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Clinical Lectures ON CASES OF DIFFICULT DIAGNOSIS.
DECEMBER 6, 1884.
Clinical Lectures ON
CASES OF DIFFICULT DIAGNOSIS. BY SAMUEL FENWICK,
M.D., F.R.C.P.L.,
PHYSICIAN TO THE LONDON HOSPITAL.
PERFORATION OF THE APPENDIX VERMIFORMIS.
WHEN a student first enters on his hospital career he i struck with the vast variety of cases presented to him. Th diseases and their modifications seem to him so innumerable the symptoms of many of them appear so closely to resembl each other, and the distinctions he is taught to regard a important for their discrimination are often in his view SI trifling, that he despairs at ever being able to overcome th, difficulties connected with their diagnosis. Experience however, soon shows him that many of the maladies h encounters are readily recognised, and that the similarity o their symptoms is generally more apparent than real, an4 careful attention to the rules laid down for his guidance will usually enable him to arrive at a tolerably correc opinion as to the nature of most of the ordinary cases pre rented to his notice. But there are some affections tha occur so rarely that only a few instances fall within th4 observation of any practitioner, and they are consequently apt to be overlooked or confounded with other maladies o more frequent occurrence, whilst the rules for their detectiOI and treatment are necessarily vague or imperfect. It il some disorders of this kind that I would from time to time invite you to study with me, examining the symptoms the3 have presented during life, and, in such as have proved fatal the morbid conditions discovered after death. I propose that we should first consider some of the more obscure diseases of the abdominal cavity, inasmuch as, on account of the great number of organs, differing in struc. ture, in size, and in functions, that are enclosed in it, the diagnosis of the more rare maladies is more difficult in this than in the other cavities of the human body; and also because increased certainty of diagnosis is likely to lead to improvements in treatment. The remarkable success that has of late years attended the operation of ovariotomy encourages the belief that if our diagnosis could be made more certain, some of the diseases now rebellious to medicine might be relieved by surgical procedures; for there can be no doubt that many of the operations performed prove unsuccessful not so much from the nature of the malady or from any special liability of the injured structures to secondary inflammation, as from the late period at which they are undertaken. I would first invite your attention to a disease of rare occurrence, which has only of late years attracted the atten. tion of practitioners, and which often presents considerable difficulty in diagnosis-viz., perforation of the vermiform Five cases of this kind have been admitted into the hospital during the past twelve months, and I have selected two that occurred in my wards as illustrations of the symptoms and course usually presented by the malady. CASE I.-A man, seventeen years of age, was admitted under my care on Feb. 14th, 1884, complaining of great pain in the abdomen, accompanied by weakness, to such an extent he was scarcely able to stand. He was very thin, with a face expressive of severe suffering, the eyes were eunken, and the skin remarkably dark around them. He referred the pain chiefly to the epigastric region, although it extended over the entire abdomen, which was tender upon the slightest pressure ; he had frequent vomiting, and the bowels had been constipated during the whole period of his illness. The pulse was 108, very compressible; tongue much furred; respiration 42; temperature 99 8°. The abdomen was greatly distended and tympanitic, but the loins and flanks were not distended, and there were no visible movements of the intestines. The hypogastric region was dull on percussion; over the caeeum the note was less dull, and percussion upon this part gave rise to a gurgling sound. On examination by the rectum a mass could be discovered in front, which was smooth, and gave No. 3197.
appendage.
the impression of its consisting of several coils of intestine united together. He stated that he had always enjoyed good health until nine weeks ago, when he thought he had hurt himself by lifting a heavy roll of paper ; since that time he had lost flesh, but had been free from pain, or any other symptom. Seven days ago he was suddenly attacked with severe pain of the epigastrium shortly after supper, and the pain had continued ever since, in spite of medical treatment. Perforation of the appendix was diagnosed, and he was ordered frequent and full doses of opium. During the next three days he seemed somewhat easier, the vomiting was less frequent, and the abdomen became less distended. The temperature sank on the second day to the normal point, and on the two subsequent days it was 97° and 976°. The physical signs remained unaltered, excepting that there was more fulness over the region of the csecum, but the pulse became gradually more feeble, and he died on the tenth day
of his illness. Post-mortem examination. A considerable quantity of pus escaped when the abdomen was laid open, and the intestines were seen to be everywhere adherent to each other, pus being situated between the adjacent coils. The part where the gurgling had been elicited by percussion was occupied by a fold of small intestine, bent upon itself, filled with air and fluid, and lying upon the csecum, whilst the tumour felt through the rectum proved to consist of some coils of intestine united together and enclosing collections of pus, and adhering by recent lymph to the back of the bladder and the sides of the pelvis. There was also a considerable quantity of free pus in the pelvis. The appendix was extremely congested, the tip being of a purplish colour and much thickened; its sides at the lower third were covered with pus and lymph, and a concretion was felt impacted in its upper third, whilst between this and the tip was an ulcerated opening. The caecum itself was congested, and contained only a few small pieces of faeces and bits of gelatinous-looking matter. CASE 2.-A man, aged fifty, was admitted complaining of pain in the chest and abdomen. He was emaciated, sat upright in bed without any drawing up of the legs, and stated that the pain from which he suffered was not severe; the tongue was furred, there was no vomiting but frequent hiccough, the bowels were greatly relaxed, and he was unable to swallow solid food; the pulse was not much quickened, and his temperature was only 9’7 5°. Although so little complaint was made of pain, the hypogastrium was tender on pressure and slightly swollen, it was comparatively dull on percussion, and percussion over the right iliac fossa elicited a gurgling sound, as of air and fluid. He made no complaint of cough or expectoration, but there was dulness on percussion over the right supra-spinous fossa along with tubular respiration and increased tactile fremitus above and below the right clavicle. He had been a soldier and served in the Crimea and East Indies, and had formerly - suffered from dysentery. Six months ago he first had pains of the chest and abdomen which had been at times so severe that he was unable to follow his employment of a labourer. He could not fix any time when the pain of the abdomen became worse, but five days before his admission he suffered from constant vomiting, which gradually subsided. During his residence in the hospital he never complained of much pain, but suffered greatly from diarrhoea, the bowels being relaxed as often as ten or twelve times in the twenty-four hours. His temperature was below the normal point, excepting on one occasion, when it reached 99°. He gradually died from exhaustion seven days after his admission, the physical signs remaining unaltered. Post-mortem examination.-There was fibroid consolidation at the apex of each lung. On the right side was a cavity, and the middle and lower lobes of each lung contained tubercles; but there were no tubercles on the peritoneum and no ulceration of the small intestines The small intestines were adherent to or the caecum. each other in the hypogastric region, with pus situated between the adjoining coils, whilst a collection of pus presented itself in the pelvis, walled in by recent lymph and coils of intestine adhering to each other. The vermiform appendage was perforated by an ulcer, which communicated with the abscess, but no concretion could be gurgling had been heard on found. Thewaspart where the percussion occupied by a loop of small intestine, situated over the caecum and adherent by recent lymph to the -
adjoining parts. Now, it is scarcely necessary for me to point out to any of you who have attentively listened to the narrative of these
988 remarkably they differ, although in each there I1ypogastrium or in the pelvis ; but when the appendix has vermiform appendage and theIJeen very short, or placed behind the csecum, or the perforaresulting from it. But in the 1tion has taken place near its origin, the structures in or general peritonitis had existed from the first, thearound the iliac fosea will be mainly implicated. Another symptoms by sudden and intense pain,ecircumstance that must tend to determine the position of
two
cases
how
was the same lesion of the same local inflammation former case were ushered in
and constipation ; whilst in the latter the inflam-1the abscess is the formation of adhesions between the mation was confined to the part at which it had commenced; !appendix and some of the neighbouring organs, which is and the pain was never severe. The patient was, in fact, un-irecorded in ten cases out of the ninety-five. The csecum, able to fix the date of the beginning of his illness, and severeImall intestines, the peritoneum, and the bladder were the diarrhoea was the prominent symptom. But what we IHgans to which the appendix was attached, and in some shall hereafter find was of great importance, was that in the iinstances the adhesion had evidently occurred some time first case the disease occurred in a person previously healthy 1before the perforation had taken place. Various cases are on and resulted from the irritation set up by a concretion ;conretrecord ions; where the appendix has been adherent to the inguinal whilst in the second it took place in one who was suffering 4anal, or has formed part of the contents of a hernial sac, from long-standing phthisis. !and the pus has presented itself in the scrotum and been From the fact of five cases of this kind having beenIsuccessfully evacuated. It is evident that an abscess in the peritoneal cavity will admitted into this hospital within the last twelve months, you might infer that perforation of the appendix is by no1usually set up so much constitutional irritation that death means uncommon, but such is certainly not the case. Duringwill ensue before it can be evacuated, but such is not always the last eight years only nine persons have come under my1the case. In one instance at this hospital the pus was own care in whom the lesion was either proved to be presentievacuated through the abdominal walls, and I have seen a by post-mortem examination or in whom the symptoms werevery similar instance in my own practice. When it is so well marked that the diagnosis could be made withisituated near the caecum it may burrow beneath Poupart’s tolerable certainty. Again, in carefully examining the ligament, and may present itself in the thigh, as occurred post-mortem records of the London Hospital during the last in a boy who was under my care in the hospital two years forty years I have only been able to find nineteen in which ago, and who perfectly recovered after pus and fasces had the appendix was in a diseased condition. It is quite certain, been discharged from the wound. Other cases are recorded however, that this number cannot truly represent all whoin which the pus has found its way into the caecum, the have died in the hospital during so long a period of thisileum, or the rectum, and thus relieved the patient from im. disorder, for in the earlier volumes only one or two instances minent danger. But whether this may be the case or no, it is are recorded. Of the whole number I have collected only one is men. evident that the experience of no single practitioner will be tioned in which pus was found in the abdominal veins, one in sufficient to furnish him with instances of all the varieties which abscess of the liver was present, five where pleurisy the malady may present, and I have, therefore, collected and two where pneumonia was discovered after death. It is 129 cases that have been publii-hed by different authors in doubtful whether we should not refer the pleurisy to the the hope that from a careful study of so large a number we extension of the inflammation of the peritoneum through may be able to clear up some of the difficulties connected the diaphragm, but the others were most likely the results with the subject. of the absorption of pus. When we remember how com. Of the whole number of cases collected only ninety-five monly pysemia takes place in cases of deep abscesses of the have been recorded with sufficient details to enable us to limbs, we cannat but be surprised at the small number of ascertain the exact results of the perforation of the appendix, cases recorded as following perforation of the appendix, but and of this number thirty-eight presented a localised collec- the explanation is not difficult. In the limbs large veins tion of pus. Sixteen are said to have had an abscess in the are numerous in the vicinity of an inflamed part; in neighbourhood of the appendix; and in all probability the peritoneal abscess the pus is walled in by adhesions, and the condition was similar to what has been described in the two surfaces of the mesenteric veins are coated with lymph. In like manner we can see why abscess of the liver is so cases before quoted, where one or more coils of the small intestine were united to the surrounding parts and walled in common a result of dysentery, and so unusual in peri. the pus, or where it was situated in the pelvis and was sur- toneal abscess ; in the former the irritating and decomposing rounded by newly formed lymph. In twelve cases the pus contents of the intestine are brought into immediate was situated in the iliac fossa, in some around the caecum, contact with the vessels laid bare by the sloughing of the in others below the fascia, the muscular fibres being softened mucous membrane; in the latter the pus is defended from or broken up. A few instances are recorded in which the immediate contact with the vascular system. But in the more pus had burrowed upwards beneath the peritoneum, and had unusual situations of abscess resulting from perforation of the formed a huge abscess round the right kidney; in six in- appendix, such as where the muscular tissue of the iliac fossa stances the presence of an abscess is noticed, but its locality or of the loins is the seat of the suppuration, we will prois not defined. But the question arises, Why in cases of per- bably find that pyaemia is asapt to occur as when inflammatory foration of the appendix is there this tendency to the inflam- action has arisen from other causes. Although the inflammation of the peritoneum being localised, whilst in perforation mation, as we have before seen, chiefly affects the lower of the stomach or small intestines such a condition so rarely part of the abdominal cavity, fifty-nine cases are recorded occurs ? No doubt the difference depends upon the nature and out of ninety-five in which the whole peritoneal sac was imthe amount of the material that is extravasated into the peri- plicated, and, judging from my own experience, I should toneal cavity. In perforation of the stomach a large quantity be inclined to estimate the proportion still higher. Of of a highly irritating liquid is effused, which quickly finds its course the amount of mischief varies greatly ; in some cases way to all parts of the abdominal cavity, exciting inflamma- the intestines are everywhere adherent, and collections of tion wherever it reaches; whilst in the case of the appendix pus are met with in the most depending parts, or are the material is solid or in small amount, and being in the enclosed between the adjacent coils; in others lymph is most depending part it does not at once reach the more dis- uniformly spread over the surface of the membrane, whilst, tant portions of the peritoneum. We thus find that even more rarely, we only meet with slighter evidences of where no abscess had been produced, it is mentioned that the inflammation. General peritonitis occasionally presents inflammatory products were met with in the greatest quan- itself as the first indication of the perforation ; in other cases tity in the immediate vicinity of the caecum, in the propor. it travels slowly from the neighbourhood of the appendix, tion of twenty-three cases out of ninety-five. It is easy to whilst more rarely it results from the bursting into the understand why only lymph should be found in one case and abdominal cavity of an abscess set up around the appendix, a collection of pus in another, for death probably occurred and which had been circumscribed by adhesions of the so rapidly in the former that there had not been time for the neighbouring structures. But at whatever period of the suppurative process to take place ; but it is more difficult to case the inflammation of the peritoneum may occur it is explain why the abscess should be confined in one individual almost always of a suppurative character, a peculiarity to the pelvis and in another to the iliac fossa. The most which in all probability arises from the decomposing nature probable reason is that as the length and direction of the of the substance which has originated the morbid action. When this accident first attracted the attention of patholo. appendix vary in different subjects, so the seat of the inflammation must vary accordingly, being most intense at gists it was remarked that the appendix often contained a the nearest point to the perforation. When, for example, foreign body, and the idea arose that this was the sole cause the free end bas been the seat of the ulceration and it has of the ulceration. Out of 125 cases which could be examined projected into the pelvis, the abscess will be situated in the as regards this point, in fifty-five it is stated that either
vomiting,
989 a mass of faeces, or some other foreign body7 collected from various authors only twenty-five, or 23 per present, and it is fair to conclude that the numbers would1 cent., were of this sex. The proportion varies with the
concretion,
a was
have been larger if a sufficiently careful search had beeni in them all ; for as the coutents of the appendixc often drop into the pus surrounding the ulceration, it is easy7 to understand that a small concretion may frequently have: been overlooked. The nature of the foreign body has varied, forr in forty-seven cases sufficiently detailed to allow of analysis9 twenty-eight were concretions, fourteen consisted only off hardened fseces, and in five others, substances such as seeds9 But why should a foreign body inI or shell were present. this part set up such serious results, when we know thatb in numerous instances the appendix has been found oni post-mortem examination to be occupied by shots, seeds,, and even, as in a case lately observed in this hospital, by lumbrici, without any apparent ill results; and vk heni we so constantly meet with concretions in the kidneyr and the gall-bladder without any manifestations of disI think int ease having arisen from their presence ? most cases the presence of a concretion by its irritationi gives rise to ulceration, and the proximity of the part to the caecum filled with decomposing materials tends to produce sloughing in what would be otherwise a mere abrasion In support of this view Iof the mucous surface. may mention that in sixteen cases the appendix is stated. to have been in a gangrenous condition, although therei is no notice in any ot them of the caecum being in a similar state. I think, too, we may find in the anatomical relations of the appendix a reason why in somei instances perforation so readily occurs. In Case 1 you will remark that the ulceration had taken place in the centre of, the process, where it was distended by the concretion, but the perforation was at the end. Now, the appendix is supplied with blood by means of a small mesentery of its own, which sometimes terminates before the extremity of the process, so that the end must derive its nutriment from the bloodvessels of the parts nearer to the faecum, and under such conditions any acute ibflammation or ulceration that obstructs the circulation must tend to rapid disorganisation of the structures. That this is by no means an uncommon cause of the perforation is shown by the fact that in the majority of cases the perforation is found at the extremity, and very rarely near to the caecum. Then how are the concretions produced ? It has been generally assumed that they are the result of a secretion of the phosphates of lime and soda, of which they piincipally are composed, by the mucous membrane of the appendix, small nodules of faeces or some undigested particles of food which had obtained access to the part serving as nuclei. This is no doubt correct in many instances, as nuclei of this nature have been shown to exist in some concretions, but in others the calculus appears to be composed solely of earthy salts. Now, in one of the cases at this hospital it is noted that the appendix was distended by a milky fluid, the communication with the caecum being obliterated, and in others recorded by different authors the appendix is stated to have been occupied by a substance resembling putty. Itis,then,to obliterations of the valve, and consequent distension of the appendix with thickened secretions, that I suspect we must look not only for an explanation of the formation of many of the concretions, but also for the cause of some of the ulcerations that occur in which no foreign body can be
practised
,
.
,
.
,
producing the perforation, for in the cases occurring in phthisical individuals 41 per cent. were females, and all of those that took place in the course of typhoid fever whose cause
sexis mentioned were also females. When noforeign.bodywas found in the appendix the proportion of females was 23 per cent., but amongst those in which a concretion or other foreign body was discovered after death there was only 17 It is evident from both sexes being equally per cent. liable in those affected with phthisis that there is no anatomical difference in structure which can account for the smaller proportion of females who suffer from perforation, so that we must seek for an explanation of the above facts in the habits or circumstances of the stronger sex. Now, it has been conjectured that the male is more liable to affections of the appendix on account of the more severe exertions to which he is exposed ; and in support of this we may remark that in the first case the patient stated he had never been well since a strain received in his occupation, whilst other instances are recorded in which the fatal illness had been preceded by an injury to the abdomen. But, on the other hand, the history of an injury is only exceptional, and in the majority of cases the symptoms of the disease present themselves suddenly and without apparent In addition to this, as we sball shortly see, the aceicause. dent occurs more often in the young than in those at a later period of hfe, when severe labour is more generally undertaken. You will remember that I before suggested that many cases arose from obstruction of the valve, probably the result of catarrh ; and this derives support from the fact that males are more liable to catarrhal affections of the csecum. than the opposite sex; for example, the numbers of cases of typhlitis admitted into this hospital for the last seven years have been fifty-nine, of whom only eighteen were females, which is at the rate of 30 per cent. Let us now examine whether we can find any predisposing cause of ulceration of the appendix in the age of the persons affected. I have included all the cases whose ages are stated in the following table :Years of age.
Under 10 10 to 20 20 to 30 30 to 40 Above 40
Number of
cases.
9 29 ............... 211 16 22
...............
...............
...............
...............
Total ............
97
It will be remarked that a considerable number have occurred under ten years of age, and half of these were under five ; indeed, the accident sometimes takes place at the earliest period of life. From ten to twenty is the most usual time, and after thirty the numbers gradually decline. This is better seen if we divide thecases according to the cause producing the ulceration. Thus, if we examine only those in which either a concretion or some other foreign body was discovert d, we find that thirty cases out of fortythree, or 70 per cent., occurred in those under twenty years of age, only four between twenty and thirty, and five between thirty and forty. If we separate those in which concretions were present from those where only particles of hardened fseces or other foreign bodies were discovered, the same liability is shown, as 64 per cent. of the latter and 80 per cent. of the former occurred under twenty years of age. But as we saw in the former table that a considerable number of cases of ulceration of the appendix occurred in persons above twenty, it is chiefly in those above this age in whom no foreign body bas been discovered. In the next table I have included all the cases of typhlitis who have recovered and who were admitted into this hospital in the years before mentioned.
discovered after death. The second case I have narrated was one in which phthisis was present, and no concretion was discovered ; and we might have conjectured that perforation would often occur under such circumstances, on account of the similarity of the stiucture of the mucous membrane of the appendix to that of the caecum, which is liable to suffer irom ulceration in this disorder. It is, however, much more rare for perforation to arise from tubercular ulceration than from the presence of a concretion, as 1 have only met with thirteen cases out of ninety-eight. Occasionally perYears of age. Number of cases. foration occurs in typhoid fever, but I have only found six 5 to 10 2 in which it took place in persons suffering from this disorder. 24 10 to 20 Two cases have been recorded in which it happened during 25 20 to 30 concatescence from other eruptive diseases ; but there is no 2 30 to 40 evidence that there was any connexion between the original 5 40 to 50 malady and the abdominal complication. 1 Above 50 It has been remarked by different writers that perforation of the appendix is much more liable to affect the male than 59 Total............ the other sex, and this is borne out by the experience of this where of seventeen were whose recorded these It will that be on both ulcerahospital, ages only tables, seen, comparing three, or 18 per cent., were females, whilst of 105 cases tion of the appendix and inflammation of the cseeum are ...............
...............
............... ......
,.........
...............
...............
990 most liable to occur between the ages of ten and thirty, when food is consumed in the largest quantity; and we may therefore assume that both affections depend upon a similar condition, and that the retention of indigestible materials in the caecum and the catarrh so produced is the most usual cause. But as typhlitis and ulceration of the appendix are both common between the ages of twenty and thirty, although concretions are less common at that period than in the ten years before it, we are justified in supposing that a catarrhal condition of the caecum, either by producing closure of the valve or by of the inflammation to the appendix, often - propagation gives rise to ulceration, although no foreign body be
of anaesthetising the mucous membrane of the tongue. Prof. Schroff mentioned this fact for the first time in 1862 in a lecture on its nervous effect read before this assembly. It is also well known that cocaine narrows the peripheral arteries when taken internally ; further, we know that cocaine dilates the pupil by means of its local application as well as by its internal use. We therefore see that cocaine has already been applied to the eye, but until now those phenomena have not been observed which I make the object of my discourse to-day. After repeated experiments with its internal use cocaine fell into discredit and disappeared from the scene. Dr. von Anrep in 1880 produced a comprehensive research into cocaine, at the end of which it was present. Most of the cases of ulcerated appendix in phthisical hinted that the local anaesthetising action of cocaine might in subjects occur at a later period of life than when it is due the future become of considerable importance. In Vienna, to the presence of concretions or catarrh, for out of those I especially, cocaine has been brought to the front through have collected only one was below twenty years of age, the interesting therapeutical work of my colleague in the seven were between twenty and forty, and three were above general hospital, Dr. Sigmund Freud. I have started with the premise that a substance which forty. All those connected with hernia were above forty years of age. paralyses the terminal sensory nerves of the mucous I have already mentioned the prevalent idea that the membrane of the tongue would not act very differently on concretions so often found in the appendix are always the those of the cornea and conjunctiva; so I undertook a series result of hardened fseces, or of indigestible materials of the of experiments on animals, which I carried out in the food, and if such were the case we should expect to find that laboratory of Prof. Stricker. My results, in brief, are as most of the sufferers had been liable to constipation. Now, follows :-If a few drops of an aqueous solution of muriate of I have collected forty-three cases in which the previous cocaine2 are dropped upon the cornea of a guinea-pig, a state of health is recorded, and of these only three had been rabbit or a dog, or if the solution is instilled in the usual way subject to a constipated state of the bowels. It is therefore into the conjunctival sac, the animal blinks for a while, evident that this theory derives but little support from clearly as the result of a weak irritation. After a period of facts. I should be more inclined to believe that the con- from thirty seconds to one minute the animal opens its eye, cretions are in most instances the result of an excessive which gradually assumes a peculiar expression of rigidity. secretion of the mucous membrane of the appendix arising If one now touches the cornea of the animal with the head of from the stimulus afforded by an undue use of solid and a pin, being careful not to come in contact with the eyelashes, indigestible food. This view derives support from the fact no reflex closure of the lids occurs, the bulb does not deviate, that of twenty-five cases in which a concretion was discovered and the head is not thrown back, as would otherwise happen. twenty are described as having enjoyed robust health, and On the contrary, the animal remains quiet, and by the three had been delicate; whereas of eight in whom no employment of a stronger irritation we can convince ourconcretion was discovered, only five had been robust and selves that the cornea and conjunctiva are completely three delicate. The presence of a concretion produces no accesthetised. For instance, I have scratched the cornea of pain until catarrh or ulceration is excited, for out of twenty- the animals upon which I experimented with a needle, five cases of concretion only two had previously complained pricked the same, irritated the cornea with an induction of abdominal pain; whilst of eighteen in whom no con- current which was so strong that it produced a painful cretion was recorded five, or 30 per cent., had suffered in sensation in the fingers and was unbearable on the this way. I have before mentioned that injuries to the tongue, and cauterised their cornea with a pencil of abdomen are supposed by some authors to give rise to nitrate of silver until it became as white as milk; ulceration ofthe appendix, and this derives some support all without a single movement on the part of the animals. from the fact that three cases out of eighteen in which no The last two experiments convinced me that the anaesthesia concretion was discovered referred their complaint to blows included the whole substance of the cornea, and not only its or strains. In four instances out of forty-three there was a surface. However, after I had cut into the cornea, the history of a previous attack of typhlitis from which the animals showed decided signs of pain at the moment, when patient had perfectly recovered ; in two of these the patients the aqueous humour gushed out and the iris prolapsed. Even died from peritonitis only, and in the remaining two both in my later experiments on animals I was unable to deterabscess and peritonitis were discovered after death. mine whether the iris also could not be ansesthetised by the of the solution into the corneal wound, or by a instillation be concluded.) (To continued instillation into the conjunctival sac, begun and kept up for some time before the operation; for experiments testing sensibility of animals which are not narcotised are ON THE USE OF COCAINE FOR PRODUCING very difficult, and, especially if they are in the slightest degree complicated, are apt to give equivocal results. I had yet to ANÆSTHESIA ON THE EYE.1 find out experimentally whether cocaine could produce aBsesBY DR. CARL KOLLER. thesia of the inflamed cornea, and this question was answered in the affirmative, when the animals upon which I produced TRANSLATED AND REVISED BY J. N. BLOOM, B.A., M.D. an artificial keratitis, by means of a foreign body, showed the same anaesthesia of the cornea as the healthy ones. ComGENTLEMEN,-I take the liberty of addressing you in plete anaesthesia lasts on the average ten minutes, when a order to inform you about some experiments which I have 2 per cent. solution is used. After such successful experiments I did not hesitate to undertaken in order to produce anaesthesia on the eye. It is not the first communication which I have made on this apply cocaine to the human eye. At first I experimented upon myself and a few colleagues; later, on a large number subject. I have already addressed such a one, in order to of other individuals ; the results of which without exception preserve my priority in this discovery, to the Convention of proved that the cornea and the conjunctiva were thoroughly German Oculists, which, as it annually does, met on the anaesthetised by its use. The sequence of the symptoms 15th and 16th of September in Heidelberg. Dr. Brettauer is as follows :-When a few drops of a 2 per cent. solution of Trieste was kind enough to bring my communication into are introduced into the conjunctival sac, or, better still, if are allowed to run over the cornea, together with an notice and to repeatmy experiments before the Convention, they increased secretion of tears, a slight burning sensation is felt, and since then the same have been repeated and confirmed which disappears after an interval of from thirty seconds to in various other places. a minute, to give way to an obscure feeling of dryness. To It is a well known fact that cocaine,. an alkaloid produced the observer an eye thus treated has a peculiar rigid expresin 1859 by Nieman from the leaves of the erythroxylon 2 A solution of cocaine in water, up to 5 per cent., can be made coca, possesses the peculiar property, by its local application, without the addition of an acid. The solution is always cloudy. The addition of an acid is to be avoided, as even a very small quantity of an 1 A paper read at the meeting of the Vienna Royal Imperial Society of acid causes a very strong burning sensation. When filtered the solution on Oct. becomes as clear as distilled water. Physicians 17th, 1884.
Clinical Lectures ON
CASES OF DIFFICULT DIAGNOSIS. BY SAMUEL FENWICK,
M.D., F.R.C.P.L.,
PHYSICIAN TO THE LONDON HOSPITAL.
PERFORATION OF THE APPENDIX VERMIFORMIS.
WHEN a student first enters on his hospital career he i struck with the vast variety of cases presented to him. Th diseases and their modifications seem to him so innumerable the symptoms of many of them appear so closely to resembl each other, and the distinctions he is taught to regard a important for their discrimination are often in his view SI trifling, that he despairs at ever being able to overcome th, difficulties connected with their diagnosis. Experience however, soon shows him that many of the maladies h encounters are readily recognised, and that the similarity o their symptoms is generally more apparent than real, an4 careful attention to the rules laid down for his guidance will usually enable him to arrive at a tolerably correc opinion as to the nature of most of the ordinary cases pre rented to his notice. But there are some affections tha occur so rarely that only a few instances fall within th4 observation of any practitioner, and they are consequently apt to be overlooked or confounded with other maladies o more frequent occurrence, whilst the rules for their detectiOI and treatment are necessarily vague or imperfect. It il some disorders of this kind that I would from time to time invite you to study with me, examining the symptoms the3 have presented during life, and, in such as have proved fatal the morbid conditions discovered after death. I propose that we should first consider some of the more obscure diseases of the abdominal cavity, inasmuch as, on account of the great number of organs, differing in struc. ture, in size, and in functions, that are enclosed in it, the diagnosis of the more rare maladies is more difficult in this than in the other cavities of the human body; and also because increased certainty of diagnosis is likely to lead to improvements in treatment. The remarkable success that has of late years attended the operation of ovariotomy encourages the belief that if our diagnosis could be made more certain, some of the diseases now rebellious to medicine might be relieved by surgical procedures; for there can be no doubt that many of the operations performed prove unsuccessful not so much from the nature of the malady or from any special liability of the injured structures to secondary inflammation, as from the late period at which they are undertaken. I would first invite your attention to a disease of rare occurrence, which has only of late years attracted the atten. tion of practitioners, and which often presents considerable difficulty in diagnosis-viz., perforation of the vermiform Five cases of this kind have been admitted into the hospital during the past twelve months, and I have selected two that occurred in my wards as illustrations of the symptoms and course usually presented by the malady. CASE I.-A man, seventeen years of age, was admitted under my care on Feb. 14th, 1884, complaining of great pain in the abdomen, accompanied by weakness, to such an extent he was scarcely able to stand. He was very thin, with a face expressive of severe suffering, the eyes were eunken, and the skin remarkably dark around them. He referred the pain chiefly to the epigastric region, although it extended over the entire abdomen, which was tender upon the slightest pressure ; he had frequent vomiting, and the bowels had been constipated during the whole period of his illness. The pulse was 108, very compressible; tongue much furred; respiration 42; temperature 99 8°. The abdomen was greatly distended and tympanitic, but the loins and flanks were not distended, and there were no visible movements of the intestines. The hypogastric region was dull on percussion; over the caeeum the note was less dull, and percussion upon this part gave rise to a gurgling sound. On examination by the rectum a mass could be discovered in front, which was smooth, and gave No. 3197.
appendage.
the impression of its consisting of several coils of intestine united together. He stated that he had always enjoyed good health until nine weeks ago, when he thought he had hurt himself by lifting a heavy roll of paper ; since that time he had lost flesh, but had been free from pain, or any other symptom. Seven days ago he was suddenly attacked with severe pain of the epigastrium shortly after supper, and the pain had continued ever since, in spite of medical treatment. Perforation of the appendix was diagnosed, and he was ordered frequent and full doses of opium. During the next three days he seemed somewhat easier, the vomiting was less frequent, and the abdomen became less distended. The temperature sank on the second day to the normal point, and on the two subsequent days it was 97° and 976°. The physical signs remained unaltered, excepting that there was more fulness over the region of the csecum, but the pulse became gradually more feeble, and he died on the tenth day
of his illness. Post-mortem examination. A considerable quantity of pus escaped when the abdomen was laid open, and the intestines were seen to be everywhere adherent to each other, pus being situated between the adjacent coils. The part where the gurgling had been elicited by percussion was occupied by a fold of small intestine, bent upon itself, filled with air and fluid, and lying upon the csecum, whilst the tumour felt through the rectum proved to consist of some coils of intestine united together and enclosing collections of pus, and adhering by recent lymph to the back of the bladder and the sides of the pelvis. There was also a considerable quantity of free pus in the pelvis. The appendix was extremely congested, the tip being of a purplish colour and much thickened; its sides at the lower third were covered with pus and lymph, and a concretion was felt impacted in its upper third, whilst between this and the tip was an ulcerated opening. The caecum itself was congested, and contained only a few small pieces of faeces and bits of gelatinous-looking matter. CASE 2.-A man, aged fifty, was admitted complaining of pain in the chest and abdomen. He was emaciated, sat upright in bed without any drawing up of the legs, and stated that the pain from which he suffered was not severe; the tongue was furred, there was no vomiting but frequent hiccough, the bowels were greatly relaxed, and he was unable to swallow solid food; the pulse was not much quickened, and his temperature was only 9’7 5°. Although so little complaint was made of pain, the hypogastrium was tender on pressure and slightly swollen, it was comparatively dull on percussion, and percussion over the right iliac fossa elicited a gurgling sound, as of air and fluid. He made no complaint of cough or expectoration, but there was dulness on percussion over the right supra-spinous fossa along with tubular respiration and increased tactile fremitus above and below the right clavicle. He had been a soldier and served in the Crimea and East Indies, and had formerly - suffered from dysentery. Six months ago he first had pains of the chest and abdomen which had been at times so severe that he was unable to follow his employment of a labourer. He could not fix any time when the pain of the abdomen became worse, but five days before his admission he suffered from constant vomiting, which gradually subsided. During his residence in the hospital he never complained of much pain, but suffered greatly from diarrhoea, the bowels being relaxed as often as ten or twelve times in the twenty-four hours. His temperature was below the normal point, excepting on one occasion, when it reached 99°. He gradually died from exhaustion seven days after his admission, the physical signs remaining unaltered. Post-mortem examination.-There was fibroid consolidation at the apex of each lung. On the right side was a cavity, and the middle and lower lobes of each lung contained tubercles; but there were no tubercles on the peritoneum and no ulceration of the small intestines The small intestines were adherent to or the caecum. each other in the hypogastric region, with pus situated between the adjoining coils, whilst a collection of pus presented itself in the pelvis, walled in by recent lymph and coils of intestine adhering to each other. The vermiform appendage was perforated by an ulcer, which communicated with the abscess, but no concretion could be gurgling had been heard on found. Thewaspart where the percussion occupied by a loop of small intestine, situated over the caecum and adherent by recent lymph to the -
adjoining parts. Now, it is scarcely necessary for me to point out to any of you who have attentively listened to the narrative of these
988 remarkably they differ, although in each there I1ypogastrium or in the pelvis ; but when the appendix has vermiform appendage and theIJeen very short, or placed behind the csecum, or the perforaresulting from it. But in the 1tion has taken place near its origin, the structures in or general peritonitis had existed from the first, thearound the iliac fosea will be mainly implicated. Another symptoms by sudden and intense pain,ecircumstance that must tend to determine the position of
two
cases
how
was the same lesion of the same local inflammation former case were ushered in
and constipation ; whilst in the latter the inflam-1the abscess is the formation of adhesions between the mation was confined to the part at which it had commenced; !appendix and some of the neighbouring organs, which is and the pain was never severe. The patient was, in fact, un-irecorded in ten cases out of the ninety-five. The csecum, able to fix the date of the beginning of his illness, and severeImall intestines, the peritoneum, and the bladder were the diarrhoea was the prominent symptom. But what we IHgans to which the appendix was attached, and in some shall hereafter find was of great importance, was that in the iinstances the adhesion had evidently occurred some time first case the disease occurred in a person previously healthy 1before the perforation had taken place. Various cases are on and resulted from the irritation set up by a concretion ;conretrecord ions; where the appendix has been adherent to the inguinal whilst in the second it took place in one who was suffering 4anal, or has formed part of the contents of a hernial sac, from long-standing phthisis. !and the pus has presented itself in the scrotum and been From the fact of five cases of this kind having beenIsuccessfully evacuated. It is evident that an abscess in the peritoneal cavity will admitted into this hospital within the last twelve months, you might infer that perforation of the appendix is by no1usually set up so much constitutional irritation that death means uncommon, but such is certainly not the case. Duringwill ensue before it can be evacuated, but such is not always the last eight years only nine persons have come under my1the case. In one instance at this hospital the pus was own care in whom the lesion was either proved to be presentievacuated through the abdominal walls, and I have seen a by post-mortem examination or in whom the symptoms werevery similar instance in my own practice. When it is so well marked that the diagnosis could be made withisituated near the caecum it may burrow beneath Poupart’s tolerable certainty. Again, in carefully examining the ligament, and may present itself in the thigh, as occurred post-mortem records of the London Hospital during the last in a boy who was under my care in the hospital two years forty years I have only been able to find nineteen in which ago, and who perfectly recovered after pus and fasces had the appendix was in a diseased condition. It is quite certain, been discharged from the wound. Other cases are recorded however, that this number cannot truly represent all whoin which the pus has found its way into the caecum, the have died in the hospital during so long a period of thisileum, or the rectum, and thus relieved the patient from im. disorder, for in the earlier volumes only one or two instances minent danger. But whether this may be the case or no, it is are recorded. Of the whole number I have collected only one is men. evident that the experience of no single practitioner will be tioned in which pus was found in the abdominal veins, one in sufficient to furnish him with instances of all the varieties which abscess of the liver was present, five where pleurisy the malady may present, and I have, therefore, collected and two where pneumonia was discovered after death. It is 129 cases that have been publii-hed by different authors in doubtful whether we should not refer the pleurisy to the the hope that from a careful study of so large a number we extension of the inflammation of the peritoneum through may be able to clear up some of the difficulties connected the diaphragm, but the others were most likely the results with the subject. of the absorption of pus. When we remember how com. Of the whole number of cases collected only ninety-five monly pysemia takes place in cases of deep abscesses of the have been recorded with sufficient details to enable us to limbs, we cannat but be surprised at the small number of ascertain the exact results of the perforation of the appendix, cases recorded as following perforation of the appendix, but and of this number thirty-eight presented a localised collec- the explanation is not difficult. In the limbs large veins tion of pus. Sixteen are said to have had an abscess in the are numerous in the vicinity of an inflamed part; in neighbourhood of the appendix; and in all probability the peritoneal abscess the pus is walled in by adhesions, and the condition was similar to what has been described in the two surfaces of the mesenteric veins are coated with lymph. In like manner we can see why abscess of the liver is so cases before quoted, where one or more coils of the small intestine were united to the surrounding parts and walled in common a result of dysentery, and so unusual in peri. the pus, or where it was situated in the pelvis and was sur- toneal abscess ; in the former the irritating and decomposing rounded by newly formed lymph. In twelve cases the pus contents of the intestine are brought into immediate was situated in the iliac fossa, in some around the caecum, contact with the vessels laid bare by the sloughing of the in others below the fascia, the muscular fibres being softened mucous membrane; in the latter the pus is defended from or broken up. A few instances are recorded in which the immediate contact with the vascular system. But in the more pus had burrowed upwards beneath the peritoneum, and had unusual situations of abscess resulting from perforation of the formed a huge abscess round the right kidney; in six in- appendix, such as where the muscular tissue of the iliac fossa stances the presence of an abscess is noticed, but its locality or of the loins is the seat of the suppuration, we will prois not defined. But the question arises, Why in cases of per- bably find that pyaemia is asapt to occur as when inflammatory foration of the appendix is there this tendency to the inflam- action has arisen from other causes. Although the inflammation of the peritoneum being localised, whilst in perforation mation, as we have before seen, chiefly affects the lower of the stomach or small intestines such a condition so rarely part of the abdominal cavity, fifty-nine cases are recorded occurs ? No doubt the difference depends upon the nature and out of ninety-five in which the whole peritoneal sac was imthe amount of the material that is extravasated into the peri- plicated, and, judging from my own experience, I should toneal cavity. In perforation of the stomach a large quantity be inclined to estimate the proportion still higher. Of of a highly irritating liquid is effused, which quickly finds its course the amount of mischief varies greatly ; in some cases way to all parts of the abdominal cavity, exciting inflamma- the intestines are everywhere adherent, and collections of tion wherever it reaches; whilst in the case of the appendix pus are met with in the most depending parts, or are the material is solid or in small amount, and being in the enclosed between the adjacent coils; in others lymph is most depending part it does not at once reach the more dis- uniformly spread over the surface of the membrane, whilst, tant portions of the peritoneum. We thus find that even more rarely, we only meet with slighter evidences of where no abscess had been produced, it is mentioned that the inflammation. General peritonitis occasionally presents inflammatory products were met with in the greatest quan- itself as the first indication of the perforation ; in other cases tity in the immediate vicinity of the caecum, in the propor. it travels slowly from the neighbourhood of the appendix, tion of twenty-three cases out of ninety-five. It is easy to whilst more rarely it results from the bursting into the understand why only lymph should be found in one case and abdominal cavity of an abscess set up around the appendix, a collection of pus in another, for death probably occurred and which had been circumscribed by adhesions of the so rapidly in the former that there had not been time for the neighbouring structures. But at whatever period of the suppurative process to take place ; but it is more difficult to case the inflammation of the peritoneum may occur it is explain why the abscess should be confined in one individual almost always of a suppurative character, a peculiarity to the pelvis and in another to the iliac fossa. The most which in all probability arises from the decomposing nature probable reason is that as the length and direction of the of the substance which has originated the morbid action. When this accident first attracted the attention of patholo. appendix vary in different subjects, so the seat of the inflammation must vary accordingly, being most intense at gists it was remarked that the appendix often contained a the nearest point to the perforation. When, for example, foreign body, and the idea arose that this was the sole cause the free end bas been the seat of the ulceration and it has of the ulceration. Out of 125 cases which could be examined projected into the pelvis, the abscess will be situated in the as regards this point, in fifty-five it is stated that either
vomiting,
989 a mass of faeces, or some other foreign body7 collected from various authors only twenty-five, or 23 per present, and it is fair to conclude that the numbers would1 cent., were of this sex. The proportion varies with the
concretion,
a was
have been larger if a sufficiently careful search had beeni in them all ; for as the coutents of the appendixc often drop into the pus surrounding the ulceration, it is easy7 to understand that a small concretion may frequently have: been overlooked. The nature of the foreign body has varied, forr in forty-seven cases sufficiently detailed to allow of analysis9 twenty-eight were concretions, fourteen consisted only off hardened fseces, and in five others, substances such as seeds9 But why should a foreign body inI or shell were present. this part set up such serious results, when we know thatb in numerous instances the appendix has been found oni post-mortem examination to be occupied by shots, seeds,, and even, as in a case lately observed in this hospital, by lumbrici, without any apparent ill results; and vk heni we so constantly meet with concretions in the kidneyr and the gall-bladder without any manifestations of disI think int ease having arisen from their presence ? most cases the presence of a concretion by its irritationi gives rise to ulceration, and the proximity of the part to the caecum filled with decomposing materials tends to produce sloughing in what would be otherwise a mere abrasion In support of this view Iof the mucous surface. may mention that in sixteen cases the appendix is stated. to have been in a gangrenous condition, although therei is no notice in any ot them of the caecum being in a similar state. I think, too, we may find in the anatomical relations of the appendix a reason why in somei instances perforation so readily occurs. In Case 1 you will remark that the ulceration had taken place in the centre of, the process, where it was distended by the concretion, but the perforation was at the end. Now, the appendix is supplied with blood by means of a small mesentery of its own, which sometimes terminates before the extremity of the process, so that the end must derive its nutriment from the bloodvessels of the parts nearer to the faecum, and under such conditions any acute ibflammation or ulceration that obstructs the circulation must tend to rapid disorganisation of the structures. That this is by no means an uncommon cause of the perforation is shown by the fact that in the majority of cases the perforation is found at the extremity, and very rarely near to the caecum. Then how are the concretions produced ? It has been generally assumed that they are the result of a secretion of the phosphates of lime and soda, of which they piincipally are composed, by the mucous membrane of the appendix, small nodules of faeces or some undigested particles of food which had obtained access to the part serving as nuclei. This is no doubt correct in many instances, as nuclei of this nature have been shown to exist in some concretions, but in others the calculus appears to be composed solely of earthy salts. Now, in one of the cases at this hospital it is noted that the appendix was distended by a milky fluid, the communication with the caecum being obliterated, and in others recorded by different authors the appendix is stated to have been occupied by a substance resembling putty. Itis,then,to obliterations of the valve, and consequent distension of the appendix with thickened secretions, that I suspect we must look not only for an explanation of the formation of many of the concretions, but also for the cause of some of the ulcerations that occur in which no foreign body can be
practised
,
.
,
.
,
producing the perforation, for in the cases occurring in phthisical individuals 41 per cent. were females, and all of those that took place in the course of typhoid fever whose cause
sexis mentioned were also females. When noforeign.bodywas found in the appendix the proportion of females was 23 per cent., but amongst those in which a concretion or other foreign body was discovered after death there was only 17 It is evident from both sexes being equally per cent. liable in those affected with phthisis that there is no anatomical difference in structure which can account for the smaller proportion of females who suffer from perforation, so that we must seek for an explanation of the above facts in the habits or circumstances of the stronger sex. Now, it has been conjectured that the male is more liable to affections of the appendix on account of the more severe exertions to which he is exposed ; and in support of this we may remark that in the first case the patient stated he had never been well since a strain received in his occupation, whilst other instances are recorded in which the fatal illness had been preceded by an injury to the abdomen. But, on the other hand, the history of an injury is only exceptional, and in the majority of cases the symptoms of the disease present themselves suddenly and without apparent In addition to this, as we sball shortly see, the aceicause. dent occurs more often in the young than in those at a later period of hfe, when severe labour is more generally undertaken. You will remember that I before suggested that many cases arose from obstruction of the valve, probably the result of catarrh ; and this derives support from the fact that males are more liable to catarrhal affections of the csecum. than the opposite sex; for example, the numbers of cases of typhlitis admitted into this hospital for the last seven years have been fifty-nine, of whom only eighteen were females, which is at the rate of 30 per cent. Let us now examine whether we can find any predisposing cause of ulceration of the appendix in the age of the persons affected. I have included all the cases whose ages are stated in the following table :Years of age.
Under 10 10 to 20 20 to 30 30 to 40 Above 40
Number of
cases.
9 29 ............... 211 16 22
...............
...............
...............
...............
Total ............
97
It will be remarked that a considerable number have occurred under ten years of age, and half of these were under five ; indeed, the accident sometimes takes place at the earliest period of life. From ten to twenty is the most usual time, and after thirty the numbers gradually decline. This is better seen if we divide thecases according to the cause producing the ulceration. Thus, if we examine only those in which either a concretion or some other foreign body was discovert d, we find that thirty cases out of fortythree, or 70 per cent., occurred in those under twenty years of age, only four between twenty and thirty, and five between thirty and forty. If we separate those in which concretions were present from those where only particles of hardened fseces or other foreign bodies were discovered, the same liability is shown, as 64 per cent. of the latter and 80 per cent. of the former occurred under twenty years of age. But as we saw in the former table that a considerable number of cases of ulceration of the appendix occurred in persons above twenty, it is chiefly in those above this age in whom no foreign body bas been discovered. In the next table I have included all the cases of typhlitis who have recovered and who were admitted into this hospital in the years before mentioned.
discovered after death. The second case I have narrated was one in which phthisis was present, and no concretion was discovered ; and we might have conjectured that perforation would often occur under such circumstances, on account of the similarity of the stiucture of the mucous membrane of the appendix to that of the caecum, which is liable to suffer irom ulceration in this disorder. It is, however, much more rare for perforation to arise from tubercular ulceration than from the presence of a concretion, as 1 have only met with thirteen cases out of ninety-eight. Occasionally perYears of age. Number of cases. foration occurs in typhoid fever, but I have only found six 5 to 10 2 in which it took place in persons suffering from this disorder. 24 10 to 20 Two cases have been recorded in which it happened during 25 20 to 30 concatescence from other eruptive diseases ; but there is no 2 30 to 40 evidence that there was any connexion between the original 5 40 to 50 malady and the abdominal complication. 1 Above 50 It has been remarked by different writers that perforation of the appendix is much more liable to affect the male than 59 Total............ the other sex, and this is borne out by the experience of this where of seventeen were whose recorded these It will that be on both ulcerahospital, ages only tables, seen, comparing three, or 18 per cent., were females, whilst of 105 cases tion of the appendix and inflammation of the cseeum are ...............
...............
............... ......
,.........
...............
...............
990 most liable to occur between the ages of ten and thirty, when food is consumed in the largest quantity; and we may therefore assume that both affections depend upon a similar condition, and that the retention of indigestible materials in the caecum and the catarrh so produced is the most usual cause. But as typhlitis and ulceration of the appendix are both common between the ages of twenty and thirty, although concretions are less common at that period than in the ten years before it, we are justified in supposing that a catarrhal condition of the caecum, either by producing closure of the valve or by of the inflammation to the appendix, often - propagation gives rise to ulceration, although no foreign body be
of anaesthetising the mucous membrane of the tongue. Prof. Schroff mentioned this fact for the first time in 1862 in a lecture on its nervous effect read before this assembly. It is also well known that cocaine narrows the peripheral arteries when taken internally ; further, we know that cocaine dilates the pupil by means of its local application as well as by its internal use. We therefore see that cocaine has already been applied to the eye, but until now those phenomena have not been observed which I make the object of my discourse to-day. After repeated experiments with its internal use cocaine fell into discredit and disappeared from the scene. Dr. von Anrep in 1880 produced a comprehensive research into cocaine, at the end of which it was present. Most of the cases of ulcerated appendix in phthisical hinted that the local anaesthetising action of cocaine might in subjects occur at a later period of life than when it is due the future become of considerable importance. In Vienna, to the presence of concretions or catarrh, for out of those I especially, cocaine has been brought to the front through have collected only one was below twenty years of age, the interesting therapeutical work of my colleague in the seven were between twenty and forty, and three were above general hospital, Dr. Sigmund Freud. I have started with the premise that a substance which forty. All those connected with hernia were above forty years of age. paralyses the terminal sensory nerves of the mucous I have already mentioned the prevalent idea that the membrane of the tongue would not act very differently on concretions so often found in the appendix are always the those of the cornea and conjunctiva; so I undertook a series result of hardened fseces, or of indigestible materials of the of experiments on animals, which I carried out in the food, and if such were the case we should expect to find that laboratory of Prof. Stricker. My results, in brief, are as most of the sufferers had been liable to constipation. Now, follows :-If a few drops of an aqueous solution of muriate of I have collected forty-three cases in which the previous cocaine2 are dropped upon the cornea of a guinea-pig, a state of health is recorded, and of these only three had been rabbit or a dog, or if the solution is instilled in the usual way subject to a constipated state of the bowels. It is therefore into the conjunctival sac, the animal blinks for a while, evident that this theory derives but little support from clearly as the result of a weak irritation. After a period of facts. I should be more inclined to believe that the con- from thirty seconds to one minute the animal opens its eye, cretions are in most instances the result of an excessive which gradually assumes a peculiar expression of rigidity. secretion of the mucous membrane of the appendix arising If one now touches the cornea of the animal with the head of from the stimulus afforded by an undue use of solid and a pin, being careful not to come in contact with the eyelashes, indigestible food. This view derives support from the fact no reflex closure of the lids occurs, the bulb does not deviate, that of twenty-five cases in which a concretion was discovered and the head is not thrown back, as would otherwise happen. twenty are described as having enjoyed robust health, and On the contrary, the animal remains quiet, and by the three had been delicate; whereas of eight in whom no employment of a stronger irritation we can convince ourconcretion was discovered, only five had been robust and selves that the cornea and conjunctiva are completely three delicate. The presence of a concretion produces no accesthetised. For instance, I have scratched the cornea of pain until catarrh or ulceration is excited, for out of twenty- the animals upon which I experimented with a needle, five cases of concretion only two had previously complained pricked the same, irritated the cornea with an induction of abdominal pain; whilst of eighteen in whom no con- current which was so strong that it produced a painful cretion was recorded five, or 30 per cent., had suffered in sensation in the fingers and was unbearable on the this way. I have before mentioned that injuries to the tongue, and cauterised their cornea with a pencil of abdomen are supposed by some authors to give rise to nitrate of silver until it became as white as milk; ulceration ofthe appendix, and this derives some support all without a single movement on the part of the animals. from the fact that three cases out of eighteen in which no The last two experiments convinced me that the anaesthesia concretion was discovered referred their complaint to blows included the whole substance of the cornea, and not only its or strains. In four instances out of forty-three there was a surface. However, after I had cut into the cornea, the history of a previous attack of typhlitis from which the animals showed decided signs of pain at the moment, when patient had perfectly recovered ; in two of these the patients the aqueous humour gushed out and the iris prolapsed. Even died from peritonitis only, and in the remaining two both in my later experiments on animals I was unable to deterabscess and peritonitis were discovered after death. mine whether the iris also could not be ansesthetised by the of the solution into the corneal wound, or by a instillation be concluded.) (To continued instillation into the conjunctival sac, begun and kept up for some time before the operation; for experiments testing sensibility of animals which are not narcotised are ON THE USE OF COCAINE FOR PRODUCING very difficult, and, especially if they are in the slightest degree complicated, are apt to give equivocal results. I had yet to ANÆSTHESIA ON THE EYE.1 find out experimentally whether cocaine could produce aBsesBY DR. CARL KOLLER. thesia of the inflamed cornea, and this question was answered in the affirmative, when the animals upon which I produced TRANSLATED AND REVISED BY J. N. BLOOM, B.A., M.D. an artificial keratitis, by means of a foreign body, showed the same anaesthesia of the cornea as the healthy ones. ComGENTLEMEN,-I take the liberty of addressing you in plete anaesthesia lasts on the average ten minutes, when a order to inform you about some experiments which I have 2 per cent. solution is used. After such successful experiments I did not hesitate to undertaken in order to produce anaesthesia on the eye. It is not the first communication which I have made on this apply cocaine to the human eye. At first I experimented upon myself and a few colleagues; later, on a large number subject. I have already addressed such a one, in order to of other individuals ; the results of which without exception preserve my priority in this discovery, to the Convention of proved that the cornea and the conjunctiva were thoroughly German Oculists, which, as it annually does, met on the anaesthetised by its use. The sequence of the symptoms 15th and 16th of September in Heidelberg. Dr. Brettauer is as follows :-When a few drops of a 2 per cent. solution of Trieste was kind enough to bring my communication into are introduced into the conjunctival sac, or, better still, if are allowed to run over the cornea, together with an notice and to repeatmy experiments before the Convention, they increased secretion of tears, a slight burning sensation is felt, and since then the same have been repeated and confirmed which disappears after an interval of from thirty seconds to in various other places. a minute, to give way to an obscure feeling of dryness. To It is a well known fact that cocaine,. an alkaloid produced the observer an eye thus treated has a peculiar rigid expresin 1859 by Nieman from the leaves of the erythroxylon 2 A solution of cocaine in water, up to 5 per cent., can be made coca, possesses the peculiar property, by its local application, without the addition of an acid. The solution is always cloudy. The addition of an acid is to be avoided, as even a very small quantity of an 1 A paper read at the meeting of the Vienna Royal Imperial Society of acid causes a very strong burning sensation. When filtered the solution on Oct. becomes as clear as distilled water. Physicians 17th, 1884.