardsT Imd infinitely j^rontcr dif- 
yfictilty in eflTectinprhis purpose than if he were to nmk*^ trHction fn*ni behind. 
] in ftliort, the employment of tbe tdKVA In at the beet a ehmiFy and most un- 
I certain mode of proceeding, and I fthali vi^ntur© in future to make it merely 
[ luppleujentary to the plan I now advocate. 

" One swallow fiiils to make a fiumnier/* and It may be said tliat the ptao- 
[ tice of turning patients a jmstiriori upwards is opposed to all oilhodojE no- 
tions* of propriety* Admit all thie. Others, with greater opportunities, may 
happily bt4 enabied to ndd to my sinj^le case \ and granting that the position 
I €tf the patient rnu)^ be accntsed of positive inelegance, it may ^ at any ratOi 
r contrast favourfLhly with our pnjceoding:^ in litbotomT and in many oihar 
) ©perations on the perineal regions. — LanctU Oct. 29i 1860, p, ;184, 



68,— ON THE USE OF CHLOHOFORM IN STRANGULATED 

HERNIA. 

B7 Tuo^Jia BRTAiTt Eaq.^ F.B.CLS.E., Atslituit Sargeon to Gay's TIoipltAl. 

[•(Mr, Bryant has the greatest confidence that in tho majority of early caie« 
['Of iiigumal hernia, tho herniii can bo reduced when the patient baa been 
I thoroughly brought under the infiuonce of chhjroform. But to effect this, 
[the patient must be rendered coinpletc^ly mastered by the nna[?sthetie, and a 
[|>erft?et eoma, or oven stf^rtnr, produced, if necessary.] 
I The following are a few of the cases which have passed nnder my notice, 
hbnt they are accurate examples of all others. 

A man, a^ed 41, was admitted under my caro into Guy's hospital, om 
1 Aug. 3, 1857, He had been the subject of n right scrotal hernia fnr four 
ryean, and had never worn a truss. The heniiii. had been down twenty- four 
I tours, and symptom* of Btrangulation had existi^d during the wliole of that 
I period. The taiis had been freely and efficiently applied without benefifct 
li^nd I was consequently sflnt for to operate, as no other measures were 
[deemed justifiable, Cbhnofunn was administered, and everything prepared 
I for operation; when, however, tho patient had been completely brouglit 
[ finder its influence, the taxis was rc-ap plied, and without tho slighteat force 
J *he hernial contents returned into the abdominal cavity ; a good recovery 
[ cn.^ued. 

A man, nged 29, the subject of a. congenital hernia of the right norotum^ 

rns admitted under my care Sept. 4* ISolL Symptoms had boen present for 
P-two day«« and wero very violent. Ho had been operated upon nine ye an 
, previously for hernia on the satiui side. A warm bath, opium, ioe locally* 
[And the talis had been emphjyed without the slightest i>encfit, and as an im- 
I fenediaie operation was indicated, I was eent for* I found the man suffering 
litererely, and the Hcrotal tumor wns very largo, tense, and painful; as it wa> 
I most di^sirable to reduce tho hernia without nperiition if possible, I applied 
I4he taxi^, but without success; chloroform was accordingly admiuistered 
1 preparati^'e to operatiun, and when the patient had been thoroug-bly brought 
ItindeT its influence, the taxis was re-applied; not the slightest force was* 

' owever, employed; tho hernia contents at onoo returned into tho abdomi* 

nal cavity, and a speedy convalescence ftd lowed. 
Many cases like the two quoted might be given, all illastratitig tho same 

point, but I believe those are quite iufticicnt to indicate the benefits of j 

fehlorofijrm in the reduction of a stranguldtcd heniia. 

I have before me twelve good exatiipleH illustrating the benufit of such a 

jpraottce, all wore, however, inguinal. The reduction of a feiTiwi^viXal^iiiiaiss^^ 



168 SURGERY. 

oral hernia by the taxis Is hj no means common ; that is, aiiooeBS oannot be 
anticipated to the same extent, as it may be in an inguinal hernia. In a 
paper which I published in the Gay's Hospital reports for 1856, I showed 
that femoral hernia required operation 25 per cent, more frequently than in- 
guinal, and subsequent experience has convinced me of the force of such a 
truth. I also showed that in femoral hernia the taxis is more injurious, and 
is more frequently followed by gangrenous bowel, such points are worthy of 
remembrance, as a caution to the surgeon to employ his taxis with discra- 
tion and not too forcibly : the administration of chloroform in such oases is 
beneficial, but the caution as just given should be practically remembered, 
for force is not indicated, and must do harm, whether employed with or 
without chloroform. 

Acknowledging it, then, as a fact that there are many cases of strangulated 
hernia which may be returned by the taxis, when the patient has been fully 
brought under the influence of chloroform ; and remomoering also that such 
a practico is demonstrated the most perfectly in those cases in which all 
other means had entirely failed, and when under ordinary circumstances an 
immediate operation would have been called for ; it may be well to consider 
how far such a fact should influence our practice, and in what way we can 
turn such information to account 

A little consideration will soon lead us into the right path ; for if it be 
true that in chloroform we have the most efl^ectual moans for producing re- 
laxation of all the muscles of the body as well as of the parts involved in 
hernia ; and if it be also acknowledged that by such means a patient is more 
speedily and more eflx^otually brought into that relaxed and desirable condi- 
tion than by any other measures which we have been in the habit of employ- 
ing, the conclusion to my mind is tolerably obvious, that in all cases we 
should at once employ the most certain and most efficacious practice, and 
neither waste time by delay, nor prostrate the powers of our patient by the 
use of other remedies when we have before us one so incomparably their 
superior. 

The warm bath is doubtless a valuable remedy, and the cases are numer- 
ous in which the taxis has succeeded under its influence, which had without 
entirely failed ; but it is nevertheless depressing in its nature, and the de- 
pression lasts beyond the period in which such depression is necessary or 
desirable. The depression associated with a strangulated hernia is very 
lasting and often very great, and to encourage it by any artificial means can- 
not be regarded as good practice ; and I feel confident that the depressing 
influence of a hot bath to patients labouring under such a disease as hernia, 
has often acted most prejudicially to the subsequent success of the case. 

Opium, a^in is a remedy which cannot be too highly praised, and when 
given in full doses, and repeated, to bring the patient, who is the subject of 
a hernia, rapidly under its influence, its useful tendency has been too often 
manifested to allow us to depreciate its value ; but if a surer and more expe- 
ditious remedy can be brought forward, and if it can be shown that by the 
use of chloroform the ends which we have been in the habit of seeking can 
be attained with greater certainty and without that loss of time which must 
necessarily take place by internal remedies, and without that lasting depress- 
ing influence which is exerted hy the hot bath, I think few surgeons will dis- 
pute the conclusion, that the administration of chloroform should be primar- 
ily selected. 

I will not consider the local applications of ice to the hernial tumour, as 
the cases we are discussing are those of strangulated hernia and not incar- 
cerated, in which the symptoms are marked and not to be mistaken, and in 
which it is hoped that no surgeon will over more allow valuable time to pass 
away by the use of such a precarious and uncertain measure. 

When strangulation of the intestines has taken place, it cannot be too 

often repeated that the more speedily that strangulation is relieved the 

better ; this truth is so recognized by the profession that it may appear too 

^te for repetition ; but let me ask the experience of any hospital 8ui|^n if 

is not exceptional for such a truth to be carried out. The cases iMok 



SUKGERT, 



rmppPiir in hospital practice nre, ns a rulo, siidi as liave beMi bnilly tront^d* 
\mnii hiivo beco mo.st unwarrantably neglected ; f*iun five* i*ix, ssuvt^n, even 
ten or twdvo days* strangulation is the rule nt Quy*s Hospital aud soma 
jsurpri^t^ is generally cxpre.s£ed when a case of shorter duration hn^ bcrn od- 
Itnittcd, The taxis* opium internallji uEid ice externally^ bave been often eui* 
l^likyed in no unmeasured proportions; and purgatives, even jn tbei^o days of 
I advanced knowledge, are not exceptional; and it is to prevent t>uch mal- 
praclico tbat I believe a simpler practico would prove most valutible, as timid 
f ^raettlioners would not allow time to pass away by the use of remedit.^H whjoli 
k althougb of valnCt are valuable only in select caaoi^, and wblch uh u rule ar^ 
f not to bo recommended. 

When. then, a strangulated hernia has taken placet what practice should 
I be carried out ? 

If quite rt'ceut, and the symptoms are i^ot severe, n warm bath» a full doat 
i of optom^ t^ay two or three gratnst and gentle taxis will generally succeed, 
jftnd in Bucb cases, and saob alone, sboald thoy be employed. 

In others when the hernia has existed for some hours or days, when the 

vomiting and other symptoms are so marked tbat there oan be no dnubt tlm6 

Itrangulation of the bowel eiists^ and not incarceratioUf I would i^nggest 

rlhat llio immediato admlnii^tration of chloroform ^huuld bo rci^orted to ; let 

lihe patient be brought completely under its inllupnco and wc may then ex* 

||N?ct, with conhiderable confidencCi that its reduction by the tuatU will ra- 

[pidly follow, particularly if tlio hernia be inguinal ; thu force which Is re- 

J quired under ?ucb an influence, is dimply nominal, anything like power 

lirould prove Injurious* and would bo most certainly unwarrantable; the 

ymost moderate up]>Heation of force is fofficient, if success is to beoLdainedi 

|«nd if it .should fall no extra p }wer will be tnoro benoticial; let then the 

^liixii^ be of the most moderate des^cription, let it be firmly and decidedly ftp- 

IjHed ; but do not allow any thing like forct* to be exerted; if succes*s i« to 

IbUow its application^ moderation will suilice ; and if failure, force will not 

•ucGeed. 

If failure lbllowit« let the operation be performed ; there is no object to bo 
gained by delay, but irreparable mischief must take place, and if iho sac ii 
jiot opened in such cases tho operation is not one of danger* 
f The evils of the taxis, and ot delay, as ficcasioned by earelesanesSi and tha 
'tise of remedies, are of gueh a iiatnre, and have made such an impression on 
my mindi that 1 firmly helieve that it would be better for all cashes of 
•trangulated hernia to he trented at imce by the adm in intra t ion cif chloro- 
form followed by the gentle taxist and on this f*uling by the minor or other 
operation, than that any chance of delay should be occasioned by the use 
of remediei4* or of injury by the taxis ; and that if practitioners would dis- 
card all former measuren^ and adupt thci^e which I have suggested, after 
experiencing their advantage, I feel sure that the cases of death from stran^ 
gulalcd heniia would be but rare, and the cases of mat-treatment would be 
leaf numerous^ 

For if men would only be convinced that by the us© of chloroforni we 
have all tho advantages *jf every plan of treatment which has been formerly 
employed, without any of their evils; that under its influonce, if the tajiiii 
is to be successfab success will be attainc?d, and free from the danger which 
attends its use without the amusthetic,^ — a** tho respired or pcrnnssddc forco 
should be but slight; and if Ihey will only be impressed with the truth, that 
tf such tneoDS fail, an iinmediate renort to operation u imperatively demand- 
ed* I feel certain that this improved practice would be followed by commeii- 
sunilD success, and that the mortality of our hospital cases would be mate- 
rially diminished. 

Since the introduction of chloroform the treatment of disb>catioas baa been 
completely altered, and the means employed for their reduction are quite 
simple, when compared with those which were formerly resorted to, via. : 
pulleys and personal strength. 

By the use of chloroform in the treatment of hernia, an improvemenl 
oqia^y important is now open to us, and I shall be much au^>tv^d \i VV« x^- 



170 SURGERY. 

unit doos not prove as fi&vorable as I am sanguine enough to believe It will. 
In biith classes of cases the evils of force are dispensed with, and its danger 
corrected ; and in both the influence of science and of manipulative power 
are well exemplified. But in hernia there is this additional advantage ; the 
delav occasioned by remedies will not bo experienced ; and I feel convinced 
that if surgeons will but rccognij«o the value of chloroform as a means of 
rcducinp^ a strangulated hernia, the evils resulting from delay and forcible 
taxis will be done away with, and a more successful practice must be the 
result. — London Med. Review^ August, 18(50, p. 69. 



69.— ON ULCERATION OP THE LOWER EXTREMITY OP THE 

RECTUM; ITS VARIETIES, DIAGNOSIS, AND 

TREATMENT. 

By James Bodsb, Esq., AsslstaDt Surgeon to the Westminster Ophthalmic Uotpital, dbc 

Notwithstanding the numerous works published on diseases of the rectnm 
during the last few years, there appears still to be great difference of opinion 
as to the best mode of treatment ; more particularly with regard to those 
ulcerations situated on the mucous membrane lining the sphincter ani, and in 
the fossa immediately above that muscle. 

There are three forms of ulceration of the lower extremity of the rectum, 
which gave rise to very acute suffering; and, although they vary consider* 
ably in position, have nevertheless been described by most authors under the 
general head of fissure. It is proposed, in the present paper, to point out 
that three distinct forms of ulceration occur iu this region, which, by ordinary 
investigation, may be distinguished from each other, and which require dif- 
ferent modifications of treatment. 

The most common form of ulcer found at the lower extremity of the rec- 
tum is that which is known as fissure of the anus. This disease does not 
seem confined to any particular period of life, though it rarely or ever ex- 
ists until after puberty. It is more particularly common among persons 
who lead a sedentary life, and for the same reason it is rather more frequent 
in women than men. The fissure appears to bo caused by a tearing of the 
mucous membrane lining the sphincter ani, by the passage either of hard- 
ened faeces, or of a foreign body contained therein. The following cases 
will, however, show that fissure of the anus may occasionally be the result 
Tof external violence : 

Case 1 . — A gentleman, aged 24, was riding a restive horse, when it sud- 
denly bolted. He was thrown, with some violence, on the hind part of the 
saddle before be recovered his seat. Ho felt some pain about the anus at 
the time, and. on changing his shirt, he noticed a few drops of blood. For 
the next few days he experienced a slight burning pain during the evacua- 
tion of the bowels, and in about a week the characteristic pain of fissure was 
established. On an examination being made, a small crack was perceived 
on the posterior surface of the sphincter ; it commenced about two lines 
within the anus, and extended upwards for about half an inch. Various lo- 
cal means were tried without benefit, and an operation to be hereafter de- 
scribed, was had recourse to with perfect success. 

Ckise 2. — A captain in the navy fell off a ladder, and came to tlie ground 
on his buttocks, with considerable force. He did not observe any particular 
pain until he went to stool the following morning, when ho experienced con- 
siderable smarting, and noticed that he had passed a small amount of florid 
blood. About a week after the accident, he applied for advice- He then, 
after every evacuation of the bowels, had pain, which lasted for several hours. 
On examination, an ulcer was found on the posterior surface of the lining 
membrane of the sphincter ; the edges were not indurated, and the surface 
was florid. An ointment, containing mercury, was applied twice a day ; and 
IB the course of a week a cure was effected. 
Persona aMicted with this disease, in desoiVbm^ i\i^ ot\^ of their sofier- 



SURGERY. 171 

ing, frequently state that while straining violently at stool thoy folt some" 
thing give way, and on looking at thoir evacuations, thoy noticed a sumll 
quantity of blood. It has moro than onco occurred to mo to be told by por« 
8ons with fissuro that the fieces wore ho hard that it was ncct^ssary to remove 
thorn with the fingers from the anus. 

This crack or fissure is almost invariably situated on the posterior surface 
of the sphincter. I have seen upwards of a hundred oases, and in only six 
did the position vary ; in three of these the fissure, was situated on the peri- 
neal surface of the muscle, and all occurred in women ; in two it was situa* 
ted on the left side ; and in one on the right. It comm(>ncos about three linuf 
from the margin of the anus, and extends upwards in a straight line to tho 
extent, usually, of half an inch, though sometimes as high as tho superior 
margin of the sphincter. If the fissure be seen within a week or ten days of 
its occurrence, it presents tho appearance of a bright red line with a shar]>ly 
defined edge, and does not appear to extend through the thiokness of tlio 
mucous membrane. A little later, if no treatment bo adopted, one or two 
florid granulations may frequently bo seen protruding above tho margin ; and 
it is during this stage that a small amount of blood is voided on going to stool. 
This appearance is very soon changed ; the edges become everted, and more 
or less hard, and the surface of the ulcer itself looks excavated and ])ale, liko 
any other indolent sore. The pain caused by this solution of continuity ia 
at first trifling and only exists while the motion is passing; but it soon bo- 
oomes most severe. It usually commences about half an hour after the bow- 
els are relieved (tho sensation up to that time being only uneasiness), and 
continues for five or six hours. As the disease progresses, the pain beeomes 
more continuous and easily excited, and even walking or sneezing will bring 
it on. At this stage, the ulceration is found to have extended through the 
submucous cellular tissue into the fibres of the sphincter ; there is a constant 
desire to pass urine, a serious addition to the other sufiering, and this con* 
tinues until relief is obtained by means of an operation. 

This second form of ulceration is situated immediately in front of tho oe 
coccygis, and was first described by Sir B. Brodie, in a clinical lecture de< 
liverea at St. George's Hospital. This ulcer, which is almost invariably 
coexistent with an enlarged and varicose state of the veins about tho rectum* 
does not, like the one just described, appear to be caused by a tearing of the 
mucous membrane, but by an injury done to it or to tho submucous eellular 
tissue. It seems as if the forcible passage of the f.'r:ces (in these cafes al« 
ways very much hardened), and the pressure caused thereby, ])ro(luc(;d a 
small slough of the mucous membram.'. Mr. Quaiii states, in his recent 
work ' On tho Diseases of the Kectum ' that he has noticed a case in which, 
**the disease having been of no long duratirm, and the suH'ering cotnpara- 
tivoly slight, the membrane appeared to be thinned from bencjith.*' The 
ulcer, once formed, soon increases in size, and usually renmins quite super* 
ficial for a considerable time ; but at length, from tho continual irritation, the 
edges become everted and hard. The surface, however, seldom becomes ho 
indolent as in cases of ordinary fissure ; and in this form of the disease the 
ulceration seldom if ever, implicates the fibres of tho sphincter ani. Tho 
pain which, as in fissure, is caused by the evacuation of the bowels is most 
intense; there is usually very little spasm of the sphincter, but the patient 
complains of severe lancinating pain, which gradually subsides into a seusa* 
tion of burning, which continues for three or four hours. 

The third form of ulcer is situated in the fossa which exists between the 
external and internal sphincters ; it is by far the moj^t painful and K^-rtous 
affection of the three, it appears to be caused either by the lodgment 'if a 
small portion of hardened fseces, or by injury done Vt the mucous membrane 
in that sttoation by the passage of some foreign bfnly, huch as a fihh-li^me. 
Two cases are known to me where the presence of a [Kilypus of the rectum 
(the extremity of which was pressed into this fos<$a every time the Uiwels 
were reUered) caused an ulcer in this p^isition. 

The nicer, at first, is seldom toare than the eight\i of an VueXi \n ^\aAfi«\«t% 
tmd it ia gmaenUf aumewbai deeply excarated. Aa the diamiiia ^t(>^««m»^ 



ITS SDBOEBY. 

the ulceration extends into the substance of the sphincter «ni ; so that, when 
the finger is. passed into the rectum, the end of it sinks into a small cup-like 
OETity, the inferior part of which is formed at the expense of the superior 
margin of the sphincter. Except in cases of long standing, the edges are not 
indurated, and the surface almost invariably remains florid. In this disease 
a certain amount of pus and blood is passed at each relief of the bowels. If 
this ulcer be not cured by means of an operation, it leads to a most trouble- 
iome form of stricture of the bowels. The constant irritation, set up by the 
action of the bowels gives rise to inflammation of the submucous cellular 
tissue; this causes thickening and hardening, by which means the calibre of 
the outlet is seriously diminished. 

The following case will illustrate this kind of termination : — 

Cage 3. — Mrs. S., aged 23, complained of very severe pain before, during, 
and after the relief of her bowels. She had consultcda s urgeon, who, on exam- 
ination, found an ulcer immediately above the external sphincter. An incis- 
ion was made through the ulcer into the tissue below ; but this did not pro- 
duce the slightest relief. Six months after the operation, she noticed that 
the discharge was much increased in amount, and she found more difficulty 
in passing lier motions, which were small and flattened. A year subse- 
quently to the operation, I saw her, and, on examination, discovered an uloer 
of considerable size situated on the posterior surface of the rectum', and 
inrolving the superior margin of the sphincter, ond such extensive thick- 
ening of the submucous tissues that the finger could not be passed through. 
Subsequently, by means of bougies, considerable benefit was obtained. 

In these cases, the pain complained of is most severe, and there is more 
spasm of the sphincter than in simple fissure : in some of these cases the 
amount of spasm is so great that the muscle increases considerably in sise. 
The pain appears to commence some little time before the bowels are reieved, 
probably this is caused by the pressure of the loaded bowels upon the ulcer. 

Diagnosis. — The diagnosis of these cases is by no means difficult The 
peculiarity of the pain complained of, the fact of its coming on either during, 
or soon after, the action of the bowels, and the case with which these ulcers 
may be detected by the finger, when it can be introduced into the bowel, 
render a mistake almost impossible. There exist only two diseases with 
which these ulcers may be confounded : to wit, a syphilitic ulcer and spaa* 
modic contraction of the sphincter. Neuralgia in the neighbourhood of 
the sphincter has such well-marked symptoms of its own, that it can scarcely 
be mistaken. With regard to the syphilitic ulcer, its characteristic appear- 
ance, the class of persons afl^ected, the existence of syphilitic ulceration 
about the vagina, remove all doubts as to the nature of the complaint. The 
diagnosis between spasmodic contraction of the sphincter and fissure is rather 
more difficult ; in fact, it is only by a most careful examination that the 
surgeon can determine whether an ulcer exists or not. There are, however, 
a few points of difference which it would be well to remember. In spasmodic 
contraction of the sphincter, the muscle very rapidly increases in size ; tha 
anal orifice becomes so contracted that even a gum catheter cannot he intro- 
duced without producing extreme suffering. This amount of spasm is most 
rare in ulceration, and it is the pressure caused by the finger on the ulcer 
itself that produces the pain. Again, in ulceration, it matters little in which 
form, sooner or later, there is always discharge of pus and blood ; in spas- 
modic contraction this never occurs. Lastly, the patient having been placed 
under the influence of chloroform, a careful examination of the Dowel can be 
made (which it is impossible to do without producing insensibility,) and, aa 
in the following case, no ulcer is found to exist. 

Case 4. — George , aged 45, a man of spare habit, sallow complexion, 

and depressed vital powers, complained of intense pain, which occurred dur- 
ing the time the bowels were acting, and for several hours after. The pain 
was not continuous, but came on in paroxysms every few minutes. Tha 
motions were very small and flattened ; but there was no discharge or ap- 
pearance of blood. On examination, the sphincter muscle appeared more 
IsTeloped than usual, and the anus was so contracted that it was imposid- 



StJUGERT. 

f^le to intrf>duo© tbe finger* A speculum nni was omploycjcl, and tlio moBt 
] Handful exnmhiatimi fiiiiod to dl&covor tujy ulcor. Uiidor tbcKi^ cjrcutjietiiD- 
a pmail boagie, about six itiehes long, wak in traduced every otbor nigliti 
1 At iirEtt the pain caused was very ^r^at* and tie wna unable to r^^tain il fow 
I Bnore Ibnn three or four minutes ; but he was soon ablo to bear it for a longer 
llirne. The size of the bougie ^as graduallj increaaed, and be vras ultimatel/ 
|©nr(4d. 

Cme 5. — A grntleman* aged 35, of sparo habit and nervous temp era mc^nt, 
[liad Buffered with symptoms \lkt^ those just de£cribed, for stx monthSf and 
[the pain bad become so severe that bo could not take exercise ; he had tried 
iTarious means to obtain relief without success. The most careful examina- 
[ lion fulled to discover any nloer» but the sphincter vras immensely hyper- 
rlrophirdi Bougies wero cmplnyed for two weeks without producing the 
iijghtest relief, and the patient was «o worn out and irntatc!d by the pain ha 
Isniferedi that he could not be induced to continue the use of thenu It waa 
[thereftjre decided to divide the sphincter, and with the exception of the pnin 
I produced by the passage of the fteecs through the wound, this patient never 
f RufFered any inconvenience afterwards* 

I should not have ini^isted so strongly on the existence of this diseaso, but 
I ime of the most recent writers f*n dit*e«^es of the rectum doubts the existence 
fof isjniple iipasmodic constriction of the sphincter. 

There fa one other precaution necessary in these cases; and that is, to 

luite certain that only one ulcer exists. It is not very unfrequent to 

two ; they may be either one above the othart or situated on opposttii 

i. 

The treatment required for the ulcer in front of the os cocoygis, and for 

fissure, varies nccording to the stage of the disease. If it be treated before 

kit hri5 hrcome indolent, local applicatbuM, and attention to the state of the 

~ oweb, nre all that is neoc?Hsary* Grey oxide of mercury and ftpermnoeti 

(►intment (half o. drachm to the ounce) or a scruple of oulomel to an ouaot 

»f lard, with ttblutions night and morning and after cacU relief of the bowoli 

irith yellow Miap and water, will usually effect a cure, Greot euro mutit b# 

llaken in the choice of a laxative, the ohjc^et being not to purge, but to ren- 

[ider the fmces soft, so that as little stretching as possible of thu ulcer shouid 

rtftke ph*ce. Confection of senna or milk of sulphur generally prodiico the 

desired effect. A very common medicine in these easels is confection of pep* 

per; this, c^imiiined with confection of senna, is very useful in cases of 

hemorrht»ids, \mi it is apt in all cases of ulceration to produce considerable 

aggravation of the patient's suffering. When the ulcer has once become 

indolent* the best nod only treatment (likely to prove beneficial) is by tho 

knife. The operation la best performed in the following manner. The 

patient buing placed on the right side, with the knees drawn up to the chin, 

the forefingi^r of the left hand is to be introduced into the rectum, and the 

knife passed up in fnmt of it; the inci>iion i?* tlien to bo made, commencing 

& few lines above the superior margin of the ulcer, and to be carried througJi 

St down to the external skin, care beiiig taken not to cut into the fibres of 

the sphincter, except in those cases ivhero the disease has already involved 

that mu«cle. After the incision has been made, a small piece of oiled lint 

may be introduced into the wound. It i** better not to allow any aclton of 

the bowels to take place for two or thr^e days after the operation ; thia may 

be €*ffccted by giving small doses of opium or a milk dlt^t. 

The treatment required for the ulcer Kittjated above the sphincter !e divi- 
slon of the muscle* Local remedies never apimar to afford the slighteBt 
benefit, but only tend to wear out tho j atienoe and spirits of tho sufferer* 
Tlio opera ticm is to be performed in tlie same way as for fissure ; but, instead 
of merely making an incision into the submucous tissue^ the sphincter must 
bo divided by one outi the wound Is then %-} be dressed in either with oiled 
lint or silk. 

It is of courie always prudent to try local means before proceeding to an 
operation ; and the best application is the ointment of grey oxide of ml^roltry, 
already mentioned. The most satisfactory method of applying \.\wn(itfia4'^ 



174 SUEGEBT. 

is by means of a suppositoiy tube. Tbe tube should first be lubricated ont-^ 
side, and then filled with the ointment ; it is then to be passed into the bowel 
to Uio extent of an inch or an inch and a half, and the piston then pushed 
down ; by this means the entire surface of the mucous membrane lining the 
sphincter is covered by the ointment. 

Some surgeons recommend the application of nitrate of silver for these 
forms of ulceration ; but it seldom proves very beneficial, and the pain it 
causes is quite as severe as that of the division. If it be attempted, a speculum 
should be introduced into the bowel ; by this means, tlie ulcer is brought 
into view, its surface should bo dried by a piece of sponge or lint, and the 
caustic freely applied. — British Med. Journal^ May 12, ItiGO, j?. 356. 



ORGANS OF URINE AND GENERATION. 

70.— ON INFLAMMATION AND ABSCESS OP THE PROSTATE 

GLAND. 

By B. n. Mkaux, Esq., F.B.(\S., Senior Sargcon to the Bradford Infinnar}'. 

[Mr. Meade has given us below several very interesting cases, not only to 
Mmind us of an operation performed by the late Mr. W. Colles, of Dublin, 
but to show that such operations as make a communication between the ure- 
tiiira and rectum, are not to bo dreaded.] 

Case 1. — Towards the end of the year 1854, I was consulted by Mr. H., a 
man about thirty years of ago, on account of a troublesome stricture which 
had existed for several years, and was then causing considerable disorder of 
tlie general health. Upon examination I found a tight constriction in the 
membranous portion of the urethra, through which a small bougie passed 
with difficulty. I also noticed a cicatrix in the perineum, and learned that 
some time previously, he had had a fistulous openine in that situation, 
through which urino hod escaped, but which had gradually healed up. At a 
short distance from the scar, the patient said he often felt a lump, which dis- 
appeared on pressure ; and I here found a deep-seated, hard substance, about 
the size of a hazel-nut, which was evidently a small cavity, communicating 
with the urethra by a blind fistula. lie said that when he made water toler- 
ably freely he felt nothing of this ; but when the symptoms of stricture were 
aggravated, the swelling became full, tense, and painful. 

By the careful introduction of bougies during a period of many weeks, I 
succeeded in curing the stricture, so far that a metallic instrument of No. 
10 or 11 size would pass freely into the bladder; and 1 taught the patient to 
pass one for himself, directiug him to do so regularly once or twice in a 
fortnight, to prevent the return of the contraction of the canal. 

Though ho now made water freely, he still complained of very uneasy 
sensations about the neck of the bladder, in the perineum, and also in the 
rectum, where he described symptoms similar to those produced by stricture 
of the gut. The little swelling in the perineum also remained, and he occa- 
sionally noticed a purulent discharge along with tbe urine. To remove this 
blind fistula, which I hoped might have closed as the stricture was cured, I 
thought it best to cut into the tumour in the perineum, and form an external 
opening ; on doing so I found, as I expected, a fistulous passage, along which 
I could pass a probe for ttome distance. After this little operation, urine 
escaped from the opening for a week or two, but the introduction of a probe 
coated with nitrate of silver, and passed deeply into the sinus, quickly caused 
its permanent closure. 

Upon examination of the rectum with the finger, I found the passage of 
the bowel impeded by a strong membranous band stretched partly across its 
anterior surface, at a point opposite to the situation of the prostate gland ; 
which organ appeared much thinned, so that a bougie when passed into the 
bladder could be felt more distinctly than usual in the rectum. Upon ques- 
tfoDing the patient, I found that some time previously to his oonsutlpg iam% 



I 



SURGERY^ ^ 175 

Biid irt the samf^ timo that the first fistalous opening formed in tijr prrinotinit 
he had suflored froiji ^ytTiptoini of infitiniiimtiuii uiid ^upptinitioii ot'thi? pros- 
tiito ; find matter bad evidently formed au4 iosUiujited itselHii viinuua direc- 
tion s, finding one outlet m the perineum « and another into the rectum, niter 
burrowing between the coata of tho bowoL and producing in^ammation and 
tlie formation of the menibrnnous bund wJiicb I bftvti tnftnttoued* Gn^nt por- 
tion of tbiti gbmdidar seubstaneo of the prostftto tseomed to have* been de- 
stroy ed| and from tbe unousy ft?eling which still remained about tho neck of 
the bladdernj uccompunied wttli oecu^^ionftl dischargefi of pus,^ and aUo from 
a boggy feeling which exii^ted in the centre of the gland, it seetned very 
prohable that ^ome chronic fli^tuloua paBSDges istill remained in the pro&tatQ 
and iti neighbourhood. 

Before adopting any further operative proceedinga for his relief, I wished 
my patic^nt to consult Mr, Teaie, of Lefids; and he suggested that th^ pros- 
tatic portion of tht! uretlira should be laid open into tho rectumi un operation 
wliich had been recommended and adopted in somewhat similar eases by Mr. 
W- Collet, of Dublin, iome years ago, and which nlso had beea tried by Mr. 
Teaie hi ma elf in several mstaneen with succesri. My patient being anxious 
to undergo? any operation that we could suggest for liia reliefs 1 at once 
reeommmided Lim to have this procedure carried out. 1 introduced a good- 
daed grooved t^taff of the ordinary curved shape into the bladder, the griKive 
of which could be felt very plainly in the rectum. The patient lying ou hta 
iide* and the .staif being held firm!y by my ausiKtant, 1 i\wn pas^^ed" a aUgbtly- 
curved Blmrp-pointcd bii^toury (the lower part of whieh was guarded by some 
liutj into the howel upon my foretingert and thrust the point of it through 
th(« centre of the prostate into the groove of the staff, above the membranous 
baJid which I have described. 1 then drew the knife downwards^ in th^ 
groove, divided thi& band, and Enid open the prostatic portion of the urethra 
into the bo w (»1 ft^r a I fo u t h al f o r th r eo - q uart e ra of an inch* Th o re was very 
littlo bleeding from the wimnd, and no urine appeared to esoapo frtim it. The 
patient was convalescent in a few day«, and tho operation was completely 
successful, removing both the obstruction of tho bowek and tlio irritation 
about the neck of the bladder. 

I have seen Mr. If, several times during the last three years, and hp con- 
tinues w*dl, with tho exception of being obiigcd to pass a bougie occasion- 
ally. On examination of tho rectum with the iingcr, tho gut is quite free 
from obj9truetion. 

Case 2,— John A,, aged 41, w&s admitted into tho Bradford Infirmary on 
Noircinber 15, 1^59, with stricture of tho arothra complicated with fistula 
in perineo, and recto- vesical, or rather nH-to-urethrol fisitula. His heaJth 
wiui very much broken down, and for Hcvoral month aho bod been in a very 
anoonxfor table state; aSt whenever he attempted to empty the bladder, the 
greater portion of the urine escapiid by the rectum and through the opemng 
in tbo perioeutn. By inquiry Into tho history of tlio case, it seemeti that 
sbQut tt year bcforo the patient^s admission into tho Infiramry, be had auf- 
ft»red from pymptoms of abscefss in or around tho prostate, which wera 
relieved by tlio matter finding its way Into the rectum, and were suecoeded 
by the escape of urine from the boweh About three months suhsuquently 
to this, a gathering formed in the poriaeom, which was opened by a country 
iujgeon, and was followed by a fistulous opening, through which urino aluo 
escaped* On tho introduction of a bougie, a strictLiro was found in the mera- 
brttnous portion of the urethra, but not a very tij^ht one, as it admitted a 
No 7 or 8-sizod instrument without much difficulty. On passing the finger 
into th« rectum the prostate could bo felt rather enlarged, but no fiofti^ning 
nor tjogginess of it could be found. The opening of communication between 
tht^ bowel and the urethra could be easily felt : it was situated just below the 
apex of the prostate. The external aperture of tho perineal fistula was within 
half-an-inch of tho front margin of the anusi and a prob« could be passed 
from it deeply up by the side of tho guti 

After keeping tbo man in the hospital for a few weeks, for tho purpose of 
improving his gooeral health, and of dilating the stricture by the |^ag«&^<;s q1 



i 



m 



SURGEBY, 



iea, I porfoTined the following fjperAtrnn cm tlic 3l«t of DeoeTiiber^] 
I- — I introclacoc! a curved und grooved HtRff into the bladder, and pas-» j 
ling a eliglitly curvf^d (tharp-poj tiled bStitoiiry on the left index finger intii] 
tJje rectum, I thru^it the point of it through the lower part of th© peo«tiit#J 
into tlie groove of the staffs and cutting downwards laid open the prfistatio ] 
ftnd part of the membranous portion* of the urethrDt into the rectum, so u* j 
to make a free communication bet Ave en tbern* I also divided the sphincter | 
ftni, passing a bistourj from tbo 6!^tulou5 opcnmg in tit e perineum througk | 
the mucous roembrnne into the guti Justin bo ve the spUinctert and then cutting I 
out. Very little hemorrhage f<d lowed the operation. The urine principally* 
•ftcap^d by the bowel for the firsl fortnight, after which it was passied la 
graduttlly increofiiug quantities by the urethra, while the fistulou:? pas^ag* ] 
mud the wound in the rectum slowly closed. The prngress of the case waa j 
retarded by the state of the stricture, which Rcemed to be aggravated by th« 
operation ; and it required the fre(|tient use of bougies for several weeks be- ' 
fore the contraction and irritability of the urethra could be overcome. By < 
the expiration of three months, however, from the time of the operatloDt ht | 
waa completely cured* 

Case 3. — In M<ty» 1855, Mr. B.* a eentleman, about 35 years of age, of da- ' 
Ucate conatitution, who had been under my care several weeks for an attack 
of gouorrhfea, from which he had almost recovered, wae seized, withoat any 
apparent cause, with symptoms of i n flam m all ou of the prostata gland* He I 
first complained of pain and irritation at the neck of the bladder : but after ] 
ft couple of day a ho referred bis sufferings chiefly to the rectum ; and on ex- 
amination considerable enlargement and tenderness of the proi^iate could be | 
felt by the finger in the bowel. ! 

Complete rest, warm hip-bRth», leeches both to the perineum and round 
the anus, were tried, but without producing much benefit; and shivering and ' 
other symptoms of suppuration made their appearance. The patient ooa* ' 
titmed to refer most of his uneasy seuBatinns to the rectum, and there wa# I 
little or no impediment to the passage of the urine, tboagh a frequent iti- 
clination to make water. 1 could feel no hardness nor deep-seated fluctua^ 
tion in tho perineum, but one part of the prostate appearing boegy to th« 
touch when the finger was introduced into the bowel, I detennined to make 
an incision into it at once from the rectunit and thus try to prevent the mat- 
ter from insinuating itself into the tissues of the perineum, or in other | 
directions. For this purpose I introduced a tubular speculum into the reo^ 
turn, with a good-sized lateral aperture, which X placed opposite to tbo 
middle of the prostate gland. The mucous membrane could l>o seen pro- 
jecting into the tubCt and distinct fluctuation could now bo felt by the point ^ 
of the finger. 1 therefore made an incision with the sharpened edge of a 
gum lancet that had a rounded blade, and after cutting to seme depth, about 
balf-an-ounce of thick pus escaped into the speculum. Considerable hem- 
orrhage followed, but it was soon stopped by retaining the .speculum {which 
had a eloped extremity) in the boweb and plugging it with lint. After thus 
opening the abscess, all the symptoms rapid [y subsided, and the patient - 
was soon well. There never seemed to bo any diacbarge of urine from tho ' 
wound* I 

Case 4. — In September, 1859, I was called in to see a gentleman, 34 yeart 
of age, who had j a st returned home ill from Scotland- He had recently been 
married, and had been seized during his wedding trip, while in the highlands ^ 
of i5C0tland, with severe pain in the rectum, accompanied with aomo obstruc- I 
tion of the bowels and difiiculty in making water* He obtained slight relief 
from taking some castor-oil i and made his way as soon as poss^ible to Glaa* 
gow, where he consulted a surgeon, who ordered some leeches to the aiitia, 
warm baths, opiate suppositaries, ice, and recommended him to travel home 
as quickly as possible, I found bini suffering from a dull pain in the rectum, 
increased by the sitting posture, from difficulty, (but not pain) in emptying^ | 
the hi adder, and also fR>m considerable sympathetic fever. On introducing 
my finger into the bowel I found a good deal of enlargement, and great ten- 
" mess of the prostate gland. He told me that previous to his marriage he 




SURGERY. 



m 



I 



Uad labouri^d for some time undt^r stricture of tlie urethra, from whicli^ how- 
eTer» he had quite recovered ; ao I have no doubt ttmt there had been sub- 
acute inflummntoTj enlargement uf the |>roi!tHte« auch as is ao frequent I j 
consequent, upon long-.^tandiiig stricturef and this had heeome aggravated 
hj thG excitement of the urinary organs oouaequont upon marmge« together 
with npgbM*t of the bo^vi:'!!*. I prescrihod perfi^ct rest in the rectiinbent pofr- 
lures, warm hip*baths frequently repc*fited, .salines with hyoscyftttius, &o* 
The-o mt*asure§ roHevod th« pain ajid general symptoms, hut after two days 
considerable hnrdnefs? nnd tenderness appeared on one side of the anus, and 
the ins^ide of the rectum was very sensitive to the pressure uf the linger, ii 
little below the situation of the prostatei showing that the indainmntiou had 
spread from the gland to the cellular tissue surrounding the intestine* The 
prostate itAolf had somewhat submded in size, and I could detpct no feeling 
of fluctuation. I now began to feur that matter had formed, and was inwinn- 
atlng itrtclf m viirious directioni!; but on the following day my patient told 
me that during the night something had burst into the bowel, which had 

fiven him great relief, and on fceliug an inclination to have an cvaciiatlon, 
e had parted with a small quantity of transparent sticky fluid, soniethLng 
like white of ef^ix^^ but of a yellow colour, some of which he had saved to 
show me* With the finger I conld nf^w feel a depression and small opening 
in the mucoua membrane of the bi^wel in the same situatiim (ratlier below 
the prostate) where I foinid a tender i*]iot the diiy before* Small quantities 
of a similar fluid contiuued to eticape for a day or two, and at the smnci time 
all the synq^toinifi, both local and goaeral, disappeared, Tlie cnlargemewt 
of the prostate aUo greatly subsided. 

On looking oyer thi^-^e cases, do they suggest any points of special interest 
to which I would oalS the reader^s attention ? In the fir^t place, I may re* 
maik that Surgical authors generally seem to have had a great dread of the 
formathin of either a natural or artiflclal communication between the urethra 
and rectum. Fa cases of abscess in the prostate* deep incision is recom- 
mended in the perineum, to prevent the mutter from finding its wuy either 
into the urethra or recturn* I am anxious to sliow that this fear as regards! 
the latter canal is in a great mea-^tiro clumericab and that it 18 often even ad- 
vantageous to make a free opening into the prostate from the bowel, in Qam 
of suppuration in that organ, should fluctuation be perouptible, as the matter 
will be so much nearer the surface in that situation than in any other. The 
diffusion of matter into the Hurroundiug tissues ia thus likely to be pre- 
vented* 

Thf idea of treating chronic suppuration in the substance of the proatato 
gland by punoture from the rectum is due to Mr. W. Colics, but he restrict- 
ed the operation to a particular clasc^ of cases. In the * Dublin Journal' for 
1845 bo says :—** There is a deser-iption of enlarged prostate in nb job sur- 
gery can render essential benefit to the sufl\jrer, ami that by a very sinjplo oper- 
ation. When wo And a patiejit in advanced life complaining of unusual fre- 
quency of mi cturi I ion, witli more than ordhiary Btraiuing, his urine di? posit- 
ing n good deal of muco-purulent sediment, and possibly a muco-purulcnt 
discharge from the urethra, we should make a very careful examination of 
tha state of the pDistate* If, under these circumstances, wo introduce the 
finger into the rectum, and find ibo gland enlarged in either lobe, arid, upon 
pressing on one particular E^pot, wo feel tho point of the finger sink, as if 
into a cavity ; aud particularly if we find this pressure causes the dis- 
charge, per nrethrnnt, of a quantity of this purulent fluid, to the amount 
varying from a few drops to a teaspoonful ; here we mny hope ti> render an 
essential service. The operaiion to which I allude is simply that of striking 
a lancet into this hollow ioft spot, which wilt generally be found to contain 
some matter.** 

Besides those referred to by Mr* Oolles, there arc many other eases of ne- 
glectt^d abscess in or around the prostate in which fistulous pas^^ages have 
formed in various directions, where a free opening between tho prostatic 
urethra and rectum will be especially useful. In both the cases of this kind 
which I have related, the inflamnaatiotL and suppuration of tho v^^''*^^^ 
XLlL-12 



Minimum. 


Maximum. 


Medium. 


60 


. . 94 


76-2 


4 drs. 


. . 6 drs. . 


. . 4dr8. 57grs. 



178 SURGERY. 

which laid the foundation for the complicated mischief that existed when I 
fint saw the patients, arose from stricture of the urethra, and occurred in 
youngish men ; and I wish to direct attention to the fact that enlargement, 
the result of chronic inflammation, very frequently occurs in the prostate 
in cases of old-standing stricture, and, when not complicated with abscess, 
is generally easily removed by the ititcmal administration of iodide of po- 
tassium, a circumstance pointed out by Sir B. Brodie in his most yaluaole 
work upon the Diseases of the Urinary Organs. — Med. Times and Oazette, 
Oct. 20, 1860, i?. 372. 

71. — Report an the Condition of the Prostate in Old Age^ founded on the 
Dissection of One Hundred Specimens in Individuals over Sixty Years of 
Age. By Dr. John Cockburn Messer, R. N. — In order to facilitate the 
consideration of the details of one hundred dissections of the prostate 
after the age of sixty, the author had arranged them into three classes — 
▼iz., 1. Those under four drachms weight. 2. Those between four drachms 
and six drachms weight. 3. Those over six drachms weight By so doing, 
a broad division was at once made between those that were comparatively 
healthy — namely, the first and second classes ; and those that were so al- 
tiBred as to be likely to affect the health of the patient, comprised in the 
^ird class. 

1. In the first class there were twenty cases, giving — 

Age . . 
Weight . 

These cases for the most part, differed from the normal state only in point 
of size, and offered no obstruction to the flow of urine. The presence of 
small black concretions was very general in these as well as in all the 
other cases. In four cases there were slight appearances of the formation 
of circumscribed tumours. In one case abscess was found associated with 
stricture of the urethra. In one the posterior lobe showed a tendency to 
enlargement ; but it was difficult to say whether the enlargement was more 
intimately connected with the prostate or with a fasciculus of the muscular 
coat of the bladder. 

2. In the second class were forty-five cases, which might be considered 
normal in condition, giving — 

Ago 
Weight . 

None of these cases suffered from urinary obstruction connected with the 
prostate during life, although the bladder was often found fasciculated. In 
twelve of these, circumscribed tumours were observed, for the most part 
only slightly developed ; in three, the posterior lobe was slightly enlarged ; 
in one, abscess was present, the consequence of general paralysis. 

3. In the third class were thirty-five cases, which gave — 

Minimum. Maximum. Medium. 

Age ... 60 87 75-2 

Weight . . 6 drs. 15 grs. 48 drs. 15 drs. 2. grs. 

In seventeen of these, the enlargement affected both lateral and posterior 
lobes ; in fourteen, the enlargement existed chiefly in both lateral lobes ; 
in one, the enlargement affected only the left lateral and posterior lobes ; 
in one, enlargement preponderated in the left lateral and posterior lobes ; in 
one, enlargement preponderated in the left lateral lobe ; in one, enlargement 
preponderated in the posterior lobe. Thus it appeared that 35 per cent, of 
all prostates after the ago of sixty are abnormally large, 20 per cent, are ab- 
ijormally stnnU, and 45 per cent, are within the limits of the normal weight. 
Tbls enlargement ia principally caused by iueieaAe of the fibrous element of 



inimum. 


Maximum. 


Medium. 


60 


94 


76-2 


4 drs. 


6 drs. 


4 drs. 55 grs, 



I 

I 
I 



tte body ; tbe glanrlulnr nho l>cing incroapctl In amount, Liit not to the same 
degree. This new iibrotis ti^^uo i^ depo.'^itod m cnucenctnc layers, and so 
forms circmuacnbod tuuioars. The frcqiioncy of thiii fibrous de[»ogil la 
shown by tbo fact that it was proB^nt in tliirtj-four out of thirty -five caaea 
of en large men tf in twenty -seven of wliich it was found in the form of tu- 
mouTB^ in Roven there was no appearance of tmoours* It nlso appeared 
that those glands In which the tumours were nmrb^d are liable to the great- 
est enlargement, as sniup thits affected were found to weigh thrrty drachms, 
and even forty- cm ght driiclimg, while those in which the tumours did not ap- 
pear never weighed morn than seventeen draclims* 

A compariflon of the relative frecjueney of enlargement of the different 
parts of the gland fihowed tliat the lateral lobes are much more liable Uy be 
atfected then the poBterior ; thirty-four of thirty-five cases were affected ia 
their lateral hjbcs, while ouly nineteen of the same number were affected in 
the po^erior lobe. It is rare to find the posterior lobe enlarged while the 
rest of tlie gland is normal ; only one such case in thirty-five was found* 
Enlargement of the posterior lobe is the chief cause of obstruotioa to the 
flow of urine ; but that may also bo the coni*equence of hypertrophy of the 
lateral lobes, especial ly when it takes the form of tumours, and they project 
iti wards upon the urethra. 

It appearsi from the nearly equal average age in all three classes, that the 
condition of the prostate does not materially affect the longevity of the indi- 
vidual. A slight difference does, however^ esist in favour of thoE^e in whom 
the gland is most nearly normah the average in these being 70*2^ and Iti tlie 
enlnrged 75'ti* 

The presence of abscess in the prostate produces enlargement to a greater 
or les^s esteuti seldom, however to the same extent as fibrous deposit- The 
most frequent cause of abscess in the prostate appears to he ob:*truetion to 
the fiow of urine, either from stricture of the urethra, enlargement of th« 
prostate, or the couiiequence of pamlysis of the bladder. Tiie frequency 
of abscess in tbo enlarged gland is in the proportion of live in thirty- five; 
in those between four drachms and six drachrnsii one in forty -five; in those 
under four drachms, one in twenty. The causes in these oases were^ — stric- 
ture of urethra in three casea ; frequent retention iu three cases ; paruly^ia 
of bladder in one cose. Tubercle i^ the only other abnormal deposit giving 
Tint* to enlargement of the pmstate noticed in these cases, and that only in 
one ease, which weighed twenty-four drachms. A similar deposit was ob- 
6f»rviN}, in the lung^^s, right kidney, and mucous coat of bladder in tliia 
subject 

While retention of urine* more or less complete, is the most import ant 
stympt^im and consequence of enlarged proatatet it is not found in every caise. 
The proportion r>f men in advanced years suffering from the consequences 
of enlarged prostate Is Indeed small. Thus amongst L600 old men, with 
an average sick list of tvvo hundredt not more than ton are under treatment 
for this disease, and half of these only occasionally. A much larger num- 
ber must be affected with enlargement, as shown hy post mortcfn examina- 
tions of the gland. In thirty -five cases of enlargement found after death, 
thirteen suffered no urinary symptoms during life, and two others only after 
the occurrence of serious lessons to the nervous system shortly before death* 
Although many of these cases were nut greatly enlarged* an me of them 
plainly showed that the prostate may be greatly altered, and yet the patient 
bo free from urinary obstruction i as in one ease, where tbo prostate weighed 
eight dmchms tliirty grains, with prominent enlargometit of tbo posterior 
lobe; iQ another, which weighed nineteen di'aehms thirty grains, with gene- 
ral hypertrophyi and great cncroacbjnent on the urethra ; in another, which 
weighed twcnty-i^is: drachms thirty grains* with the eahtrgemoiit priclpally 
seated in the lateral lobes- 

On considering the favourable circumstanoeB for the formation qI ■^\\q%' 
phatic calculi in cases of enlarged prostate, it i* ^urpnnug t\\viV^\fe%^ liftiv- 
cre tio n a are no t mo re freq a eu t !y fSj u n d - f th e tliir ty • &v o civ«ii?> vfL l\\v^ ^X\vc »\ 
clasi, phasphatfc calatli tn^ero found in two, the largest wev^VViVT^ &^>*ib^ 



180 SURGERY. 

drachms fortj-five grains ; in another, two uric acid calculi, of about thirty 
grains each, were found. — British Medical Journal, May 19, 1860, p. 383. 



72.— ON A NEW FORM OF CATHETER FOR DILATING 
STRICTURES. 

By BuxTOV 8HILL1T0B, Esq^ F.R.C.S. 

I have often tried, in gevere cases of stricture, the old plan of retaining a 
catheter in the bladder, until I could pass a larger instrument; and I have 
usually found that if I could once pass a No. 1, or even No. i, the difficul- 
ties of the case were overcome. There were, however, several objections 
which prevented my adopting this plan as often as I otherwise thought it 
advisable to do. 

Firstly. The time that elapsed before a full-sized catheter could be passed 
(usually four or five days.) 

Secondly. The necessity of keeping the patient in the recumbent position 
during the whole time. 

Thirdly. The irritation and soreness induced by keeping the catheter in 
80 long. 

Fourthly. The frequent change of the instrument as the dilatation ad- 
vanced, often produced so much pain as to cause the discontinuance of the 
treatment before the cure was complete. 

Fifthly. The longer the time occu- 
pied in the dilatation, the greater the 
discharge, and the greater the difficulty 
in getting rid of it afterwards. 

Those objections, strengthened by 
the observation that I could frequently 
skip one or two numbers, even after 
the first six or eight hours, induced 
me to try a catheter having the form 
of a short cone, commencing ^ about 

"j ' "^ ^ one inch and a-quurter from tne end. 

This figure is a diagram of it. The ex- 
tremity is made rather smaller than need be, and there should also bo a hole 
near a, so that urine may flow through as soon as it has passed into the 
bladder. 

The first part, from a to 6, is of the size of a No. 1 catheter; it then 
gradually increases in the conical portion from 6 to c, up to the size of a 
No. 6 catheter, and this size is continued along the remainder of the tube. 
My second size commences at No, 6, and after the first inch and a-quarter 
increases, in the next inch up to 10 or 12. 

My first trial of an instrument constructed on this principle was made on 
a gentleman who had suffered from stricture for the last twenty years. Dur- 
ing this time he had submitted to internal division, and the stricture had 
once (eighteen months since) been dilated to No. 8, by tying in the cath- 
eter. This occupied four days. For the four previous months, a No. 1 or 
No. 2 gum-elastic bougie had been passed frequently, but whenever a No. 3 
was tried, it was invariably followed by retention. This case, therefore, did 
not appear to be a very favourable one. I commenced on Thursday evening, 
at eleven o'clock, having previously ascertained that the seat of the stric- 
ture was near the bulbous portion of the urethra. I passed the catheter 
carefully through the stricture, and soon found the conical part firmly 
grasped by it ; tne urine, however, passed through the catheter. I then tied 
in the catheter, so as to exert a little pressure upon it, sufficient to prevent 
its slipping out again, and gave him a dose of opium. I visited my patient 
the next morning at nine, when I found that the catheter had passed up to 
ih» handle, so that the portion of the diameter of No. 6 must have gone 
through the stricture. I then withdrew it, and passed the one commenoing 




Ith No. 6; this T tied in firmly, and left it in until fight in the evening, 

I ^hen t wa^ obliged to withdraw it^ the patient being attacked by diarrhoBa^ 
to wbieb he was very liable, and which was uncontrolled by astringents and 

I cipiuui. Previously to withdrawing it^ I eicerted a flight amount of presaure 
upon the instrument, iind auocecded in passing it fairly through the stric- 
ture, EO that in twenty -one hours I had Bucceedcid in dilating it from No. ^ 
^ iUd. 10, My patient did not iuffer from retoniiou or epasni, and but very 
^ litly from soreness* I did not make any attempt to pass the instrument 
win for nine days- 1 then passed the larger sized catheter- Not the 
jMhteBt pressure or force was used* and I succeeded in passing it through ^ 

I Ha lar as No, 8 or 9 ; if I had used a very slight degree of force it would i 
have gone tbrougbt but £ did not like to run the risk of producing retention 
as the patient was compelled to trail f^act business for some hours afterwards 
I expect that by passing the instrument about once a- week, and letting the < 
patient sleep wiih it tied in, once every fortnight or three weeks, a cure will I 
eventually be made; and I belie V0| that whenever strictures are capable oil 
diiatotton-r thi& plan will be found to involve the least loss of time, the least 
pain, and the least inconveniBnce : and whether it be used by tying in the 
calheter, or by simply passing it, the conical form will be found to dilate , 

L-tuote qnickly and to be withdrawn more easily, on account of its shape. 
The part where the c^me commences will vary with the seat of stricture, ' 
hut any instrument maker can easily furnish the requisite catheter. Whero 
this plan does not cure, it will at least be free from risk or danger, and will 
ciuickly convert an unmanageable strlctura into a perfectly munugeable one ; 
or if time i:^ of great importance, the tying in of the instrument for one | 
night per week will dikto the stricture, witbout encroaching upon the next j 
dtiy^—Mtdkal Times and Gaieiie, July 7, 1660, /*, 5. 



73. — Na& Operation for Pkj/mmis. By M. RiDRRAU*— The welUknowa 
operation for pbymosis* practised by M. Hi cord, leaves scarcely anything t^ j 
be desired under ordinary circumstancas, at leust in the opinion of the mtw} 
I jorily* Some, however, object to the permanent exposure of the glnus whiols I 
lo oxtensivo a removal of the foreskin entails* To meot the viewi of tar- 1 
geon^ holding this opinion, we quote frotu tJie * Jourmil of Practical Madictnej 
and Surgery,^ the deseription of an operatiou, de^iigned and successfully j 
practised hy M. liidreaut a Frenoh uiilitary surgeon, | 

** Stretch the prepuce by dravving tbe mucous membrane forward, and th# j 
skin back, so as to lay hare tbe orifice of the fireskin \ introduce a slender j 
oylindrico'Conic wooden rod into the aperture of the prepuce; porform 
circular incision at about half a line from the mucous margin, dividing the ' 
«kin only, which immediately shrinks backward on the glans; maintain the 
mucous lining upon tbe wooden rod, and remove circnkrly a sufficient quan- 
tity of it to give frco play to the gkns in tbe aperture resulting from the 
operation* Join the edges of the wound of the »kin and of the mucous raem- 
hrane by a few small needles and twisted suture. If a vessel bleeds, apply 
one of the sutures on that spot," 

The wound heaU in a few days with water dressing, and then tbe condition 
of the organ Is perfectly normal, tbe glans being covered or exposed at will. 
Examination of tbe anatomy of the parts eiplaina tbe success of tbis opera- 
tion. The constriction is seated in the mucous membrane, and this is re* 
moved. Moreover, the skin of the penis unites with the mucous membranB, 
not by a diminution of its substance, but by accommodating itself by numer- 
ou« wrinkles (In the usual manner of skin surrounding the spliincters) to tbe 
I dlestioed aperture ; accordingly, the moment it is divided circularly, it may, 
} without difficulty, be drawn back upon the penis- This operation possesses 
I advantages peculiar to itself; a very limited portion of tbe textures is re- 
moyed, a covering for the glans is retained ; no deformity results; the cica- 
trii; is linear, so imperceptible as to be mistaken for the natural junction of 
I the skin and mucous membrane, and is entirely conceded ^Wu t\\a y'^^^^^l^ 



182 



SUBG£BT. 



is drawn forward upon the glans ; the portion of mucoufl membrane removed 
being replaced bj integument. — Duh, Hospital GazcUe, Aug. 1, 1860, /9.2d3^ 




I 




74.— TWO CASES OF STRICTURE OF THE URETHRA SUCCESS- 
FULLY TREATED BY THE URETHROTOME DILATOR. 

(Under the care of Jomr Wood, Esq., King's College Hospital.) 

Two cases of stricture of the urethra were operated upon by Mr. Wood, on 
the IHth of May, with his new instrument, the ** urethrotome dilator.*' The 
first of these cases was that of a man of about forty, who had been suffering 
from stricture for many years, and had never had a larger instrument than a 
No. 4 passed. The stricture was situated three or four inches from the me- 
atus, and admitted a No. 2 catheter pretty readily. The second case was 
that of a gold-digger lately returned from California, where he first became 
afflicted with stricture, the result of gonorrhoea. In this case the urethra 
was very irritable, the stricture being 
situated in the most common locality — 
namely, at the junction of the bulbous 
with the membranous portion of the ure- 
thra. A No. 4 catheter was passed by Mr. 
Wood, after much careful manipulation. 

The instrument which Mr. Wood has 
but very lately brought under the notice 
of the profession combines the method of 
dilatation with that of the internal divis- 
ion of strictures, and consists — 

1. Of a long steel staff, of about the 
calibre of a No. 2 catheter, grooved along 
its convexity, except for about two inches 
at its point, where it is curved to that ex- 
tent. 

2. Of a German silver canula, of the 
size of a No. 12. conical at its point, on 
the under surface of which there is a 
slit about half an inch in length. This 
canula is fitted with a convenient handle, 
fixed at an oblique angle. 

3. Of a flat steel stilette, the point of 
which consists of a lancet-shaped cut- 
ting edge, about three-quarters of an inch 
long, working in the groove of the director 
by means of a thumb- plate and spiral 
spring. 

The method of using this instrument 
seems to be simple and easy of applica- 
tion. The steel director is first passed 
through the stricture into the bladder, 
which fact may be ascertained by the 
urine trickling through the groove. The 
position of its point is always indica- 
ted by the groove, which is situated on 
the convexity of the instrument, and the 
short curve at its ppint allows it to bo 
turned in any direction. The dilating 
canula is then slid over the director down 
to the stricture, which its conical point 
enters for a certain distance. Then the 
Mtileiie is slid within the canula down 
the groove of the director, and on press- 




SURGERY, 



im 



ing the fing<?r*p1ate at its oxtremitj the cutting edge is pro traded for about 
Bcjuarterof an inch ihroagh the slit at the pnint of tlie eanulat and utill 
Blldiog in tljo gmovc m the director, Jt returns wliliin the canula by the 
spiral trpring in the handle cstrcmitj of the instrument* The dihiting 
canuln h n<jw pushed on, and tf it tlooe; not pass tiirougti tbo f^trjcture^ thia 
may he scarified at its inferior, hiternl, or even superior asjieets, and the di- 
lator pushf^d throvig:li it. The dnfttinq- and cutting portioua of the in»tni- 
ment are noiv withdrawn^ at ill leaving tiie ongiiml director. Over this ugain 
an elai^tic catheter is passed into the hi adder, and the director withdrawn 
through it. In the two ciises in which Mr. Wood operated* the iti^trutneut 
answered perfectly, the operation being performed without the nid of chloro- 
form. In the first case there was no bleeding, and in the second only a few 
drops of blood escaped. Little pain was experienced by the patients* who 
walked home shortljafterwardB, suffering little nneaninesis. 

Mr, Weed, in hie remarks t^fter the operation, made reference to the rela- 
tive yahie of his instrument with those for the internal division of stricture* 
from behind, in which a comparatively large-eUed instrument must be passed 
througb before gcarUteation can be had recourse to. He said that the chief 
recommendations of the urethrotome dilator were — I. The safety with which 
it might be used. 2, That the cutting portion of the instrument would only 
cut the indurated and contracted tissues of the strictures, and only just suffi- 
cient for the passage of tbe dilating canuta« *h Tbat all previous dilata- 
tion of the stricture became unnecessary. 4. That it affords a ready means 
of combining dilatation with limited section of the stricture. 

May 10th. The second patient presented himself to-day, having suffered 
scarcely any inconvenience from the operation, since which tbe urine has 
been passed more freely, and in a larger stream. A No, B* then a No, 9i 
aad finally a No. 10 catheters were passed with ease* 

Tbe particulars of theee two cases were funiished by Mr. Charles S.'^Mathews, 
assistant house-surgeon to the hospitah — Lancet, Jalj/ 21, 1860^ p, 5H. 



75,— ON ALLAIlTON\S OPERATION FOR STONE IN THE BLAD- 
DER, 

By BiRV^itQ lloLT^ Eiq.. F. R. C. B* agr«0on to tho Wefltmtnsnjr HQapltnl 

[This operntir^n ha^ often been declared tn be imprnpfsr, when the stone, or 
the prostate, are large. It wtMjld appc^ar, bowiiver, that these two olyectiona 
are not good <mes, as the fi die wing eases show.] 

J, IL, a child agad eight years, was aduntted into the Westminster Ilea* 
piUil under my care, Aprih lB6tJ| suifering from stone in the bladder. The 
symptoais had existed for eight months prior to his admission, and consisted 
in difficulty and frequency of micturition, which required considerable strain* 
ing to effect; occasional pa^i^sage of bloody urine; and. but rarely, pain at 
the eitremity of tbo penis. The boy having been placed under the influence 
of chlorofonn, a sound was pasjsed to the neck of the bhidder, where its furtb* 
er progress waa arrested by some foreigu body, which a slight amount of 
pressure jmfliced to disiphtce. The sound being thus fairly introduced, a 
stone wa« immediately detected, which, from the extent of surface traversed, 
appeared to be large, 

1 decided on performing Mr* Allar ton's operation. On May 8th, while 
under chloroform, a staff as hirge as the urethra would admit was introduced, 
and the stone immediately detected. The child was now secured in the ordi- 
nary maner, and tbe forefinger of the left hatut being passed into tbe rec- 
tum, the exact situation of the prostate was ascertained, A sharp-pointed 
and somewhat triangular knife was now thrust into the mesian line of the 
perineum, with the back towards and about three lines in front of the auns, 
the finger in the rectum guiding the knife, and preventing it» belv\^ ^t4wa\- 
ed. An incision w is now made directly upwards, nnt\ t\ic ^Tcii«i\ft ^\ ^^ t\ftl3L 
cut into by opi^nwg tho urethra immediately m froul o! lAiii i^ito^VaX.ft\ ^"^^ 



184 SUKGERT. 

the knife was now ran backwards and forwards to a slight extent so that it 
might be fairly divided, the tegumentary opening being enlarged as mnch as 
appeared necessary in its withdrawal. The forefinger was now remoyed 
from the rectum, and passed into the wound, with the nail in the groove of 
the staff, which thus formed an accurate guide for the director, which being 
made with a handle at right angles, was passed along the groove into the 
bladder. The assistant was now directed to pull the staff gently bat 
firmly upwards towards the symphysis pubis, whilst I palled the direc- 
tor gently downwards, and the forefinger of the left hand, being passed 
between these two instruments, was gently wormed between them with a 
twisting motion, dilating the parts as it proceeded until the neck of the blad- 
der was reached, when both staff and director were withdrawn, and the dila- 
tation was continued still further by rotating and movine the finger from 
side to side. The forceps were now introduced upon the finger, which was 
withdrawn as they passed into the bladder, so that to the present time no 
urine had escaped. The stone having been detected, the blades of the for- 
ceps were separated, when the gush of urine carried it between them, and 
with gentle traction it was removed. As was anticipated, it proved of con- 
siderable size, measuring two inches long and one inch wide, and weighing 
240 grains ; it was of the triple phosphate variety. The hemorrhage was of 
the most trifling description, and beyond the smarting attendant upon a 
wound he hardly suffered anything. There was no involuntary escape of urine 
after the operation, but it was passed at will, for the first week through the 
wound, but afterwards per urethram. Eight days from the operation he was 
walking about the ward, and in a fortnight was discharged cured. 

The second case occurred in a spare, feeble man, aged sixty-five, who had 
suffered from stone for four years prior to his admission. The urethra ad- 
mitted a full-sized sound, and the prostate was perfectly healthy. The 
bladder was, however, considerably contracted, not holding more than four 
ounces of urine ; and the stone, which was readily detected, was large and 
dense. The same proceedings were adopted as have been already described; 
but the stone, proving oven larger than was anticipated, eluded the blades of 
the forciips. A large pair were consequently had recourse to, and the stono 
removed. It was found to measure two inches and a quarter long by one 
inch and a half in breadth, and weighed 570 grains. It was of the oxalate 
of lime variety, coated with phosphates. The patient was comfortable du- 
ring the evening, and passed his urine at will. He was, however, seized in 
the morning with a rigor, and died suddenly. 

The post-mortem was made twenty-eight hours after death, and the blad- 
der having been removed, the incision was found to be exactly in front of the 
prostate. The bladder was now cut into, and the mucous membrane corre- 
sponding to the neck was found to be congested and slightly torn, not, how- 
ever, extending into the prostate gland, and much less than is met with in 
the lateral operatioh. The kidneys were in an advanced stage of cystic 
disease : the heart fatty ; but the other organs were healthy. 

The third case occurred in my private practice, in the person of a gentle- 
man aged seventy-five, of spare habit, who had suffered from diseased pros- 
tate more or less for the last eight years, during which time he had occasion- 
al hemorrhage, sometimes slight, and sometimes sufficiently severe to call 
for the exhibition of gallic acid, the bleeding being at all times provoked by 
any extra walking or jolting exercise. Although there was no pain ot the 
extremity of the penis after micturition, yet the symptoms to some extent, 
simulated those of stone, and the bladder was from time to time carefully 
examined both by myself and others, without, however, detecting any foreign 
body. Early in 1859, while at his seat in the country, he was attacked with 
inflammation of the bladder, characterized by rigors, great frequency of 
micturition, spasms of the most violent character, and occasional pain at the 
extremity of the penis, the urine depositing the usual amount of muoo-puru- 
Jenty tenacious deposit. Suitable remedies were had recourse to, and in the 
coarse of three months he recovered ; the spasms entirely subsided, the urine 
regained its healthy charaeter, but the di£^o\x\ty oi QiL'^\x\%\oTi\)A4«Q far in- 



SUH6EET. 



185 



k 



creosed as to prevent his pn^sinf^ more than an onnce at a timo* He wn* 
thereftiro dircctod to pas& his own catheter three or four times in the day 
and m0iU which he aceompUsiliitd without either difficuUy or ^uflFcrring. In 
tlie wintnr of 1839, hthig again in the country^ ha had another but more se- 
vere attack, wliich app irf^ntly arose from standiug on damp ground, and it 
Wfts evident^ from a sudden discharge of pus and vstreme tenderness of the 
prostate, that an absceas of that gland had formed and burst* His sjmp- 
ttims werp oow very distressing, the bladder mueh more irritiiblo, and the 
pain at the extremity of the penis more decided ; and being now tninhle to 
pa«s any nrinn naturally, he was compelled to rely entirely upon the catheter, 
which waei paF^ed every three hours* The bowels were daily removed by 
enemata. Tfi© horizontal position was maintained, and all the known reme- 
dies had recoursQ to, belladonna, copaiba, and chlorodyne giving the great- 
est relief. 

In the spring of the present year ho was removed to town, the frequent 
and altnnst irresiHtibio urgencies continuingi and the pain at the extremity 
of the penis being more acute. Opium, in the form of suppositories, was 
th^ only drug that now aflforded the sligbtes^t reliefs 

On Sunday, June 15thT after violent straining at stool, the bladder became 

more than ujfually irritable ; and being requested to pass his gum catheter, I 

immediately detected a calculu?, rough, und so far as could be asci-rtained 

'"jbf such an instrument, not very large. A consultation with Mr. Arnott and 

"if, Caesar Hawkins was held t and ad lithotrity offered no chances of relief, 

Allarton's operation was decided upon. 

Oil June 27\h he was placed under the influence of cbloroform, and the 
operation, as already detailed, was performed. Not the slightest flifHcnlty 
was f?3cperieneed in reaching the neck of the bladder, but the gtiss© of the 
prostate previ^nted the interior being explored, or the «tone being felt with 
the finger. The forceps were consequently substituted, and being burled to 
a coupiderablo depth* a stone was cnnghtnnd removed, proving large, smooth, 
an d pol J sh t^d. A n ( i th er wai 50 ugh t f o r an d re m ve d , w h i e h b ro an ace u rate 
resemhiance to the int^t, It waii, therefore, evident there must bo a third, 
which, after Might diihculty, was abo incladed between the blades of the 
fiirceps, but being larger than either of the fonner ones, it required some 
little natienee and gentle traction to remove it. Tho parts, however* 
yieKled, and the third, somewhat roughened* i^tono was now abstracted* 
The first nieajsured If in. by 14 in. : tho secoud» If in, by If in*; and tho 
third, 1| in. by H in, r the weight of the three being 960 grnlos. The in- 
cision was in^ignifienntly small ; the hemorrhago very tritling; and my pa- 
tient being now placed in bed, Hhortly recovered from the elFecta of the 
ch!orofi*rni, and simply comphiined of the slig:ht smarting of the wound* 
The D*'ck of the bladder retained its contractility, and there was not any 
involuntary er^cape* The sappository was iutroduced as usual ; and, ex- 
opting when tho urine was withdrawn, he slept tranquilly. For the first 
^ ee days lie progrewsed in the most favorable manner ; the intervals 

re in creased, tlie catheter being introduced every four, instead of every 
three, hours ; the spasms were \ch^ frequent nnd less IntGnso, and he Wtti 
nearly relieved from the pain he had prevjnusly experienced, when* on the 
fourth day he was seized with rigors, estrcmo and urgent pain in the region 
of the stomach, vomiting, and his pulse, which was eseeedingly weak, rose 
to 13(>; !=kin hot; countenance anxious; and the urine presenting an ap- 
pearance of bloody jelly. Opium and stimulants were administered, the 
hiadder was injected with tepid water, and he rallied. He* however, con- 
tinned ejEceedingly ill for three or four days, when the attack gradually sub- 
lided ; the nr ine became more natural* but the spasms of the bladder recur- 
red ; and fearing the poiaibility of a euleulusf having descended from the 
kidney, he was again examined, under the influence of chloroforDi, without 
however disooverlng any foreign body ; a roughness was detected with th© 
gum- elastic catheter, but not with the sound and in aW \iTo\ii\V\\V\.^ i^t.i^feTv&^^ 
upon a calcareous contiag of some portion of the mucG\iB tnttt\\5rmT5t^% Vb.- 
deed* tJi/* rras sub^equentl^r aac&rtahiGd to be tlie case^ fox ^I'liciTi \\sXto4^^^sk^ 



SURGERY. 

ft Hthotrity «pM>oii, a portion of grlttj matt[\r was removed, and ercntanlly 
the correnpoudin^ mucous surfaLG, coated with pboi^plmtea^ came a way in 
the eye of the catheter. Small particlei? of the siioie deposit huve fri»m time 
to time cfscaped. The frequency and spRstJis Lnve now <5t)tirely suhsided ; 
lie ifl enabled to pass per uretbram fi'om two to threo ounces of urinR ; the 
bladder will retaiji from tmi U^ twelve ouncea ; tbp wound baa so far bealt«d 
as to be hiivdly pt?roPptibl*?, an<i when neces&ary ho can introdace his own 
oatheter* The bowels which have hUberto required enoimita of water, bavft 
acted naturally Bince taking the confection of senna: and an examination per 
anum proves the proijtate lu be dtrainlshed in size. He is dally gainiug fle&li 
and ^ti'cngth, and when the weather wifl permit drives out. 

The proi^ent cases have been described jsimply a?^ examples to pror© that 
large c«lculi and an enlarged prostate form no bar to the operation, and, a« 
far ai^ they go, establish the facility with which a largo stone can be removed 
without injury to the neck of the bladder. It is true that the mortality is 
about the average ; but as in the fatal case tliere was probably sufficient 
cause in the state of the kidneys and heart superadded to the rigr>r, from 
which per^ou!^ in advanced years frequently die, I cannot consider It as in 
anv nmniier mititnting against Hie operation, 

'The caj^e of the boy was iaterenting in showing how circumstances may 
alter and modify symptoms generally relied upon as characteristic of stone* 
The pain at the extremity of the penis waa the (exception, and not the 
rule, and evidently depended upon the stone generally occupying the same 

Sosition and requiring to be displaced before the sound could be fairly intro- 
uoed. The diagnoisi!^ wa^ CiTrrect in reference to its size, which it must be 
admitted very fur exceeded the average of such casesi at such an nge. 

In the second cajie, the facility with which the stone was detected, and the 
ringing sound, alFurded sufhcient evidence of its size and density to preclude 
any advai i ta ge fro m li tho t ri ty f 

The tiiird case must be considered as the most impi^rtant of the three. 
The size of the prostate^wluch did not permit the finger to reach the blad- 
der after tho necessary incisions had been made, the long duration of the 
disease, the inability to pass any urine without the introduction of a cathe- 
ter, the irritable state of the bladder, the emaciated condition of my patient, 
and the presence of three such very large calculi, were siufficient to test the 
operation to the utmost. I may mention that this gentleman had been sub- 
ject to severe bilious attacks which very much resembled the one that super- 
vened on the fourth day, and that the issue of the case proves the symptoms 
to have depended upon a deranged liver. 

I have described the operation ns it was performed? and although the 
precuution c»f introducing the finger between the director and the sound may 
not be absolutely necessiiry, yet I am convinced it ^simplifies the operation 
to such a dt^gree that no surgeon of common intelligence need fear uudertak* 
log it. The eicti-actiou of the stone require* care and gentleness, A min- 
ute lost is a minute gained, if a large calculus can be removed through 
the neck of the bladder withont injury ; and I feci convinced thi;! can always 
be eflfected if the nece^i*ary care is excrcis^ed. In almost all the descrip- 
tions of the ordinary forms of operatingT the direction is, to have a large ex- 
ternal wound. Such is not necesftary ; and if a stone can be r^smoved, with- 
out bruising, through a moderate wound, it is certainly better than making a 
large one. 

From all that I have yet seen of Mr* Allarton's operations, I consider it 
a most valuable one ; the wound is less ; the hemorrhage is less ; tho con- 
stitutional disturbance is less ; there is no chance of infiltration of urine ; 
and, as a matter of comfort to tho patient, the ability to retain the urine is 
of the utmost value and importance. — Lancet^ ^tpL 8, 1860, p. 234, 



L 



7'd — Om Alhirlon^$ Lithotomy Opera lion. By Nathaniel WAliDt EBq,tl 
^^U^C^S.f Assistant Surgeon to the Londou HoB^gYtei*— \[^\i^ \taA<aral opera^^ 



SUEGERY, 



rtinn geiierallj requires miicb preliminary study^ atitl constant cnulion and 
cnrvt in tirder to execute it with prceUiou ajtij vrlthout n&k^ tUo chu'f dungHr^ 
bcin^ tbe iiUppiug of the iaatrument from the groove of the staft*, and the 
I woujMling the bl udder or rectum.] 

Tiu^ coti3|HirutLvelj greater safety, fiimplicitji and facility of the operation 

I recotnineuded by Mr. Ailsrtuu appear to me to constitute its peculiar rneritB* 

On tlic six accadoiis on which it b«s been performed at the Li>ndnu Ho^pitiil, 

I either by my colleuguc'«» Alcitsr*. Critchett aisdGowlland* or by myficlf, the 

^ Btvi^a recommended by Mr* Albvrtou have bceti folio wed with but a slight 

' Tariatiou* The staff luivinf^ been introduced into the uuinjtcUd bhidder, the 

I progtivte was made out by tlic left index finircr fiassed into the rectum, aud 

[Its ape£ was steadied by it against the stuff. A scalpel, with the blade half 

^ an inch longer than the length of tbe finger in the rectum, and having a 

Straight cutting edge and curved back» was introduced with the cutting edge 

upwards into the perineal rapht% about half an inch in front of the unusi and 

I paiised steadily downwards* aud backwards^ until it;^ poijit impinged in the 

[groove of the staff, cutting through tho lower wall of the backpart of tlie 

mcmbrauoua portion of tha urctbri,, ju?it m front of the point of tbe index 

I £nger« 

The knife was then carried forward about tbe eiglith of an inch along the 
I ffTooTe of the staff, aud was then withdrawn by sweeping it upward:* and 
BK»rwardi [tuA regards the operator), so as to make a median cutaneous inci* 
Iftion about an hich in length. A common hone probe, set in n rough bandlet 
I WBfi next pasied along the groove of the stuff into the bladder. The Ktuff 
^wafi then removedi and the left index finger* well greaned, being ])a^sed 
along tlie upper surface of the probe to tbe prostatic u ret lira, arrived througb 
thia, after several graduated rotations, into the vesical cavity. The forceps 
.were next introduced along the upper surface of the finger, and the calouH 
[removed. 

Thu!^ it will be seen that the only points in which this lithotomy differed 
from Mr* Allarton's directions were — tbe use of the form of scalpel nlluded 
[ to, aud the incision of the membranous urethra by drawing tbe koife for- 
wards and upwards, instead of passing it towards the prostate in tbe con- 
(trary diritction* Tbe eases were all suecesafuh and the patients rapidly 
\ recorered. 

Independently of the many recommendatory points in this method of 
I uretliral lithotomy insisted on by Mr* Allartoni tbe n€cessh}f of injecting Uie 
J bladder before cutting dots not exisl-, inasjoucb as the cavjty of the vis^eus is 
[not cut inff} ; and the bladder is not in danger af being wounded, as* the in- 
"ifon nearest to it is carried away from it towards the operator- But tbcre 
important rca^^on why the Madder should n(4 he injected, am} it is 
S:— The prostate gland is taken to be. so to speak, the land-mark of tbe 
[operation* This organ in children is very snnill, and it requires a little 
jeuucaiion of the finger in order re^idlly tc^ detect it. If the bladder is tense 
I in consequence of retained urine or injected fluidt the walls encroach on 
[the immediate area of the gland, and the prostate Is then not easy to be felt, 
I On the contrary, when that vis^cus is not distended, the prostate stunda out in 
comparutivtdy prominent relief, and can easily bo felt by the finger, and 
^ iteadied aguin^^t the staff, 

I have little diiubt that Allarton's operation will* in coarse of time, he 
generally adopted for tbe removal of mnnU or average-volumed calculi from 
\ the bladder, and I cannot but think that since its introduction it would have 
I received ere tbls a greater amount of sound surgical sanction had some 
I litliotomists of this day, of the highest authority, deviated, in a spirit of in- 
Lquiry, from a beaten track; and experimentally tested the applicability and 
I efficiency of the modified Marian operation, the revival of which must be 
regarded as a useful addition to the resources of the healing art, and as a 
I tigli compliment on the part of modern to ancient surgery. — Lancet^ June 
p, 1860, p. im. 



188 



SURGERY. 



77.-_ON LITHOTOMY. 

By Professor N. R. Smith, of the Univendty of Haxyland. 

[InstrumeDts at all complicated only increase the difficolty of this important 
operation, which is becoming more and more simplified, especially since 
barton's operation has become popular in this country. Nevertheless, we 
think it right to let our readers see what other people do, and espeoiallj our 
cousins over the water, who are making rapid strides both in surgery and in 
journalism to overtake the mother country. Professor Smith, of Baltimore, 
has used this instrument with great success for thirty years, in more than 
100 cases. He describes it as follows:] 




The staff ia a silver canula, with a sligbitly-spiral fenestrnm cut out of its 
doraumt ond oontinaed to near its point; a\oii^ ^\& \)i:v& Vmi^ ^\^^«. Yon 



StmGERT. 



[iee tli6 cutting director attached to tlie handle of tlio instrumont hj a Btroxvg 
lliinge* Thi,*^ has an angle about an Inch from its lower extremitv^ end at its 
fttnd IS a cutting iKJint^ like tLnt of a broad scalpoL On the inferior border 
I0f ibis angular iinrtion is a groove, which receives thi?, back of the knife* 
I When, as the binge allows, you eitend the director, it standt^ out at right 
agles to the shaft. When you depress it, you s»ee the scalpel point enters 
|"th© feneslrum of the ataff at the doraura, and cannot deviate from it. In the 
bellow of the staff ia a Hhort cylinder^ concave towards the handle. To the 
entre of the concave end is attnched a fine, flexible pteel wire, which paasea 
p through the handle of the ins^trunnent along a small canal* The ojlinder 
rati dee freely along the ennal of the itaff, and drags the wire index where the 
[Enife encounters it in the Rtaff. 

I now proceed with the operation, the patient being placed in the uiual 
I attitude, and chloroform having been ndminifttercd* 

You see I introduce the staff with ease, and touch the ptone with it. I 
isarry the handle well forward and to the left side, I now bring down the 
I binged-cutting director, and with precision apply its point to the integu- 
Imeuts on the left of the anu^f and nearly on a level with its anterior margin* 
lit is thus directed somewhat obliquely upward and forward, behind the bulb 
[ <>f the urethra, toward the ini^mbranou» portion. I now pre^s the director 
T firmly down, and It cuts its way inttj the hollow of the etaff, between the 
I bulb of the urethra and the crust of the penis, tt ija firmly fired, and can- 
not change its place. 

I now apply the back, of the gorget-knife, the handle of which has an 
I angle with the blade, to the groove in the cutting director, and penetrate 
[the hollow of the staff* I now press the body of the staff well to the right 
fmide, so ns to make more room for the incision in the left perineum, and I 
cause the knife to glide along the spiral opening in the fitufF, directing its 
edge obliquely outward and downward. You see that it drags along with it 
L the wire index, which oauses no irapediment, I have reached the extrejnlty 
f of the stag' in the bladder* I now withdraw the knife, and, aa I do so, dilate 
I the outer portion of the wound. 

You see me now introduce my finger before I withdraw the staff. I pcne- 
I ttate the bladder with it^ — the incision ia sufficiently free. I now raise the 
I cutting director, and withdraw the stafl-'^ retaining the index finger of tha 
I left hand in the wound. 

Guiddd by the finger, I now introduce theie forceps (comparatively small 

f mnd short.) I sei?,e the stone without difficulty, and am now attempting its 

|«f5traction. I feel it break in the forceps, it being friable. I eitrnet the 

^nnemal portion, T feel often frogrnents with the finger. You fee 1 have 

no difficulty in seizing them. I reach every portion of the interior of the 

bladder with the finger. I have now citraeted the last fragment, and feel 

Ithat the bladder is free. I shall not inject the bladder, because I eiphire it 

n> freely with the finger, and feel that nothing remains* The operation i« 

Domplcted. You observe there is but little hemorrhage — none requiring any 

fiechanical expedients to arrest it* 

' ^aball introduce no cauula, which T often use. I omit it In this case, 
ause the opening ia free and the perineum not deep* and because, in the 
ecent case of Gov. Hicks, I found it to create irritation* 

In Braithwaite*a ' Retro«pcct,* voh 3^, you will find a description and 
jilate of an instrament, the invention of which h claimed by Mr* Corbett, 
af the Glasgow Royal Infirmary, and which is identical witii mine, eicept 
that the bend in the staff is angular and not abruptly curved as mine ii. 
This deviation only impairs the usefulness of the instrument, 

I published an account of my instrument in 1S31, and, from that time to 
be present, have employed it in presence of the medical classes of the Uni* 
llrersity of Maryland* 

I The advantages which I claim for this instrument are, that it greatly iioi- 
Iplifies and abbreviates the operation-^that it gives unity aad eomV\%M\\^ \Pt 
he inciBion— that it obviates the danger of wounding ihci attfti-j %A VWVck^^ 



190 SURGERY. 

and the danger of the slipping of the knife or gorget from the groove of the 
staff. — Maryland and Virginia Medical Journal^ May, 1860, p. 345. 



DISEASES OF THE SKIN. 

78.— STATISTICAL ANALYSIS OP FORTY-TWO CASES OP 
RODENT ULCER. 

By Jonathan HnrcniNSOir, Esq. 

[This gentleman has published a valuable series of cases on this subject, 
T?hich we have not space to give in detail. We will, however, give some of 
the most impoitant results.] 

The parts by far the most liable to be affected by the rodent ulcer are the 
eyelids and adjacent portions of cheek. Next to them the nose is its favorite 
site, and the third in the list are the cheeks. On one or other of these posi- 
tions almost all the rodent ulcers occur. No case has yet been recorded in 
which this ulcer occurred in the integument of the extremities or on that of 
the trunk, if we except one case, in which the nipple was the part in- 
volved. It is a remarkable fact that in only one instance was the upper lip 
the primary seat, and that in no single case was the lower lip involved either 
primarily or by extension. This fact is of great importance, when it is 
borne in mind bow frequently the lower lip is the seat of epithelial cancer. 
The single case in which, as just stated, the upper lip was affected, is not 
wholly exempt from doubt as to whether, indeed, it did not approach to the 
epithelial claims of growths, since, unlike what occurs in a rodent ulcer, a 
lymphatic gland was enlarged. 

Questions of TreatmenL — The rodent ulcer is to be viewed, as far as our 
knowledge extends, as a local disease, which spreads by continuous growth. 
There is not a tittle of evidence in favor of the belief that it can be influenced 
by internal medication. The object which the surgeon must keep in view 
is to remove the whole of the diseased parts, and to procure a soft, supple 
cicatrix. If there be any tension on the cicatrix, the irritation thereby pro- 
duced will be almost certain to induce a relapse of the disease. By means 
of deep escharotics, such as the chloride of zinc, complete destruction of the 
diseased parts may in many instances be ensured, and a very healthy and 
pliant cicatrix is usually obtained by this remedy. In many of the favorite 
seats of rodent ulcer, — ^the eyelids to wit, — the use of escharotics is very in- 
convenient ; and in these, free excision, followed by the transplantation of 
healthy skin from the forehead, cheek, or temple, is the best measure. 

Aphorisms respecting the Rodent Ulcer. — 1. That there occurs not infre- 
quently on one or other part of the face a form of ulceration which is charac- 
terized by an indurated edge, and by a tendency to spread to adjacent struc- 
tures, without regard to diticrcnce of tissue ; which is very slow in its pro- 
gress ; does not cause much pain ; does not induce cachexia, and is never 
JoUowed by enlarged glands or deposits in the viscera. 

2. Sections of the indurated edge of this ulcer (or of the portions of new 
growth which are sometimes produced about it) do not exhibit the cell-struc- 
tures met with in epithelial or scirrhous cancer, but only those of organis- 
ing fibrous tissue. 

3. This ulcer differs from lupus exedens in that it never occurs in the 
young, and never gets well spontaneously, while lupes exedens but rarely 
begins after the age of thirty, and usually tends after the lapse of time to 
cicatrise spontaneously. The two, also, further differ, in that lupus has 
a tuberculated, inflamed border, without any degree of induration ; while 
the edges of the ulcer in question presents an extremely indurated ridge, 
without tubercles, and comparatively free from inflammatory congestion. 

4. The ulcer in question differs from cancer in that there is but seldom 
present any tendency to the productiou o5 XLCYr m%.l&T\Al^ that it never 



SUEGEHT, 



191 



catiFCB th^ glands to enlarge nor induces morbid growths in the internal 

5. Although it must he freely admitted thnt this dieeage is clusely tdWtd 
to concert and that in its inveteracy under treatment, mul its tendency, if 
not removed, to spread deeply and citen&ively^it well deserves the do^igtia- 
tton i)f "locally malignant /* yet it is inconvenient in praetico to call it ** can- 
cer of the ekin/* since there are other f<:trmB of ciitanetjus cnncer (the epi- 
thelial, seirrhouB, melanotiCi &c. ) csaentially different from it, and of a far 
higher degree of malignancy. 

6, The term ^*a peculiar ulcer occurring in the eyelidi," ii too vague, and 
also involves an erroneous statement as to uniformity of location, on ohjtc* 
t^m which, also, in addition to what has been etated above, applies to "can- 
cer of !he eyelids," Bince this ulcer is met with on many other parts beside* 
the pulpebrae. 

7» To the designation of Eodcnt Uicer given to this disease by Lehert, 
and adopted in this country by Paget (see Lectuies on Surgical I'atlndjigy) 
no objection appdies, escepting that it is more vaguo than desirable. Of those 
in use it is certninlj the best, and isbould the disease beoome generally rc- 
eognieed by the profession under that name, the vagueness of its metming 
will by custom eoon cease. 

8. The rrtdent ulcer is most commonly met with betwoeh the ages of 50 
and 60, and is equally frequent in the two sexes. 

9. It occurs but very rarely on any other region than the integument of 
the face, and is most common in the eyelids* 

10* It is a singular and v&ry significnnt fact that no case has jGt been re- 
corded in which the rodent ulcer attneked the lower lip, either primarily or 
by extension, while that part is well known to be a very frequent seat of 
epithelial cnncer. 

Ih The Diagn^ms of rodent ulcer is uaually easy. An ulcer with a hard 
fiinuous edge, situated on some part of the skin of tl;e upper two- thirds of the 
fuce, of ioverul, or, perhaps, many years' duration, almost painlesm and oc- 
curring in a middle-eged or elderly person, of fair health, and without 
LuUrged glamls — such a sore is almost certain to be of tho rodent type, 

12* T]m prognosis of rodent ulcer varies with the stago of the disi^a^se and 
the treatment it is intended to pursue. If left to itself it will slowly but 
suvel}' advance both in extent and depth, and will probahiy destroy the pa- 
tient*8 life in the cours^e of from ten to twenty -iive years, death being event- 
uully produced by the eshau^tion conaequent on suppuration, benuirrhnges, 
pain, &c,, and very probably aggravated by inaljility to take sufficit^nt If^od 
owing to the diseased state of the mouth* If the case be seen in an early 
stage while complete removal either by knife or oi^charotics is practicable, a 
favourable opinion may be given as to the probable nun-return of the disoasc* 
The younger the patient the more rapid will be the course of the disease, and 
ric€ versa; and the younger the patient the more nearly is the disease allit?d 
lo cancer, and the more likely to recur after rcniovah 

13. The only Ircalment which the rodent ulcer admits of is local, and the 
basis is that which obtains its freest removal with the least injury to the 
parts concerned* In some localities, and in some stages, eschurotics such 
as tho chloride of zinc, may be adviftuble, hut in most excision and trans - 
plantation of akin is the more certain imd satisfactory. 

14* A widely-diflused knowledge of the true pathology of rodent ulcer 
may be expected to result in considerable advantage to the sufferers from 
that disease, ^ince it will encourage to the early and free adoption of local 
measures and to the employment of excision lujd transplantation even in 
Hume eases which, if considered cancerous, would certainly be beyond reltuf 
by surgical uTt^Meditai Tifn€S and Gazciic, Sfp(* SD, J 860, p. y05. 



192 SURGERY. 



79.— ON THE TREATMENT OF FAVUS. 

By Dr. W. T. Gaisumkr, Physician to the Royal Tnflrmary of Edinburgh, Lecturer on CUnScal 
Medicine and on Practice of Physic. 

[In the case which forms the text of the following remarks, the head was nt 
first covered witli yellow crusts, of long standing ; exactly four days after- 
wards, there was not a vestige of a crust to be seen, nor even any broken 
surface, though the patches of absolute baldness and the stunted and di- 
minished hairs in many places, showed clearly the deep hold the disease 
had taken. The change was entirely due to the successful poultices of lin- 
seed meal.] 

After so much has been written about favus, and so many perfect cures 
have been recorded in periods varying from six weeks to several months, I 
am almost afraid to state my conviction, that the satisfactory result above 
mentioned, obtained in four days under linseed meal poultices, was quite as 
much entitled to the name of a cure as any that I have yet seen or heard of 
either in nature or in the records of medicine. To speak of a cure of this 
disease, with opportunities of observation extending over less than a year or 
two, is, in my opinion, evidence of nothing else than the most entire ignor- 
ance of its habits. I do not, however, doubt the cure of favus. Soap and 
hot water, with abundant scrubbing, the hair being kept short, will common- 
ly keep the yellow crusts indefinitely in abeyance ; as will also, perhaps 
more thoroughly and eflFcctually, the simplest oil inunction. There seems no 
reason, therefore, to believe (though hospital physicians can but seldom faopo 
to witness the result) that those simple means long and perseveiingly used, 
will not effect the cure of a disease which owes its origin and perpetuation to 
nothing else than want of cleanliness. 

Under ordinary circumstances, what takes place after an apparent cure of 
favus is this :— So long as the hair is kept shaved, and an alternation of oily ap- 
plications with soap and water is maintained, the disease does not reappear ; 
but on neglecting these precautions for a few weeks, yellow dots begin to 
crop up, and these rapidly extend so as to become distinct favus crusts, 
which in no long time, if unintcrfered with, will cover the whole head. I 
have repeatedly kept cases under observation after the head had been com- 
pletely cleared, in order to observe the first beginnings of the eruption after 
the suspension of the treatment ; and I have also employed a great variety 
of medicated ointments and lotions, including sulphurous acid, iodine and sul- 
phur ointments, empyreumatic oils, mecurial ointments, and mixed medica- 
tions of various kinds. After most of these, I have seen the disease reap- 
pear about as quickly as under the simpler treatment by oil and soap, if 
there is any of them in which I have faith more than another, it is in empy- 
reumatic oils, as the juniper tar oil or common pitch ointment. But the in- 
veteracy of the disease evidently depends, not on the difficulty of removing 
its Tisible traces, but on the complete infiltration (so to speak) of the scalp 
with the sporules of the fungus in all old standing cases ; and no treatment 
will be of the slightest avail towards a radical cure that is not deliberately 
and carefully pursued until a complete new growth of scarf skin has been 
obtained, perfectly free from all traces of the noxious germs. This must, of 
course, be the work of a considerable time ; just as it is a work of time, and 
of unwearied attention to simple details, to rid a virgin soil of ragWeeds and 
whins, or even of stones. No application of a specific can be expected to 
meet the one case, any more than the other. 

One point, not always observed by those who have written on this subjoct, 
is, that favus is often, perhaps even in the majority of cases, implanted on 
the basis of a previous eruption ; in other words, that the fungous crusts, or 
vegetable mould, are sown on a soil already the seat of impetigo, eczema, or 
some other variety of disease of the skin. Sometimes the original disease 
has died out when the favus first comes under treatment ; at other times, it 
stiU joorsists and requires separate treatment. In the course of considerable 
MJid varied experience of true fieivus, however, I have not seen a single case 



SURGERY. 

thnt ^id not at once yield to local treatment, to tbe exterimiaTe Indicntod 
nbovf ; and I am very for from believing that any constitutional di.sordijsr 
htkA to do Tvllh the production of the fuogiiB, farther than that favtis and 
other diseases may ariBo fiiraultaneoiisly+ under exposure to the same causes 
of fiUhi neglect, and hyfjienic errors of ©very kindi in every variety of 
bodily constitution. — Edhu Med, Journal^ Ma^ I860, p, 1003, 



W\^— Glycerine in Skhi DiuoMes^^—This substance baa been justly recom- 
mended in varioua affeetiong of the skin^ and oepociaUy in those attended 
w i th dc sq u amati on. In th at t fi ) u ble some a ft\>ction pityri a $is cupit is* i n vv h i eb 
tho hairs become dry and fall off» during the abnnaant epidemic ojcfiiliation, 
undiluted glycerine mny he applied with excellent and durable etfect. In 
jiityriusis ruhnt and pUi^riasis sitjiflej;^ a mLitare, composed of equal part^ 
iif oil of abmmds mid fjflycerine, and one- half of oiide of zino, baa proved 
very useful.— Uuiiwi Hospital GazetU, Maif 15, I860, p, 158, 



81, — Treaimenl of Empiions arouTtd the Anu4f^ — By JosfiSPH Bell, Esq*, 
Gateshead. — Occasionally we see obstinate cutaneous ulceration surround- 
ing^ the anus in children. Considerable tumefaction attends it betimes, and 
deep fii*:iures arc occassional ly seen. This disorder is probably herpetic^ and 
aUuofit always can be cured with yellow wash* The proportions being from 
one grain to one grain and a-balf of bydrarg- bichlorid, to one ounce aq- 
ealcM. The part h to be frequently batlied with it^ and should the lotion 
produce pain it is to be diluted with water, and when at re»t a little lint 
snaked in tbe lotion is to be applied and left on the part ; deobstruents being 
t%l the same time admiuisitered, — Med. jfVmM and GaztiU^ July 7, IrfGOtjj* 23. 



82. — On the Therapeutical Mf^thods of preventing Pitting of the Face in 
Omfuent Small- Po:c.^By Dr, Stokes, Dublin, — During the last five years 
Dr, Htokes has employed giiita-poreha aud collodion in a considerable num- 
ber of cases of conEuent small- pox, for the purpose of preventing pittlog 
of the face. In most of tbe cases the crust came off in large flakes or 
patches, composed of the dried exudations and tbe covering mateml, l*far* 
iiig the skin uu injured* This kind of treatment was most Buecessful in 
cvuses of a typbtiid character, but appeared to be not ho well adapted to those 
presojiting u more sthenic type* Dr. Stokes considers that the application 
of poultices over tho face is the surest method of preventing disfigurement 
in small-poic, Their use should be commenced at the earliest period, and 
eoQtiiiuea to on advanced stage of the disease. In most oases they may be 
applied even over the nose, so as to cover the nostrils* This plan ebould 
fulfil three important indications of treatment^ — namely, to exclude air, to 
moderate tho local irritation, and to keep the parts in a permanently mobt 
state, so as to prevent the drying and hardening of tbe scabs. The beet 
poultice is formed of linseed meal, wliich should be spread on a soft material, 
ssich as French wadding, and covered with gutta-percba paper or oiled silk, 
Tbe conclusions to which Dr. Stokes arrives are thfi following : 1 . That tiie 
chances of markiogare much greater in tbe sthenic ^fr inHammatory thfm in 
the as tb c nic or ty fihoid confluen tsmall^pox. 2. Tbat,coDsideringthecbauge 
in the cbaracter of disease observed during late years, we may explain the 
greater frequency of marking in former times* 3. Tbat» in tbe typhoid 
forms of tho disease tbe treatment of the surface by an artificial covering, 
such as gutta-percha or glycerine, will often prove satisfactory* 4. That, 
io tho in«jre active or non -typhoid forma tbe use of constant poulticing* and 
of every other method which will lessen local iiiflamraation^ fieemfe ^j^ W \3ti% 
best mode of preventing di^^fieurement of the fafi^. — BrituK and Fortxgtv 
Medico- Chirureicai He vkWf JuJu 1360, ^, 248. 
ZLH.—li 



tM SURGERY. 



DISEASES OF THE ETE AND EAR. 
83.— ON CORELYSIS. 

By J. F. BTBBATrxiLD, Esq., Editor of tbe Ophtbalmlo Hospital Beporti. 

[A short notice appeared in the journals ahout three years ago, upon the 
Bohject of Corelysis. Mr. Streatfeild has now matured the operation, and 
we insert the most practical parts of his paper, which, in the original, would 
occupy too much space for this work. Mr. Streatfeild has been perfectly 
successful in freeing the iris whenever it is adherent at its pupillary margin, 
whether to the lens or cornea, or to a false membrane in the pupil itself. 
He now names his operation Corelysis (meaning Pupil freeing, from Kdptf 
and XvuLp. 

My paper will throughout appear to ha^ a double bearing, as it refers to 
the two cases in which either the pupil is bound to the lens or cornea* or to 
a false membrane in its area, but they are alike and are here always consid- 
ered together, for in either of them it is required to free the pupiL 

As to the prevention of pupillary adhesions I have no otiier suggestion 
but that the old belief in belladonna and mercury should be cherished, that 
the former should never be neglected at any time in the treatment of iritis, 
and the latter should be generally administered in very frequent small doses 
continued for some time after the disappearance of the inflammation, with 
good food or perhaps some iron or other tonic, as well as the specific medi- 
cines. At the conclusion of the treatment of a case of iritis the absence 
of any adhesion should be ascertained, if the iris is not perfectly active, it 
may be because of a single band between it and the lens ; and if at this time 
the atropine will not cause its separation, it is certainly, in my opinion« to 
be divided. 

Until I commenced freeing the pupil in so many of the cases in which it 
is bound, I believe adhesions were disregarded, as far as any surgical or 
other remedial attempt is concerned, in any less serious cases than uiose of 
virtual blindness, that is to say, that unless there was very extensive poste- 
rior adhesion, the pupil was closed, or so in effect,, the adhesions were al- 
lowed as of course. If belladonna was applied it was for the purpose of 
discovering an interval of the adhesions for the contemplated artincial pupil, 
whereby the iris was to be torn, cut or excised, the adhesions themselves 
being left, and a confessedly ill-placed pupil made by one of the old meth- 
ods. Belladonna will in fact seldom effect the severance of pupil-adhesions* 
when a patient applies because of them, and not for the efficient inflamma- 
tion, then no longer existing ; it may do so, it should be tried, and the dis- 
covery of an interval of non-adhesion of the pupil is to me of as great im- 
portance for the operation on the membrane which obstructs the pupil as it 
IS for making an artificial pupil, in these cases the most urgently requiring 
an operation, or in any case for corelysis. This new method can, therefore, 
be only compared with corectenia, corotomia, corectomia, and some others, 
all of which are really operations on the iris, not like corelysis on that 
which confines the pupil, or occupies its place. These adhesions then have 
been permitted, but if all useful vision is lost in any case, the iris has been 
cut through or a part of it removed and an artificial pupil, necessarily out 
of the axis of vision has been formed ; these pupils are certainly not the best 
that could be imagined, and the operations on the iris, supposing them un- 
necessary in these cases, are also, it now seems to me, too severe, but for 
those of them in which the lens-capsule certainly cannot be cleared in the 
area of the pupil. If, for the sake of conservative surgery, the iris should 
not even always be operated on for occlusion of the pupu, there has been 
introduced an heroic operation, which I believe to be quite unjustifiable, for 
the deliberate extraction of the transparent lens in these cases ; if, by corel- 
j^sis, a cataract is discovered, it can be removed by way of the restored pu- 
piJ, bat I believe the lens is seldom opaoue in cases of occlusion, and I 
MDow that although adhesions may eiast D^lw^eii lik^ i«]iaA membrane oe- 



STTRQERT. 



V» 



oluding the pupil t aiid the lens-CApflule» with whicli it U m apposition, th(*y 
are probably oaly partial and rauch weaker tban the cupsDle itself, fit atiy 
mte ill tbeoiiae^ pr^seDtinjrf tbeesteniiil appearances to wlilcb I shall alludr. 

When corelyais, instead of doing nothing operative or making an artiiicini 
pupil, *eomsi to be tht^ alternative, it is b<?ouus(^ tbeordiinirjniedjcinal agents 
used to prevent the adhesionj^ or for tbcir detriohment, havebi^en ineffVctual ; 
mercury has been tried, aad no ciliary rodntsas ot other Jfigna of latent in- 
tiammation e.Tist, etill the tentative use of belladonna may be made in any 
ca$ei altbougb it has probably been tried^ and that when the adhesions raon* 
recently established would be much more likely to give way* I do not know 
for certiiin how recent must be the adhesioni!, which, by the use of belbi- 
donna, will give way, whicli will be tlins separated, or on what other condi- 
tions of treatment, or the state of the patlcnt^s health^r this will de[jend ; old 
bands will be extended by its ubq, if they are narrow and isolated, and re- 
cent adhesions, ofifif^mt far a$ Iknou\ may entirely disappear. (It is a com- 
men init^tuke to suppose that of course adhesions found to exist with iritis^ 
have resulted from the present inflaniinution of the iris), AVhen the adhe- 
sions are t4> a false niembrano in the area of the pupil, I believe this mem- 
brane, however slight it may be, can only be dispersed by corcdysis ; no me- 
dicinal agent will remove it, if it exists after the inflamiiiation baa ended. 

Atropine — or, applied to the skin, belladonna rubbed down with glycer- 
Ine-'^hould be used without delay in the cases^ whether recent or dt'ter- 
miucd, in which the pupil may be or has been involved; if employed when 
the pupil can dilate fully ^ the iris is so removed from the lens that it can 
hardly become bound to it liy the opposite effect of the iritk, and then 
lymph having been effui^od hetwe«n them, the midriatic efl*ect will, perhaps, 
be enough to cause their i^o[iaration, and if not the patient^s vision ia thereby 
probably improved for a tlinci and it is altogether essential to the surgeon 
for an exuct knowledge of the state of the case. It is most important tliat 
the agent should be repeatedly employed ; a solution of a quarter of a grain 
of sulphiite of atrnpia Uy an ounce of water, will produce full dilatation in 
a healthy eye (but, in iritis, past or present, the effect is varied in the dif- 
ferent cases), A itrong atropine solution cannot cause more dilatation than 
this, but by it the effect Is brought about more rapidly, it aim probably lasts 
longer, and, when tho iris is inSamed, perhaps it i^ the best to he employed 
(a shade worn by the patient may promote the dilatation or its contimi* 
ance) ; and if these means have been ineffectual they should be persevered 
in, whilst inflammation exists, because the treatment otherwise adopted may 
give an opportunity of dilatation in time, but if there is no inflammation 
they rnay be hopelessly discontinued- That posterbr adhesions not unfre- 
quently become detatched is proved by the opthalmofscopio eiaminatious, in 
whicht with a pupil properly dilated, their remains are seen often as a circle 
of irregular pigmented dots, or one or two opposite the margin of the pupil 
when it has been contracted ; these, and, after corelysis, the like dots are 
compatible with very good viision: 

The basis of the new method of operating is expressed in the title first ap* 
plied to it of ** reinstating the pupil/^ it is founded on the wish to restore the 
normal state of the purt^, to imitate it better than by artificial pupil, or to 
improve the vision of those patients with bands of adhesion after iritis, in 
whoie cases they have been left, if not with impaired vision, with probabil* 
ity of a recurrence of the infiammation which had caused them* For thia 
piirpoBe the pupil must be freed, andt if it was praetioable, could be only 
fonnd by the attempt in the different eafses in which it is bound. Could tho 
bands of adhesion confining the pupil be broken through by operation with- 
out injury of any of the parts concerned; and could the pupil be released 
from any of tlie membraneSi which after iritis have blocked it up^ by their 
being dispersed by operation, and the natural aperture of the pupil be thus 
made free again to dilate and contract in any degree 1 This position I have 
practically endeavoured to take affirmatively, and now 1 bold\\,%ti^ "^VtnX 
Mffmchim are very prejudicial to the future mtegrity oS t^ie eioVftvfi^ ^^'^vx 
conviction^ hut this cna add Uttie to the tostmioiiy o£ those TfVs Wvci ^(iiaxvLi^ 



196 SURGERY. 

escperienced aatborltj ; of posterior adhesion, Von Graefe has said ** that the 
principal cause of the recurrence of iritis is the existence of synechia, especially 
when broad and inextensible.^* Adhesions not only may induce a second 
iritis, but when the iris is first infianed they may protract the recovery in- 
definitely ; a single point of adhesion may do this, as in a case of mine In 
May, 1859, in which, with mild mercnrials, a syphilitic iritis had ended in 
resolution, with no ill result but a single point ot adhesion to the lens, all 
redness of the globe had therefore disappeared, but opposite this one band it 
remained exactly there, and there only tor a long time afterwards. 

Of the advantages of corelysis, whenever we may consider its possibility 
instead of making an artificial pupil, I believe the most important to be the 
optical superiority of a central active pupil, the appearance is also an advan- 
tage dependent, in fact, on much the same qualities as those for vision; these 
better optical qualities which almost alone need be considered being the na- 
tural position of the reinstated pupil, and the better recovery of its normal 
adjustment in size ; this power of dilating and contracting being often perfect 
n cases in which the bands of adhesion nave been few and narrow. Of the 
operation, I must say, in anticipation of the objections of those who believe 
the lens-capsule is so very easily torn, that in about fifty cases cataract has 
only once allowed, when I have known for certain beforehand that the lens 
was clear ; this case was one of the earliest on which I have operated, and 
the first spatula-hook I had had made and then used, was not perfectly 
rounded or well polished ; of other ill results of the operation I say nothing, 
for I believe, if the cases promise well for the operation and all care is taken 
in its performance, there will be none, or that none have resulted that do not 
more frequently occur when the iris is operated on for an artificial pupil: of 
this I shall speak again. When I call the operation trifling, I do not mean 
that it is so to the operator ; for him, I believe, it requires much considera- 
tion beforehand to determine upon its adoption, an examination by daylight 
and with atropine and the ohthalmoscope, the latter to decide if any space 
seeming clear is really unobstructed, or if occlusion seeming complete, really 
has no space left for the instrument to bo admitted. Besides this perfect 
knowledge of the state of the parts, and so of what can be done, it requires 
the closest attention on the part of the surgeon, during the operation, to tho 
exact place of the lens, and above all things that the end of the instrument 
introduced through the membrane or beneath the bands of adhesion should 
be then at once carried away from the lens and kept always forward. 
Lastly, of tho advantages of corelysis, I must remark, that when other aper- 
tures of the body are obstructed by disease, we do not think of making a 
false passage, or a counter-opening if it can be avoided ; and if corelysis 
is impracticable or unsuccessful, still as before, we can make an artifieud 
pupil. 

Corelysis should certainly not be attempted until the ciliary redness and 
other signs of inflammation are past ; I do not propose it as a cure for iritis, 
though it may divert its return. The inquiry should bo always first made 
before operating, if the lens is transparent or not ; this, in tne case of an 
occluded pupil, can only be learnt by the probabilities connected with the 
amount of vision left, but, of course, if the pupil is only limited by bands of 
adhesion, atropine and the opthalmoscope will goto prove an uncertain case. 
If the depth of the eye can be examined, it is well for a favourable conclusion 
of the case to know also that there is no cognizable vitreous disease or white 
patches in the choroid, &c. If, with adhesions of the pupil to the lens, cor- 
nea, or a false membrane, I have known the lens to be opaque (corelysis,ybr 
its own salce, is out of the question), I have proceeded to operate for the cat- 
aract, then always using atropine ; if by extraction, the corneal section is 
made very readily, and without need of the chief ordinary precautions, then, 
and especially at its conclusion, necessary ; a membrane filling the pupil 
may be opened out with one or two needles to make a way for the lens, as 
the common practice has been ; or if separate points of adhesion of the pu- 
nillary margin exist, I have preferred my spatula-hook for their detachment. 
If it ia to be done by solution : in the case oi a ia\«« t(i«Tc\st«3i«^ I have nsed 



SUKGEEY, 



m 



ilm BnQ needle or aeedki to open oat thfl membriiue (without enlarging the 
pupil), and thon to the cataract itself; or in tb© ea«e of bauds pfirtially con- 
fining the pupil, I Imve introduced tbo needle where they cmi be mostoon- 
Tenlently reached^ and witli it broken them through us u preliminary step: 
two needles may, in &ueh acaset he well usedif hands of otlhesLon at opposite 
6tdee of Ihe pupil are to be reached. The needle operation for the oataraot 
with iris adhesionsT and eubsequent Itnear-txtraciton^ muy be wl*11 adopted if, 
as is ofteu the catM^, the patient is young, and the inflamiuatlon hai^ not beea 
allowed to proceed to more seriou* injury than the limiting of the pupih 
The patients are not so old os most of thoge who require an operation for 
eataractf ao that '^diviMion'^ of the lens will LiaTe this advantagOv and linear- 
extniction afterwards, if the pupil is large enough to allow of it, will curtail 
the tiLivk that by the sound eyo may he better performed. This ** ei traction 
through a closed pupii" by a small orhirgo section, however, is hardly con- 
nected with the subject of core lysis, but a^ a supplement to the hitter oper* 
at ion when it has revealed a cataract not before kuiiwn or believed to exist; 
indeed it is espijciully applicable to e^omtj cases In which corelyaii4,/ar ilsttft 
aA I have mentioned, should not be attempted, those in which a cataract in 
known to exist, or the occluding ntembrane is quite opa^^ue and far back in 
the contracted pupil, &o, ; and coreljt!i!», as I wish it uuder^^tood, is for 
those eases in which the disease of the pupil is the only serious morbid uEec- 
tion that existfi. 

The iustrutnents necessary foT oorelysis are, besides the §p ring-speculum 
and forceps with which to hold tlie eye, a broad needle, my spatula-book, 
and perhaps oanula, scissors, and forceiiB, The broad needle should be a 
etna)] one, only to make au opening large enough, without cutting, to admit 
the other instruments (this may be proved beforehand with the aperture 
miLde by it in a piece of leather), so as to retain the aqueous humour as much 
AS possible. The spatula- hook is figured and described at page 8 of tbe first 
Tolume of the * Ophthalmic Hospital Reports :' the thickness of the epatuk 
part, **the terminal quarter of an inch," should be equal, and not much re- 
duced so that it may bo very blunt (the instrument, especially at its extrem- 
ity, and the houk, should be highly polished J ; the only difference I have 
made from the instrument figured Is that the one I now uae is rather less alto- 
gether in its width and every way; the spatula part should, moreover, be 
wider than the diameter of the round part of the instrument (made so next 
the handle for facility of turning it ** in the corneal wound upwartk or dovvn- 
wardfi^J, that when it is in the anterior chamber, the aqueous humour may 
be belter retained* The canula instrument should bo the smallest, and well 
polished: the scissors should have blunt endu, and tbe outer side of the bhide 
U:sed should be kept next the lens during tbe operation. 

Of the dangers of corelyssis in anticipation of the operation, especially of 
causing cataract, I have already spoken, in comparing the reinstated pupil 
with iris-operations, I do not know how severe an injury of the lens-cap- 
ftole IB necessary to produce a cataract, but I am sure with instruments 
well made for tlie purpose I frequently touch it without any ill result; 
batf aa I have snid, I always keep the end of the instrument rather for- 
ward, that is to 8Qy, against the posterior surface of the iris or pupillary 
exudation, in detacSiing bunds or a false membnine, that 1 may touch the 
lens as lightly as possible, I should not be so careful in this matter but 
for the difficulty of perceiving the minute di^tiinoe between the iris and 
the lens, and of appreciating the slight changes of place which would bring 
the instrument upon the lens: so that, during corolysii^, I constantly bear 
in mind to keep the end of my instrutnent away from the lens, I have, at 
the present time, a case at Moorfiejds In wliicn the lens would, according 
to the common not ion v have been expected to be changed from Its trim spar - 
oncy* 

My me th (id of operating is the following: atropine hat been applied to 
the eye; the patient is rc^cumbent, and 1 stand behind him. I Wvvs tiW%«v\ 
a broad needle which is sni table to the spatuU-Hook, \\\at x%, a^iWrn^is eiw- 
plaincd, a Jitd<? mder than it; the patient baa prcVjuVjVy tiikeu GV\oTCjloi?sft^ 



196 8UR6EBT. 

I securo with toothed forceps in the right or left hand as it may be most con- 
venient, a fold of the conjunctiva close to the corneal margin on the side op- 
posite to that at which the punctare is to be made, thus 1 draw the eye suf- 
ficiently in the desired direction and steady it. (It is best to secure a consid- 
erable fold of the conjunctiva close to the cornea, and to have a deep hold 
of it that it shall not give way ; sometimes it is convenient not only to draw 
the eye with the forceps in an opposite direction to the proposed eomeal 
puncture, but at the same time to rotate the globe somewhat on its antero-pos- 
torior axis* : this may be done either way by having the conjunctival fold a 
little to one or other side of the direction in which the ^lobe is to be drawn.) 
It is impossible, in the variety of cases in which corclysis is applicable, to 
say generally which way the globe is to be held, because, for instance, if an 
adhodion of the pupil is most conveniently to be reached from above it may 
be detached without any rotation of the globe, if it is so prominent that the 
brow will not interfere ; or in another case the reflection from the cornea of 
the light of the window opposite the patient may make some rotation of the 
globe, when it is held with the forceps, more convenient than a change of 
place on the part of the operator. It is also impossible to say where the 
puncture should be made in the cornea, even at what distance it should be 
from the margin : this is, in each case, very important, for, when made, 
the corneal opening is a fixed point from which alone the operation has to be 
carried on to its completion. I have not generally made it very near to the 
margin (perhaps at a line from it), but my rule will be found by considering 
first, that a (posterior) adhesion should be always detached as close to the 
lens as possible ; second and third (in this special instance), is the band cor- 
responding to the position of the pupil when contracted or dilated? and so at 
what part is it of the convexity of the lens ? of which the natural curve is to 
be considered (Fig. 1), as it should not be pressed upon by the instrument 
as it passes over it to reach the band at its point of attachment, the sever- 
ance of which alone is to be attained ; on the other hand, it can never be re- 
quired to make the puncture far from the corneal margin, or the end of the 
straight instrument might come upon the lens, which it would be much more 
likely to injure than the flat side of the spatula would. 

Fio. 1. 




a. A posterior adhesion of the ecntracted pnpil. 

b. The same, of the pupil when it has been less contracted. 

c. The normal iris. 

d. The lens. 

«. The spatula-hook introduced through the cornea in the best position to detach an adhesion at c» 

f. The same, to detach an adhesion at h. 

The figure is Intended to shew that to detach adhesion &, the spntula-hook mnst not be introdneed 
so near to the margin of the cornea (seen in section) as at e, or the adhesion cannot be reached at ths 
point fifiU attachnunt toWumt pressing uptm the lens. 

The easiest case of pupil-adhesion to be detached is whtBn a single band 
connects the pupil with the lens, then the corneal puncture may be made 
most conveniently, peiiiaps (as in Fig. 2, M, n.) not exactly on the opposite 
side to that at which it is, or at a quarter of the circumference of the comeai 
but between the two, that the spatula-hook may be advantageously used as 
a spatula or as a hook ; as a spatula, that is to say, for its blunt edge, the 
instrument is most generally useful, and perhaps most safely or easily used* 
as the stretching of the iris that may occur, is thus more distributed than by 
collecting some part of the width of the iris, to which the band is adherent, 
in the hook to be severed at once. With the instrument entered in the di- 
reotion I have described, the baiid, if it does not detach before the blunt edgOi 
wJU pasB downwards with the sloping diTection oi tke iaatrument, and be ar* 



SUKGERY. 



1^ 



nested by the hoot, with wliich it can b© then broken throagb. If two suaU 
bi\iuli» exii^t lit opposite points of tho pupU, the spatula-book will bo most 
c*jnv<!nieivtly used when entered from a part of the cornea, towards ita mar- 
gin, midway between tbem (see Fig, 2, N. m,)* and then, if the hook of the 
»patula is required for their detaebment, the instrument muistbo semi rotated 
when the ixr^t one is separated, before the instramtnt 13 apidied to the Kec- 
ond band. Wlieu tbo instrumtnit h thus rotated in the anterior chamber (the 
aqueous humour «;houlcl not hnve <>scaped and) the end of it should be brought 
forward towards tlie eentrul part of tho cornea, that as the blunt edge instead 
of the flat side of the instrumorit pusses the lens, it may only touch it lightly. 
If at alL If many bands exist tho instrument is introduced to most advantage 
from the side at which there is the greatest interval for its admission {see Fig. 
2 N, n,), the division, of pupil attachments buing ali^^ays attainable oxcoptiiig 
Oil the side at which the instrument Is boiug Uised (Fig, 2n M, m.), Tho bro^d 



M 



Tif. 1 TEi« four dlM^romi Ah^m' {iiingEilflcil) vnrlouj {tnatcrbr iuthealans ^f tbu pnplls, nil iiiidflr tb« 
Influence^ '>riitmplDC. 

Jf, #11, Tbe ft!x pointt of nttiichiTicint. nearly nqql-fllffrjant, are so mucli the more. dtCIlctjlt: the twn, 
« nad b, cannfit he ntviMy d^itni^h^d wUli tbc Bpatulot-liuok LntruiJtic^il throu^li iha oomeaJ murfia 
tlm» mmt uonvenkntly for tlie ot1]t»ra> 

Jf- n. Tho fbEtrumvut^ ta t^oeh tho point of adhenlon, la bett entfirisd vh«r« It 1i ior at c) and not 
at tt or at b. 

N'. m, Thi? flpatiUn-Ii<Kik »boa1it bti brouffbt upi ta the two oppcMitta adbeilons (4 and h} from « 
iwfliit mlitway tu-twei'm tbem. 

^ r». With fluch Tartoqa adhefiloris tbo Laibnimont la m^ to mnA adTHOtai^e at tbf) wld&Bt iaitr* 
v&l i;betvrp«iii a and b} and Q&a bo poMad (aa U la «bowa at h) iunn bebLud tbose on Uw same al^o as 
the corneal Dpcoliig. 

needle to make the opening: in theeomea, is directed towanls the pupil and is In- 
troduced with a thrust wttbout cutting, us fur us tho widest part of its blado* 
to which its siae in relation to the sputulu-hook has lieen oulculated be- 
forehand; it is then quickly withdrawn, and the spatula- hook as quickly 
j>assed in by the opening tlmt is mado, the hook being on tho upper or 
lower ed|ij0 as may bo required, the end of tho instrument is brought up 
bL> the adhesion and pussed under tho margin of the pupil (as at b^ in Fig, 
2, N. fl,) eloso to it and fur enough beneath the iris; the end of the 
upatula being at tho same time kept in apposition with it, the inatru^ 
mcnt is then brought towards the pupil up to the adheaion, not pre st- 
ing the iris forwurds or the lens backwards, but just between them, 
that th© attachment may bo released^ as it ^nerally will bo very 
readily at its place, without tearing the iris or compressm^ iW \«^&% 
in all thig it must be remembered that the Ions is not Mt m its \>Gs\\ACi^^ ^«!i 
dtrectioo of the spatula-hmk im a matterof oidculation throXigXiQUlA^^^^^^*^^ 



iWO 8UBG£RY. 

It if to take haa been determined and is well known ; and the iris or its pa- 

elury adhesions will offer no appreciable resistance. If all the cautions I 
ve given respecting the lens, appear contrary to what I have said of the 
unnecessary fear commonly entertained of its being wounded, I can only 
say, that by taking such care I have had the success which induces me ao 
confidently to ask attention to the new proceeding, and I do not know that 
cataract would have resulted from less care-taking. The withdrawal of tiie 
apatula-hook should be, of course, with the flat part in the direction of the 
length of the corneal puncture, and it is effected without any chance of the 
hook being caught in the cornea, if the edge of the spatula, without the hook^ 
la kept lightly pressed into the corresponding extremity of the linear wonnd. 
. The most important cases for corelysis remain to be considered. I have 
known vision more impaired with bands confining the pupil to the lens, than 
with a false membrane, leaving to all appearance in the pupil no free space 
whatever; the case of simple bands of posterior adhesion with very imperfect 
vision, may be possibly explained by various complications of the iritis, 
which has caused the adhesions limiting, but not blocking up the pupil ; and 
the other case in which a complete false membrane filling the pupil exists 
with fair vision, by its being only a very fine network, thinnest at its centre, 
in the pupillary area. These false membranes generally have been recog- 
nized as surgical (artificial pupil) cases, but only to be operated on when se- 
rious loss of vision is the patient's complaint. The occluded pupils which I 
am about to consider, in an operative relation, are also most important, in- 
asmuch as they are most difficult, and as they are certainly irremediable but 
by operation. Here I will premise that it seems to depend very much on 
the diagnosis of the false membrane, if corelysis can effect a cure when the 
pupil is filled ; the cases suitable for the operation are not those in which a 
perfectly opaque patch in the pupil is seen with an iris, more or less stand- 
ing forwards around it, the membrane is not of a dead white, but gray by 
daylight, or half illuminated by the transmitted light of the ophthalmoscope, 
and it is little behind the iris, which does not fall back towards it, or is not 
bulged around it, and is not discoloured ; the condition I allude to, in which 
the iris is in its natural place, and the membrane filling the pupil is about 
on a level with it (which, with its partial transparency, are, 1 believe, the 
indications for corelysis in cases of occlusion), is probably to be explained 
by two circumstances in which it differs from the opaque membranes with 
prominent iris, the closed communication between the anterior and posterior 
chambers not being altogether impervious to the aqueous humour, and the 
membrane not being firmly attached behind to the lens-capsule, so that there, 
ss it is not closely adherent, some fluid transition is allowed. Indications 
favourable to the operation, are the evident contractions of the fibres of the 
iris when the eye is exposed to a strong light, a large anterior chamber and 
the (occluded) pupil not very small, improvement of vision, so as to read 
large type, by the use of atropine, &c. My best results have been, I think, 
in cases of young persons who have been judiciously treated for a first at- 
tack of syphilitic iritis, and to whom some mercury has been already given. 
If the false membrane seems altogether to occupy the pupil, it must be ex- 
amined with atropine and the opthalmoscope, for the discovery of any possi- 
ble gap in it, by which the spatula-hook may be introduced, a chink even 
smaller than the end of the instrument may be made to admit it, and the 
membrane is torn through with the hook of the spatula, or divided with the 
oanula scissors. If the hook of the spatula is to be used, the instrument 
must be introduced through the 'cornea, on the opposite side to that at which 
the opening is in the memorane, and in this way I have generally concluded 
the operation at once : the canula scissors can only be used when introduced 
from the same side of the cornea as the opening in the membrane, and prob- 
ably, only with safety after the spatula has been passed between the mem- 
brane and the lens ; this method, therefore, I hove not followed since the case 
of Sharp, I have referred to. When no space at all is left in- the occluding 
fmbrane, the plan I have adopted is to introduce the broad needle throng^ 
ooraea, in anj direction which may appeax to b^len^wise of tiie i 



SURGEKT. 



sni 



brane, then to adTance the needle across the pupil to the ofppnsite iiideof th** 
nifiubraiie, and tran&ftx It just within the pupil cbse to the iris, hut earefuUy 
not to cause bleo^ing from it, raits ing the membrane from the hn» with the 
needle a^s soon, as the point has pierced it, and advaiicii>g the uocillo a Uttlc 
to make the opeuine larger, wberobj there ifi no greater fear of wovintling 
flny part, as the tiecdle has been passed acivss the pupil, and the cfniveadty 
of the letii^i and beneath the iris. Because of the Bpherical proniiuence of 
the lens which h close behind the pupils it is clearly impossible with saft^ty 
to pierce the membrane with the needle on the game side as that bv which it 
is passed through the conjea, but I do not know whether it would be safe In 
any case^ and the pupil could be cleared by pa,'*sing the canula pci^sors at 
on re through the cornea, and the blunt point thr^jugh the crevice i when there 
is (me t in an occluding mcinbrancT without previously using the spatula to 
lift the membrane and aeparate it from the lens, by all which the aquetius 
humour 13 &o much let escape, that aa in Sharply cai*o, the scissors could only 
be adopted at a subsequent operation, which » of course, it is very desirable 
to avoid. I passed the gpatula-hook once through the membrane, and close 
behind it, to separate any ti laments that micht Cf^nnect it with the lens, bat 
I did not venture, at that timet to use the ficrsBors, because of the diminnllou 
af the anterior chamber which ha^ then resulted. I am incHned to the adop<^ 
tton of my early plan, of passing the spatula hetwetn the lens and the mem- 
brane« hejhrc the latter is operated on, in every case. 

As to the after treatment of a ease in which the pupil baa been freed, I 
have no special knowledge j I have had atropine applied after tho operation 
night and morning, the eyelidi closed, to insure rest to the eye, perhaps 
with a bandage and cold water at first, with a folded rag constantly until 
any ciliary redness has faded, or it is no longer agreeable to the patient* I 
have never known any more exteusive inflammation than that of the iris it* 
eelf, follow ^orelysis ; in several cascH, by this consequent iritis, the pupil 
has o^ain become occluded or bound to the lens by adhesions, ami then no 
benent has resulted; in two or three, the pupil has been more obstructed 
than it was before the operation ; and if it is not, at once, subject to treat- 
ment, this traumatic iritis is fatal to the operation and altogether hopeless ; 
leeches and other autiphlogiitio treatment are the means 1 have employed 
for its reduction. 

In operations generally on old remains of lens- capsule, icc.r in tho pupil- 
lary area, cither loug after operation for cataract or wound of the lens, 1 
have lem-nt to fear especially two conseouences that are not uncommon or 
incoDBiderable ; either tlic protrusion oi the vitreous humor into the pupih 
through tho opening made, or chronic indammation in the ciliary region* 
perhaps consequent upon or coexistent with the formett or, as I have thought, 
by dragging upon the suspensory ligament p Both of the«e ill-results may 
occur, the former on account of tho transparency of the vitreous humor is 
dfteu not known to have happened, and the latter is only manifested Rome 
time after tho operation. Once lately I discovered that the former had taken 
place by the bleeding which occurred from (?) the ciliary processes: tho 
blood filled the empty aqueous chamber except in the centre, where the 
vitreous had come forward and was pressed agaiudt the back of the comea 
(I had torn open, with two needles, somo remains of capsule. If ft in the pu* 
pillary area, after extraction of cataract), the blood surrounded the vitreous 
aw a red ring before the iris, and through the centre of the cornea the clear 
vitreous humour and the pupil ** opened out/* tho patient saw at that time 
very well. To obviate this projection of the vitreous humour into the b4|u©* 
ous chamber, which some have thought to be actually advantageous, when 
a fal9« membrane (lens-capsule, &:cO is rent^ as in the ca^e 1 have just men- 
tioned, the needles should not be passed farther than is just necessary through 
die membrane, or it should be divided with cunulascissors; it should not 
be lacerated very extensively, or repeatedly, and in the oases also of old 
traumatic cataract (remains of lens and lens-ca|>fiule)once o^etaltii, w\,v\\i^ 
best to be satisfied with a fair result for vision altlvoug\\ ftunv^N ■![it>tV\5>VL* t^\s\w\ 
in the pupil which might be removed ; because i\i^m ^onvm\% qI VTx«.-c,t^»- 



802 SURGERY. 

sale, &c., after extraction or wound of the lens are held in the ciliary region^ 
by means of the {suspensory) ligament^ which has been perhaps confirmed and 
toaehened by the former operations, and in their removal the vitreous humour 
is always likely to come forward and perhaps also irritation of the ciliary 
body, is induced. Considering this to be so, and the ill-results there have 
been, I devised the method of tearing through the ligament in detail, before 
attempting the removal of the obstructing lens-capsule, dec., it is obvious 
that if it is seized at once by the forceps, as it has been usual to do in these 
cases, the instrument has one-half, more or less, of the suspensory ligament 

Fig. a. 




Fig. 3. c ciliary procMt ; «. saspensory ligament ; ;r jr, jr jr ahmnken lena-capsaie, .euaiiui of 
lentf Ao, 

«, shows the manner of eoparatiug with the needle (s) the lens-capsule at Its margin. In detail. 

6. ahows how advantageously the oanula forceps (y), are opposed by the retaining influence of tli« 
aospensory ligament, in such a case as the foregoing. 

opposed at once to its traction, and acting very favorably against the re- 
moval (diagram, 6, Fig. 3,) thus in fact, it is well adapted to support the 
healthy lens, and as I have said, it is, in an abnormal state, probably 
stregthened ; however, with force applied at some one part of the ligament 
it is easily there torn through and the needle-point will effect this at various 
parts, and so entirely separate the lens-capsule, dec, and leave it to be re- 
moved with the oanula- forceps, with little disturbance of the vitreous humour 
and without irritation of the ciliary body. In other surgical operations the 
gradual separation of parts to be removed is the rule whenever it is applica- 
ble, and in ophthalmic surgery it is often to be followed ; the iris itself 
must not be dragged upon to a great extent at once ; and so, in corelysis, as 
I have said, I have always avoided its ciliary separation (iridodialysis), or 
any laceration of its substance in detaching the strongest adhesions of the 
pupil, by taking them in detail, — Ophthalmic Hasp. Reports, No. 11, |?. 309. 



84.— ON IRIDECTOMY IN GLAUCOMA. 

By William Bowmam, Esq., F. B. 8., Surgeon to King's College Hospital, and to the Boyal London 
Ophthalmic Hospital, Moorflolds. 

[In the * Dublin Quarterly Journal of Medical Science,' a review lately ap- 
peared intended to discredit the treatment of glaucoma by iridectomy, as 
advocated by Von Graefe. Mr. Bowman was the first English surgeon who 
applied this treatment, and being convinced of its importance, has since con- 
stantly advocated its employment. The term * Glaucoma,' as now under- 
stood, embraces much more than the etymology would import Mr. Bowman 
says:] 

The treatment by iridectomy has been no hap-hazard guess, but a rational 
conclusion gradually worked out. The dominant idea guiding the mind to 
the appropriate remedy has been that of the existence of augmented intra- 
ocular pressure, as the main characteristic of the glaucomatous process. In 
fact, whatever the essential nature of that process, its concomitant seems to 
be a marked tendency to hardness or tension of the eyeball : and thereupon 
arise the naost senouB secondary effects, — ^pax«\7«\a of the retinai oftentimes 



I 



STTEGERT. urn 

Iptcd eirculation, conge)»tionsT in flam mat ory attacks, with ihmr vari- 
tttifi&qnencesT — ending souner or later, a ad with more or leii^s intermis- 
^dus^ in total loss of sigtit, and a spoiling of all tba tissues of tho cyebalt 
The general states met with in practice and falling under the ^eiioral heads 
Jif amaurosis with excavation of the optic nerve, chronic^ subacute, and acute 
l^ucomsi all j^eemed to be allied to one another and may ba tc*rmed 
gl a u CO miito n h disease s ,* ' Som e are vary bIo w i n tb o i r p rogre s« ♦ and th e lo sn of 
power hi the retina very g:radiial; there in* no inflammation or even con- 
gestion : in others there h conge[?tion, sflght or considerable, intonnittent or 
continuous* In others, aguhi, acute mid intense iuftannnation arises. A 
glaucomatous state may also come on in tbe course of other diseases, choroidal, 
retinal* or cataractous. To relieve in tra-oeular pressure seems to be th« 
prime indication in all, and it is rational to suppose that it will ho the moro 
eflectuaU the less deterioration of atructuro tbe retina has previously suffered . 
To relieve this pressure is to disarm the glaucomatous state of its chief 
perih and apparently to restore the eye to tho influence of the reparative 

{jo^vers belonging to It as a living organ. The tension once relieved* and po 
ong as it remains so, the circulation tends to its natural equilibrium, and the 
retiitft which has been compressed recovers itself more or less* or ceases to 
degenerate, in a dogvee usually corresponding inversely with tho intensity 
and duration of tbf? preceding pressure. 

It is certain that this ciitic would never have attacked the new pmctic© 
had be really read Graefe'i memoirs, or believed the cures rei>nrtcd by 
otbersi to ho genaine. }Jo aays, **Graefe*s doctrines, us publishi'd by the 
Sydenham Society, are plausible, but in a practical science of this nature 
we require something more than doctrines; cases must b<» given* and Graefe 
was witter than bis coantrymen* of the I^mdon Uphthalnnc Hospital* and 
kept tits cat in bis bag." Will it bo believed that the reviewer can have 
read the memoirs of Von Graefe which he criticiBCSi which are enriched with 
numerous cases, fully detniled and epitomiaedj and constantly referred to^ 
illustrating all tbe main doctrincB advanced? As for tbe oiperienc© ac- 
quired in England, I shall at pre**eijt speak only for myself; and I can as- 
sure the reviewer, in tbe most decided terras, of the reality of the influence of 
thjt operation in relieving, even pe^nvanentl3^ the unnatural tension of glau* 
imnmtoua eyes* and nf its eftect in arresting the glaucomatous process, and 
often in restoring sipjht in a marvellous manner. My own cases in the hos- 
pital and in private have been numerous, and bear out the above general 
statement. This it is that makes me ^o ansiouf* that the profc^f^sion should 
be rightly lnfi>rmed as to the signs of gkuoonia in its rclievablo stages, and 
should bo ready to sanction the timely application of the only known real 
remedy. lean hardly concf^ive a greater comfort in practice than to be able, 
by this operation, to rescue sight thus imperilled, and to escape the dis- 
heartfniag task of treating a disease, evidently tending to blindness* by the 
old, mefl:Vctive remedies. The reviewer may class the eminent author of so 
great a boon with *' Hahnemann, Preis^nitz, and De Leeuw," but be may 
depend upon it ho will be powerless to "arrest the spread of the * glaucoma 
epidemic' in England," I could, indeedi heartily wish that when be has 
further examined tho evidence, and dispasjajc^nately perused what ho criti* 
oises, he will make trial of tho operation for himself, in which case I doubt 
not ho will be satisfied with his result!** 

In speaking in these terms of iridectomy in glaucoma^ I must carefully 
guard myself from being supposed to uphold it as a sovereign remedy equal- 
ly valuable in all forms and stages of the disease, and under all its various 
complications. At present the operation is being extensively tried in caies 
where augmented intra*ocular pressure evidently eiists; and the proved 
tendency of tbe operation to relieve this injurious tension, the certain cause 
of secondary mischief, makes it our duty ti> employ it, when the patient is 
otherwise apparently drifting into inevitable blindness. It may be our 

• R*^fi»nf1ftR' to llip iT]>r»r1 of fflse* ofopeTnttom for Gfiiiicnma ftt the MTOTfLte\iV4^o4^\*Dt^^'^*^ ''sa 
tli« 'OyhUMlnDio iierjfital MepprtM,' b^ m^ Mend Dr. B*rl<jr, vfhq \t (^\ille ofaV* to ^^^ttfl.'titotfittM* 



804 SURGERY. 

miefortmie, and that of our patients, that our experience is as jet less com- 
plete than a few more years will make it ; but meanwhile we can only act on 
the light we possess, and store up the results for the future benefit of others. 

While the modem doctrine and treatment of glaucomatous affevtions is so 
new, it is to be expected that errors in the diagnosis may occur even among 
well-instructed practitioners ; and the operation is doubtless in some danger 
of being brought into discredit hv being undertaken in cases to which it is 
not rationally applicable, or by being defectively executed. I do not see 
how this can be avoided ; it is the necessary fate of all novel proposals, and 
this one must face the ordeal. It is the part of intelligent men to make al- 
lowance for these incidents of human progress, rather than to allow them to 
prejudice the march of truth. 

In the present state of our knowledge it may be right to try the operation 
experimentally in some cases to which more extended experience may show 
that it is not usually applicable. Experience hitherto shows that it is most 
valuable when performed early in acute cases, in which turbid effusions exist, 
the absorption of which goes on rapidly when the tension is relieved. Tem- 
porising measures in such cases, such as bleeding, mercury, colchicum, and 
even the simple puncture of the eye, whether of the aqueous or vitreous re- 
gions are not to be relied on, and occasion dangerous delay. It is also most 
useful if performed in the subacute form, when the visual field is not as yet 
seriously contracted, but where the symptoms are steadily advancing. If 
postponed here till the sight becomes greatly impaired by gradual alteration 
of the tissues of the retina, and of the optic nerve-entrance, the ultimate ad- 
vantage is smaller, though usually lasting. In many instances we are called 
on to treat patients already almost blind from the progress of the disease under 
one or other of its various forms. Here it has often been the means of spar- 
ing them a little sight, sometimes permanently, at others not. I have also tried 
the operation in some examples of blind and tense glaucomatous globes, the 
seat of excessive or wearisome pain, and on several occasions have been well 
satisfied with the result. How intractable such cases are apt to be under 
the usual palliatives is well known. 

As for the operation itself, a large experience has convinced me that, 
though usually a simple proceeding, not liable to accidents, it is occasionally 
one of the most delicate and critical in its nicety of all the operations on thie 
eye. The anterior chamber has to be entered at its extreme rim, where the 
sclerotica overlaps the cornea, close in front of the iris, which often bulges 
much, and which must on no account be pricked, lest the vitreous humour 
or tho lens, immediately behind, should be wounded ; in either case a most 
serious complication. The bulging of the lens, in many cases, and the dila- 
tation of the pupil, add to the risk of injury to the lens. A little blood, too, 
escaping into the anterior chamber, either before or after the excision of the 
iris, may obscure the^ parts from view, and add to the chance of involving 
the vitreous humour or lens. It is obvious that these difficulties and con- 
tingencies ought to be acknowledged and recognised in order that they may 
be guarded against. In very few instances indeed can they lead to accidents 
in skilful hands. When blood occupies the anterior chamber in the course 
of tho operation, it is wise to remove it, either by a gentle stroking move- 
ment of the curette over the cornea towards the incision, or, if that do not 
suffice, by carefully introducing the end of the curette within the incision it- 
self. On two occasions only have I known the lens to become opaque after 
the operation, where the capsule was not directly injured (as it ought never 
to be) by the instrument. One of these was in my own practice, another in 
that of a highly esteemed colleague. 

I am unwilling to extend this already long comment on the review by any 
inquiry as to the rationale of the operation ; but there is much in fSavor of 
Von Graefe's original suggestion, that the diminution of intra-ocular pressure 
may be largely due to the lessening of the iris as the surface secreting the 
aqueous humour. My own opinion, however, was, and is, that the more di- 
reci communication opened between the vitreous and aqueous regions of the 
ej^e facilitatea the play of currents between, ilbfim, SkTid. tkus allows an ezoMt 



STIBGITBT. 



mn 



P 



df fluid behind to come ftirw^ard to the c^orneul aurfaoe, thfougb which eifis- 
mo^is is much easier than through the ptistorior coats, the BolcrcitiCf ehoroidt 
and retina* This would go far to oxpliiiii the upparontly eontradictoiy in- 
6uiMice of the oppraticm in rftising tho tension to the natural degree when 
preYiously dlminishtHl \ for tJiis alio it is capahle of doing in some cases, as 
shown long ngo b}^ Von Graefe himself* That the size of the piece eicised 
in ghiucoma has o direct relation to tho cifect produced is true according to 
hiii latest obsBrvations* confirmed I believe* bj those of Donders, and of Arlt, 
the (Jist Dgui^'^hed and mo it able professor of VioDua. I can also add mj* 
own eorrpborative teatimonj. Von Graefe is thus led (in his lutest memoir^ 
fust published] to insist once more, as ho had done in his first paper, on the 
necessity of removing a considerable portion of the iris (not, however, so 
much as a third, or even a fourth, of ita circuit), where it is wished to re- 
duce permanently the intrtt'Ocular pressure* A small iridectomy U iu* 
sufficient, much less any more puncture, such ai some aro still IncUoed to 
rely upon* 

In c<>uclusion, I may remind tlie rOTiower, that after the reading of Mr* 
Hulke*s excellent paper ou the Pathology of Glaucoma* at the Medical and 
Chirurgical Society, on January 12, 1858, both Mr, Critchett and myself 
endeavored, from our own eiperience, to enforce the importance of Von 
Graefe*s new proposal (see the * Medical Times and Gn^ette,' January 2*^), 
and that in our weekly operations at Moorfield^i all comers have hud the 
opportunity ever since of watching the progroas of our numerous ca^es, as 
well as of those of our cMleagues. Mr, Hulke n<lvocated and explained this 
treatment In detail 1 in an able paper, **0n the Surgical Treatment of Glau- 
coma/* in the * Medical Tintes and Gazette,^ March 27^ 1656* (see * Ri^tro- 
speot,* vol, xixvii, p* 194), referring to the favorable experience of Moor- 
fields and to my owu private praclice, in which nt that lime i had the ad* 
vantage of his tessisttauce. He has recently reverted, to the subject in n 
seeond paper at tho Hod leal and Chirurgical Boclety. To both these latter 
communications 1 venture to draw the attention of practitioners* The re- 
viewer is in error when he states that there has been any holding back of 
opinions or of facts on the part of those who have introduced the operation 
into England* — Mfdieal Tlm€!i and Gazette, Aug. 25, 16G0, p. 177* 



65.— ON GLAUCOMA AND ITS SURGICAL TREATMENT* 

Bf J. W* E(JLK«j Esq., F.R,CJ., AdsktaTst Bnrfpjon U} Ktnfj'fl CQllogc Hospital, Wld to the Ki>ji*l 

IOuT readers will do well to refer to previous articles on the subject, by Mr* 
lulke, in vol. xxxvii* p» U>4* and vol, xl, p, 173*] 

Premonilori^ s^mpiom^- — Kapidly increasing presbyopia; the appearance 
i>f a coloured halo round the €ame of a candle ; the spontaneous appearaTico 
of flashes and other spectra. Intercurrent obscuration of virion, attendtjd 
with vagne orbital and frontal pains* slight hardness of the eyeball, and con- 
traction of the field of vision. The pupil is large and sluggish; the size of 
tho anterior chamber is much diminished. The duration and intensity of 
these symptoms are very variable* but they are rarely absent. 

AcuU gluuconia. — The active &t^go sets tn as a sudden and violent out- 
break, often at niglit* Violent racking pain in the eyeball, often attended 
with sickness, and f^dlowed by rapid extinction of sight Tho pupil is widely 
dilated and rootionless ; and the leus has sometimes the peculiar greenish 
tint which was formerly considered so characteristic, Tho ciliary vessels 
BI9 swollen; tho oonjuactivais red and often chemosed; the globe is very 
hard ; tb^ cornea is dull, wckd its sensibility is lovrered* Remissions are fol- 
lowed bj fresh p&roxysms, and complete, irremediable blindness always 
eosuoFp 

Chronic glaucoma — The premonitory period slowly g\\3L(?fem\ci^^ vsjc^an^* 
Tho obscujfttJou^, which were at first erftnescent and Eft"|^iuEBAp*2>^ Vy \q^\£ *^^'' 



206 SUBG£BY. 

tenrals, become more frequent, and last longer. The contraction of the 
Yisual field progresses. The tension of the globe increases. The iris be- 
comes dull ; the aqueous humour turbid ; the cornea dimmed and flattened. 
Mr. Hulke lays stress on the flattening of the cornea, which is easily de- 
monstrated, because it has been recenUy stated that the cornea becomes 
conical in glaucoma. 

Ophthalmoscopic signs. — Excavation of the optic nerve entrance, and pul- 
sation of the retinal vessels. To these capillary apoplexy of the retina is 
often added ; and sometimes there are small blood-clots in the vitreous hu- 
mour, which is unnaturally firm. It is only late in the disease, when all the 
component structures are undergoing atrophy, that the vitreous humour be- 
comes fluid. 

The nature and causes of the glaucomatous process, — All the leading features 
of the glaucoma are due to excessive tension of the eyeball from a sopor- 
abundance of fluid within it, which distends the vitreous humour. This 
fluid — serum — is derived mainly from the choroid. Many circumstances 
show that the retina is only passively concerned. Glaucoma might be con- 
sidered a serous choroiditis. Mr. Hancock has advanced the theory that 
spasm of the ciliary muscle forms an essential part of glaucoma. The 
author has, however, found complete atrophy of this muscle in some dissec- 
tions of glaucomatous eyes ; hence the inference that this muscle is not con- 
cerned in maintaining the glaucomatous condition. The author hak been 
unable to trace any connexion between glaucoma and gout or rfaeomatism. 
Some other diseases and injuries of the eyeball occasionally assume a glau- 
comatous type. This is especially the case with wounds of the ciliary region 
and sclcrotico-choroidal staphyloma. 

IVeatment. — Generally the age and broken health of the subjects of glau- 
coma forbid antiphlogistics ; venesection is inadmissible ; leeches and coun- 
ter-irritants are useful as adjuncts, but cannot ulone cope with the disease. 
The excessive tension of the globe is suggestive of the evacuation of some 
of the superabundant fluid by tapping. The old surgeons, Antonius, Nuck, 
Jobus, & Meekren, and others, were familiar with this operation, but they 
practised it chiefly in hypopion, onyx, and hydrophthalmos. Wardrop 
(* Med.-Chir. Trans., 1813,) tried it extensively. With a view to lessen ful- 
ness and congestion, he tapped the anterior chamber in superficial and deep- 
seated inflammations of the eye. The operation was at first warmly taken 
up by other surgeons, but soon fell into disuse. In our own day it has been 
strongly advocated by Desmarres, but it has found little favour with English 
surgeons, though most have occasionally pei*formed it. In glaucoma the 
relief that paracentesis comas affords is too transient to render it of much 
value. Paracentesis scleroticae has been practised by Desmarres and Han- 
cock in glaucoma, though with different objects. Mr. Hulke reverts to this, 
after fully describing the operation of iridectomy as proposed by Dr. A. 
von Graefe. 

Iridectomy consists in excising a segment of the iris, in its whole breadth, 
from the pupillary margin outwards to its insertion. This is effected through 
an opening of corresponding size at the extreme edge of the anterior cham- 
ber. Iridectomy may be practised at any part of the iris. Graefe usually 
makes it outwards ; but adds that, when desirable for the sake of appearance, 
it may be made upwards. This latter position has been adopted by Mr. 
Bowman, and is that which Mr. Hulke has generally chosen. JBy removing 
the iris in this manner, the pupil is at once enlarged up to the corneal inci- 
sion, which forms, as it were, the base of a coloboma iridis, and the edge of 
the lens, with the suspensory ligament, stretching in front of the vitreous 
humour and the ciliary processes* are exposed to view. The little blood 
which oozes into the anterior chamber from the cut edges or surface of the 
iris, should be at once pressed out or removed with a scoop. The after- 
treatment is very simple. A light compress may be applied for a short time 
as a precaution against hemorrhage. This may be replaced after an hour 
or two bjr a piece of wet rag. The room should be shaded. Usually noth- 
Wff else 13 necessary. At mat the aqueous Yixxmowi IxVokles away ; but the 



SUBGERT. 



2iJ7 



corneal wound »oon lieals, and tho anterior clmmber fills again. The liard- 
nesK of the eyoboll i* at once lessened, and a natural tension is grutjually 
attained ; the pain abates, and soon altogether diaappears. As regards vj - 
sloHt tlio ultimate results are iutimately dependent on tbe period at which 
the iridectomj is performed, being more pej'fect where it has been early 
undertaken tbim where it has been postponed. In the premonitory period, 
where the symptoms are well marked, the propriety of operating cannot Be 
doubted. In acute glaucomaT where the operation is done during the first 
inflammatory attack, or soon nfterwnrdft, virion is very completely restored. 
In chronic glaucoma, the resuita an^ loss uniform and less de aided. This i* 
In consequence of the insidious nature of the disease — atruotural changes in 
the retina creeping on pari passu with the gradually increaping tension, 

Allegf.d objtciion» to irtiUttomy. — 1* Its reported uniform failure in th^ 
hands of some surgeons. This is in great probability to be generally at- 
tributed to its having been practised in cases which were not true instancet 
of this disease. Many failures hare proceeded from its having been done at 
far too late a period. 

2, The great difficulty of the operation. This has been much magnified. 
It does not require more skill than moat surgeons possess, and when chloTi>- 
form is used it becomes really a simple matter; hut oven were it difficulty 
which it is not, in the absence of other known means of cure, we should be 
no moro jai»tified in rejeotitig it on this account, than we should be in refaa- 
ing a put ion t the benefit of nemiotomy where the taxis and other measuros 
had failed. 

3, The diBfignrement produced by the coloboma iridia is so slight that it 
cannot constitute a real objection. 

4, Its supposed injurious action on accommodation^ Further experience 
has corrected some misiuiprcssion which at first prerailed respecting its 
influence on the adjustment of the eye. The previously o listing presbyopia 
is not increased by removal of a portion of the iris; indeedi the refracting 
pow^r of the globe sometimei actually increases after iridectomy — probably, 
as Graefe has fthown, in consequence of the flattened cornea resuming its 
natural curvature. 

To avoid these alleged disadvantages, paracentesis scleroticce has been ad- 
Tocated b^'^ Middlemore, DcsmarrcSi and Ilancocluas a substitute for iridee- 
totoy. Middlemore proposed to evacuate tbo turbid -^ diffiurnt, ritrcQus hu- 
mour with a grooved needle, and to replace it with a syringeful of clear 
water. But, except in very old cases, the vitreous humour is much too 
firm to flow out along a grooved needle ; and probably few English surgeons 
would adopt Dosmsrres' suggestion, of Introducing a probe and breaking it 
up* Mr. Hancoekt considering a spasm of the oiliary muscle to be an es- 
sontiaT part of glaucoma, divides Ihii* muscle by striking a knife through 
the ciliary region backwards and inwards towards the axis of the globe* 
But Mr. Hulke has demonstrated, by microscopic el examination, advanced 
atrophy of this muscle in many glaucomatous eyeballs ; whence it foUowe 
thfit the ciliary muscle ii? not actively concerned in maintaining the glau- 
comatous process. In al! probability, the success of Mr. Hancftck's opera- 
tions is solely due to the draining away of some of the superabundant fluid ♦ 
According to this view it is simply a peculiar mode of paracentesis, and can- 
not rank as a substitute for iridectomy until it has been thoronghly estab- 
lished that it mrmantnibj relieves excessive intra-occular tension, which, 
hi common with most surgeons, Mr, Hulke has found that topping the vitre- 
oQi humour foils to di.^ikzncff, Jufy 21, 1660, f . 61. 



206 SURGERY. 



86.--ON THE DIVISION OP THE CILIARY MUSCLE IN THE 

TREATMENT OF GLAUCOMA AS COMPARED WITH 

IRIDECTOMY. 

By Hbhbt Havoook, Btq. F.R.C.S. Senior Bar^eon to the Boyil Weetmlnflter Ophthslmie 

HoiplUL 

[A great difference of opiDion exists between Mr. Hancock, Mr. Hulke, and 
others, on the new operations on the eye for ihe relief of glaucoma. Wo 
cannot pretend to decide between these eminent ophthalmic surgeons, and 
therefore we prefer to let each party speak for itself. Mr. Hulke, in some 
very talented papers, has called in question Mr. Hancock's practice ; and 
here Mr. Hancock defends himself, and, we confess, makes out a rery good 
case. Mr. Hulke's operation is like that of Von Graefe's, namely, iridec- 
tomy. Mr. Hancock says that his operation of simply dividing the ciliary 
muscle is sufficient. He maintains that the appearances of the blood-Tes- 
sols in glaucoma are due chiefly to the constriction exercised by the ciliary 
muscle, and that to remove this constriction it is only necessary to divide 
the muscle, and that this is the best operation. He says :] 

My first operation for the division of the ciliary muscle, was performed 
on the 9th of September, 1859 ; and on the 11 th of February, 1860, I pub- 
lished an account of the operation, with cases ; at the same time stating that 
I was led to adopt this mode of treatment from the belief ** that the patho* 
logical and ophuialmoscopic appearances of the blood-vessels in glaucoma 
were due mainly to the constriction exercised by the ciliary muscle ; " and 
that to remove this constriction I operated as follows: — "I introduce a 
Beer's cataract knife at the outer and lower margin of the cornea, where it 
joins the sclerotica. The point of the knife is pushed obliquely backwards 
and downwards until the nbres of the sclerotica are divided obliquely for 
rather more than one-eighth of an inch ; by this incision the ciliary muscle 
is divided." This is the description of my operation which I published : it 
does not contain one word about ** striking a knife through the ciliary re- 
gion towards the axis of the globe," which is the incorrect version given by 
Mr. Hulko — a proceeding which would be carefully avoided by any one con- 
versant with the anatomy of the eyeball, from the risk of wounding the lens 
which would inevitably attend it. 

As my operation has now been before the profession above twelve months, 
and still continues to be attended with the best results in the hands of 
my colleagues and myself, I cannot admit that iridectomy is the only known 
remedy for glaucoma. I propose, therefore, to consider, in the first place, 
the validity of Mr. Hulke's objections to my operation, as set forth in the 
paper already alluded to, and read before the Royal Medical and Chirurgical 
Society. Next, to inquire into the results of the operation of iridectomy, 
as furnished by Dr. Bader*s papers in the * Ophthalmic Hospital Reports' 
(Nos. 9 and 10) ; and lastly, to give the results of my own operation up to 
the present time, with my reasons for submitting it to the profession, not as 
the ** only known," but as the best operation for the treatment of glaucoma. 

1. The principal points upon which Mr. Hulke insists are, **That the 
leading features of glaucoma are due to excessive tension of the eyeball, 
from a superabundance of fluid within it, which distends the vitreous 
humour; that this fluid (serum) is derived mainly from the choroid ; that it 
might be considered a serous choroiditis." 

2. ** That the excessive tension of the globe is suggestive of the evacua- 
tion of some of the superabundant fluid by tapping." 

3. That he has ** demonstrated, by microscopical examination, advanced 
atrophy of this muscle (ciliary) in many glaucomatous eyeballs ; whence it 
follows that the ciliary muscle is not actively concerned in maintaining the 
glaucomatous process." 

4. *' To avoid certain alleged disadvantages, paracentesis scleroticse has 
been advocated by Middlemore, Desmarres, and Hancock." 

5. **That in all probability the success of Mr. Hancock's operation is 
solelj- due to the drawing away of some oi \\ie ^u^^tabundant fluid. Ac- 



SUBGEBY. 2Q0 

cording to this view, it is simply a peculiar mode of paracentesis, and can- 
not rank as a substitute for *• iridectomy,' until it has been thoroughly estab- 
lished that it permanently relieves excessive intra-ocular pressure," which, 
in common with most surgeons, Mr. Hulke has found that tapping the 
vitreous humour fails to do. 

The assertion ** that the leading features of glaucoma are due to excessive 
tension of the eyeball from a superabundance of fluid within it," and that 
%** excessive tension of the globe is suggestive of the evacuation of some of 
the superabundant fluid by tapping," are contradicted and rendered unten- 
able by other portions of Mr. Hulke's paper ; whilst the results he gives of 
the operation of iridectomy directly prove, that the operation is only of 
value when the fluid, for the evacuation of which it is performed, is actually 
not in existence to be evacuated. 

We are told that the reason why iridectomy has failed in the hands of 
some surgeons ** has proceeded, in many instances, from its having been 

performed at far too late a period that the propriety of operating in the 

premonitory period cannot be doubted that in acute glaucoma, where 

the operation is done during the first inflammatory attack, or soon after- 
wards, vision is very completely restored ; whilst, in chronic glaucoma, the 
results are less uniform and less decided." 

We may hence infer, that throe stages of this disease are recognised : the 
premonitory, the acute, and the chronic, and that the success of the opera- 
tion is greater the earlier it is performed. It is this great practical fact 
which seems to me to be fatal to Mr. Hulke's theory of glaucoma being due 
to a superabundance of serum distending the ** vitreous humour,*' more es- 
pecially as that gentleman, in the same paper, describes the vitreous humour 
as being ** unnaturally firm in this disease;" and that it is only at a late 
period, when all the component structures are undergoing atrophy, that the 
vitreous humour becomes fluid, at which time the results of the operations 
are admitted to be **lcs8 uniform" and ^Mess decided." And I am still 
further supported in the opinion I have expressed here and elsewhere, that 
fluid is not the cause, but the result, of the disease termed glaucoma, by the 
following very corroborative paragraph, extracted from Mr. Hulke's paper 
on the * Pathology and Morbid Anatomy of Glaucoma,' read before the 
Medioo-Chirurgicul Society, Dec. 12th, 1857 : — ** With a view to relieve the 
tension of the globe, I have seen the sclerotic freely punctured with an ex- 
traction knife, after which firm counter-pressure with the finger upon the 
opposite side of the globe only causitd the protrusion of a very small bead 
of yellowish vitreous humour, such great firmness had it." Whether the 
tension of the globe was relieved by the puncture is not stated. 

Nor is it by any means so conclusive as Mr. Hulke appears to imagine, 
that, because he has ** demonstrated advanced atrophy of the ciliary muscle 
in many glaucomatous eyeballs, this muscle is not concerned in maintaining 
the glaucomatous condition." The word ** many" is very indefinite and in- 
conclusive. Mr. Hulke does not state in how many instances he has found 
this muscle atrophied, or what proportion these instances bore to the number 
of glaucomatous eyeballs which he examined microscopically. He does 
not inform us whether these glaucomatous eyeballs were obtained after the 
death of the patient or before, or, if from the former, the time which had 
elapsed between the death and the examination; for the changes which take 
place, especially in diseased eyes, are so rapid, that very little reliance can 
be placed upon such' examinations when they have been deferred for any 
length of time. Neither, where the glaucomatous eyes which he examined 
had been obtained from living patients, does he tull us the stage of the dis- 
ease at which they were extirpated, or the circumstances which necessitated 
their extirpation. It had been but justice that these particulars should have 
been mentioned before a sweeping pathological statement was unhesitat- 
ingly advanced. 

1 have already alluded to the three stages of glaucoma described in Mr. 
Holke's paper — the premonitory, the acute, and the obroiuc; \a \i\A oAxoX^- 
■ion thai itii only late m the disease that the componeivl «\x\]l<^\.\xt«i^ oi >^^ 



210 SUBGERY. 

eyeball undergo atrophy ; and that whilst iridectomy is most saccessful dar- 
ing the first two stages, its results are less uniform and decided in the last ; 
whilst Dr. Bader states, in his report, ** that the prognosis of chronic glau- 
coma depends upon the stage in which the eye affected is operated upon : 
when blind for some time, it is not expected to retain signt; a chronic 
glaucomatous eye, with mere perception of light, is rarely improved bj 
operation. 

Mr. Hulke's microscopical examinations, therefore, cannot be admitted as 
at all conclusive or of much value against my proposition, ** that the ciliary 
muscle exercises considerable influenco in maintaining and aggravating the 
glaucomatous condition," and still less against my operation for the division 
of this muscle. They only prove that in certain cases of advanced glauco- 
ma, in which an operation is admitted to be rarely successful, the ciliary 
muscle may have undergone atrophy with the rest of the tissues ; but they 
by no means prove that this is the case in all or even in average instances, 
as we cannot for one moment imagine that any surgeon would extirpate a 
glaucomatous eye capable of relief by operation, unless under very peculiar 
circumstances. I presume it is only recently that Mr. Hulke has discovered 
this condition of advanced atrophy of the ciliary muscle in glaucomatous 
eyeballs, otherwise he would scarcely have omitted all mention of a fact of 
so much importance in his paper upon the ** Pathology and Morbid Anato- 
my of Glaucoma," read before the Royal Medico-Chirurgical Society in 
December, 1857. 

On the other hand, my friend and colleague, Mr. Hogg, has kindly fur- 
nished me with the particulars of two glaucomatous eyeballs, extirpated at 
an advanced period of the disease, in which his microscopical examination 
demonstrated the ciliary muscle as highly developed, and anything bat in a 
state of atrophy. I do not, however, advance these cases as of themselves 
sufficient to controvert Mr. Hulke's assertion — their number is too small; 
but, at the same time, they afford pretty conclusive proof that the ciliary 
muscle is not atrophied in all cases even of advanced glaucoma. Neither 
can I admit that the success of my operation in any way depends upon, 
much less is solely duo to, the drawing away of some of the superabundant 
fluid ; or that it is a peculiar mode of paracentesis, to be classed with the 
operations of ** paracentesis scleroticse" of Middlemore and Desmarres. 

I think I have succeeded in showing that, according to Mr. Hulke'a own 
statements, there is no superabundance of fluid in those cases most likely 
to be benefitted by the operation ; therefore the drawing away theory falls to 
the ground, and is still further negatived by cases No. 15 and 16, appended 
to this paper. 

The object for applying the term paracentesis sclcroticaa to my operation, 
and classing it with the procedures of Middlemore and Desmarres, is trans- 
parent enough. Paracentesis of the cornea and sclerotica, as practised by 
these two surgeons, has not met with any amount of success. If, therefore, 
the profession coul4 be impressed with the notion that my operation was 
nothing more than one or the other of these proceedings, and that any trans- 
ient good which it might bo the means of effecting was due to the mere 
evacuation and draining away of fluid, it would be looked upon as deficient 
both in value and originality, and would, as a matter of course, fall into dis- 
repute, and proportionately give greater prominence to the operation — 
iridectomy. It is true that the word paracentesis means literally, a ** pierc- 
ing through," but its application in surgery has hitherto been restricted to 
the operation of tapping. If we were to attempt to describe the operation 
of tenotomy in club-foot as ** a peculiar mode of paracentesis" of the lee, or 
of the foot, or if wo were to designate the operation of extraction of hard 
cataract as **a peculiar mode of paracentesis" of the cornea, wo should ex- 
pose ourselves to the charge of pedantry ; yet the name may with equal 
propriety, be applied to these operations, or even to iridectomy itself, as to 
my operation for the division of the ciliary muscle. Hence the term as ap- 
plied to this operation by Mr. Hulke is a misnomer. 
The opeiationn oi mddlemoTe and De&moxrea were introduced for the 



SURGERY. 211 

aTowed purpose of relieving intra-ocular tension by the evacuation of fluid. 
My operation, on the contrary, is introduced for the avowed purpose of re- 
lieving the constriction of Ihe several coats of the eye by division of the 
ciliary muscle. 

Au increased quantity of fluid may or may not be present, and, when 
present, some may flow by the side of the knife ; but this is merely a coin- 
cidence, not by any means the primary object of the operation ; for mere 
evacuation of fluid without division of this muscle is quite incapable of af- 
fording permanent benefit. 

In my former paper I pointed out the variety of opinions entertained by 
the supporters of iridectomy in this country as to the modus operandi of the 
operation. I would here venture to suggest another. I believe it will be 
found in the course of time, that the element of success is the same in 
iridectomy as in my operation — viz., **tho division of the ciliary muscle." 
That, from the situation in which Von Graofo makes his first incision, he at 
the same time cuts it through, and I have little doubt it will ultimately be 
found that the extent of this incision may be advantageously curtailed, and 
the tearing away of the iris altogether dispensed with. 

{Mr. Hancook then goes on to say in another part of his paper :] 
have now to offer a few observatious upon the results of my operation 
up to the present time. 

I also propose to add the present condition of several patients upon whom 
xnj operation was performed some months; and I do this with the greater 
confidence since Mr. Hildigc, in commenting upon the operation when first 
announced, fell into the error of assuming it was mere paracentesis, which 
he asserted produced merely temporary benefit, the symptoms returning in 
from one to three months ; whilst it has been expected that the profession 
would accept and become devotees to the operation of iridectomy from a 
number of operations, the results of which are calculated at the compara- 
tively short interval of from two to three weeks from the time of operation. 

I have always felt that Mr. Hildige's objections possessed great weight, 
and my attention has consequently been carefully directed to this point, and 
the result has been to strengthen me very considerably in my original con- 
yiction, that my operation did not relieve by evacuating fluid, but by remov- 
ing ^constriction. I scarcely know of a single instance in which the patient 
was benefitted immediately, or even shortly after the operation, experienc- 
ing the disappointment of a relapse ; whilst, on the contrary, in very many 
instances, the relief has been so gradual that, for some three or four weeks, 
it has been scarcely appreciable. 

The class of cases in which improvement is most rapidly manifested, is 
that of acute and subacute glaucoma, and what has been termed ** evanes- 
cent obscurations." In chronic cases, and those of total blindness, or where 
a mere perception of light has remained to the patient, the improvement has 
been of much more tardy manifestation, rarely taking place under a fort- 
night from the operation, after which it usually increases, and rarely, if 
ever, recedes. 

The great value of this operation seems to me that by an almost painless 
proceeding, however severe the previous suffering has been, the pain is 
almost invariably removed. Not only is this the case, but, if fairly tried 
(which I am justified in assertine it has not been by those who appear to be 
so anxious to disparage it), it will be found that whilst capable of effecting 
an equal amount of good as ** iridectomy," it is free from the danger and ob- 
jections attending this operation. For instance, — 

a. It is much more easily and rapidly performed, and the incision made 
into the eyeball is much smaller. 

6. The operation is attended with so little pain that there is no necessity 
for ohlofofbrm ; the sickness and accidents resulting therefrom are conse- 
quently avoided. 

c As the eye does not require to be fixed by forceps, the danger of lace- 
rating the ** rotten" conjunctiva, or of rupturing the BUB^ei^BOTy W^iqasa'qX. 
of the lens, is likewjjie avoided. 



212 SUBGEfiY. 

d. The incision is made at once by a Beer's knife, and does not in any 
case require to be enlarged by scissors. 

e. As the incision commences at the margin of the cornea, and is carried 
obliquely into the sclerotica away from the cornea (not backwards and in- 
wards towardsthe axis of the globe, as erroneously stated by Mr. Hnlke), and 
as the iris is left intact, and is not to be seized by forceps nor drawn oat by 
a hook, there is no danger of the lens escaping, being broken ap, or so injured 
as to cause traumatic cataract. 

/. The integrity of the iris being preserved, the opearation is not neces- 
sarily or oven beneficially restricted to the upper segment of the cornea in 
order to obtain the compensatory support of the upper lid. The patient, 
moreover, retains the power of adapting his vision to near objects ; and in 
the majority of cases there is no permanent disfigurement of the eye, or colo- 
boma iridis. 

g. The iris not being injured, hemorrhage from its lacerated edges cannot 
occur; thus it can neither be necessary to employ a scoop to remore the 
blood, nor to moke a counter-opening to admit of its escape. 

h. The incision is so small that it is impossible for the lens or the vitreous 
humour in anv quantity to escape through it. The necessity of extirpating 
the eyeball, therefore, from either of these causes, or on account of hemorr- 
hage, as I have already shown, cannot by any possibility occur. 

i. It relieves pain by the removal of the constriction of the eyeball, and 
the consequent pressure upon the nerves from the undue constriction of the 
ciliary muscle. 

j» By it the impediment to circulation through the blood-vessels is got 
rid of; they are placed in a favourable condition to recover their normal 
state, and the probability of a recurrence of the effusion is greatly di- 
minished. 

k. Where it fails, it does so little damage to the eye, that iridectomy may 
subsequently be performed, if considered beneficial to the patient. — LanceU 
Oct. 13, 1860, p, 355. 

87. — On Division of the Ciliary Muscle, in Acute Glaucoma, — Of the value 
of Mr. Hancock's important and successful operation of division of the ciKary 
muscle, we (£d. of Lancet), have now abundant evidence ; and to-day we re- 
cord an illustration (selected from amongst a number in the Westminster Oph- 
thalmic Hospital) which we had the opportunity of personally examining, and 
of witnessing the good effects produced, in a female nearly sixty years of age, 
effected with acute glaucoma. The patient was blind on admission, but in 
three weeks she was able to read large-typed words in the Bible. It was a 
case well verifying Mr. Hancock's views. 

A surgeon recently writing from Paris, assured Mr. Hancock that he had 
the satisfaction of receiving M. Desmarros' testimony regarding the results 
of this operation in a case of glaucoma in which he had tried it. It was de- 
scribed as a very bad case, and the effects of the operation were all that 
could be desired, quite as complete as after the performance of iridectomy. 
It was the intention of M. Desmarres to continue the practice, more espe- 
cially in his bad cases, one-half of which he should treat by paracentesis, 
the other half by Mr. Hancock's method. In our ** Parisian Medical Intel- 
ligence " for May 19th, the successful result of the latter procedure in a case 
of acute glaucoma of extreme severity, in the hands of M. Desmarres, is thus 
announced : ** Within twelve hours of the operation all the symptoms had 
improved, and at the present moment (it is now five weeks since the event) the 
patient is fully as much benefited as if the most successful iridectomy had been 
performed." It will be seen, therefore, from the results already obtained in 
London and elsewhere, that the success of the operation is established, and 
Mr. Hancock has thus rendered a most important service to ophthalmic 
science. 

For the notes of the following case we are indebted to Dr. Sansom, the 
medical registrar to the hospital : — 



SURGERY. 213 

Harriet B , aged fifty-eight, was admitted into the hospital on thc2l8t 

of March. She complained of intense pain in the right ^lobe, and throbbing 
pain over the brow; the sight was wholly gone ; the conjunctiva was greatly 
congested ; the sclerotic presented a purplish glow ; the pupil was dilated 
and irregular, and the lens opaque and disorganised, presenting a greenish 
appearance. The light used for opthalmoscopic examination could not pen- 
etrate the disorganized lens. The eyeball was exceedingly tense, but the 
sliffhtest pressure caused most severe pain. The patient was thin and pale, 
and presented the appearance of having undergone much suffering. Her 
previous history was as follows : — She had never had any disease of the eye 
until the present attack. Three months ago the e^e watered as if she had 
caught cold in it, but she paid little attention to this. Occasionally, towards 
evening, she experienced the sensation of flashes of fire before the eye, and 
the flame of the candle seemed surrounded by a halo of colour, but all un- 
pleasant symptoms disappeared t4)ward8 moming. On the 14th of March (a 
week before admission) it rapidly became worse, great pain occurred over 
the brow, and a tense throbbing pain referred to the back of the orbit. The 
eye, she said, seemed so tight that it would burst. The symptoms continued 
to increase. 

On March 2drd, Mr. Hancock divided the ciliary ligament, and a quantity 
of fluid and disorganized vitreous humour escaped. The eye was kept from 
the light. 

March 26th. The pain has entirely left her; she is able to tell the num- 
ber of fingers held up oefore the eye which has been operated on, the other 
being closed ; the iris has been slightly drawn into the wound. 

30th. Pain continues entirely absent. She can now distinguish the out- 
line of any object, and she says that the sight is improving every day. — 
Lancetj July 7, 18G0, p. 7. 

88.-.CASES OF GLAUCOMA TREATED BY DIVISION OF THE 
CILIARY MUSCLE. 

By Jaius Bousk, Esq., Surgeon to the Koyal Westminster OphthjUmio Hospital. 

As it is possible that some of our readers may not know the exact steps of 
Mr, Hancock's operation for the relief of glaucoma, the following extract from 
that gentleman's lecture, published in the 'Lancet' of Feb. 11th, may be 
deemed acceptable : — *' I introduce a Beer's cataract knife at the outer and 
lower margin of the cornea, whore it joins the slerotica; the point of the 
knife is pushed obliquely backwards and downwards, until the fibres of the 
sclerotica are divided obliquely for rather more than one-eighth of an inch : 
by this incision, the ciliary muscle is divided, whilst the accumulated fluid 
flows by the side of the knife." 

If the reader will refer to the lecture from which the above extract is taken 
(see Retrospect, Vol. xli. p. 197), he will find that Mr. Hancock was induced 
to perform the operation just described from having noticed in several cases 
of acute glaucoma a peculiar constriction around the cornea corresponding 
to the situation occupied by the ciliary muscle ; the operation was followed 
by most satisfactory results. 

The following cases are the more interesting, inasmuch as they did not 
present that peculiarity ; and it will be seen that the operation was equally 
successful. 

Ca9e 1. — H. W., aged 46, married, the mother of children, was admitted 
under my care on May 4th. During the last eleven years, she had suffered 
from occasional attacks of pain (accompanied by dimness of vision) in the 
left eye. Two months ago she was attacked with pain in the left eye, which 
prevented her from following her usual occupations. A week ago the pain 
became so intense that she could not procure sleep. During this time her 
sight was very limited ; she could not see more than two yatdft V>^iot^\i«t> 
and then the objects looked confused; beyond that dlstauoe^ eN«T'j>Xivck% Vi.'O- 
peared to he denae fog. She complained of intense t\iTo\>bm^ ^mi Viv ^^ 



214 SURGERY. 

oyeball of the left eye, ciroumorbital pain, and ocoasional flashes of light. 
The pain was more severe at night, and at times appeared to affect the whole 
head. She could not distinguish any object. On examining the eye, the 
cornea was found to be slightly ulcerated. The anterior chamber was totj 
much flattened, partly from pushing forwards of the iris, and partly from the 
stretching of the comea^from the intra-ocular effusion. The pupil was 
large and immovable. The conjunctival and choroidal veins were large. 
Pressure on the eyeball caused extreme pain. She had had no sleep for a 
week. 

May 4th, 2 p.m. The ciliary muscle was divided; a considerable amount 
of fluid escaped. Within an hour after the operation, the pain was relieved, 
and she passed a most excellent night. 

May 18th. She had had no pain since the operation ; and, on a watch be- 
in^ given to her, she could tell the time ; and could distinguish silver from 
gold. The eye had nearly regained its natural appearance. The anterior 
chamber was of the same depth as that of the right eye. The ulceration of 
the cornea had healed, leaving only a slight cloud. 

May 28th. She had had no return of pain, and saw perfectly. The cornea 
was rapidly clearing. She was made an out-patient. 

June 15th. She came to show herself, stating that she was perfectly 
well. 

Case 2. — A. H., aged 47, married, the mother of seven children, looking at 
least ten years more than her age, was admitted on May 18th under my care. 
Four years ago, her sight began to get weak, not being able to thread a 
needle without glasses. One night in the middle of last September, she was 
attacked with violent pain in both eyes and around the orbits, especially 
the left. The following day, the pain increased in intensity, and compelled 
her to keep her bed. The sight of the left eye became seriously affected, 
vision being very limited and indistinct. The right eye was affected, but in 
a less degree. 

In December, she cnme to the hospital as an out-patient; at that time the 
sight of the left eye was completely lost ; the pupil was large and somewhat 
irregular ; the vitreous body was too opaque to allow ophthalmoscope exam- 
ination. The pain was so intense in that eye and side of the head, that she 
could not sleep. Under these circumstances, the ciliary muscle was divid- 
ed. The operation completely relieved the pain ; but there was no return of 
vision. The right eye improved very much after the operation ; in fact, she 
was so much better that she ceased to attend. 

May 16th. She again applied for advice ; the right eye had become so much 
worse, that she could no longer see to read. She could distinguish lai^ 
objects, but not sufficiently to recognize a face. The pupil was large and 
fixed, the cornea was flattened, and the iris pushed against it. The vitre- 
ous body was semi- opaque. She complained of great pain in the right 
temple and side of the head. She felt so giddy, that she did not like to 
move about. 

May 18th. She was admitted into the hospital; and the ciliary muscle was 
divided. 

May 30th. She had progressed favourably since the operation, the mist 
had entirely gone, and she was able to read for a short time without incon- 
venience, but it caused subsequent uneasiness. She stated that she could 
not look very long at an object without the eye becoming slightly "dazaled." 
She was made an out-patient. 

June 15th. The sight was improving — every day becoming stronger. She 
could now look at an object for a much longer time without inconvenience. 
She saw everything perfectly. 

Aug. 13th. The sight perfectly good in the right eye. She finds that if 
she takes cold there is slight mistiness for a day or two. During the last 
month there is slight return of sight in the left eye. She can now peroeive 
the window-frames. 

Case 3. — h, N., aged 30, single, a dressmaker, was admitted under my 
care on June 8th. Two years since tVie sigVit \>ega.xi to ^<&\. ^vbcl wid misty ; 



SUEQERT. 215 

sbe had pain from time to time in the temples across the forehead , after 
each attack the sight was less good. A year ago, she became decidedly 
worse. The pain in the eyes and temples was more severe, and the sight 
was so much affected that she could no longer see anything distinctly. She 
could only read large print, and see to do the coarsest work, and this very 
indifferently. She had not menstruated for two years. 

On admission, the pupils were large and fixed ; the refractive media were 
tnrbid. Ophthalmoscopic examination showed dilated veins on both retinss. 
The optic discs could only be seen imperfectly; they appeared slightly 
cupped. The eyes were very hard, and the anterior chambers and cornesB 
were flattened. She complained of iridescent vision, and pain in the eyes 
and head. She was given a watch, but she could not positively tell the face 
from the back. She thought she could distinguish very large type, but the 
attempt to read caused pain and dizziness in tlio head. The ciliary muscle 
was divided in both eyes. 

June 18th. She had had no pain since the operation. The irides had as- 
sumed the natural size, and acted perfectly. This morning she threaded a 
needle, and read some ordinary sized print. She said she had not seen so 
well since the first attack two years ago. 

August 13th. The sight continues satisfactory, — British Medical Journal, 
Aug. 18, 1860, p. 645. 

89.-^N GLAUCOMA AND THE OPTIC PAPILLA. 

By Dr. Mackbnzix, Glasgow. 

I have long since established to my own satisfaction the three following 
conclusions regarding glaucoma : — 

1st. That the sea-green appearance behind the pupil, whence the name 
arose, does not depend, as was once generally supposed, on any thickened or 
discoloured condition of the vitreous humour, but on a diplochromatic state 
of the crystalline, by which it absorbs the extreme prismatic rays, and re- 
flects the middle ones. 

2nd. That the vitreous fiuid in glaucoma is superseded by an unhealthy 
secretion, which over-distends the eye, makes it feel hard, causes severe 
pain by pressing on the ciliary nerves, and obliterate the sensibility of the 
retina ; a state of matters which I found to be susceptible of relief by para- 
centesis of the eye, through either the solorotica or the cornea. 

3rd. That in advanced cases, the optic norvo behind the eye shows itself, 
on dissection, in a state of atrophy, deprived more or less of its proper ner- 
Toua substance, and flattened. 

Ophthalmoscopic investigations have added some new facts to our knowl- 
edge of glaucoma. One of these is the pulsation of the arteries of the 
retina ; and another, the concave or excavated state of the papilla of the 
optic nerve. Neither of these phenomena, however, is peculiar to glaucoma; 
both of them being occasionally met with in other diseases of the eye. The 
former of them seems to indicate an increased resistance to the flow of blood 
in the vessels which supply the retina ; the latter may be regarded as the 
effect of one or other, or of both, of two different causes, namely, the atro- 
phied condition of the optic nerve, and the increased pressure on the inter- 
nal parietes of the eyeball, from the superabundant secretion which occu- 
pies the place of the vitreous humour. 

These phenomena can scarcely bo discerned in the advanced stages of 
glaucoma, owing to the diplochromatic and muddy state of the crystalline. 
To see them, then, the student should bo directed to examine a case, in 
which the dioptric media have as yet lost but little of their normal colour 
and transparency. 

To discern the pulsatory movement of the vessels, requires a sharp and 
experienced eye, and the observer will find it of service, whiVe d\T^^NA\\^\v\% 
attention to this point, to have the patient's head 8up^0Tie^,«ii^Wi^^v&^«Aft^ 
eye Btemdsed bjr tao Bngera of an assistant. 



216 SUBGEBT. 

If the indirect or inverted method of ophthalmoBCopio obsenration be se- 
lected, an optical deception is apt to bewilder a beginner, as to tbe condi- 
tion of the entrance of the optic nerve, a nearly circular spot, thon^h not 
unfrequently oval, variable in size, but measuring on an average 0*6 line in 
diameter, and which, although styled papilla or coUictdtu, is, in its normal 
state, nearly level with the retina, and even a little depressed in its centre. 
In the direct method, where the observer regards the illuminated non-in- 
verted fundus oculi through an aperture in a concave mirror without the 
aid of any extraneous lens, the great magnifying power of the cornea and 
humours of the patients eye, gives to the papilla an apparent magnitude 
larger even than that of the pupil ; but in this way, it cannot be well seen 
as a whole, and generally requires the eye of the observer to be brousht in- 
conveniently near to that of the patient. Instead, then, of using the pa- 
tient's eye as a powei*ful single microscope, in actual contact witn the ob- 
jects on the fundus oculi to be examined, and thus viewing them directly, it 
is better to obtain a smaller but more defined image, although an inverted 
and virtual one of tbose objects, by converting the patient's eye for the time 
into the object-glass of a compound microscope, which we do by holding in 
front of it a thick convex lens. The image which we then see of the seve- 
ral parts of the fundus oculi is an inverted one, like that of an object exam- 
ined with any ordinary compound microscope ; the entrance of the optic 
nerve is seen towards the temple instead of the nose ; the macula lutea ap- 
pears to the nasal side of the optic nerve instead of the temporal, and a 
little below the level of the nerve instead of above it ; while the principal 
trunks of the retinal vessels, instead of branching in the direction of the 
temple to embrace the macula lutca, seem to bend towards the nasal side of 
the eye. The apparent position, in fact, of all the objects on the fundus, 
viewed in this way, is the reverse of their real position. 

The most important optical deception which arises from viewing the fundus 
in the indirect method, as well as the most puzzling to a beginner, affects 
the papilla. The student has probably heard, that the papilla, in the glau- 
comatous eye, is cupped or excavated, but to his view it appears quite the re- 
verse, it appears rounded and prominent. 

To comprehend clearly that this is an illusion, all that one requires to do« 
is to impress with the head of a pin, a small dimple on a bit of paper, and 
put this under a compound microscope, with the concave side of the impres- 
sion uppermost. The same appearance will then be seen, which is presented 
by the papilla of the glaucomatous eye, viz., that of a rounded and pro- 
tuberant surface. 

This optical deception arises from the inversion which the image suffers by 
being viewed through the compound microscope. We judge that an object, 
viewed with a single eye, is convex or concave, solely by the manner in 
which light is reflected from the body under examination. The light which 
falls obliquely on a convex surface illuminates that side which is nearer to 
the source of light; the side farther from it is in shade. The light which 
falls obliquely on a concave surface illuminates that side which is farther 
from the source of light ; the side nearer it is in shade. Let the source of 
light remain in the same position, but invert the image of the object illumin- 
ated, so that the light which falls on the farther side of it may seem to fall 
on the near side, which is the case when we look through the compound 
microscope at the hollow on a bit of paper, or when we examine the optic 
papilla through the compound microscope formed for the occasion by the 
patient's eye 2^lus the convex lens held in front of it ; and both the dimple 
on the paper and the papilla, although they are actually cupped or concave* 
will then appear convex and prominent. 

If, on the other hand, wo turn the convex side of the dimple on the paper 

uppermost, and view it with the compound microscope, it appears concave* 

The inversion of its image causes the light which falls on its near side, to 

appear as if it fell on its farther side, and thus the eye is subjected to a de— 

oeption the reverse of the former, and from which it cannot free itself. If 

there be cases, then, in which the end oi IVie o^Wc \i«tf^^\k)ui\hQ eye ao* 



SURGERY. 217. 

taally projects in a convex foim, they will offer, when examined in the indi- 
rect n^ethod, the appearance of a cup or depression. 

Such facts have long been familiarly known ; the apparent transmutation 
of an intaglio into a cameo, or that of a cameo into an intaglio, under the 
compound microscope, being a common source of amusement, nilly discussed 
by Sir David Brewster in his * Letters on Natural Magic, Letter V.' Im- 
portant as their bearing is on pathological examinations of the eye, they 
seem to have escaped the notice of ophthalmoscopists, till attention was di- 
rected to the subject by Dr. A. Weber, in a paper in the * Archiv fur Oph- 
thalmologie,' Band II, Abtheilung I, Seite 141. 

In a highly interesting communication in the same journal (Band IV, Ab- 
theilung fl, Seite 1), Dr. H. Miiller has directed attention to the normal, as 
well as to several diseased states, of the optic papilla. 

His account of the entrance of the optic nerve into the eye. and the dia- 
gram which he gives in illustration, fully remarkably with the thirteenth 
figure in Mr. Bowman's ** Lectures,'* and the corresponding explanation. 
From the statement and figures of these two observers, especially those of 
Dr. MUller, it may be gathered that the lamina cribrosa is normally some- 
what concave towards the interior of the eye ; that the fibres of the optic 
nerve, suddenly losing their white substance and dark outline, enter the eye 
on a level with the chorio-capillaris; that at this point the whole nerve, from 
the change which its fibres have just undergone, is considerably and rather 
suddenly reduced in thickness ; that the fibres, bending more or less ab- 
ruptly outwards, and spreading around, become clothed by the exterior or 
raaially disposed layers of the retina ; that the edge of the opening through 
which the nerve passes into the eye, as well as the fibres themselves as they. 
traTerse that edge, form a slight elevation or approach to a papilla, leaving 
in the situation where the trunks of the central vessels of the retina gener- 
ally make their appearance, a small foveola. 

Dr. MHUer points out the difficulties which attend the anatomical examin- 
ation of this depression, arising from the softness of the part, and its liabil- 
ity to change on being touched ; and shows how these difficulties may best 
be obviated. He directs attention to the varieties which exist in different 
individuals; varieties in the depth of the depression, from 0*2 to 0.5 milli- 
metre; varieties in its form and position, for it is not always symmetrical, 
and does not always correspond to the middle of the nerve, but is sometimes 
considerably nearer to the macula lutea, or has one portion of its edge more 
raised than the rest : varieties in the dispositions of the vessels, for while the 
large trunks generally emerge from the middle of the foveola, one or more 
sometimes seek a passage for themselves close to the edge of the chorio- 
capillaris, so as to make their appearance by the side of the nerve ; facts* 
all of which should be carefully borne in mind by ophthalmoscopists. 

In regard to abnormal prominence of the papilla, Dr. Mtiller shows, that 
this is likely to arise from an atrophied state of the exterior layers of the 
retina, a thickened condition of the primitive nervous fibres, as well as in- 
filtration of the nerve by blood, iufiammatory exudation, or new formations. 
He relates a case in which a concretion in the site of the lamina cribrosa 
caused a protuberance of the papilla. The very earliest stage of encopha- 
loid tumour should show an abnormal prominence of the papilla. 

On the other hand, intra-ocular pressure, and atrophy of the nerve, exist- 
ing either singly or in combination, are the causes of abnormal excavation 
of the papilla. In case of intra-ocular pressure, either simple, or combined 
with atrophy of the nerve, paracentesis, either corneal or. sclerolical, is 
likely to produce a change in the depth of the excavation, sufficient to be re- 
cognized on ophthalmoscopical examination. 

Morbid excavation of the papilla varies in depth, reaching in extreme 
cases to a millimetre beyond the level of the choroid. In such cases, the 
sides of the excavation are nearly perpendicular, or are even concave, and 
its edge, of coarse, independent, so as partially, or even com^\c^\.^Vj>\j^\i\^^ 
from view the course of the vesaeh as they pass from t\ie \>o\Xcv\3Cv <^^ >^\^ ^^- 
oavation and over its edge to the retina. In slight ca&es, t\iQ &\^e^ oi ^*^ «^* 



218 SUBGERY. 

caration are conveZf and its form that of a fannel. The lamina cribroscu 
under such circumstances, keeps its place, but in more advanced stages, it 
is pushed back, and the excavation is much extended laterally. Such ex- 
treme cases of expansion are not the result of uncombined atrophj of the 
nerve, but must arise from the supportinfj resistance of the parts being 
weakened by previous inflammation, whence they come to yield more read- 
ily to intra-ocular pressure. — Ophthalmic Hos, Reports. No. II, p. 252. 



90.— ON THE OPHTHALMOSCOPE AND ITS APPLICATION. 

By Hatvis Walton, Esq., F.B.C.S., Sarsreon to St Mary's, and to the London Ophthalmie 

Hospital*. 

[Mr. Walton believes that the origin of the ophthalmoscope is to be traced 
to a communication.] 

In the twenty-ninth volume of the * Medico-Chirurgical TransaotiouB,' 
by William Cumming, Esq., formerly house-surgeon to the London Hospi- 
tal, ** On a Luminous appearance of the Human Eye and its application to 
the Detection of Disease in the Retina and Posterior Part of the Eye." 

[It would appear that Mr. Cumming's attention was attracted to the sub- 
ject from the description of cat's-eye amaurosis by several authors ; i.e. 
amaurosis in which there is a luminous glare like that occasionally seen in 
the eyes of some animals, this Mr. Cumming shows to be natural to the 
healthy human eye, when the pupil is widely dilated and the eye seen in a 
certain light.] 

His simple process of examination is this: — "Let the person under exam- 
ination sit or stand eight or ten feet from a gas light, looking a little to the 
side ; standing near the gas-light, we have only to approach as near as pos- 
sible to the direct line between it and the eye to be viewed, at once to see 
reflection. Or, in a dark room, a candle being placed four or five feet from 
the eye, if we approach the direct line between them, we shall be able at 
once to see it in many cases. If solar light be admitted through a newly 
closod shutter into a dark room, the luminosity may bo seen when the pupil 
is tolerably dilated, the patient standing five or six feet from the aperture, 
and the observer occupying the position before indicated." 

"These, then, are the circumstances necessary for seeing the luminosity. 
That the eye must be at some distance from the source of light, the distance 
being greater in proportion to the intensity ; that the rays of light diffused 
around the patient (and sometimes around the eye itself) should be excluded; 
that the observer should occupy a position as near as possible to the direct 
line between the source of light and the eye examined; hence it is sometimes 
necessary for the observer to stand obliquely, that his eye may approach 
nearer to the direct line." 

** The appearance of the reflection itself not only varies much in colour 
and intensity in different persons, but also from the circumstances under 
which it is seen ; viz., the greater or less intensity of light, the position of 
the eye examined, and the distance at which it is viowerd." Many other 
similar modes are given. 

Three times I have seen the eye accidentally illuminated. The first time 
that I was called to a consultation in the country (an occurrence which a 
man is not likely to forget), I saw a beautiful illumination of the eyes of a 
gentleman who was sitting in the corner of the waiting-room of the old sta- 
tion of the Great Western Railway, a few feet behind a gas-lamp; and asso- 
ciated with it was this coincidence, that the gentleman, himself blind, who 
came to town with his servant to take me to one of his pupils, who had 
been wounded in his eye, was at the time tolling me of his own blindness, 
and called it " cat*s-eye amaurosis." After that, I witnessed the same thing 
in a ladt behind the gas-light, in a druggist^s shop. I again saw it in my 
study by my microscope lamp. 
Mr. Cumming*a paper, with all its ox^Qx\mQiita fMidi w(x^<^^^^lw^ and not 



SURGERY. 219 

less its originality and philosophy, bases all tho application of the discov- 
ery in the mere illumination of the interior of tho eye-ball ; full illumina- 
tion being taken as the indication of health, and the absence of it as indi- 
eation of disease in the retina and posterior part of the eye ; for instance, he 
writes :— 

** The establishment of the fact of a similar reflection from the healthy 
human eye to that from the eyes of animals, appears to me chiefly important 
in its adaptation as a mode of examining the posterior part of the eye. The 
retina and choroid, hitherto concealed in the living eye, and little opportu- 
nity being afforded of examining their condition after life, in consequence of 
their diseases not terminating fatally, considerable uncertainty has attended 
the diseases ascribed to these structures ; but the existence of this luminosity 
having been recognized, its non-existence or abnormal appearance may en- 
able us to detect changes in these structures heretofore unknown, or satis- 
fJEUStorily to see those which we only suspected.'* 

If we dilate tho pupil by atropine we have a means afforded of seeing the 
condition of the retina and choroid in every case. The cases I have exam- 
ined in this way have confirmed the general impression that the retina is not 
fireqnently the seat of change in amaurosis ; for, out of several cases of amau- 
rosis, in which the non- opacity of the cornea, lens, and humours, allowed this 
mode of examination, I found but two, in which the retina was so changed 
tiiat the reflection was not seen. 

Among tho physiological conditions of tho eye enunciated by Mr. Gum- 
ming, are these : that the choroid is the principal reflecting structure, the 
light returned from the retina and concavity of the hyaloid body doubtlessly 
increasing the effect; that the brilliancy is considerably augmented from the 
concentrating influence of tho concave shape of the retina, and tho focal dis- 
tance of the Tens ; that tho luminosity of the healthy eye appears to be in 
proportion to the light colour of the pigment. The reflection from the albino 
IB evident in ordinary day light. Ho further observes: — 

"On placing a middle aged mnn, an albino ten or twelve feet from a gas- 
light, the reflection was extremely vivid, and of a pinker colour than or- 
dmary, while the light transmitted through the choroid and iris evidently 
increased the effect. On placing close to his eyes a black card with an 
aperture a little larger than tho pupil, the reflection was brighter than that 
from the eye of a fair person examined side by side, but was of a more de- 
cided pink colour. 

•* In persons of fair complexion and blue or grey irides, it is generally 
more brilliant and more readily seen than in those of dark skin and irides. 
In the mulatto, it is also dusky ; but in them, as in persons of swarthy com- 

Slexion, a silvery reflection is sometimes seen, and is most probably a re- 
iection from the retina. In the albino, this reflection produced by the vas- 
calar choroid is most brilliant and lightest in tint. In proportion to the 
darkness of the pigment, its lustre is diminished and the colour becomes 
more dusky.*' 

Perhaps there appears a contradiction hero, but there is really no discrep- 
ancy. The choroid is found to reflect greatest where the pigment is want- 
ing. The pigment has nothing to do with the reflection ; on the contrary, it 
interferes with it, and therefore lessons the illuminating power. In man, the 
pi^ent is less abundant and less intense in color than*in many of tho lower 
animals ; it is brown, rather than black. 

It was then the first grand principle, the comprehensive idea, that Mr. 
Camming gave us. He did not see the optic disc, nor tho retinal vessels. 
The peifecting of tho discovery and the practical application, involving as 
they did tho cufficulty of inventing an instrument and the working out of 
much detail, were reserved for other labourers. These were found in Ger- 
many. It would be fruitless to trace the instrument through its stages of 
development. I will merely give the names of its several improvers, aa fox 
as I can ascertain, in the order of time : they are, HelmVioVlz^ 1^vx^\,q> ^q^- 
oioSf and Anaffnostaki^F. 
The opbtbaJmosoope atpreaent in use is a portable AiU\e conciikN^ mYCCQit, 



220 SURGERY. 

made of silvered glass, having a hole of sufficient dimensions in the centre, 
with a handle of about ten inches. The hole is usually too small ; it should 
be of sufficient size to admit of distinct vision when the instrument is held 
with the requisite obliquity ; the edges should be smooth and free from 
splinters. A double convex Ions, of from two and a half to three inches 
focus, is needed as an appendage ; but the power should be regulated by 
the usual range of the observer. It should be set in a frame wit£ a stem of 
three or four inches long, which renders it more readilj used. I know that 
mirrors of different curve and lenses of varying power compose the appara- 
tus of some surgeons. That these varieties can be brought into requisition 
according to one's fancy, is undoubted ; but I believe that they possess no 
utility, no decided practical advantage. 

The ophthalmoscope demands an artificial light. Under an emergency, I 
have employed a candle, and with the faint illumination have gathered some 
although an imperfect, idea of the interior of the eye. A steady lamp-flame 
is needed for the full effect. Whenever I can command it, 1 employ gas^ 
and use a small argand burner, at the bottom of which is an arrangement 
with glass collar that ensures a steady flame, that slides on a vertical rod 
with a pedestal. It is a gas-lamp much used by the artizans of the watch- 
making district of Clerkenwell, and sold at a lamp shop in Clerkenwell 
Green. A very light blue chimney whitens the light by reducing the pre- 
dominant red rays, and the eye is then more naturally seen. 

The examination should be made in a dark room. 

As a rule, the eye should be prepared by having the pupil dilated by bella- 
donna or some of its salts. Now and then persons are met with, especially 
fair young persons, whose naturally expanded pupils enable us to dispense 
with the artificial enl irgement, particularly if it be not more than a mere 
glance within the ©ye that is needed , and above all, near-sighted eyes may 
be so examined ; but generally, in adult age, and still more in old age wiUi 
its discoloured lens, and in all cases where a thorough survey is called for, 
the natural pupil will not suffice. Vain discussions have been wasted on this 
question, which may be resolved into this common-sense remark* that if the 
desired object can be accomplished without interfering with the pupil, all 
the better, as the sequel will show ; if it cannot, dilatation must be re- 
sorted to. 

The pupil is generally more contracted by the light of day, than by the 
light of the ophthalmoscope. Often when it has appeared too small to allow 
of any serviceable examination, it has dilated sufficiently when the room has 
been darkened, and remained of such capacity as to afford all that was de- 
sired. 

Unnecessary dilatation should always be avoided, because this unnatural 
state produces positive discomfort from indistinct vision, the degree and du- 
ration of which, from days to weeks, is proportionate to the dilatation and 
the healthiness of the eye. Patients frequently leave the surgeon on ac- 
count of this, even when they have been tore warned. In spite of all assur- 
ance to the contrary, they are likely to attribute the temporary annoyance 
to the use of the ophthalmoscope, and declare how detrimental it has been to 
them. Any increase of disease is often set down to the same cause. 

It is not generally known, indeed it is my own observation, that, when a 
strong solution of ataopine is used to the one eye, the vision of the other is 
apt to be impaired for one, two, three, or even more days, and that without 
any apparent alteration in the pupil. The power of adjustment seems to 
suffer particularly. I shall not stop to discuss the physiology of this ; I think 
it sufficient to mention the fact. 

These are reasons why strong solutions should be avoided ; and weak ones 
answer our purpose quite well. I have seen symptoms from the strong ap- 
plications that leave me in doubt that they were those of belladonna poison- 
ing. In one instance I believe that death was so caused. The physician 
who was called to the young mentioned his suspicions of such, without know- 
JDff that the drug had been used. A aix-ovxiieft bottle of lotion, containing 
tbirtjr- BIX grains of the sulphate of atropine, ^«l* ox^^t^^%» wi«^^-\ation. 




I 



SUEGERT. VHV im 

irith directions for tlie wagih to be consERtitly applied to thi? pje. TlieBC were 
fully carried (^ut* Tl>e eye was kept j^ttturated with wetted lint ; H<iveral bot- 
tles were mi uied. What a htrge quantity mirat have pa^eefl into the throat 
through tlie hicrymal conduits I 

Under Tf^ry eioeptional circu in stances only therefore, and which the ea- 
gncity of the surgeon must determiuo, should a strong solution ha uetedi and 
tkeii only in small quantities. Half a grain of the sulphate to an ounoB of 
wat**r is what I ordinarily employ* A single drop, put on the conjuiictivn, 
suiEces* I depress the lower eyelid* and with a hrusht my finger, or any 
convenient thing, apply the drop. D i lata T ion is much slower^ but it pasees 
iiWB^j quickly, and the disagreeablee incidental t& the stronger form do not 
appear. Dr. Garrod has Rhown by his experiments that dilatation may be ob- 
tained by a grain in soveral ounces of water, but it must be- remembered that 
healthy eyes are easier influenced than diseased ones. 

It has been asserted that the retina is likely to become congested by the 
atropine. I have not been able to confirm thi;^ statement ; and it is difficult 
to reconcile !*uch a statement with the observation of my colleague, Mr. Tay- 
lor, that the eye iw more tolerant to the ophtiialmoscupic eiamination wbeu 
atropine is used, than other wise* 

[In a subsequent paper, Mr. Walton proceeds to dteoased statea of th« 
eye, first notieing cataract] 

Cataract. — Few surgeons have long been engaged in active ^uty without 
being aware of the difficulty attendant on the di?ignosia of incipiout cataract. 

T is it the general surgeon only who may be so puzzted, From my own 

Pional knowledge, such men as Tyrrell and Dalrymple were deceived, as 

e progress of cases showed. It would bo easy ft>r mo to adduce parallel 
examples occurring among living practitlonors* Indeed, tilt the ophthahnos- 
copo appeared, we were necessarily often in difficulty ; and no one felt tliis 
more tnan myself, as the means at our disposal — the catoptric test and the 
concentrated light — were not enough. It was especially so in old agp, when 
the natural coloration of the lens, the amber hue existed, and particukirly 
when it was un usually developed, for then streaks of opaoity at the back 
of the crystal lino lens, or goneral hazines« of this body, were easily over- 
looked » The coloration itself was liable to bo mistaken for disease, when 
there eo* existed impaired vision from any cauie* 

A wine- merchant was assured by a geiitlemaTj engaged In ophthalmic prac- 
tice In thi.* metropolis, that he had cataract. An operation was proposi?d, 
iind eonsentoft to. The chloroformist was even named. I was consulted, 
in order to satisfy some friends. I found the lenses very highly coloured, 
but not opaque, for I could see distinctly all the fundus of the eye. Much 
hepatic derangement with a very debilitated system seemed to be the cause 
of defective sight, and a few weeks' treatment confirmed tlie diagnosis I had 
given^ 

Whenever, therefore, there is a suspicion of cataract^ an ophthalmic inrei- 
tigation should be instituted. A less intense light than ordinarily employed, 
is preferable, because it is possible hero to over-illuminate the eye, and the 
stria? may nc*t be seen. With very high illumination, opacities moy be leps 
apparent than witbout the ophthalmoacope. It is on this account, tr>o, that 
the eye should be examined at first without the lens. A source of fallacy 
mnat here be guarded against. The dots of pigment that are so often 
seen on the capsule of the lens as the result of inflammatory attacks, by 
whioh the iris and the capsule have been brought into apposition, at* also 
cicatrices or spots on the oomea, must not be mistaken for cataract opa- 
cities. It is enough to direct attention Ui this point to prevont that mistake* 
Positively, cataract may now be detected before a person is himself aware 
of it* 

A lady applied to me for defective sigbt in the left eye. I had little doubt 
that I saw radiating stritt in her lens ; but to be quite sure, I used the oph- 
thalmoscope, and had the fullest evidence of cataract. 1 Vo^k^^ iiX "Cki*. tsVBS:^ 
eye^ and dipcovered a few small and irregular Vmeat o'^ac\t\G^^ tsVyOvv \ \\^^ 
not seen in m^ naked eye examlnatioD. I vpas toM, va ^xi'^^^t Sj^ ev^ <;^^ti- 



222 SUBGEBY. 

tions, tliat that eye was quito well, and vision was not impaired ; yet I foand 
by some delicate visual tests, that there was not perfect i(ight, but the derange- 
ment was so trifling, that it had not. been noticed. I thought this a great 
triumph of modern science. 

It is of no small diagnostic value to have a correct idea of the condition of 
the interior of the eye in cataract, to ascertain whether the loss of sight is in 
proportion to the degree of the opacity, and, in fact, depends on it, or on a 
more extended diseased state. Wo can get this knowledge by no other 
means. Do not considerations like these warrant an often repeated asser- 
tion of mine, that for what we have gained in this respect alone, the ophthal- 
moscope is of immense value ; and if wo went no further, might be truthfully 
considered amongst the greatest additions to recent ophthalmology ? 

Another condition of the crystalline lens can be learned only in the recent 
state by illumination : I mean. Partial Dislocation of this body backwards^ or 
tunsting out of its place by direct violence* This may be palpable later when 
the opacity has pervaded the lens, but certainly not by any ordinary means 
till then. 

Disease of the J^treous Humour seems to cause more astonishment to an 
inexperienced observer than any other morbid changes ; partly, I suppose, 
because any physical alteration apart from greater fluidity was never sup- 
posed, and because the moving about of shreds and granules, and flakes and 
threads, are such palpable and material things. We now know that this 
body, which certainly is of low organisation, since it is often very rudely 
treated in certain operations, and portions of it are lost with apparent impa- 
nity, does become materially altered, partaking of disease that invades the 
eyeball generally. Apparently, at times, it is the sole seat of morbid phe- 
nomena, which are great impediments to vision. This is quite new to us; 
and no speculation, guessing, conjecture, or indication, brought it within the 
range of probability. In inflammations of the eyeball in general, it mostly 
becomes opaque, and looks muddy, and more or less hides, as in a fog, the 
fundus of the eye. Careful examination generally discovers minute bodies 
in constant motion, I have seen opacity of it, in the greatest degree, with- 
out any other symptom that I could detoct, or any caui$e ; and some oases 
that seemed quite hopeless, from the degree of turbidity, and the correspond- 
ing loss of sight, and the absence of all indication for treatment, have got 
quite well. So frequently have I seen the cloudiness pass away entirely in 
acute specific inflammations of syphilis and rheumatism, even where there 
were floating patches and filaments, which wo call exudations, that I have 
little prognostic dread of it, as compared with cloudiness unaccompanied by 
acute disease. 

Floating objects are not uncommon in the vitreous humour while its trans- 
parency remains ; and they may exist alone or in connection with diseases 
of the retina or the choroid coats. These are generally seen by the indivi- 
duals themselves, and are often the circumstonces that induce them to apply 
for relief. This brings mo to speak of muscae volitantes, in connection with 
the internal ocular inspection, and that only. I think that any one who has 
studied the writings of Sir D, Brewster, and the masterly essay of Dr. 
Mackenzie, himself a sufferer from muscae, or investigated the subject with 
pains and care, cannot fail to conclude that they are minute floatimg bodies 
in the eye that cast their shadows on the retina, and that they are far 
back in the posterior part of the eye, almost in contact with the re- 
tina. As a consequence, this upsets the theory of pressure on the re- 
tina by varicose vessels causing them ; but it does not invalidate the sup- 
position that certain parts of the retina may be so pressed on, and ren- 
dered insensible, causing the loss of function to be manifested in fixed 
spots, or black disc that have not the motion, and other characters of 
muscaB. 

I have not, so far as I remember, been able to detect moving bodies in the 

vitreous humour; but, in connection with other internal disease of the eye- 

baJJ or defect of sishtt I suspect that ordinary muscaB are too minute to be 

seen with the oph tnalmosoope. It ia becoimxk^ ql ^t«\%l«nt idea that titey 



SURGERY. 223 

may always be found if looked for. It is a fact whicli cannot be accounted 
for, tbat floating bodies in the vitreous humour are not always seen by a per- 
son, and that the perception of them varies. 

Effusion of Blood in the Vitreous Humour is another newly recognized 
state. It is most threatening when extensive, because vision is quite ob- 
scured, and the eye to all appearance lost. It is nearly always impossible 
to trace the source; but, I presume, it must generally be from retinal ves- 
sels. It may be traumatic or idiopathic. The first is the rarer, and the 
amount of hemorrhage bears no direct relation to the severity of the acci- 
dent; a mere tap on the eyeball may produce as much internal bleeding as 
a smart stroke ; and I shall presently show that a blow about the region of 
the eye only, may cause intra-ocular hemorrhage. The second, the idio- 
pathic variety, may, like the first, be unaccompanied by any external sign 
whatever ; indeed, only now and then is there associated redness of the sur- 
face of the eyeball. The subjective symptoms, by no means always present, 
are flashes, corruscations, combinations of colour, and spectra. The actual 
condition, therefore, the diagnosis, cannot be known, except by the oph- 
thalmoscope. In partial effusion the clot may be seen in the always more 
or less hazy vitreous humour. Hut the whole of the interior of the eye may 
be so darkened that no illumination can be obtained. I do not know how 
much blood is needed for this. Amon^ the idiopathic cases the worst have 
occurred in eyeballs long subject to chronic inflammation, and the hemorr- 
hage has quite destroyed the sight. Two of my patients lost their eyes in 
this way in the night. I have known recovery ensue many times when there 
has been so much effused, that I could not illuminate the eye ; and I do not 
give a decidedly unfavourable prognosis, except there pre-existed disease of 
the eyeball. 

In the first case that I met with, I suspected the eye to be lost, but com- 
plete recovery ensued. A gentleman in good health, and with, as he thought, 
perfect eyes, perceived large soot-like bodies floating before the left eye. 
There were occasionally coloured clouds. He at once came to me. In a 
cloudy vitreous humour I saw the extravasation. There was no other ob- 
jective symptom. I saw him two days after, and the vitreous humour was 
quite obscui'ed. At the end of five weeks ho could read any type, but was 
a little interrupted by some floating shreds in the vitreous humour tempo- 
rarily obscuring the type. A few weeks later his sight was quite restored, 
and I could not detect any abnormal ophthalmoscopic appearance whatever. 

I will give the particulars of another case that occurred in the practice of 
my colleague, Mr. Taylor, and closely watched by him. Through his kind- 
ness, I saw the patient twice. 

Mr. C. an artist, aged 30, applied to me for advice last February. A few 
mornings previously, on commencing work, he found that the sight of the 
right eye was obscured, to use his own words, ** by various forms of dense 
matter, like those produced by blood dropped in water, or wreathe of blood- 
coloured smoke, the denser parts of wliich, when looked at against a strong 
light, appeared of a brilliant brown red.*' About two-thirds of the field of vision 
were totally obscured, the lower third being of a pale green colour, through 
which he could discern objects ** with tolerable distinctness." During the 
following two days, the obscuration extended over almost the whole field of 
yision, and the colour of the wreaths deepened to black centrally. His writ- 
ten description was accompanied by a beautifully executed water-colour 
drawing of the spectrum. 1 hough his health is generally pretty good, yet at 
the time his strength was rather reduced by over- work at his profession ; ho 
had had several slight attacks of bleeding at the nose, and had a bad cold 
and cough. The external appearance of the eye was perfectly natural. 
With the ophthalmoscope it was impossible to distinguish the fundus of the 
eye, the vitreous humour being of a dense grey or smoke colour ; here and 
there only a faint red tinge could be perceived. As the eye moved, numer- 
OOB small spots and filaments were seen floating across the pupil. In ^V^xsX 
three weeks the optic disc could bo seen dimly as tViToueYi «l io^\ «oc>\l^i^AT^ 
file zetinai Tossels oould be distinctly traced, and a smsll ds^iVL i«^ v^\.^ ^^ 



2S4 SUBGE&Y. 

source of the hemorrhage, was seen on one side. The improTement was now 
rapid ; and a little more tiian two months from the seizure, the sight of the 
eye was completely restored, though it was apt to become ^m after a few 
hours* work ; and a few floating filaments could still bo seen in the vitreoas 
humour with the ophthalmoscope. 

Perhaps the commonest morbid change in the retina is Hyperamia. The 
colour or the fundus of the eye is chnuged, being more red, and sometimes 
of a dark red. A portion of the optic disc is obscured by vessels, or the 
whole is covered thinly, so that the disc is yet made out, or thick enough 
almost to obscure it, and then its position may be more readily traced by uie 
vessels as they pass outwards, but which soon losiB their distinctness. 

This is a state that always exists in a greater or lesser degree with the 
train of symptoms called by Dr. Mackenzie " asthenopia,'* and supposed by 
him to be a defect of adjustment only. His reasoning is clear and powerful ; • 
his conclusion is inevitable, and, but for the opthalmoscope, every one must 
have been satisfied with it. It is worth referring to as an example of the 
fallacy that we may fall into by attempting to solve such subjects by reason- 
ing alone. I may recall the disease to the minds of my hearers by telling 
them that "asthenopia" is the "choroiditis" of Tyrrell. It is the affection 
of those who for the most part got their living by minute sight. They are 
obliged to discontinue with their work, because the vision as it were gets fa- 
tigued, and the objects confused or indistinct, and vanish from view alto- 
gether. A slight cessation, a wink of the eyes, a look at a distinct object, 
or, in the worst cases, a pause for a minute or two, enables them to continue. 
It is strange that the indistinctness comes on when the vision is required to 
be sustained on minute things only, and not when large and distant objects 
are looked at. IJut it is not peculiar to the overworked eye. I have seen it 
in children learning to read, in the idle man of pleasure, and in the vigorous 
mechanic. I begin to think that it is almost a defect of organisation, ren- 
dered worse or apparent under much or peculiar use of the eye, and the gen- 
eral inutility of treatment, short of cessation of that employment which ren- 
ders it annoying, tends to this conviction. I could fain dwell longer on it. 

Among other ophthalmic revelations of retinal changes, are those of dots, or 
patches aJTwhite, usually seen in the oged, and associated with feeble vision. 
I do not know that their nature has been made out. 

(Edema of the retina, rendering the membrane pale and of a yellowish 
tinge, less shining than in health, and apparently raised around the optic 
disc, is fully recognised. 

Pigment Deposit on the retina, in every form of spot, and in extent from a 
few dots to almost complete covering, with but small interspaces, is the most 
remarkable change in this tunic, and not less in the absence of any co-exist- 
ing external symptoms. I have seen an amount of deposit that seems incom- 
patible with any vision on first examination of a patient for slight feebleness 
of vision, which is, of course, a physiological puzzle. Many times I have 
doubted the visual power till I have carefully tested it. 

Choroid. — The choroid, like the retina, becomes hypenemic ; but the most 
striking change is Atrophy, chiefly manifested by the removal of its pigment ; 
a common consequence ot chronic inflammation. The alteration generally 
begins near the optic disc. At first a yellowish change is seen, and then the 
orange-coloured choroidal vessels appear, and these become more distinct, 
ultimately disappear, and leave a white spot, which is often mistaken by the 
inexperienced for the optic disc, especially if the disc be injected. With the 
loss of pigment, there is a deposit of grey or deep black spots in other parts, 
as if the colouring matter was removed from one portion and taken to an- 
other. Associated with this, extravasated blood, in small quantities, is not 
very unfrequent, so that the whole fundus of the eye has a mottled and varie- 
gated appearance, and withal a person may be able to read. These altera- 
tions rarely exist without some disease of the retina. 

Early in my professional career, indeed in my studentship, I suspected 

thit in so-caUed Syphilitic Iritis there was something more than the name at 

£rst Jod me to infer, and this chiefty on aceoxxnV oi ^^ wibaequent damage, 



SURGERY. 



225 



the very dtrpctive eye that remainei] after the iris Imd rf"cr»%-^f!rf*d. I was 
imrticularlj attracted to this in a yr*ung w^iamii^ during my dresspTship. 
Tht^ eje secmod perfoct wht^n the inflammatmn wm [lassedi yet she could 
hardly count my fitigors. Well da I remember this being attributed by the 
pjentleman^ whose patient she was, to tleficieiicy of active treatment in the 
first instance, a remark which explained nothing, Tbe evidence of implica- 
tion of the eyeball by several local and general ***ymptoms were unheeded by 
me* for I looked on them^ as I was taught^ merely as the conaequencea of an 
inflamed iri;?* that being the part which the disease prlmavily uttacked, and 
on wbteh it spent its violence. It was with inexpressible delight, some years 
after, that I read Dr. Jaeoh*s most valuable monograph on inflammation of 
the eyehfill, and became convinced by it that iritis, so caMed, was not disease 
of the iris alono, but general inflammation of the eyeball; andi indeed, who 
ever saw the iris df sic o loured and paralysed by inflammation freni syphiliR, or 
rheumatism, or struma, withont vision being materially impaired ? I have 
©voT found that ^)r, Jacoh^a writings fitana the test of timfl, and are les^a 
eclipsed by the advancement of knowledge than those of any modern oph* 
thalniic author. Ophthalmoscopic eiami nation docs not render thcin obso- 
lete, but adds confinnation. 

It is no longer a secret why syphilitic eyes become spoiled. But with 
faint implication of the irisi and little symptom of redness and pain, the ret* 
ina may be spoiled, as wo see by the tJeposit c^f lymph, and choroidal daroago 
is subjoined i>y strnctural alterations. I once gave a wrong prognosis in a 
c^ise of rheumatic inflammation of the eyeball, that annoyed me for a long 
time, and created a great desire to discover the cause of an eyeball being so 
insidiously lost, With but very slight external evidence of implication of 
the iris, I gave assurance of complete recovery ; but, to the great disappoint- 
ment of alt, blindness ensued* This, together with ophthalmoscopic eiperi- 
enee, has taught me always to give a guarded opinion, and I may hero 
remark, with regard to prognosis in general, that most of us are too apt, 
in critical cases, at a great risk to our reputation and comfort, and without 
any adequate advantage to ourselves, to be too prophetic, and to promise too 
much. It is true that patients almost force us into it, and when we commit 
ourstilvest it is our desire for a favourable issue that betrays us. 

A more ettended knowledge of sytihilitic disease of the eye, has oon- 
vinced me that tbe posterior part of the eye, certainly the retina and tbe 
choroid, and perhaps also the vitreous humour (whieb is indicated by huKi- 
ness and iloccoli), are always involved, I never saw an example witliout 
impaired vision, and all observers know that vision may become misty prior 
to any palpable iritis. Before I ever looked through an ophthalraoseopej I 
made the vision the chief ground of the diagnosltt in the incipient stngo of 
the disease* Many a case of reddened eyeball presents itself, and looks io 
like iritis, that the most oipcrienced observer cannot say at once that there 
J3 or is not this affection; but the test that never fails me is trying the see- 
ing power, and if I find no deflcienoy here, I am sure that there is only sur- 
mee inflammation. 

A surgeon in very large practice, in London, and well known to all of us, 
•ent very lately for me to see a patient whom lit^ bad attended with rheuraa- 
tisra, and now, as he supposedj afflicted with rheumatic iritis* The eyeball 
was much injected, aod whether super fieially or not, I could not tell. This 
iris was clear, I tried the sights and when I found that the almot^t micro- 
eeopic inscriptian on my watch could be read, I was satisfied that there was 
no iritis — ^no *' eyeball-itis," The calomel and opium pill, which was just 
commenced, was left off, the usual diet was allowed, and an astringent lotion 
given. In a few daj-^s the eyes were well. 

Mil re than all this, the ophthalmoscope teaches ns that the retina may 
he the sole seat of syphilitic action* My attention was flrst drawn to this 
in a medical pupil saturated with secondary syphilisr <wid who lost tbe sight 
" on e eye w i tho u t any e xte m al sy m ptom s . Inte nval mft\icti\\QTi -, Vve^K ^n <iT ^ 
howcd that there was inflammatorj exudation over ike tan^u^ ^>^ ^Jtisi ^^©^ 
XL1L—I5 



L 



SUEGEET, 

€jb5Ciiriiip the fypUo disc find retioal vessels, Wheu I wa» Lo^t consulted* | 
fortujjau4y for liim, his sight was almost clear. 

Among tho appear&nces at the fuadys of the eje, after the acutci stage < 
eyphlLitic eyeballitla baa passed awaj, are dots and patches of depoedt i]^^ 
dineretit forma and sizes, more or less darkened iviih plgmeitti over the I 
retina. The optic disc is often changed, sometimes contracted and ill de*! 
fined, and greyi>*h ; Bometimes, apparentljr more spread outi and pre^entlni^j 
tnany abnormal aspects. The charoid becomes patchy with white ^ yelloir|| 
and hrowQ ; its pigment is Lost in spots, allowing the if esse Is to be seen^ aodl 
exposing the sclerotic coat. I 

The ophthalaioscope has not increased the difficulties of ophthalmic prac^l 
tice, ou the contrary « it renders it easier, after a man has takt^n the requisite! 
trouble to learn cert&in preltminaries* What time used not to be spent iml 
investigating cases of impaired vision, to discover to which of the subdivitl 
sions ot amaurosis it belonged ? How numerous the qnestionSf bow tedioUf | 
and unsati:^ factory the eiamination ? Now we at once ha^ a peept and se#f 
things as they are, and when we are puzzled, the patient is not made to | 
suffer for it. I believe, too, that the ophthalmoscope will reduce ophthalmia j 
literature; the treatises will devote less space to the disoasca of vision, be*! 
cause less is needed. There will be more fact, which is always put in t^m 
amall space, and leea of wordy tlicory. 

There is just one topic, rotipceting therapeutics, that I venture to int 
duce^ Do not abandon a patient, am] say that he is iucurubic, merely 1 
cauee you see thi^ or that change lu the eye ; it is one i>f the dangers of a I 
speciality. Let nothing short of diiwirgaui nation prevent you from seeking | 
iadications of treatntent, and catch at the sliadow of a chance. We knoirl 
m little of tho natural reparative power, of function and of vitality, that w^-J 
ought not to dare, except under remarkable and well recognised couditionai« j 
to give a fatal prognosis, I 

Do not look on a diseased eye merely as suoh ; remember that this orgaiij 
is but a part of a whole, and tliat recovery, or partial recovery, often eusuos^ 
contrary to the eicpectatlon of the most cicperleiiced, W^bich of na has not 
*een this exemplihed in disease of the lungs, and kidneys, and liver, by spe- 
ciali.st^ in these departments ? — Bniuk Med. jQUrnalt June 10| Aug^^l^andi 
18, IS^UO, pp. 452, 51)7, G43, ^ 

91, — On the Surgical T^ealmcnl of Short SighL — Mr, J, V, Solomon, ofi 
tho Birmingham Eye Infirmary, has hit upon an operation by whieh th« f 
focal range of short-sighted persons, whose comeae are not conical, may be 
doubled in length. Ho has found the plan equally auocefisfu!, whether the 
eyes are prominent or smalls the aqueous chambers deep or shallow. He 
has tested the operation on ouBes varying from the age of 12 to 45 years*.! 
A man of the latter age, who had worn double concave glasses of immcnsftt 
depth (No, l(j) for a great number of years, and, unaided by lenses, could I 
see with elearne^d the features of a person to know them at a distanoe of J 
nine feet only, obtained at once by the operation an increase of seven feet in J 
his fooal range. In a child of 12 years of age, the operation increased tkftl 
reading distauce from four to eight inches, and the power of identifying i 
persons' features from twenty to forty yards ; and in one of ItJ years, tbe ] 
effect was still more remarkable, I 

These results have been obtained by dividing in a trtmsvtrst dlrectioiil 
0oni6 fibres of tho muscle of the leai^— the ciliary muscle, Mr, Solomon I 
does not consider it material which part of the muscle is selected for divU I 
sion, hut generally prefers either the upper or the lower part of tho circle. 
Supposing the latter situation to be selected, and tbe patient to be seated in 
a chair, the operator stands behind, and fixes the globe with the left fingers, 
as in extraction^ holding a catiiraot* knife in his right band; with tho flat of 
lh& bJade directed upK^ardsy he pushes the point in succession through the 
eorneo-^^cIerotiG union » the pilhvis of the iris, and the ciliury muscle.. The] 
direction givGu to the iu strumeut ia obVu^uoV^ ioi«ii^^t»S^ ^sA outwards. 



SQBGEBY. 

Care is takoa lb at the inciaion in the muaole is of the game leTiglh as thf^ 
puDOture of ODtraoee ; namely, about two or two lines and a-hali in diame- 
ter. In some ca»ea, Mr. Solomon had found that the power of adapting the 
eye to distant objects has been increased by practice and lapse of time. 

In a yoang mau who had been myopic from his childbood, and had •nffered 
for the last three years from coDgestion of the retina, the visual power and 
focus hare been so much increased that the outline of large buildings at a 
distance of a mile and a half can now (six weeks after operation) be dis- 
tioctlx made out ; wliereas, before the ciliary muscles were divided, they ap* 
p eared at tnisL— British Medical Joumalf May 26^ 1 300, p^ 393, 



92. — Eheutnatic Ophthalmia trealtd by the Galvanic CurrenL By Hahhy 
LoBB, Esq., M*R,C.S.— B, J. had suffered more than fifteen years from re- 
peated attacks of rheumatic ophthulmlat through which the pupil of one eye 
had become permanently contractcdi and the sight of the other much in- 
jured* Being warned that a repetition of these attacks would be followed 
by total loss of sight, he was led to constider whether some means of preven- 
tion hitherto untried might not oxiit. He had found by experience that gal- 
vanism applied to the limbs removed rhenmotio pains ; he therefore thought 
that a modified current applied to the eye at the commencement of an attaok 
might prevent its occurrence, and if applied for a sufficient length of time 
the eure might be permanent* 

On the approach of the nQxt attack, he accordingly applied an excited 
thirty *Bix link Pulvermacher chain, the posUive pole upon the spinet the nega- 
tive upon the closed eyelid, upon retiring to rest. This was allowed to re- 
main on during the night. In the morning, every trace of the disorder had 
vanished. 

Other attacks followed at gradually increasing intervals of time, but they 
were invariably arrested by the same mennsi the consequence being that, 
daring the last five years R. J., has found that his eyes have been gainiug 
Btrength, enjoying the umoterruptcd use of his sight during the whole time. 

The above case, communicated by the patient himgelf, requires no com- 
ment from me, as it is related in so plain and straightforward a manner. At 
the same time I may corroborate it by stating, that in all cases of ophthal- 
mia for which I have used the continuous galvanic current a rapid oure has 
been effected.— Lanccf, SepL 1, 1860, p, 210, 



93. — A Simple M(}de of treating a frequent forui of Entropion. By M, 
SiCHEL. — There are varieties of this affection wliloh only yield to appropri- 
ate operative procedures, but there is one form which almost always pre- 
cedes the others, and which can be relieved in the great majority of cases 
by very simple means. It is well known that in ophthahnia accompanied by 
violent photophobia, and by great distension of the vessels of the conjunc- 
tiva, the patients insensibly accmire the habit, especially when the intlam- 
mation has become chronic, or strongly contracting the eyelids, with the 
double aim of excluding the rays of light and of expelling the foreign bod- 
ies which, from tbeir sensalionsi they believe to be present at the front of 
the eye. ^Thb constant contraction of the orbicularis at last inverts the free 
edge of the lower eyelid, the very narrow tarsus of which yields more 
teadily to the blepharospasm than that of the upper eyelid, which has a 
more considerable vertical diameter. After a while the cart Huge of the 
lower lid can no longer resist this incessaut action^ and it undergoes an in- 
curvation which becomes more and more considerable, until at last com- 
plete inversion is produced. When the affection baa attained this degree, 
the means now to be mentioned are usually of no avail. 

The entropion is confined in most cases to the \owet e^eW^. \V\*xevq«\ 
^tqnen^jr ^ u^er chrome ophthalmifi &nd the operalloTiiQT (iB.Va.tft,^V, ^Ua^ 



2S8 SURGERY. 

the patient, either from indispoBition to open them or firom exoessive sensi- 
bility of the retina, keeps the eyelids too long closed. In this variety of 
entropion termed spastic, the advice is usually given to practise frequent 
tractions on the lower eyelid, or to keep it everted on the cheek by means of 
adhesive strips. In the author's hands these means, powerless against the 
permanent contraction of the orbicularis, have always failed, while a very 
simple manceuvre has generally succeeded. In the place of producing com- 

Slete abduction and depression of the eyelid, it should be only moderately 
epressed, and stretched vertically by means of the index and medius fing- 
ers, so as to sensibly separate it from the anterior surface of the eye. The 
pulp of one of the fingers is next applied above the inferior edge of the or- 
bit, upon the adherent part of the eyelid, and gently carried from before 
backwards into the anterior portion of the cavity, until the free edge of the 
eyelid is strongly everted. The pressure must be made very gently, the 
finger slicing along the anterior portion of the floor of the orbit without 
compressing or irritating the globe. This simple manoeuvre, repeated every 
quarter of an hour or onener by the patient himself, leads to the re-estab* 
ushment of the eyelid in its normal position. The same procedure, with some 
modification, may bo advantageously employed for the treatment of entro- 
pion of the upper eyelid — an affection which, indeed, is much moro rare, 
and infinitely more difficult to cure. — British and Foreign MedicthCMrurgi' 
eal Review, Oct, 1860, p. 544. 



MIDWIFERY, 

AND THE DISEASES OF WOMEK, ETC. 



94,— NEW PATTERN FOR THE OBSTETRICAL FORCEPS. 

By Dt* SmrEL T, Kif iqbt, BalUucie, 

[Dr# Smcflllo^s short forceps haye been in common use in Americn and 
England for nmnj ye are, modified by Yarious pracUt loners, Dr, Davis 'a 
forceps nre notliing more tban one of these modificntifin&* Dr, Knight'i! 
forceps havo a Ins^er pelvio curve, Imre no fenestra, have Finnller blndesi 
taper more gradimlly from the hnntllew to the blades, and the blados ore more 
convex, especially near tbdr terniinwtion ; and, fin ally ^ the bk*les m'e more 
narrow, rendering their introduction simpler. All these seem to ns to be 
great advantag^es. We consider that tlio flireeps, if made to be introduec^d 
more easily , etipecinlly the upper blade, and If made to fit the head better, 
might be mucli more frequently used* These forceps of Dr* Knight's are 
the best kind we hare seen engraved, and wo only wish he had sent ue a pair 
from America, that we might have shown them to our fr&enda*] 

The objections to Davis' or Hodge^s forceps (as they are variously termed ) 
offered for sale by tho instrument makerSf and the only ones now kept us 
0tc>ckon hand by them^ are — lat. The pelvic curveiflgTeaterthenneeesgary, 
according to the laws of mechanics. 2d, The suddenness of tho curve, with 
the fenestra beyond, demands too great an amount of metal at tho point of 
curvature. This is the precise spot where the greatest volume of the head 
is brought in contact with tho perineum, when these in^^truments are used in 
eitractingt and by this abrupt tension endangers, one might almost say in* 
sureis, in unskillful hands, the rupture of this part* 3rd* Tho large size of 
the fenestra allows too free a protrusion of the ftetal cranium through them* 
By this bulging of the cranium, the bi parietal diameter of the fietal head U 
but bttle reduced* 4th, The fenestra increases the breadth of the blades 
more than in convenient or necessary, particularly in many palkological 
eonditioos for which the forceps are especially appUcaUe, 

Those who have constructed the forceps, by taking a cast of the curve of 
the bones of the pelvis denuded of the soft parts, have seized a physiological, 
but not a pathological, idea. The diiference of the aiis of the outlets of the 
recent and of tbeoony pelvis is known to all obstetrical students. Nothing 
can be more false, therefore, than to adapt the pelvic curve of the forceps to 
the nxis of the cavity of the bony pelvis and its outlet. The position of the 
patient during the operation must also be taken into consideration* Were 
it required to operate whilst the patient was in horizontal position, stretched 
upon tlie plane of a bed, the pelvio curvature of tho forceps would have to 
be increased. But, in the proper position for the ap pile at ion* the depres- 
sion of the handles of the instrument easily compensates for the curve in the 
blades* It munt be granted that the straighter tlie blades* tho greater the 
mechanical advantage and the increased certainty of action. This is partic* 
nlarly manifest at the point of outlet over the perineum* When the curva- 
ture of the blades is great and sudden, a sufficient elevation of the handles 
cannot be obtained Tby the operator with proper mechanical effect. The 
danger to the perineum, from tho cun^ature of the blades and their sndden 
springing from the handle;*, is not the only objection to the physiological 
forceps of the learned Professor of the University of Pennsylvatiltv^ 'tW 
fenestra are not only usele^^s, but injurious. They 'weviVfeu ^w X^iati^s^ "Bticv^ 
render them more UkcJy to slip^ &n6, when tbey a\i"p^ tVi^y Usttx ^i^^TWVk'COL^^a 





the foetal icalp, Moreov^eTi the protrasion of the soft parta through them 
increases the res [Stance more than the polished metallic sarfaces of the plain 
hlades* When the forceps Tvith plain blades, according to the measure- 
ments given, are properlj applied, it is impossible for them to slip. They 
grasp the head neourately, and the strength of the bladeu makes good their 
position. The proper force to be used is, therefore, more easily estimated 
by and la entirely under the control of the operator. The fenestra weaken 
the blades, rendermg them, to a certain degree, flexible and elastic, often- 
times yielding before a reaistance, both justifiable and oecosiary to accom- 
pli»h the end in view* 

The breadth of the blade of the plain forceps and tHo moulded con veil ty 
of ihelr interior face, which adapt them accurately to the arch of the orflnium» 
eatireij preYenin auj cutting or muUlating tif 1ii& te\aV wi^l^^ In no ©per'- 



MTDWTFERT. 



231 



ntion, irhen thpj bare been usedi has the print of their npplicaHift kfiii left* 
In the gradual taper from the handles to the blades, they sppiVMil more 
tiaarly to Dr. SmeSUe^s forcepai and at this point give a deeided adrantiige» 



MeasuTements &f Hodge^$ Forcep^^ 

Weight, iTb. I ttt 

Trom ju^tht ta end uf handli^^ fl'B. 

Length of prA>|ML>r briule^dlrectUnet^' 

Breftiltli ti/r»U«le at brondeat i^irt* LS» 

Pifrpendir.tilar *!]evn,ti*m i>r [joints orbbid^^s where 
tbv imsitumeat \a EuLd on a horizon tjil siirEiicu^ 
U8-4h, whiob IndicatcfitLcdogred gf curvature 
ortho bkd«j. 

BmdUi oTfoneatr^L, 14' 



Measurement &f Knig^Wx Forceps* 

Whole If nsttb, HI luoJic*. 

Woight, 16 OK. 

FrotD joint tn end of Imndle^ 6| In. 

Length orpitrnDo] ehank^^. 

Length iif projjt^r MruJ**^ diri-ctlljiflt 6. 

Brentltli ofblnde at broadi^it parti 1|. 

Pyrpi^ntitculiitr «lf vntEon of polnlA at bljules wbftre 
lIiu ihatniinent ialjild on a. borlzonlii] Hnribti^^ 
Is SI, which tadlcatea tlic dcgro4) uf curTnture 
of the bladfit* 



" Hnndreds of modificattous*" eajs Cazeaux* " have lieeti propoBed in the 
forcep? Bince the days of Levret and SmolliG, nearly all of which have fallen 
into oblivion. Some of them were quite iugenioaUi but they iraporfactly at- 
tained the end their authors had in view, and otUors were ncarlj deetitate of 
T&lue or utilitj.^^ The present art iota would not have been penned were it 
not for the honest coavietian, obtained by a sad axpertencei that it were bet- 
ter for suffering females that those now in common nse tbrougb*>at tbia 
country should also fail into oUiinon* The partioular faults in their con- 
struction have been pointed out, and it m to remedy tbese that the prei- 
ent instrument is offered. — Maryland and Virginia Medical Journal^ April 
I860, p. 272. 



^ 



95.— THE FORCEPS AND PERFORATOR COMPARED. 

By Dr, CjUlBlxi D^yri) Dom^ Lonth, 

Towards the close of last year an article was oontributj^d by me, and 
printed in the * Medical Times and Cassette,' on the subject of Cross 
Freseutationa, The principal points illustrated in that paper were tbo 
following I — 

1. That in tho event of cross preaentation of an average-sized fcDtm in an 
ayerage-sized female with a normal pnbie, the result to bo anticipated IB rup- 
ture of the uterus and death of the mother by eihaustion. 

2. That laceration of the a tern e may also occur in the coarse of a natural 
labour. 

3. That if the mother be not deformed, and have an averago-sizcd pelvis, 
while on the other band tbe contained foetus is comparatively small, as in 
premature births, or abortions, the mother may be delivered in safety by the 
natural powers. 

4. That podalic version is an efficient means of delivery as far eis the 
life of the mother is concerned, and not necessarily fatal to the life of the 
child. 

3* That the operation should be performed ae ioon aa a tranaverse preaen- 
tation ia diagnosed, and the vaginal and uterine pa^floges permit tbe intro- 
dnction of the hand. 

6* That ia cases of version from all causes at the ninth month, one 
mother in fourteen is lost^ and sixty per cent* of the children still-born. 

It is unnecessary to carry these inferences further ; I Jihall theref ire briefly 
consider the treatment appHcable to another class of difficult labours, which 
farms the Immediate object of this article. 

One of the diseases liable to be developed in the course of protracted par- 
turition is vesico- vaginal fistula. Mr. L B. Brown, who has conducted the 
treatment of twenty-six cases of this disease, and published minute deballm 
th^i^ofi maintains as the result of his eiperience and o\)aorvaX\ciiii^%\.^^^\'CjK>> 
TB^iial £stula had in almoBt every instance beeu con&ec^xL^iit otL '^k^Vi^a^m^ 



I 




pressoro of the child's head cm tho ino therms vagina, and atrofiglj recnmmeDdii 
obslotricirma not to fiit day^ fkitd Digbta with women iu labour* but at odou 
afford to tbe pattent tbo aid ndapttad li> the clrcumstunces of the caae* *^ Dr^ 
Veit *' aliowj^T *' 1- That tho danger fur the child when the birth is completed 
within twelvo hour^, is only hulf @a gnt*l its when the kbf»ur ia |>rotmoi€^lj 
to twenty -four hv>urf!, nnd that furtbL*r protmetitm is hUU more datigorcjus*J 
2* The danger is increased when tho s(.*caiid ^t«ge of liiboiir last* longer tha 
two hem re* 3* Tbe tniile sex ia more endangered tliHU the female-'* Pro4 
tr acted labour may thon not oidy bo the means of Impeding the perfect re 
covory of the molhtr by originating daDgerous complications* hut aLso i 
endangering the life of tbe child* 

iJeUvery by the forci^pB and perforator are long eetaldi^hed obstetridl 
operations. Tho following cases indicalo the principal distinguishing fea*J 
tur<i of these two mt'thods of delivery. The first does not of uecessity de^l 
stroy tbo llfo of tbo child; by the second the life of the child is intcntionaltj"] 
sacrificed- 

Case 1.— In 1852 I was requested to visit a female in lingf^ring labotiri 
ghc mentioned to nie that ghe had been very ill all night. On examination' 
I aacertuiiuMl the pa:<sagt*B to be well diluted* tlie presentation cephalic, and 
tho existencf^ of no impediment from retained urine and fa?ceB. After wajt^| 
ing several bourn to assure myself that the natural powers were acting 
iu efficiently 1 I called on a mediral friend (Dr. Gillespie, Lelth)* to get thvl 
loan of a pair of long forceps, as I had not a proper pair by me* We visited^ 
the patient together^ and extracted the child instrumentally* The child waff 
alive* The mother made a good recovery* Low diet, a dose of opium, and a 
general aperient, were all me remedies adopted in the after-treatment of the 
oa«e* 

Cast 2*-^In October, 1854, 1 was requested to attend a patient at her con* 
£nemeiit^ Mrs* C. was a prim a par at about 30 years of age, and resident al J 
St* Mary *fl- place, near mipping* I aat up all night with tbo lady, and 
towards morning, getting weary of the charge, determined to extract by the 
forceps if such could be accomplished. She bad made no progress, and 
there was no difficulty in sati.sfying myself as to all the points of tbe preseu* 
tution* However^ the space left for tlio application of this instrument was 
so slight in consequence of the largo size of the ffx^tal head, and the swollen 
state of the surrounding parts, that tbe blades could not be lutroduced ; I 
determined therefore, to consult with Dr* Lever, of London, before perform- 
ing oraniotomy. It was his opinion that the use of the forceps was imprac- 
tJeable, and perforation imperatively demanded. We accordingly anaesthe- 
tised tho lady, introduced the scissors, broke up the nervous matter of the 
child, and extracted. The mother recovered well with very simplo treat- 
ment. She was put on low diet, took small doses of calomel and antimony, 
one or two aperient senna draughts, and tonics* 

Dr. Lever was of opinion that the child had been dead some days, which 
removed any qualms of conscience that wo might have had, had we been 
breaking up tbe c ere bro- spinal axis of a mature living child* 

In these, as in all other cases, it has been mj custom to apply the binder 
after delivery* It is important always to have the attention directed to the 
Btate of tbe rectum and bladder, as accumulation of urine or faeces retards 

Sarturition, and their removal by the catheter or enema further delivery* 
[o such obfitiicle occurred in these cases. 

The long forceps is now in more frequent use than the short. The instru- 
ment consists of two doubly curved fenestrated blades, variously shaped, and 
oonstruoted according to the taste and judgment of the Practitioner, The 
iieoeasity for their use being determined, the patient is placed on her left 
side at the edge of the bed, the passages lubricated if necesi^ary, and tbe 
forceps warmed and greased. The blade is gently insinuated with »t.s con- 
cavity applied to the convexity of the child's head, tbo upper or anterior 
blade being applied firstt then the inferior blade* If the forceps do not 
/oct, n blade must he withdrawn and re-applied so that this object is at- 
tulned- 



1 



MIDWIFERY. 



2m 



ureupi ara efficneioua partially bj compressing the foetal beaJ^ but 
more particularly by a kiod uf utidulatory Iractioti wbicli the operdtor shuuld 
BX^tt in Ibe direction of tbo uxla of the pelvis during uterine aotioiit or if 
this be waittiugt at int^rvak^ In using mucb force as ia needful to chaoge 
thD poi^itioti of the head^ groat care h reijuisite to iirdd Injuring tliu aoft 
parts of tbe mother, or lacerating the perineump 

The instruments required lor ujo pttrformanco of craniotomy aro a pair of 
■oissors with eho older -straps, a crotchety and a pair of boue forceps. Be- 
sidoe th©i=e there nre many other weapionstliat aro found of service in partic- 
ular cfis^os. The flci«?8orfl or perforator have sharp outer margins* Either 
should by introduced by the right handi the left hand being usjed a^ a guide 
and guard, through a parietnl booe and not through a suture, pushed into thy 
^kull and moved about in such a way as completely to break up the brain 
and medulla oblongata. The force should be applied at right angles to the 
parietal bone, to preveut the instrument slipping and tearing up the scalp or 
doing other injury* The crotchet is then used to complete the operation. 
It may be u.se<i to tear up the bruin a& well ns to extract. It can be fixed 
on the parietftli^one, nn the occipital, or on the foramen ovale. Before using 
strong extraction force with the crotchet the firmness of the hold should be 
_ited. The craniotumy furceps become UHefuUn many instances us a meani 
f^^#- Applying traction to the child. It is a rule ojdy to work during ih# 
pains, 

Bucb are the formidable initriiments that were required in the treatmeBt of 
the two cases detailedi We come neatt to consider what are the cases in 
which the forceps should be applied, and what are those suitable for the per- 
forator. Dr. Davis used the forceps six times among 7302 deliveries i 

L Three were uncomplicated head cases* 
2. Tvvo were firat children in twin cases. 
S. One was puerperal convulsions- 

Dr, Ilicketi of Nassau, mentions the indications for the use of the forceps 
in a large number of instances which, tabulated, giva the following resslta ;— 

1. Disproportion between child's head and mother's pelvis , 287 

2. Feebkness and absence of pains ♦ . * . 260 
* 3, Weakness, exhaustion, and illness of the mother (hernia, 

phthisis, &c.) ♦,,,.- tV-l 

4, Prolapsus of the nmbilica! cord with the head - - ^ 

5. Spasmodic and pre te ma tu rally painful pains . * *22 
6* Face prosentationn . . . * , 2f> 
7* Ecclampsia and cftnvulsions , » . * \2 

8. Prolapsus of smaller parts of child wjth head , • 8 

9. Placenta Pr.'jyvia, 3; other hemtirrhagofl, 7 ; total * 10 

10. Oblique presentation of the head , . * .7 

11. Rigidity of the structure in elderly first- bearing women 4 

12. Great swelling of soft parts * , . .4 

13. Erysipelas pudendorum . . * , * 7 

14. Putrescence and consequent unusunl oentractillty of uterus 1 

713 



Dr. Davis performed crojiiotomy nine times among 7302 deliveries t 

I, In consequence of deficient pelvic space » • 3 times. 
2* ,1 I, pelvic contraction caused by hip- 
Joint disease * . ^ - - 1 
B* It It carcinoma uteri . . * 1 

4. ,t „ patient aged 14 i years . . 1 

5. ,« „ face directed to pelvic . . \ 

6. tt ft tiglditf of ofl uteri » \ 



MIDWTFEET. 



Tli<* pre ceding data iodtoate that defieieat pelvic space is one cnmmonM 
condition ri?quiring opertttjvo procedure ; in what cases, then, of pelvio ooart^ 
traction tnny the forceps be applied with siiecesst and in what must the [ 
f orator be resorted t(> ? It is difBcult to como to a definito couclusiott 
this pointf a8 each cnse requires to be considered indlriduallv'. In the In-'] 
Stance dctaltcd, craniotomy was performed ia conseqiience of disproportloii 1 
between the child's head and the pelvis, attended bj comparatire feebtenesi,! 
of the pains. In many oases, however, requiring this operation, or the lea 
BeriouB one, the forceps, the pelvis is distorted, as well as of an unequal] 
size. Although it 19 impossible to lay down rules applicable to every indi* 1 
Tidual instance, we can comi^ to conclusions, which admit of general appli«*l 
cation. Tho conjugate diameter of the normal pelvis varies from four inches I 
at the brim, to four and a-half inches at ttie outlet. Dr. Simpson, of Edin« j 
burgh, used to lay down the following rules that the forceps could be applied 
if the conjugate diameter was; three and a-quarter inches, and that etnbryul-* 
sio was to be adopted when tho conjugate varied from one and three-qu 
inohos to three auil a^uarter inches. 

We come next to in<|uire what is the frequency of these operations com^ I 
paredwith other obstetric operations, and with midwifery practico jn general | 
and what is the mortality attending the operations. The results of the sta- 
tistics of different authorfi are mora various than is desirable, and are exhib- 
ited by the following figurea ; 

LfiboursL 
Dublin, . , ..Harke, ,10,199 

„ ... CoHins.,.,.. 16,654 
Parte. ..... Baudelocque, 1 7,38B 

„ ...... Lachspelle.. 32.2'I3 

Eoivin,.. ...20,517 

Vienna , , ♦ .Bon. * , 9689 

Heidelberg . Nsegele H 11 

Berlin Kluge 1111 

Dresden Csnia ,,,,,. 2549 

Berlin Sieboid 209:i 

London . . . .Dtvia TMy2 

ITaisau Bicker . , . .304,150 

The following ilgures give more minute particulars with reference to the 
frequency of these two operations in British Midwifery — 





Propor- 


Crani- 


Proper- 


Forceps 


tion, 


otomy, 


tioQ. 


U 


lin 728 


49 


1 in 24« 


27 


617 


iia 


141 


31 


Titil 


e 


239S 


U 


2S3 


13 


1854 


96 


214 


16 


1282 


35 


274 


13 


737 


65 


31 


1 


1711 


6B 


16 


6 


185 


IM 


14 





283 


300 


7 


1 


2093 


G 


1217 


9 


811 


4223 


72 


165 


1S43 



Simpson I Forceps in 472 casea. 

Lover ...... 1 j, 618 „ 

ChurciiUI 1 ,, B46 ,, 

Karaabothara... .1 ^^ 611 „ 

Collins 1 ,, 617 ,, 



1 Graniotomj in 1417 

1 „ m 

1 ,, Ut 

1 ,, 805 



t** 






It may therefore be with safety inferred that in British Midwifery foreepi 
cases occur once in 550 births^ and craniotomy once in 530 births. 

With regard to the mortality attending forceps cases, Dr. Kicker men* i 
tions that out of 4223 instances 93 women died either during, or soon aftetf J 
the operation, and 684 children were still-b^m. Hence 1 woman out of 48}, 
deliveries by the forceps died, and 1 child out of G^il* 

Dr. Rioker also states the results attending the breaking up of tte ffBtuSt ' 
which may be arranged under two divisions ;^— 

Nci Proportion. Lived. Died, i^o InFonnation. 

Perforation 143 lin 2196 88 35 20 

Embryotomy 22 1,3825 10 6 

In the course of the preceding remarks have been CDnaidercd— 1 . The 

mode of using^ the forceps ; S. The method of practtaing craniotomy ; 3. 

The circumstanees demanding the performance of these two operations ; 4, 

The diameter of the pelvis that ftdmits of the use of the forceps or tbe per- 

^rmaiice of craniotomy \ 5. Tlie coin]^&t&\At^ ^^^ency of the two opem- 



MIDWIFEEY, 

Ixtms ; 6« The success attending each. The tnve^tgatloft mt^ht bo profile- 
bly carried to a muoh grcator length « but the object of thia paper has been 
rather to associate this atatij^tical iuqalry with actual casog* thau enter iulo 
minute dctaiU,^Mtd, Times and Gazette, Jul^ 28, 1860* p. 74* 



96.— ON A NEW METHOD OP VERSION IN ABNORMAL LA- 

BOUR- 

1 Wjiveral coutineutaL writers have meutioaod the possibility- of version by 
|<I^P^mal manipulation, — as Wigand, Mattei, and HtoU; and MartlUt of Jena^ 
P llii related many cQeee in which htj was euccesssful in turnini^ by external 
ni»fnpul«.tion. All these writers have need external manipulntiou only,^ 

Before I had read their plans of operating, I had already employed a 
me^ihcHlf combining the power possessed by external manipulation with the 
power and certainty derived fi*oni prosBnre and touch through the cervix, 
and whicht even since the perusal of them, appears to me more satisfactory, 
und more eaBilj managed by those who have not given ^ nor are able to give, 
to the external dia^osis of foetal position such care and skill aa Prof. Carl 
Kstorle ; for even Martin, of Jena, insists that by hi» plan it is necoftsary — 
1st, that immediato delivery be not called for ; 2nd, that there be a capacious 
pelvis; 3rd, that there be active pains; 4tb, that the child bo living. From 
the following remarks and illustrative cases, I think I shall show suflimently 
tbftt the mclbod [ have employed does not require such conditions. Accept- 
ing^ then, the valuable fact, that tbe f^tus lU ntero eau be turned without 
tbe neoeasity of the entry of the baud into the utcru-f, I ihall now prove tbft 
exteniive applicabiUty of the plan I have adopted to labour in \U variouB 
oonipUcations^ 

I do not consider it needful to stop here to prove the major proposition, 
because it will be immediately acknowledged, after a few trial* on tlie plan 
described below* The pointi to which I wish therefore to draw the attt^ntbn 
of the profossiuti are — Ist, the moat certatn method of operating; Sadly, 
the general reasons of its superiority to other methods ; and tirdly, the casci 
to wbich it is moro particularly, and also exclusively, adapted. 

In considering the first point — viz., the most certain method of operating, 
it will be neeessaiy to reflect upon the principal facts m regard to version, 
Otie of the most important, and one which more particularly bears upon the 
method presently to be alluded to, is, that if we place hy any means iu our 
power the foetus in utero in a transverse direction and abdomen downwards, 
the knees of the fiBtus are opposite the os uteri : and if the os Is largo 
enough to introduce a finger, tho knee can be hooked down and the pvesenta- 
tioa secured. Thus it is evident that it is merely necessary for the fcetua 
to assumo the above position, where delivery by knee or foot is sought for, 
or where wo wish that tbe delivery may be at oar command. I shall defer 
alltiding to version of cephalio into pure breech presentation till I speak of 
the metnod of operation, 

Tho next fact to he borne in mind is that, should tho foetus, el thernaturallj 
or by tho method to bo described, present by it« back to tho os uteri, tho 
case would be very rare in which one side or the other was not the more do- 
pendent, and consequently one or tho other knee bo within finger-reach of 
the os« 

The third fact needful to reflect upon is this, that the shape of the cavity 
of the fully -dovelopod uterus being oval, with tbe lon^axis placed vertically, 
the tendency of the slight pains towards the end of pregnancy is to place 
the longer axis of the fmtus in a corresponding direction ; or, in other terms, 
to cause it to present by the head or breech ; fto that if the Cait\x^ W ^V ft.ti^ 
time situated transversely, a slight preponderance of foTC<s m e\l\\«it Stvt^^- 
Itou will be mBcmnt to detennine the ultimate ptf^iieBtatW^. \V ^''s^ ^^^ 




L 



MJDWIFEEY. 

thug perceived that, the lipad boing heaTier than the pelvic oitTcmity, th© 
uaturtil tetideiicj of a spontaneoui recti6catjoa will ho to head prcsontation ; 
hut tit the same time it would have taken hut little farce to have cauatid it to 
rise to the fundus. 

JBatio^ premised the^e consideration?, we will di shells s the other facts as 

^ttn&f ftttse in the application of the above principles, taking for granted thut 

It is admitted pnssihle to turn the fcetus m tjttro from the outside. The 

method I have found BuccegsfuK and very oniiy of applicatioiit is conducted 

: — ^Wo will suppoie the eimplest coudilioii, a case where the uterus ifi 

>e» meinbmnes unbroken, Uie liquor aninii plentiful, the os uteri ex* 

1 lufficiently to detect the pre mentation, which is cephalict and in Ute 

tliV fourth poaition (occiput to left side); the patient is in the ordinarj 

pdtitfoti, the trunk curved forwards aa much as possihle* to relax the ab- 
dominnl muscle?. Introduce the left hand, with the usual precautions, into 
the vaj^inn, so fur as to fairly t<.«uch the foetal head, even fthonld it recede an 
inch* (This generally rcquireH the whole hand.) Having passed one or 
two fingers (if only onOi let it he the middle finger) within the cervix, ati4 
r^fttiiig them on the head, place the right hand on the left aide of the brcecki 
at the fundus nterh Employ gentle pressure and slight impulsive move- I 
tnents on the fundus towards the right side, and simultaneously on the head 
towards the left iliac foSFa. In a very short time it will be found that th« 
head is >rimng and at the same timo the breech is descending. The shoulde 
ifl now felt by the hand in plaoo of the head, it in like manner is pushed i 
the left, ajid at the same time tlio breech is de pre seed to the right iltac foasa. 
The ftrtus is now transverse ; the knee will be opposite the os, and, the 
membranes being ruptured, it can he ^eiced and brought into the vagina. 

Having now the labour at command, the case must be treated according] 
to the circumstances which call for turning. In obedience to the law al>ov« 
stated, when the fcetus is placed transversely, a slight impulse will deter 
mine the final position of the head. When the leg is seized, therefore, it ill 
advisable to place the right hand henenth the head in Its new position on th«| 
left side, and gently press it towards the fundus. The same law renders it 
very easy to convert the cephalic* shoulder, neck, or even natural transversefy 
into a breech case. In either of these conditions it is merely nvomi*urj tdT ' 
pu*h up the head, and, removing the left hand from the vagina without 
bringing down the knee or foot, place it on the breech in the right iliac 
fusj^n, so as to deprpsa it into the cavity of the pelvis. No extni force should 
bo uHcd, for it will be found to obey a v^^ry ** gentle persuasion." Indeed, 
the change is completed somotimes spoutaneiiusly, and the foot is at hand 
before \im ex pec tod* The breech now presenting, it is advisable to retain 
it till labour is fdrly set in, hy a firm bandage placed externally, and, should 
it be required, a pad on either side of the fundus. It should now be treated 
as nn ordinary pelvic presentation. 

We have in the above ease supposed the f<Btus to have been placed with 
the back to the left side (first and fourth positions). Should it, however, b« 
certainly ascertained to be placed in the opposite direction (second and 
thiTd position), the alteration required is to make the pressure and impulses 
in the opposite directions, following the same rules. But suppose the exact 
position cannot be made out r in that ea«^c it should be considered as being 
in the first and fourth, and treated as atiove directed ; and for the following 
reasons: — lat. The foetal head presents in that position (back to left side) in 
from sixty 'five to eighty per cent. \ consequently the practice would be cor- 
rect in that proportion* 2nd. Should the child be turned over on its backf 
one aide is almost certain to be the most dependent \ consequently a knee or 
a foot will bo within a finger's reach. 3rd, tShould the lower li rah s not be 
near, it can he readily converted into a breech case, whereby the breech will 
he close to hand* Suppose, again, the liquor amnii has escaped — although 
it certainly does make the operation more diflicult, stilh as the case to be 
quoted will show, it is easily managed even then, the principal impediment 
being- the activity of the uterus-, should that render it troublesome, suspend 
i£ for the moment^ either by chlorofoTm ot o\AMm, asii 1 believe the esoapa 



of the wnters will be found to be no objection to operation. Wltb respect 
to otber conditions which may retard or interfere with it^ tbey must be 
treatt'd in the ^ame manner and on the same principles us apply to the ordi- 
nary metbod* and require tlio same judgment on tbe part of the operator, 

In considoving» secondly, the general advantages of this o^n^ration over the 
ordinary metbodt I disclaim all intention of un necessarily depreciating an 
exceedingly valuable and ancient operation — nno which has saved niimborleia 
Hve^i and one with which, at present, we cannot dispense. Htilh if it can be 
ehowOi that in a considcrahle number of cases requiring version, the opera- 
tion can be acconiplished as quiokiy^or even more go, without the necejsity 
of introducing the hand into the uterust with the exception of one or two 
fingers passed a little way into tb^^ os, I am suro that such a modification of 
this moro or Iqsb ha^jardous operation will recommend itaelf without any 
panegyric on my part. For in that oaso it will readily be perceived that we 
shall avoid — 

1. The addition of the hand, and perhaps arm, to the uterine content! ; 
and tbe irritation, present and future* caused by it* 

2. Entry of air within the uterine cavity. 

3. Liability to rupture of uterus. 

4. Much of the pain and dirftross felt in tbo ordinary plan. 

5. The removal of the coat, and baring the arm of the operator ; and, as n 
minor consideration, — 

6* The fatigue and pain endured by tbe operators while tbe band is in 
utero. 

I think the remoral of these objections a matter of considerable importance* 
even if option were giv*cn us in all citi^ea ; but more especially so when we 
add to this tbo power the plan I have snggewted gives us — namely ♦ of being 
enabled tn turn under circumstances totally impoBftible by the older method. 
I feel confident tlmt all Impartial practitione^-i will, after a fair tiiah adopt 
it — 'I will not say to the total exclusion of the other* but certainly u[>on 
erer/ possible occasion in preference ; for there is one thing upon which much 
etresH can be laid, which is, that the unsuccessful attempts to accomplish the 
new method, instead of increasing the difficulty of delivery by the older 
plan tends rather tt> muke the latter more easy ; at any rate, the foetus can 
easily be returned to its original position. 

Prof. C. Esterle ha« shown great ikill and patience in endeavoring to de- 
tect during the seventh and eighth months of t»regnancy tbe position of the 
fc£tus, and deserves great pralso fur practically showing tbe possibility of 
version at that time; but as such opportunities are rarely to be found in 
ordinary daily practice, and as it scarcely can be expected his skill and ex- 
perience are to be met with except tn such ftfl devote their time specially to 
that snbjeett — and as, coupled with other reasons, it is a practical fact that 
tbe majority of the mal presentations and eomplications of labour do not come 
to the knowledge of the practitioner till labour has set in, or till, ub in hem- 
orrhage, active interference is necessary. — I think that I am not overrating 
the value of tbe above easily-applied and safe method of version i for the 
finger inside the cervix gives a iure indication as to progress of tbe pres- 
sure on the broi?ch above. 

It may also be noticed as an advatitage that tbe membrane need never 
bo ruptured, as was generally practiced, though not always by the older 
method. 

Tbe third point 1 proposed for consideration was the question — ^To what 
CftseB is the aliove method more peculiarly appUcable, and to what conditions 
is it exclusively so 1 

From the foregoing remarks, it will be readily soon that it can be applied 
at the earliest period a tnal presentation is detectable. As soon a* the finger 
can enter tbe oorvix* so soon can version be performed, converting all forms 
into breech presentations. In malpositions of the head, perhaps it may bo 
found capable of improving its po,^ition without having T^cowt^ft tci CiQTO^\&\j& 
podahc version; in puerperuJ eonruldon.4, dimhn:?hing t\ie gTealx\^Y\\\ ^^^ 
caios from the Addition of the hand to Ih© contents ot t\ke utet\k&\ \tLXi^xtQ^ 



I 




k. 



brimn, when version is decidetl iip«n^ it wHl save the pressure upon th© 
uteri flgninst i\w projecting partH of tlit* brim. To these ptijtitA 1 shnll ^Mtii 
ill a future conmiuniciititJTif aud shall for the proseot confine my s^ elf to the 
advnntngeF this mt^tbod gives us in placenta pravia — at lt*ttst, In every form 
of parjeud insertion. 1 have as jet had no opportunity of teBting its appli- 
cabtlity in absolutely central insertion, and perhaps we can scarcely liope 
for any peculiar advantage in that condition, which become s so formidable if 
the OS continue undikted. Although in moflt writings it li »aid the hemoir- 
bage whicb in these oases has already occurred is gpne rally sufficient to di- 
late the OS, still many will present such a prolonged rigidity of that part, 
that death niay take place before entry of the whole band can i>e effected ; 
and it has so happened that this form liaa in my own experience been by far 
the more frequent. These cases are the more serious oecAUse of the diffi- 
culty of ohtniniug a firm comprcBs on the bleeding part. The contracted cer- 
vix generally has been seen where the hmnorrhuge has begun ^ometimea be- 
fore the full term {at the seventh or eighth month), when tbe lower portion 
of the uterus has not fully expanded. 

Case 1. — Mrs, B., of Walworth, a delicate, feeble woman, the mother of 
six children, about thirty-eight years old, and eight months advanced in 
pregnancy. For the four previous days she bad been losing blood in gushes. 
Her attendant requesting me to see hen 1 found her^ on nij arrival, very 
blancbedi pube thready, very weak, and quick ; voice very feeble ; alto- 
gether in an exceding low state from flooding. The os uteri was about the 
size of a crosim^piece, thickened, irregular, and unyielding; the placenta 
presenting tlire© parts across it ; the membranes not broken ; no pains had 
appeared; foetus alive ; movements feeble and conyulsive ; head presenting. 
Blood was still ooaing. I, therefore, gave her plentifully of spirits and 
water 't and introducing my hand into the vagina, 1 endeavoured to gently 
dilate tbe os. After trying some time, with very little effect, I thought it 
would bo a great advantage If I could tarn without entering the uterus, and 
put in practioe tho method previously described. The bead receded to the 
left side as the breech came down. The shoulders then presented ; but in a 
minute m<ire they followed the head, and then the leg wns easily felt through 
the membranes. Having broken them, I drew the knee into the ragtna, 
and, plugging the os with the leg and breech, and keeping up a slight trac- 
tion, 1 waited to allow rallying further* I aLso gave a dose of secale, with 
Btlmulants, to ensure contraction subsequently* As the os expanded, I gen- 
tly drew down the fcetus, which was fully born (but dead) in about three- 
quarters of an hour* She did not lose half an ounce of blood during the 
whole process, nor during the removal of tbe placenta, whicb was slightly 
attached, but not adherent Had she lost another gush, she must have died 
at the time* However, tbe quantity already lost had been too much ; for, af- 
ter lingering out tbree weeks of extreme exhaustion, she died. 

CflnS^r 2* — Mrs, , of Castle- street. Boroughs aged about thirty-five ; 

thin, hut tide rably healthy ; eight months advanced in her eighth pregnancy. 
During the fortnight previous to my seeing her, she bud lost blood by 
gushes and clots, at no time very severe i and about six hours before thert 
was a small gush, with clots, and at tho same time the liquor amnii escapfH!, 
but no paina followed* I found there was still some bleeding, though not 
extensive, with clots in the vagina. Her appearance had not been affected 
by the loss* The os had been dilated to hnlf tbe full si^e, hut now it was so 
excessively irritable, that upon the slightest touch of the finger it contracted 
BO that only one and at the most two hngers could enter. The placenta was 
stretched two-thirds across it posteriorly. It hero seemed to mo that if the 
leg and breech of tbe foetus could be made to form tbe plug, the patient 
would be secure* Tbe only wsy possible, without much risk, was to en- 
deavour to put in practice the method before described, which was easily 
done, though not quite bo readily as in Case 1, in consequence of the irrita- 
hiiity of t\w cervix; still it was eiFected, notwithstanding tho escape of the 
waterBi wlthoat any tVircc or pain, and uudet circumstances whicb would 
h&re precluded entry of tbe whole kaivi. By Taea-Taa oi V^o ^i^^ra in the 



MIDWIFERY. 



339 



oa» I (Irew down tlio knee into t agin a ; ami Mr* Woodwian i th« senior ob^ 
Btotrle eterk) havings passed a loop of topo through tbo bend of the knee, I 
l^h tho case in bis charge, wlih instrnotioua not to hurry the birth, but to 
keep up gentlo traction^ and to plug tho cervix. In about three hours* the 
OS relaxed and dilated to its full size, when tbe fa>tus was brought down. It 
had apparently been dead for a day or two. Not the slightest drop of blood 
was loi^t during the whole procesH of tu ruing and extraction, and the woman 
recovered without a single bad symptom. 

Case 3.— Mrs, P., a fine, hoalthy person, well made, who had always had 
rapid labourij. At the time I saw her, she wa^ at the full term of her 
seventh pregnancy. Having been seized twice within the prerious month 
with a gush of blood (each time about a half a pint) she was kept quiet* 
Twenty 'four hours before I saw her, she had had the third gushi wluoh had 
continued ever ^ince, I saw more than a pint, and the nurse said ^he had 
lost altogether as much more. At the time of my visit, tlie face was not 
much blanched, nor was the pulse much aHeoted, The os uteri was fully 
dilated, the pla:^enta half-way over it ; uterus perfectly Inactive. The liq- 
uor amnii had eacaped, but tbo foBtal head was high up ; uo violent bleeding, 
but considerable oozing. There can he no doubt that the older method of 
version would have been very practicable. Stilh as every cJrcumstanco was 
favourable, I turned by the method previously recommendedr and found it 
very easily and speedily managed. In about two minutes sooner than I 
expected, the foot wag in my hand, and drawing the leg through and the 
breech to the os uteri, I kept up a gentle traction. No uterine action ensu* 
Jng, seeale was given. In a quarter of an hour pains appeared. Alter the 
breech had passed the corvixt findinc: the funis pulsating, I hastened tho do- 
livery, good pains assisting. The child, although not breathing when born, 
was soon recovered by avti fecial respiration. No hemorrhage appeared dur- 
ing the operation or cic pulsion of the foc^tuSi The placenta not being thrown 
off soon, and a little hemorrhage appearing, it was removed, being rather 
firmly attached. 

Cast 4* — Mrs* C, Borough, aged about twenty *eight, of strong constitu- 
tion p At about three woeks to completion of full terra of her fourth preg* 
■nancy . About three weeks before she had been seized, after a fright, with 
sudden and severe flooding. This passed off till twelve hours before I wo* 
called to her^ when the was taken with a sudden flooding, nearly equal to a 
chamber- vesaelful, accompanied by faintiugi, wh^ch continued during tho 
twelve hours before I saw her, I found her perfectly blanched ; pal;!o very 
feeble ; extremities cold ; could still swallow, and had taken about half a 
pint of brandy. The oa uteri was about the size of a five*fihilling-pieco; the 
placenta protruding, apparently centrally attached, but on carefully eearch- 
iiigl faund a portion of it tlunni?r at the posterior aspect, and, carrying th« 
finger backwards, the membranes were reached, unhroken ; the ht^ad pre- 
itenting. Being anxioua to have command of the labour, with as littb shock 
aj possible to tbe patient in her very low condition, I employed the method 
mentioned above, with so much ease and rapidity that in about one minute 
Uia foot was in the vagina. In this case the membranes were ruptured at 
the beginning of the version ; this, however, made no differenco to the oo- 
oomplishment of it. Continuing to make a plug of the breeeh, I waited till 
the system had rallied by stimulants, and in order to allow the os to expand 
and the pains to come on. In about an hour and a half the pulse improved, 
and two doetjs of secale were given ; about half an hour later, gentle traction 
being employed, the child was b<>m dead. The placenta wan expelled by 
natural efforts. No hemorrhage occurred after I commenoed version. Soil 
recovered satisfactj[>rily. 

Case a* — Mrs, , the mother of eight children, about eight mooihe ad- 
vanced in pregnancy, was taken in tho night — i^even hours hefure I saw her 
— with sudden do4>ding, which was estiiuated at more than two quarts. Four 
hount after she sent for her attendant, who found hjr wiiU Viet ^^Vt^mVaa* 
Gold« bhinched, and lying before the fire- From that time t»v\\ \ la^ ^a.eT ^^ 

' beon Jc^in^ blood by amtmuoatt oozing, consldeT^^ to \ia iL\iOU\W& ^ 



MIDWIFERY. 

pint. On my nrri%'al, I found herblnnclied, polec scurc<Ay perc<*ptiblet toic« 
strong, and cnns^idoraMe musoular power. The os was dilatable, abtmt the 
fiizo of a crown -'piece* but bad not boen so more than on hour. The plaoetita 
came at thrit timt^^ only to the margin. It had before been fett over the os 
in part* Tde liquor am nil had c reaped ; do paine. As the oozing waa still 
Momg on, 1 was aniiouii to secure a plu^. I therefor© directed and assisted 
Mr. Wadkma (the senior obstetric clerk) in perforniing- verskm by the 
method alwvo de scribed, which was done iti a few minuter* The moment the 
hdad rose into the iliac fossa, the ohoulder presented, and then as instantly 
the fcKit was fn the hand of the operator. During this time wo gave largt^ly 
of stimulants f and apparently the patient had still considerable power. By 
the weight of the arm traction was kept up against the cervix^ and In tibout 
half an hour the child was born (but dead), without any hemorrhage at all. 
The uterus contracted well, and the placenta came away n at u rally. Warmth 
and *timu!ants were employed ; but the pulse be^n to flag still more, and 
1^ powers gradually failed, till, about half an hour after, i*ho died, rather 
suddenly. It seems to me that if the version had been performed as soon a» 
the OS wae capable of admitting a ^nger, the draining of blood might posBibly 
have been prevented. The quantity lost at first was not precisely known till 
after death, and, coupled with the muscular power and uterine pain^, there 
did not geem any justification for retarding delivery, as has been rc^com- 
mended in extreme exhauBtion. — Lanc^U Jnlif 14 and 21, 18G0, pp^ 28, 55* 






97.— ON THE OPERATION OF TlTRNrnG IN L.\BOUR 

OBSTRUCTED THROUGH CONTRACTION OF 

THE PELVIC BRIM. 

By Or, KoMWBT Biiiina, F*R-C.P^ PhyiltlaTi to Ibo Royal Maternity Chwity, &e. 

On the 2nd of February » 1853t my agsistanco was required at a protracted 
labour by a midwife of tlie Royal Maternity Charity* The patient, a pluri- 
para, had always had lingering labours, and the last child wa.^ still -bora. 
She was now in labour at term. She had been seen by a surgeon at tea 
p*m* the day before. The head was at that time presenting at the brim, and 
it was reported that she had been in labour some hours without progress. I 
eaw her at three a*m, on the 2nd. The pains had then remitted ^ the patient 
was weak and restless, her pulse Bin all* The head was in the first poj^itioa* 
The sacral promontory projected so as to be easily reached by the tinger.\' 
The antero-posterior diameter was estimated at ■i50^\ The cranial bonea ' 
overlapped consiidenibly at the sagittal and lambdordal sutures, the skull 
being somewhat flattened between promontory and pubes- But still the full 
transverse diamcler of the head had not entered the strait, nor could it do «o 
unless under the influence of considerable additional force. A fair degree 
of uterine contraction now returning. I waited an hour ; when, finding that 
the force required could not bo supplied by the patient, that there was no 
advance, that symptoms of exhaustion were appearing, and being satisfied 
that the forceps would not deliver a living child, I lessened the head and de- 
livered by crotchet. The eittaction was easily accomplished ; for the mo* 
ment the capacity of the head was diminished, strong expubive action set 
in. The placenta was removed in five minutes, and the uterus contracted 
well The patient recovered favourably, 

SSecond Labour. — ^The woman had disregarded my injunction to have 1 about . 
brought on prematurely in the event of another pregnancy, so that on Feb.! 
I5th, 1859, she being in labour at term, my assistance was again required* J 
When I saw her, the os was fully eipaaded, head and foot presenting. At 7 
the patient^s strength was still good, I do tern lined to deliver by tumingwj 
The version was effected under chloroform withont diflSculty, the preaentinM 
leg' being brought down. The head was jammed for twenty minutes in tha'f 
Mm botw^een the promontory of the sacrum and the symphysis : it wa&i 
dntffg'cd thratigh under considcraUc iorte, cb\^t^ti^ m\o \Vi^ oiavity with & 



MIDWIFERY. 241 

sudden slip. Tho child was born asplijxiatod, but in half an hour cried 
loudly. It was not of a large sizo ; tho head was much compressed at the 
sides. Mother and child did well. 

Commentary, — This case gave me both satisfaction and surprise. I little 
expected that a living child would be born after the head had been subjected 
to such great and protracted compression. Had not tho head been of some- 
irkat less than average dimensions, the result would not, I believe, have been 
so favourable. Still in this case, all tho conditions of safety to the mother 
and child could bo secured by bringing on labour at the end of the eighth 
month, and resorting to version should the head not freely enter tho pelvic 
brim. Here were a conjugate diameter of 3'50^\ and a head below the aver- 
age dimensions. In niost instances, the natural forces, if of ordinary 
vigour, might overcome a disproportion of this kind. In this particular 
case the natural forces were iusufliciont, and it became necessary to choose 
between the forceps, turning, and craniotomy. I postponed craniotomy as 
the last resource. It is possible that the forceps might have been success- 
ful; but cases which I snail hereafter relate will show that, except under 
special circumstances, this instrument will not effect delivery obstructed 
through disproportion, with less risk to tho mother or with more safety to 
the child, than can be attained by turning. Tho last operation could place 
the child's head in the most favourable position for entering the contracted 
brim. The hold obtained upon tho legs and trunk would give the obstetri- 
cian a degree of power which neither the natural forces, nor the forceps, 
nor both combined, could supply. The power so obtained, when exerted, 
would equalize the transverse diameter of tho child's head and the conjugate 
diameter of tho pelvis most directly, and with tho least possible violence. 
Brought into the brim base foremost, tlio plastic skull most easily adapts 
itself to the rigid distorted contour. The compressing force, first bearing 
upon the skull in its extremo transverse diamotor, soon lessens this, because^ 
above the promontory and on either side there is no obstacle to the expan- 
sion of the skull. On the other hand, the forceps cannot exert the requisite 
degree of compressing force under equally favourable conditions. The 
oompression cannot be api»lied directly to the transverse diameter of the 
skull ; it must fall either obliquely or in the occipito-frontal diameter. In 
either case, tho compression, by lessening the occipito-frontal diameter, 
must increase tho bulging of the bi-parietal diameter, and bring this — the 
obstructing part — into more violent impaction between the promontory and 
symphysis. The instrument thus adds to the very difficulty which it is 
Boaght to overcome, and calls for a supererogatory increment of forco to 
balance that excess of resistance which it has itself created. 

Turning has this great advantage, that it brings no artificial difficulty to 
enhance that difficulty which already exists. 

The case before us docs not mark the limit of the applicability of turning 
in contracted pelvis. It is true that with a conjugate diameter of 3*50^^ and 
a small head, the passage through the pelvis was not effected without some 
difficulty, and some risk to the child's life. But experience bus proved that 
a living child of full sizo may be extracted through a yet smaller pelvis 
with safety to the mother. We must, therefore, pursue the inquiry, and 
8tudy fresh coses, before we can determine tho limits of the conservative 
application of turning in contracted pelvis. — Lancet, April 21, 1860, p. 39i). 



98." Pregnancy with Duplex Uterus, [In a work lately published by 
Professor Kussmaul, of Heidelberg, a most elaborate array of cases is 
ffiven, iUostrative of pregnancy in the perfectly developed duplex uterus. 
Amongst others occurs the following anecdote.] 

" One of oar most celebrated accoucheurs met with a remarkable case in 
a woman who had a duplex uterus and a double vagina. Bli« OtS^L^^ Vvd^ 
whether she might become married ; and ho gave liei the qAV\c«^ V^idX \1 i^ba 
did so, she ahould only make use of one of her vaginn. In QOMt«ib oi ^asba 
JLLIL-'—lff 



242 lilDWIFERT. 

she was brought to bed of a child. Sed quid Jit ? After three montiis she 
again fell in labour, showing clearly Uiat she had twice conceived, at differ- 
ent times." ** Truly a most remarkable case !" adds old Baldinger. Lob- 
stein states, that he ** delivered a woman of two infants, one a month after 
the other ; and was able to convince himself that she had two uteri, and to 
each a distinct vagina." 

In cases of parturition with such duplex uteri, labour may occasionallj 
be quite natural ; but generally it is the contrary. The malformation of the 
womb and of the vagina, as well as the abnormal shape, size, and axis of 
the uterus, may be assigned as causes which render parturition difficult and 
perilous. Many of the women who have borne children under such circum- 
stances have died during the puerperal stage. — Edin, Med, Journal^ July 
1860, j>. 61. 

99.— PUERPERAL CONVULSIONS SUCESSFULLY TREATED BY 
SUBCUTANEOUS INJECTIONS OP MORPHIA. 

By Professor Boakzoki, of Wartzbarg. 

Since the attention of the medical profession was first directed by Dr. 
Wood, of Edinburgh, and more lately by Hunter and B6hier, to the aiavan- 
tageous effects of subcutaneous injection, especially of narcotics. Professor 
Scanzoni has employed this method with success in numerous cases of neu- 
ralgia, hyperaesthesia, dec, but he attaches especial importance to the fol- 
lowing case of puerperal convulsions, because it seems to prove, in accordance 
with toe views laid down by Hunter, that the subcutaneous application of 
narcotic agents furnishes a means of acting on abnormal irritations of the 
brain with greater rapidity and certainty than the administration of the 
same remedies by the mouth. It will, doubtless, be admitted that opium, and 
its different preparations, deserve the first place in the treatment of pner- 
peral eclampsia. In his own experience, the observation of a large number 
of cases has convinced Professor Scanzoni that a kind of intoxication pro- 
duced by opium leads with more certainty to a favourable termination than 
any other means recommended in this terrible disease. But, unfortunately, 
it is not always possible to administer a sufficient quantity of opium or mor- 
phia; sometimes the comatose condition of the patient, at other times the 
rapid succession of paroxysms, prevents administration by the mouth; and 
opiate enemata are occasionally rejected as soon as they are received. The 
subcutaneous injection, however, supplies the means by which these difficul- 
ties may be overcome, and a sufficient quantity of opium introduced into the 
system to render its effects certain. Numerous experiments have convinced 
the author that, although the effect of this method is not always persistent 
(the neuralgise, for example, are not always cured by it), yet there are con- 
stantly produced, — within a very short time, often a few minutes, after the 
injection, — certain phenomena, which can leave no doubt as to the action of 
the opium upon the brain. Such symptoms are drowsiness, giddiness, head- 
ache, sickness, feeling of constriction in the throat, even vomiting, and de- 
pression; or, if the dose is large, somnolence. These facts, taken along 
with the known effects of the subcutaneous application in delirium tremens, 
mania, chorea, tetanus, &c., induced him to try the same treatment in puer- 
peral convulsions, and with the most satisfactory results. After three injec- 
tions of meconate of morphia there occurred only two attacks in nine hours, 
while previously there had been three attacks in an hour and three-quarters. 
This diminution of the convulsions after the injections is so much tne more 
remarkable, since experience has shown that, as a general rule, the parox- 
ysms become not only more violent, but follow at shorter intervals as the 
labour advances. And although the author docs not imagine that he has 
discovered in the subcutaneous injection an infallible panacea for this dread- 
ful malady, he is of opinion that the following case should induce physicians 
to give this means a trial : — 
Gase. — D.| aged 2L, primipara, ftttong qlu^ toWt&\.^ "wqa brought into the 



MIDWIFERY. 



24a 



IviTig-in ward at & quarter to cig^ht o'clock on the morning of June Sth, 1859. 
Labour httd commonGed in tlie niglit^ and she had been seized with nervont 
jjaroiyams and loss of eonsciousnpBs; no account waa given of the nature of 
the altackfi ; tho patient remetnbRred nothing of what had occurred during 
the night. The whoUi bndy» and uspHOiallj the lower extremities, were 
iematoufi; on the right sklo the tongm* sltowed marka of being bitten by 
f teeth; the utcruB corresponded to the pit c^f the stomach, and seemed 
Iciently coneifitent; sounds of the foetal heart distinct. On estamintition, 
the OS uteri was dilated to the size of a(*i3tpcneet tho hag of waters was partly 
formed, and the head presented : the nrine was very album hiousi and ex- 
hibited under the microscope numerous fibrinous cylindera. At eight o'clock 
the waa seized with a second convulsive attack, which was of a very marked 
oharacter, and histed for some minntes. On recovering oonsciousncsa, ahe 
oouid answer (juestiotis, although slowly. A third attack succeeded at a 
quarter to nine, a fourth at a quarter to ten. a fifth a quarter to twelve, and a 
sixth it five o'clock,- — the last the most violwrtt. After the fourth paroatvsm 
consciousness did not return, and the breathiug became stertorous^ At ten 
o'clock she was bled to about eight ouncest an enema with twenty-five 
drops of laudanum waa given, the body was put Into a warm bath, while 
cold irrigation waa applied to the head. As opium could not be ad- 
ministered internally, a solution of the meconate of morphia was now, at 
three different times injected under the skin, the quantity amijunting in all 
to about 10 grains (75 centigrammes) of opium* The labour advanced 
very slowly i At three o* clock nojtt morning the membranes burst; the os 
' dilated to the sizo of a half-crown ; the head still high up above tho brim ; 
Bounds of tho heart very distinct* After this period tho dilatation went on 
more quickly; at seven o'clock the oa was larger than a crown piece, very 
extenaible and dilatable, the head high up and immovable; complete loss 
of eonsciouHnei^g, profound coma. In these circumstanceSi which left lit* 
tie hope of saving the patient, and in spite of the high nosition of the head and 
the incomplete dHatation of the os uteri, it was decided to employ the forceps. 
Their applicjition was by no means easy, hut the extraction presented no 
difficulty* After a few tractions, a foetus was horn, which breathed feebly at 
first, but soon began to moan vigorously ; the placenta followed* During 
tho operation there was no paroxysm. Some wine and ten drops of tincture 
of amber and muse were now given to the patient, which revived her a little, 
but did not restore consciouaaoss. At eleven o'clock, a seventh attack eame 
on, bat was slight and abort; after which j^ho heoamtt excited, and tried to 
oseape, but towards morning ahe gre%v calm* At nine in the morning she 
could answer questions put with a loud voice* During the whole day she re- 
mained like a drunk peri^ou ; pulse 13B. The muse waa stopped ; nothing 
but lemonade given* Towards evening tho abdomen was aomewhat painful. 
During the night there were several slight attacks of mania ; she constantly 
attempted to escape. In the morning she answered rationally; pulse 103. 
The oedema had dtminlshed, tho abdomen was still tender; there was diffi- 
culty of breathing ; and numerous rales, fine and coarse, in the lungs* Warm 
bath^ lemonade, expectorants, were prescribed. In the evening the patient 
was completely herself again; pulse 133. June 11th and 12th; She slept 
well duriag the iitght, the expectoration becomiug ea^y, and the pain of the 
abdomen relioved by fomentations and poultices: pulse 120; tho urine con- 
tained little albumen, and no fibrinous cylinders. June 13th : Good condi- 
tiou; oedema gone, abdomen soft; some incontinence of urine during the 
night was relieved by leaving in a catheter. All medicines were now sui- 
pended ; the patient was put on good diet ; and ordered to take every morn- 
ing a glass of chalybeate mineral water* On the 17th there was no albumen 
found in tho urine; and on the 2lst the patient left the hospital with her 
child, being advised to continue the use of steel for a considerable time. — 
Bull Gin. dt* Therap.—Edin. Msd, JoumaU Maif 1860, p. 1045* 



244 MIDWIFERY. 

100. — Poit-partum Hemorrhage. By P. Hubbert, Esq., Croydon. — Much 
has been written on kneading, plugging, emetics, ice, &c., none of which 1 
think can be fully relied upon, but 1 have always succeeded by tiie simple 
plan of injecting about half a pint of very cold water (iced if you can get it) 
into the rectum, giving at the same time cold brandy -and- water, with a 
drachm of Curtis's liq. sccalis cornuti in it. There is less difficulty in this 
operation than in injecting the uterus, which I imagine, when attempted, is 
not always done. The application of the infant to the breast frequently 
fails to produce the desired contraction. I invariably caiTy in my midwifery 
case a small elastic enema instrument. — Lancet, Sept. 8, 1860, p. 250. 



101.— ON THE DIAGNOSIS OF DROPSY OF THE FALLOPIAN 

TUBE. 

By Dr. J. Y. Simpsoh, F.R.8.E., Prof, of Medldoe and Midwiferj In the Univenlty of .Edlnborgb. 

[The characters by which it can be determined whether a cystic tumour, 
lying in the pelvis, is due to the dilatation of a Fallopian tube, are shortly 
these :] 

First. Its free and independent Mobility. — The tumour is freely moveable 
in the cavity of the pelvis, and does not move synchronously with the uterus ; 
but, on the contrary, it remains at rest when the womb is moved, and can be 
readily moved about by the exploring finger when the womb is kept firmly 
fixed, either by the hand placca above the pubes, or better still, by means of 
the uterine sound introduced into its cavity. 

Secondly. Its elongated Form, — As the fluid collects in and distends the 
tube in nearly all its length, the resulting tumour is of an elongated conical 
form, with the rounded base corresponding to the obliterated fimbriated ex- 
tremity and the apex at the upper angle of the uterus. 

Thirdly. Its wavy Outline. — In all cases the surface of the tumour feels 
more or less undulating and indented, for, in most instances, the distended 
tube is folded once or oftenor on itself, and tortuous ; and when it is not 
thus wavy and convoluted, the smooth outline is interrupted by the pressure 
of bands of plastic fibrine stretching over and indenting it. 

I have also referred to the comparative size of the tumour and its situation 
in the ordinary position of the Fallopian tube as guides — though certainly of 
less value — in enabling you to discover and recognise the disease. If you 
have satisfied yourselves in any case as to the existence of the characteris- 
tics which I have attempted to pourtray, you may proceed at once to con- 
firm your diagnosis of the disease, and initiate your treatment by introduc- 
ing an exploring needle into the interior of the cyst, and examining the fiuid 
that escapes, which, as I have stated, is usually perfectly limpid and clear. 
It is, no doubt, a matter of considerable difficulty to make out clearly in cer- 
tain cases the actual presence of a tumour with all the characters I have de- 
scribed ; and to decide positively that it is a dropsy of the Fallopion tube 
will demand a certain amount of experience on your part, and no small care 
and caution in conducting the examination. But the difficulties of the case 
will be lessened, and the diagnosis will be rendered more certain, if you will 
always take the precaution to investigate the pelvic organs by means of 
both hands simultaneously— one being placed over the fundus uteri, and 
pressing down upon the pelvic organs through the abdominal walls, while 
two fingers of the other hand are passed into the two canals at the outlet of 
the pelvis, for the purpose of examining the state of its contents from below. 
Where the patient has previously had a family, the abdominal walls are soft 
and flabby, so that the pelvic organs can be readily felt through them ; and 
where they are firmer and less yielding, by putting the patient under the in- 
fluence of chloroform they will be so &r relaxed as to enable you to have all 
the parts thoroughly at command. 

Prognosis. — In the great majority of cases the disease has remained un- 
recognized, and unsuspected doling tYie \V{«^m^ ol V)ti^ "^vXXsfiV «xid has only 



MIDWIFERY. "^^^f 245 

been tlisco^cre^ after death when the body waa sulijcctod to a post-mortem 
ciaminatlnn ; and this H more particuhirly the case where tlio cyst i^ not of 
very large size, md ita contents consisst simply of a seruus flaid. But where 
Sflme morliid pn>cess has been going nn in the hiteHor of the cyst, and the 
iiltered nuico us membrane has lieeome the sent of inflammation in its higher 
gmde?:, or vvliere it has hern gnhjeeted to injurytRo tljat the contents become 
mixed up With purulent effusions and bloody extravasations, the ultimate in- 
BU« U apt tn bo lessfuvourable. For in such cases itsomptimes happens that 
the cy?=t-WiiU Ijecomes uh^erated through or hurstB. and the morhid and iiri- 
tatriig fluid escaping into the cavity of the peritoneum Ht^hts up a degree of 
inflammation on its serous Buvface that proves rapidly futuK lu some few 
oases, nf^aiuT the disens^e may be recofrnifted durtu^ Itfe» even when tbo 
cyst is of the simplest kind, init where it h nf sufllcii-'nt si^se to give rise to 
the series of symptoms to which I have alludod* In such ca'^es you may 
succeed in diiigno^ing the disease in the manner I have described to yau, 
and in conducting it to a favouralde tenninntion by an appropriate plan t>f 

TrcM^^n L^MMicfd treatment of any kind seems tt> hn of hut little avail for 
the cure of this kind of mjilady . Tlio only effectual mi^anr* of affording ndtef 
to the patient, and her only hope of n permanent cure^ i?* the removal of the 
fluid by puncturing the cyst. — Med^ Times and Gazelle, July SU 1960| pA*X 



I 



h 



r02.^CASE OF SPONTANEOUS EXPUL=;TON OF A FIBROUS TU- 
MOUU OP THE UTERUS. 

By Lif. JntiiErit G^itrvtrtti SwAt^^R, Phyjl^iliiii-Aoaoiiolioar to tbo Brbtol GenflT&l UoaplUL 

The case I am about to relate is a good instance of the manner in which 
the m$ ffiedisatrix naitirm may sometiiuesT under faTourablo circumstanceft, 
effL-^ct the removal of a tuinuur which is quite beyond the reach of a surgi- 
cal operation. 

A !adj% aged f37t previoaslyin good health, married on August 14th, 1850, 
And on July 22nd, IB5?, miserrmt'd, when about eight weeks pregnant. At 
that time she was staying in Edinburgh, and was under the care of Dr. Dun- 
can. About six wfeeki^ after the miscarriage, she eiperienced considerable 
pain in thft left limc region, accompanied with rigors and feverishness; and, 
on phicmg her hand upon the part, thought that she could detect a slight 
swell log. About ten days after that, she was attacked in tfie night with n 
great deal of hemorrhage from the vafjinn^ and aftervfards with an increaHfl 
of pain in the part affected. The pain ivas more severe at some times than 
at (Others, and nes'er entirely left hen About sii weeks after the hemor- 
rhage, ehe again went to Edinhrirgh, and cimsuUod Dr. Duncan, who ex- 
atnined her, and detected an enlargement on the left side of the uterus, 
Soim afterwards she left Edinburgh and went to Kissingen. She now never 
entirely lost the pain, and always found it increase at the menstrual periods. 
At thi^ time she could herself feel the tumour, especially iu the morning. 
She relumed to England in July 18,58. She was tlien in tolerable health in 
other respectjit but yet was never entirely without pain, and had a return of 
hemorrhage at each menstrual period* In October 1858, she came to Clif- 
ton, and soon after consulted Dr. W. tiudd, who then o:samined her, and 
distioctly felt the uterine tumour. Ho presenbed medicines for her which 
had tho effect of restraining the hemorrhage at each period, until, on Feb- 
ruary 24th, 1859, she menstruated for the last time, and then became preg- 
nant. 

She continued pretty well during her pregnancy, with the ejcception of a 
good deal of sickness, and occasional pains in the left side, especially in 
walJclng, She was not able to dis^tingni^h the tumour after the second month 
of pregnancy* On November 2Gth, 185&, I was sent for to attend her in 
her confinement. The firsL stage of the labour went on favoux^wW^ ^ <A- 
though rather slowly, and oeoupied altogether about foTiy-«i\^VL\\\o^Ts. 'W^i 
first part of the second st&ge was tolerably expedUloua; but lo'wat^* ^^itw^ 



246 MIDWIFERY. 

of this stage, the progress of the head became less rapid, although the p&iDtf 
still continued powerful. At last the head became completely arrested at 
the lower outlet, and remained in that position fur four hours. As the pains 
began to diminish very much in force, I applied the short forceps, and deliv- 
ered her of a fine male infant. The placenta was expelled without anj 
hemorrhage. For the first week after delivery, both mother and child went 
on well. When I called on the eighth day (Sunday December 3d), I found 
my patient feverish, and complaining of headache, which she attributed to 
taking rather too much animal food on the previous day. I prescribed au 
aperient and a less stimulating diet, and called to see her on the following 
Tuesday. She was still rather feverish ; the pulse was 104 ; and she com- 
plained of dull aching pain, with slight tenderness on the left side of the 
abdomen, just above the ilium. I ordered her eight grains of Dover's pow- 
der, and three grains of hydrargyrum cum creta, to be taken at bedtime; to- 
gether with poppy-head fomentations to the abdomen. On the following 
Thursday, the symptoms were much the same ; and she was directed to re- 
peat the powder, and apply bran poultices. As the pain and tenderness 
still continued, I agreed to meet Dr. Budd in consultation on Tuesday* 
Decembor 12th. 

We found her in much the same condition as regards the general S3rmp- 
toms. On examining the abdomen, we felt that the fundus uteri reached 
nearly as high as the umbilicus ; and the uterus itself was as large and hard as 
an uterus just td'ter delivery, before the expulsion of the placenta. The en- 
largement was more perceptible on the left side of the uterus, which was 
also somewhat tender on pressure. We were both of opinion that some un- 
favourable change, such as subacute inflammation and softening, was going 
on in and around the uterine tumour, which had been ascertained to exist be- 
fore the occurrence of pregnancy. She was ordered to repeat the Dover's 
powder and fomentations, and also to use an opiate suppository. On the 
next day, the febrile symptoms and tenderness were somewhat increased. 
When 1 called on Friday, Dec. LOth, the nurse showed me two pieces of 
a fleshy substance, which had passed per vaginam since my last visit ; the 
largest of these pieces was of the size of a hen's Qgg^ and appeared to be 
made up of concentric layers of fibres. On examining it microscopically, I 
found that it consisted of unstriped fibres resembling those of the uterus. 
The expulsion of the substance was attended with a sanguineous discharge, 
like the lochia in appearance, and at first not at all offensive. This con- 
tinued for several days, during which time a great number of smaller pieces 
were expelled, sometimes with distinct pains; the discharge and febrile 
symptoms still continuing. To promote their expulsion, ergot was given 
on each day, together with opiate enemata and suppositories, to relieve pain 
and tenderness. On Monday, December 18th, we found that the portions 
expelled were assuming a darker colour and a putrid appearance ; and the 
discharge was becoming of a reddish-brown hue and very offensive. This 
was accompanied with a short hacking cough and hectic fever, and the pulse 
still kept up to 100 or more ; although in other respects the general condi- 
tion of the patient was not unfavourable. She was put upon a generous 
diet, and ordered to take quinine ; and the nurse was directed to syringe out 
the vagina frequently with chlorinated lotions. During this fortnight, the 
offensive discharge still remained, and broken down shreds and portions of 
tumour were repeatedly coming away. The uterus, which at first could be 
felt nearly as high as the umbilicus, gradually diminished in bulk and sub- 
sided in the abdomen, until, on Monday, December 25th, we could scarcely 
feel the fundus above the pubes. The whole of the tumour appeared by 
this time to have been expelled. On collecting all the portions and putting 
them together, they were found to form a mass about the size of a man's 
fist, and to weigh rather more than half a pound. The treatment adopted 
on December loth, was continued up to ithis time. The discharge now be- 
gan to improve very sensibly, both in quality and quantity, and the hectio 

nrer to diminish ; while at the same time our patient was steadily gaining 

stroDgtb, 



I 

I 




k 



MIDWTFEEY. 247 

On Tuesday, January lOthi I860, tbere vrm a very slJgbt pale miicoufl 
(liBchargc, which was not at all offeDslvo. The uterus was now ao much re- 
duced in bulk tliat It could boI bo felt. There was no figror; the puUe wa^ 
c^4 ; and the cough bad almost eutircly ceased. From that period she {^ro* 
gresfied rap[dlv» and in another fortnight had completely recoveri'd. 

Remarks.— lu this case, before the occurrence of pregnancy* the presence 
of a fibrotjs tumour occasioned considerable hemorrhage at each menstrunl 
period, and also a certRUi amount of pain, symptoms which ure commonly 
noticed in connection with these morbid growths. But after the putient be- 
came pregnant, it is surprising how little tJie prooesa of gestation wiis inter- 
fered with. There was a marked improvement of health, and no symptoms 
of the presence of a tumour was observed, except occasional pain in the left 
side after walking. Buring the progress of parturition the tumour gave rise 
to no untoward complicntitin, eicept, perhaps, that it had tho effect of re- 
tard mg the second stage of labour ; but of thl» I am by no means certain* 
After the birth of the child, a fibrouj* tumour is very likely to occasion 
poatpaTinrn hemorrhage, from its ifjCfrfering with the due contraction of tlie 
uterjac fibres ; but in this casii nothiug of tho kind took place. But U la dur- 
ing the changes which take place in the uterus after delivery, that we have 
most reason to dread tho results of a fibrous tumour. As Dr. West romjirk?, 
" it may interfere wiih the process of in vo hit ion of the womb after delivery, 
and may either itself undergo a morbid softening and disintegration, or muy 
he the occasion, either in connection with inflammation of its own suhstanoo 
and of that of the womb, or independently of them, of pcritonitJ3, ulwayi 
dangerous, too often fatoi/* In the case I huvii just described, tho termina- 
tion was much more fortunate* The tumour no doubt was one of thosn 
which are imbedded in the walls, and between the fibres, of the uterus^ with 
which tljoy have a very slight connection. In all probability, it was much 
nearer the mucous tlnm the serous surface of the womb, and thus it was that 
during tho degeneration and absorption of the uterine fibres after didi very, it 
lost it-s connectioDs with tho uterus^ and consequently it J! vitalltyp and this 
gove rise to inflammation and ulceration of the uterine fibrei between itself 
and the mucous surface, until a sutMcii^nt opening having been made, it was 
caftt ofl:" piecemeal into the cavity of the uterus; and thus the natural pro- 
ce^ftea in this instance, instead of being destructive, as they usually are, w