CONTRIBUTIONS TO THE PATHOLOGY, DIAGNOSIS, AND TREATMENT, OF

627 stimulant

suppositories.

An account of this

highly-interesting

CASE OF LARGE STRANGULATED INGUINAL

by Mr. W. Scott, was read before the MedicoHERNIA.—OPERATION.—RECOVERY. Chirurgical Society, in the spring of 1845, and from its pracTHOMAS BOURNE, Esq., Surgeon, Radstock, near Bath. tical value might well have been published in their Transac- By tions. DANIEL R—, of Radstock, aged seventy, formerly a sailor, On May the 19th, this man was free from all urgent symp- and who was at the battle of Trafalgar, where he was severely toms, sleeping well, and with full control of his rectum and wounded in the head, states that he has had paralysis of the bladder. right side for fourteen years, and been the subject of a large case, drawn up

May, 1846.

J. A. W.

______________

reducible inguinal hernia of the same side for thirty-six years. On Saturday, April 19th, at seven P.M., I was sent for to see him, when I found him suffering from all the symptoms of strangulation. I applied the taxis about a quarter of an hour, and this failing, I had him placed in a warm bath, where I employed it again; afterwards a tobacco enema was administered, without success. As faecal vomiting had taken place, and all the symptoms were becoming more aggravated, I urgently advised an operation, to which the patient and his friends soon consented. At midnight, having made the preliminary arrangements, I commenced by making an incision from the upper part of the swelling, carrying it down to the lower part, Having carefully cut through the coverings, I reached the sac, which I divided above and below, and found a large quantity of thickened omentum adherent to it, requiring considerable force for its separation; this accomplished, I felt for the stricture, which was found to be at the abdominal ring. Having passed my finger to this situation, I divided it with a bluntpointed bistoury, cutting directly upwards. The bowel had a favourable appearance, and was at once returned. Sutures and plaster were applied to the wound ; an opiate was afterwards given, and the patient placed in bed. 19th.-Slept a little during the night; bowels opened twice; he is somewhat feverish. 20th.—Has passed a good night; there is slight tenderness on pressing the abdomen. To have a dose of castor-oil and a saline mixture; low diet. Bowels have acted rather freely. 21st.—Has had rather a restless night; face flushed; tongue furred; pulse quick; bowels opened once; no abdominal tenderness. 22nd.-Slept well; the wound has been dressed, and looks favourable ; there is less fever. To continue the saline mixture and low diet. 23rd.-There is great enlargement of the scrotum, and the upper part of the wound discharges pus; one of the sutures to be removed, a poultice applied to the wound, and a spiritlotion to the scrotum; to have a more liberal diet. 24th.-Passed a good night; bowels have been opened; the wound and scrotum look better; appetite improving. 25th.—From this date up to the present period (May 6th, 1846) the symptoms have been of a favourable character; the wound has nearly healed ; the bowels have acted regularly, and the appetite continued good. Remarks.—This case is interesting on account of the very large size of the hernia, which became strangulated in a patient who had been paralysed for fourteen years ; and the firm and old adhesions of thickened omentum to the sac precluded all hope of relief, excepting by an operation, which he bore well, and which terminated favourably. Radstock, near Bath, May, 1846.

ON CAPSULAR CATARACT. BRETT, Esq., F.R.C.S., late Superintendent of the By Eye Infirmary, Calcutta; Surgeon to the Western Institution for Diseases of the Eye. So3iE months since, I observed a communication in THE LANCET, announcing a novel method of operating for cataract, as practised by M. Sichel, an ophthalmic surgeon of Paris-viz., that of making an incision through the sclerotica and choroid, followed by the introduction of a hook, as adapted to capsular In the third volume of the India Journal of cataracts. Medical and Physical Science for 1837, I published an account of this operation, with a drawing of the instruments and mode of operating. The method suggested itself to me without the knowledge of any surgeon having previously adopted it. Subsequent experience has taught me to abandon this operation ; and as truth, unbiassed by any favourite theory, is the object which I have in view in making this communication, I am anxious that inexperienced operators may not be misled by this " novel mode of operating." I never practised it but on two occasions, and those only where the capsular cataracts were small, so that the incision into the sclerotica and subjacent coats of the eye was not very extensive. I have made the incision transversely-i. e., at right angles to the direction of the fibres of the recti muscles; and perpendicularly-i. e., in a parallel direction to that of the fibres of the recti muscles. In both cases, the vitreous humour is apt to escape in considerable quantity. But there is this further disadvantage in the latter method-that not only are the sclerotic and choroid wounded, but, from the incision extending much further back, the sensible retina, the membrana Jacobi, and the ciliary nerves, are likewise injured. It is therefore a most hazardous operation, and not to be depended on even under the most experienced and skilful hands. During a recent visit to Paris, I ascertained that this operation is not generally approved of at the French metropolis. It cannot be denied, that in all operations posterior to the cornea and iris, whether with the needle or by incision, most important and delicate structures are injured. Besides the sclerotic, and the vascular choroid coats, the minute filaments of the ciliary nerves are wounded, and deep-seated inflammatory action is " not unfrequently set up, even in the simple operation for displacement" of the opaque lens ; whereas the cornea is wounded by a clean incision with comparative impunity. We constantly observe, in ophthalmic practice, that wounds and accidents to the cornea inflicted by sharp instruments, when judiciously treated, are not dangerous : they heal by first intention, without involving the transparency of this structure. With still greater impunity, under skilful hands, guided by scientific principles, can wounds be designedly inflicted on this part, and this not only once, but repeatedly. It may therefore properly be CONTRIBUTIONS TO THE asked, cui bono such dangerous measures-such penetration of vitally important structures by the posterior operation. A minute flat needle, very sharp at its point and edges to the PATHOLOGY, DIAGNOSIS, AND TREATMENT, OF extent of one line, introduced through the cornea near its VENEREAL DISEASES. margin, or anywhere outside of the circumference of the most dilated pupil, can be readily carried through the aqueous BY WILLIAM ACTON, ESQ. chamber to the opaque capsule, (or to a capsulo-lenticular SURGEON TO THE ISLINGTON DISPENSARY, AND FORMERLY EXTERNE TO THE VENEREAL HOSPITALS OF PARIS. cataract, where the lens is either soft or fluid.) A slight rotatory motion is then effected; and on withdrawing the needle, what is the consequence? The aqueous humour escapes, ON THE EMPLOYMENT OF NITRATE OF SILVER IN THE TREATMENT OF ULCERS ON THE GENITAL ORGANS. and the shreds of capsule, as well as any flocculent or softer portions of the lens, immediately protrude forward into the Cases in, which nitrate of silver should not be employed; can anterior chamber; the pupil is preserved in a state of dilatation caustic clrive the disease into the system? Is the salt calnable of by the unguentum belladonnas. Other remaining shreds of bubo ? Considerations on the necessity for general producing capsule retract behind the iris; the sharpuess of the needle is treatment ; mercury objected to, and the opinions of its advoadequate to dividing the toughest capsules. Such an operacates considerecl ; on the inutility of sarsaparilla and iodide of tion may be repeated twice, thrice, or as often as requisite, potassium. with a certainty of ultimate, often of speedy success, and little IN my last paper I attempted to lay down as a general rule, or no injury to the visual organ. Let us therefore hear no more of these posterior operations of extraction—" craignez de vous that all sores on the genital organs should be treated with I propose speaking of £ tromper; noais ne craignez jamais de laisser voir cc2cx autres y-ue caustic; in my present communication the counter-indications to that treatment. vous avez été trompé !" Dorset-street, Yorttnan-square, May 1846. Experiments on a large scale clearly show that after a sere F. H.

628 has existed three days, no means we can take will invariably succeed in preventing the constitution becoming contaminated; up to that period, however, we may consider that the disease is completely under our control, if the preceding directions have been followed. Although, then, we cannot absolutely promise our patient freedom from secondary symptoms after that time, still, in nine cases out of ten, we may reasonably hope that they will not follow; and therefore, so far as local and general measures are considered, cauterization is most desirable and needed ; still, with all these indications calling for its use, circumstances may be present which counter-indicate the employment of caustic. In the first rank stands acute inflammation. Experience proves here, as elsewhere, that although nitrate of silver may ’, be useful in allaying irritability, and in curing subacute inflammations, its employment in acute inflammatory attacks is ’ very doubtful, or, at most, useful in but a very few instances; and though surgeons may derive great benefit from its employment in chronic ophthalmia, in scrofulous constitutions, and in subacute inflammation of the urethra, few, if any, ever recommend it in acute affections of these organs, unless in the single exception of erysipelatous affections of the skin, in which it has been, like many other applications, much vaunted, subsequently laid aside. When chancres are attended and with acute inflammation, caustic will be worse than useless; experiments prove that phagedena destroys the virus, and they likewise show us that caustic increases instead of allaying inflammation; therefore, when present, recourse must be had to opium, rather than to nitrate of silver, as I shall attempt to show on some subsequent occasion. But it is not alone in acute inflammatory chancres that we must lay aside the use of caustic; we should never apply the salt when previous applications have irritated the sores, or we might continue its use ad infinitum, without healing the ulcer. On April’ 12th, 1846, a gentleman who had previously suffered from chancres, and experienced the benefit of cauterization, had connexion with a suspected female, and observing an excoriation the next morning, himself applied nitrate of silver most plentifully; the eschar fell in twenty-four hours, and, the patient states, a quantity of pus escaped; he thought it necessary to burn it a second time, and applied the caustic freely; in two days, feeling alarmed at the pain and redness, he called on me. A pustule, exactly similar to those delineated as following inoculation in the atlas of my work on venereal diseases, appeared on the penis; the white pellicle was surrounded with an inflamed areola, and there was some pain. I felt pretty well convinced that this was the result of irritation alone. I prescribed water-dressing, and the pustule healed in a few days. Now this is one of a large class of cases where diagnosis is difficult, and which are often seen in private practice, arising from irritating applications. A few days, however, generally clear up any doubts a surgeon may have; for if it be the result of irritation, the pustule heals; if of chancre, the disease loses no time in progressing, and the surgeon has the certainty of treating a venereal sore, instead of one of these

irritated excoriations, which I havemore than once submitted to a course of mercury, under the supposition that the patient has a virulent disease. Another counter-indication to caustic is induration of a sore; the surgeon should never cauterize a genuine Hunterian chancre, or one attended with induration; if he does, he will cause great pain, the sore will become irritable, and gangrene will often follow, as I have observed in several instances. Cauterization of such sores shows great ignorance of the objects and aim of the employment of nitrate of silver, as well as of induration; for as these sores secrete but little, we have scarcely any virus to destroy. If it were our object to destroy the mass of Induration, we must have recourse to a much stronger and deeper caustic than nitrate of silver, such as Vienna paste; but even destroying the induration would be of no good, as experience shows that where it exists, the constitution is already contaminated, and if removed, we should have no criteria to go by of the state of the system, until secondary symptoms break out. The ulceration on indurated depends on the hardening impeding the cicatrix formsoresand to remove this, absorption must be brought about by ing, mercury, as I shall hereafter show, in speaking of indurated chancres. From these considerations, then, I never employ caustic where there is induration, and I do not find patients complaining as they are said to have done formerly, that destroying chancres with caustic produces secondary symptoms, from driving the disease into the system, a charge it is well to avoid, however impossible such a thing is believed to be by well-educated persons.

simple seen

During the course of treatment, a patient will occasionally complain of vague pains in the groin, in some cases shooting down the cord; the finger can, however, detect no tenderness or enlargement in this situation, and we may generally set

down these cases to irritation of the extremities of the nerves, which will disappear as soon as the irritation ceases. In my own practice, the occurrence of bubo is very unusual, and when observed, follows usually in persons who have suffered previously from swellings in the groin: in these instances every precaution must be taken to avoid their reappearance, by enjoining rest; but I have great doubt if low diet is necessary, although a recumbent position is highly desirable, and on the first appearance of swelling or heat in the groin, leeches and cold applications must be resorted to. Bubo, let it be remembered, depends not so much on the treatment as on the situation of the sore, as I have elsewhere

stated.* In the local treatment of uncomplicated chancres, I have found these simple means the best adapted to a speedy cure; and I must protest loudly against any general or constitutional treatment being employed, provided the health be good; in such cases the patient need not observe any restriction as to diet, but it is better to abstain from horse-exercise, or violent excitement of any kind. But must no mercury be given to expedite the cure and prevent secondary symptoms ? The result of numerous cases treated during the last five years, and which still remain under my observation, induces me to believe that mercury is by no means necessary either in expediting the cure, or in preventing secondary symptoms, as without it, the local cure is rapid, and secondary symptoms do not occur, except in such feeble proportions that they should not enter into our calculations. It is true, the exceptional cases may injure the reputation of the surgeon, and he may be told that had the patient taken mercury, constitutional infection would not have followed; but in nine out of ten other cases, the patient will justly extol the merits of his surgeon, who has spared him a course of mercury, which immunity from constitutional disease proves to have been unnecessary; and I cannot lead myself to approve from expediency, what I believe to be scientifically wrong and unnecessary, or to sanction the treat. ment of those who may assert that every chancre or sore on the penis should be treated with mercury, on the plea that if secondary symptoms follow, the surgeon at least cannot be blamed, and the treatment without mercury called in question. I hope there are few practitioners who will lend themselves to this system of special pleading; if there be, they will find, to their cost, that they give mercury where none is required; and give an insufficient quantity in cases calling for its administration. There is another large class of practitioners, however, who give mercury in almost all sores appearing on the genital organs, on the same principle that I have recommended the application of nitrate of silver-namely, that perhaps the sore is not specific, but in the absence of any absolute dia, gnostic sign, they wish to be on the safe side, and guard the patient from secondary symptoms. Did mercury act like nitrate of silver, and confine its effects to the local influence on sores, this idea would be tenable; but to effect the purpose, the sore must be acted on through the constitution; and will any surgeon assert this can be done nine times in ten with impunity, particularly when experiments prove that in these nine cases recourse to mercury is unnecessary, and when employed, gives no absolute guarantee against secondary symptoms, as the recorded cases of these mercurialists prove. We further meet, in private practice, with another class of extremely welleducated surgeons, who believe that mercury should be given in most primary sores, and in the very earliest stages; and they prescribe it from a deep conviction that mercury thus given prevents absorption of the virus into the system; or if it does not prevent this, causes at least the absorption of the antidote at the same time, and in consequence the disease will not (say they) be followed by secondary symptoms. This school has, however, assumed as proven several points which experience by no means sanctions or corroborates. For instance, I know not any series of experiments to show that mercury will prevent absorption; on the contrary, mercury is by many believed to hasten this process, and as such, it is largely given. The belief in its acting as an antidote in the circulation seems founded on no facts whatever that I can discover. If it be pretended, when mercury is given in the earliest stages, and no secondary symptoms follow, that the immunity depends upon the treatment, no conclusion can, I think, be more impotent; for these gentlemen seem *

Practical Treatise

on

Venereal Diseases, by Wm. Acton, p. 248.

629

forget that in nine cases out of ten the same thing whole surface. These symptoms rapidly passed on to dissoluhappen where mercury has been altogether abstained tion in the worst cases. This is the pathological fact of the from, and they have thus attributed to their remedy book: the relation of this special form of disease with interwhat is the natural course of the disease, apparently through mittent and remittent fever, chronic dysentery, and sloughing not having seen syphilis running through its entire course unchecked by mercury; for how few, (except, perhaps, the ulcers, is pointed out in the course of the work. Scattered up and down in the work arenumerous interestarmy surgeons,) brought up and educated in the metropolis, have watched one hundred cases which were not treated ing facts, relating to general subjects, on the habits and with mercury. When they, therefore, see cases treated with manners of the Chinese Some of the most prominent people. mercury not followed by secondary symptoms, they have of these we shall refer to. briefly concluded that mercury has prevented these, whereas, the The Minden was fitted up with a ventilating apparatus records of hospitals and private practitioners, who treat cases without mercury, prove that the same effects follow the non- under the direction of Dr. Reid. Dr. Wilson speaks of it mercurial treatment, and its advocates have the high satis- approvingly, as having been simple, of having done its work faction of believing they have saved nine out of ten of their well, and of continuing perfect for three years in its machinery patients by a course of mercury. Let it, however, clearly be after daily use during that time. understood, that these observations apply exclusively to the Dr. Wilson remarks on the frequency of scrofula, ophthalmic unindurated chancre. This sore requires a peculiar treatment, both local and general, as I may have occasion to show in a diseases, and elephantiasis, among the Chinese. The followfuture communication; and much of the diversity of treat- ing is an interesting passage relating to the Chinese pedal ment, as well as course of disease, depends upon authors not mutilation. regarding the marked distinction attending the course of " Through the kindness of the surgeon of the Belleisle, who the indurated, as compared with the simple ulcer. Almost all surgeons are unanimous upon the inutility of iodide of obtained the preparation at Chin-Keang-foo, the subject, with having destroyed herself, the writer had potassium in simple ulcers, and few now prescribe sarsaparilla; aangreat many others, opportunity of examining the mutilated foot of a Chinese in fact, the treatment of uncomplicated cases of chancre is woman but with its natural articulations remaining, expe- so that dissected, now purely local. Experiments have indicated this, and of the retained the position they had occupied bones all rience has sanctioned it, to the almost entire exclusion during life. It is that of a person from twenty to thirty years other treatment. of age, and appears to have been of the ordinary artificial Queen. Anne street. Cavendish-square, May, 1846. form, and nearly, though perhaps rather over, the average size; certainly the writer has seen several considerably smaller. to

will

,

Its extreme lenfyth is fnnr inches and

REVIEWS.

a

half-

by which the curtailment and deformation are accomplished is, of course, pressure, but the manner in Medical Notes on China. By JOHN WILSON, M.D., F.R.S., which it is applied, judging by the different accounts given of is not always the same. It must be forcible, and far greater Inspector of Naval Hospitals and Fleets. London: Churchill, it, than can be obtained from bandages, which are worn at all Solio. 1846. Princes-street, pp. 267. periods of life, and long after the growth of the foot is fully WHEN the Minden was fitted o’ut, in the spring of 1842, as a arrested, which is probably, in most instances, before the girl hospital-ship, and sent to China, the chieftmedical post was is five years old. The principal effects of the treatment are, entrusted to Dr. Wilson. The present volume of medical to prevent the proper development of the parts, distort the notes is compiled chiefly from his experience on board the organization, and in great measure destroy the functions of the foot. The extended sweep of the ankle, as well as the Minden in the Chinese Seas, and at Chusan, Amoy, and more limited motion of the metatarsal joints, is lost, the artiHong-kong. surfaces being firmly ankylosed. culating " We may briefly mention that the diseases so fatal to the In the preparation just seen, the os calcis, instead of its British troops on the coast of China, were, remittent and natural broad base, and posterior rough projection, has a intermittent fever, dysentery, what he terms anomalous flux, conical form downwards, and slopes forward from the leg, so and sloughing ulcer. These diseases were most severe in that a straight line projected beyond the foot, from the inner of the tibia, falls not before, but behind, the extremity 1843, and the number of persons attacked in this year would aspect of the bone. The bones of all the toes, except the great one, seem to have depended on accidental causes, the year 1844 are bent under the metatarsal, at their points of junction, being comparatively healthy. In the treatment there is lying parallel to, and in close contact, with them. The natural of the foot is much deepened by pressure applied to its nothing to call for particular attention excepting the use of arch buchu in the dysentery and flux. Of this remedy two ounces extreme points, and the forced elevation of the tarsal, and tarsal extremities of the metatarsal bones. Its depth in the of the infusion were given two or three times a day in the present instance, measured from the inferior aspect of the chronic forms of dysentery, attended with wasting discharges, bones, is fully two inches. Its depth of arch, in reference to with tendency to dropsical effusion, and, as the the length of the foot, looked at as a skeleton, and without periodic fever, writer adds, " in such cases it did good service." Dr. Wilson regard to its use, does not, it must be owned, give it an unis anxious not to fix too high a value upon this remedy, and sightly appearance. But the arch is not seen without dissection. It is so filled with fatty matter, that the sole is a will certainly not flat he sums up its claims as surface ; and the foot of a Chinese woman, in this respect, cure, or tend to cure, many cases of chronic flux; but in those bears no resemblance to that of the Arabian, which, when which have been specified, and, it is thought, with sufficient helped a little by imagination perhaps, allows the brook to its hollow without wetting it. It more resembles, precision, it will act beneficially, for the most part, and will flow through it much indeed resembles, from its short, stumped, wedge-like often, with the co-operation of other means, lead, though that kind of club in which the foot is generally turned form, would fail. to of slowly, health, when other courses treatment inwards. This, which is sufficient credit, is claimed for it, but nothing " That a whole race should take so much trouble, inflicting more." This is the therapeutic fact of the book. and undergoing so much pain, to deface and damage the body, In pathology we have described, in the treatise, what is strange. It is the most universal and curious kind of Dr. Wilson terms "flux," an epidemic disease, to be called mutilation practised in any country, and shows how dangerous neither dysentery nor diarrhoea. This disease, in its severest it is to permit fashion leagued with false notions of beauty to with the wholesome operations of nature. There is forms, commenced with vertigo, loss of muscular power, tamper little doubt that the practice began at first, in a small way, with jactitation, drunken expression of countenance, di- and with slight results, in the desire of doing what they might, lated pupils, and mental torpor. The pulse quickly be- by artificial contrivances, to help in the formation of a small well-arched female foot, and that it crept on with increasing came rapid, feeble, fluttering, and often intermittent; there force, though by scarcely perceptible movements, till it was also profuse sweating and loss of animal heat in the exreached its present universal extent, and power of, at once, tremities ; sometimes, vomitings of bilious matter, sometimes destroying the beauty of the organ, and all but annihilating livid white soft and a purging ; great thirst; a tongue ; lips, its functions. While the foot is stunted and crippled, the leg dusky hue of the countenance, sometimes extending to the wastes, loses its symmetrical roundness and waving outline " The process

follows:—"Buchu

’