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Lectures ON CLINICAL SURGERY,
MAY
ON
SURGERY,
DELIVERED DURING
THE WINTER SESSION OF 1854-5.
BY JAMES
SYME, ESQ.,
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.
LECTURE XVIII. HYDROCELE.
affection regarding the treatment of which there has been, till within a comparatively recent period, great diversity of opinion and practice. The common treatment in this country was injection with port-wine, which, however, was so liable to unpleasant occurrences, that many surgeons ’ z’ were dissatisfied with it, and preferred other methods, such as incision, excision of the whole or a portion of the sac, and the seton. It was alleged that these methods, though more painful at the time, did not occasion so much subsequent suffering as the port-wine injection, and were nor attended with so much danger of sloughing of the scrotum, or even of death itself, which was known to have occurred occasionally, from the escape of the wine into the cellular substance. While the treatment was in this unsettled state, hydrocele was often e’hosen as the subject of thesis at graduation, which implied that it was one admitting of a great diversity of opinion. Since that time, however, a fluid has been introduced for the injection of hydrocele, which accomplishes the object with such certainty and safety as to have left no room for discussion, and the treatment of hydrocele may now be said to be as near perfection as can be supposed possible. After the treatment by injection had been first suggested by Munro, a Scotch army surgeon, various fluids were tried by others, and an admirable paper by Sabatier, in the Memoirs of the French Academy of Surgery, contains an account of experiments made with almost every conceivable fluid. When I was house-surgeon at this hospital there happened to be, at one time, twelve patients with hycrocele in the house together; and it was suggested by one of the surgeons that as it was a pity to use so much port-wine as would be requisite, cold water might be tried instead : this was accordingly done, with the effect of curing some of the patients, while others remained in the same state as before, and one died. Since that time cold water has not been used again here, but one surgeon tried insufflation of air with no very satisfactory results. The introduction of iodine, however, put It has been tried in various an end to all these experiments. forms, but in my own practice, I have been long satisfied that the pure tincture of our pharmacopoeia is the best ; about two drachms should be thrown in, without much regard to the size of the hydrocele. The curative effect of injection, whatever be the nature of the fluid, is to produce a degree of inflammation, attended with such a degree of lymphatic effusion, as to cause the obliteration of the serous cavity, or else so to change ’, its surface as to prevent the undue secretion of fluid. In the case of tincture of iodine, I believe obliteration is always produced. There is in the museum a beautiful specimen, sent there by myself, of a hydrocele in which the cure is in progress, and where thick bands of lymph are to be seen between the surfaces of the sac, with interspaces occupied by serous fluid. I have also dissected testicles after the cure was complete, and have always found the two surfaces firmly united. The advantages of this method of treatment are, that it is effectual with very little pain to the patient, and at the same time perfectly safe. I have been told that the injection of iodine into the cellular substance is not injurious; but I confess this is an experiment which I should not like to try. I recollect going to assist at the injection of a hydrocele with
HYDRoCELE is
an
I
port-wine in a patient who had been before operated on by of incision, on Mr. Benjamin Bell, by his favouriteendmethod of last century. My which he wrote a book towards the friend, who went to perform the operation, spoke exultingly of the superiority of injection over incision. He then drew off No. 1653.
1855.
fluid, and injected the port-wine; but, on attempting to draw it off, could not get a single drop to come away; it had been forced into the cellular substance, and excited so much inflammation as almost to kill the patient, who, I need not say, was not much impressed with the improvements of modern surgery as far as they concerned his case. For performing the operation, the best syringe is one which was, I dare say, familiar to all of you in youth-viz., a common sixpenny squirt, which holds just about the proper quantity, and fits accurately to the canula, on account of the softness of the metal of which it is composed. If you go to the shops, and ask for an instrument for injecting hydrocele, there will, perhaps, be shown to you a glass apparatus, with a metallic nozzle, and I know not what other niceties. This I would call the foppery of surgery, quite unworthy of gentlemen who have in view the single object of the effectual treatment of their patients; you wiU always find that the best workmen use the simplest tools. But while I speak thus of the syringe, I would recommend you to be very careful about your trocars; see that the trocar fits accurately to the canula, and that the margin of the latter does not project beyond the surface of the former, otherwise the sac is liable to be pushed before the canula, so as to impede the injection and endanger the testicle. You should always avoid using the instrument more than once or twice without its being sharpened. Before entering the trocar, reilder the sac tense by grasping it in the hollow of the hand, and take care to select for the puncture a part where tluctuation can be distinctly perceived; then push in the instrument till you feel that its point is free in the cavity, and, withdrawing the trocar, push on the canula a little further. Be sure you do not puncture where the testicle is; for the organ is by no means con. stantly pl’.,ced at the posterior and inferior aspect of the sac, but is so.netimes situated anteriorly. In examining for the position of the testicle, you are aided by the feelings of the patient, who experiences pain when it is squeezed, but none when the sac only is handled. I had a few days ago under my care a general officer, who hud been under treatment in India for hydrocele, and had suffered most excruciating pain during its injection, and afterwards took iodine internally to-an almost incredible extent, with the effect of greatly impairing an iron constitution, but without causing absorption of the -re-effused fluid. As the hydrocele presented no unusual character, I recommended a repetition of the injection, which he was at first very unwilling to submit to, through dread of repetition of the pain; but he at length made up his mind, and I performed the operation in the usual manner, and vrith the usual result. He called on me the day before yesterday, and said that he must admit there had been no pain from the operation. In this case the difference of suffering, and also of result, can, I think, be accounted for only by supposknj that the testicle had been injured in the first operation. The only other point to which I wish to direct your attention is, that some hydroceles present certain peculiarities; some are small and round, looking like a supernumerary testicle, the real one being usually placed below the sac, and, when evacuated, are found to contain a fluid, not clear and strawcoloured like that of an ordinary hydrocele, but colourless and slightly opalescent, owing to the presence of multitudes of spermatozoa, which are seen when a drop is placed under the microscope. The distinction thus established by the microscope has been supposed to be a reason for difference of treatment; but this I believe to be quite an error, as I have always found these spermatoceles, as they have been called, no less amenable to injection than the ordinary kind. You may recollect my showing you some time ago a good example of the fluid from one of these collections; in that case the sac was injected with iodine, and the cure was quite satisfactory. But whatever confusion the microscope may have caused in the treatment of this form of hydrocele, it has much more to answer for with regard to spermatorrhoea. It is not surprising, considering the excursive tendency of the animalcules in question, that they should occasionally leave their proper ducts, and pass out with the urine; and if a patient, who has been led to think that there is anything wrong in that quarter, unhappily has his urine examined microscopically, and learns that any of these long-tailed creatures are present in it, he readily believes there is something very far wrong; and I have known persons driven to the very verge of madness, if not to actual iasanity, on account of that which, I believe, would be found to happen with every one, if the urine were examined at proper times. Sometimes -the fluid is found between the vessels of the cord, and, in this case, which is more strictly called hydrocele of the cord, the tumour generally attains a larger size. This form of the disease has been also supposed less amen-
the
Lectures CLINICAL
5,
s
448 able to treatment by injection than common hydrocele ; but there seems to be no good ground for such a distinction. Not long ago I received a letter from a gentleman in London, he had a large hydrocele, which Sir Benjamin Brodie had told him was one of this last kind, and was therefore incurable; but having happened to learn that I did not regard any such difference as an objection, wished to know if I would undertake his case. I had no hesitation in complying; and he returned home completely relieved in less than a fort-
tails of four spermatozoa projecting from it, and many of the free spermatozoa had the remains of cell contents attached about their necks; lastly, many cells were present which were evidently destined for the formation of spermatozoa, the rudiments of which could often be more or less distinctly traced in their interior. These appearances show that the spermatic animalcule did not in this case enter the sac by penetration from without through its parieties, as has been supposed by some to occur in similar cases. ]
stating that
night.
INTERNAL DERANGEMENT OF THE KNEE-JOINT. [The patient having been brought into the theatre, Mr. Syme said :-] Many years ago, gentlemen, in reading the observations of You observe, this large tumour reaches quite up to the Mr. of Leeds, I was much struck with some cases menHey, groin, and thus presents features of a hernia rather than a tioned by him under the title Internal Derangement of the hydrocele. The first question to be determined in examining Knee-joint," in which the articulation was affected with some a scrotal tumour is, whether it is a swelling of the parts natuobscure injury, producing more or less lameness, and interrally contained in the scrotum, or whether it is produced by fering with the perfect motion of the limb, and remedied by the descent of a portion of the contents of the abdominal acute flexion, followed by sudden extension of the leg. From cavity. With regard to this point, the best criterion is the state that time I had been on the look out for such cases, without of the cord at the external ring ; if, on taking hold of it there, ever meeting with one, and though I never doubted Mr. Hey’s you find that nothing more is present than its natural con- accuracy, I could not but wonder that that of which he had seen stituents, you are sure that the tumour is not a hernia; and several examples should never have occurred in my practice. this I find to be the case in the present instance. It is fur- The other day, however, a case of this kind came under my ther evident, from the sensation communicated to the fingers, care, and you did not see it, I think it would be although that this is a collection of fluid; in fact, an ordinary hydrowrong if I omitted to allude to it; but before speaking of it, I cele, which I shall now proceed to inject. will read you the account given by Mr. Hey of one of his cases. [Having drawn off twenty-two ounces of straw-coloured " In 1784, the Honourable Miss Harriet Ingram, as she was lluid, Mr. Syme remarked:-] with a child, and making a considerable exertion, and playing When all the fluid has been removed, it is right to feel the herself forward, and stooping to take hold of the stretching testicle, which you could not do before, in order to ascertain child while she rested upon one leg, brought on an immediate if it is in a fit state for injection; a moderate degree of en- lameness in the knee-joint of that leg on which she stood. largement is certainly no obstacle to injection with iodine, The disorder was considered as a simple sprain, and a plaster which, on the contrary, appears to be the best means of pro- was applied round the joint. As the lameness did not diminish moting its diminution. in the course of five or six days, I was desired to visit her. [Mr. Syme then threw in about two drachms of tincture of Upon comparing the knees, I could perceive no difference, iodine, and having shaken the part well to ensure the diffusion of except that when the knees were placed in a state of complete the fluid over the whole surface of the sac, directed the patient, extension, the ligament of the patella of the injured joint who suffered little or no pain, to walk to his bed. He then re- seemed to be rather more relaxed than in that joint which had marked :—] received no injury. When I moved the affected knee by a At the time of the injection some pain, often very slight, is gentle flexion and extension, my patient complained of no felt in the part, and extending up the loins; in the course of pain, yet she could not perfectly extend the leg in walking, the day, the tumour begins to increase again; and, about the nor bend it in raising the foot from the floor, but moved as if third or fourth day, the swelling caused by inflammatory effu- the joint had been stiff, limping very much, and walking with sion is at its height. No treatment, however, is required, ex- pain. I thought it probable that the sudden exertion might in cept rest and moderate living for a few days, when the tumour some degree have altered the situation of the cross ligaments, gradually subsides, and ultimately disappears entirely. or otherwise have displaced the condyles of the os femoris with [After the injection, the fluid re-accumulated, being at its respect to the semilunar cartilages, so that the condyles might maximum about the fourth day, the integuments of the scrotum meet with some resistance when the flexor or extensor muscles being at the same time being slightly red and oedematous. A were put into action, and thereby the free motion of the joint few days later, the tumour having already considerably dimimight be hindered when the incumbent weight of the body nished, the patient left the hospital. pressed the thigh-bone closely against the tibia, though this On the 21st of April Mr. Syme brought before the class a derangement was not so great as to prevent the joint, when man, thirty-six years of age, affected with a large scrotal relaxed, from being moved with ease. To remedy this detumour of the left side, of nearly globular form, reaching rangement, I placed my patient upon an elevated seat, which up to the external ring, with the testicle at its lower and had nothing underneath it which could prevent the leg from anterior part as a distinct prominence, having the ordinary backward towards the posterior part of the thigh. being characters of that organ, while the rest of the tumour was I thenpushed extended the joint by the assistance of one hand placed obviously a collection of fluid; the vessels of the cord were to just above the knee, while with the other hand I grasped the be felt expanded over the anterior part of the sac. The patient During the continuance of the extension, I suddenly stated that it had commenced six years before as a small leg. moved the leg backwards, that it might make as acute an swelling immediately above the testicle, and had since conwith the thigh as possible. This operation I repeated tinued to increase. Mr. Syme, after pointingout its charac- angle once, and then desired the young lady to try how she could ters, said that it was evidently a hydrocele of the cord, but walk. Whatever may be thought of my theory, my practice that it was impossible before puncturing it to say whether it proved successful, for she was immediately able to walk were a spermatocele, or contained serous fluid like an ordinary without lameness, and on the third day after this reduction hydrocele. He also remarked that if the direction usually she danced at a private ball, without inconvenience, or regiven for puncturing hydrocele were followed in this case, ceiving any injury from the exercise."* there would be danger of wounding the testicle. He then The case to which I wish to direct your attention was that drew off, by canula and trocar, about a pint of nearly colour- of a young man, about thirty years of age, who came from less and slightly opalescent fluid, remarking that he had no the to consult me on account of stiffness and pain country doubt, from its characters, that it would be found to contain in the right knee, of four or five days’ standing. He had spermatozoa, since he had repeatedly met with as large tumours been for some years liable to attacks of this kind, but of this kind. Having emptied the sac completely, he threw in they had generally passed off quickly. His case differed about two drachms of tincture of iodine. The fluid re-accumu- from that of the young lady mentioned by Mr. Hey, inlated, so that on the third day after the injection the tumour asmuch as it was impossible to extend the limb completely, had again attained its former size, and at the present time even by external force, but, as in Mr. Hey’s case, there (April 24th) it has already begun to diminish again, and is was nothing to be felt wrong about the joint, except a loose but slightly tender to the touch. The fluid was examined cartilage in the pouch above the patella, freely movable, and microscopically by Mr. Lister, who found it to contain numerousi evidently having nothing to do with maintaining the derangespermatozoa, of which some presented their ordinary appear-ment of the knee. As movement of the joint to any considerunder the ance and lashing movements, while many were coiled up as if: able extent caused acute pain, I placed the just escaped from cells; others were distinctly seen in the influence of chloroform, and following Mr.patient Hey’s principle, interior of cells, some of which contained a single spermatozoon, ,
’ ’
others
as
many
as
three
or
four;
one
cell
was seen
with the
,
Vide
Hey’s Observations in Surgery, 1810, p. 336.
449 bent the limb to the full extent, and then attempted to extend it, but at first did not succeed in doing so completely; but after repeating the process several times, and shaking the limb in every direction, while the muscles were completely relaxed, I felt something give way in the joint, and then immediately found myself able to extend the limb completely, and the patient was from that time free from lameness. Mr. Hey speaks of some displacement of the crucial ligaments or semilunar cartilages as the probable cause of the lameness in these cases; the latter appears to me the more likely explanation; but, as Mr. Hey says, whatever may be thought of the theory, the practice proved successful.
FIRST
QUARTERLY METEOROLOGICAL
AND
CHEMICAL REPORT AT THOMAS’S HOSPITAL FOR 1855.
BY ROBERT DUNDAS
THOMSON, M.D., F.R.S. L.
PROFESSOR OF CHEMISTRY IN ST.
THOMAS’S
ST. &
E.,
HOSPITAL COLLEGE.
THE present quarter appears to have been the coldest on record since 1814; at that period the cold commenced about Christmas, 1813; whereas, in the present year, it began on the 10th of January. In 1814, the weather became warmer after the 21st of March; but, in 1855, the cold continued till the beginning of April. For three months the thermometer has been on some portion of almost every day near the freezing point,-the mean temperature of the whole quarter having only been 35°’4. The mean temperature of February was 300’8; with easterly and north-easterly winds. These winds also predominated during January and March. The greatest cold registered in England, with compared thermometers, was 00’8 at Berkhampstead. At other places it was 3°, 5°, 7°, and J0°. The lowest temperature at Elgin, in Scotland, in lat. 57°, as determined with compared thermometers by Dr. Geddes, was 3°. The effect of the protracted cold upon the aged has been very strikingly registered in the bills of mol" tality throughout the country-a result which must be perceptible in all cold countries, and which seems to render very old age, in regions where long winters exist, an impossibility, at least under the present laws of mortality. Persons in advanced life should, therefore, not emigrate to the more northerly states of North America or Canada, but seek a more tropical climate. This is a question deserving of attention by insurThe lowest temperature at St. Thomas’s Hospital ance offices. was 18°’S on the 18th of February, while the highest temperature was 54°’2 on the 21st of March. The barometer in January was high : on all the weeks considerably above the average. In all the weeks of February, with the exception of the last, below the average. In March also the pressure was below the average. The amount of water which fell in the form of snow was nearly an inch. Snow fell on eight days in January. The fogs have not been so dense as in the preceding year, which may be due, in some measure, to the low temperature of the river, and the resulting diminished evaporation. REPORT ON
CHEMICALS, &c.
1. the
Zop.s.—In consequence of the differences in the seasons, quality of hops varies greatly in different years. The general external characters by which hops are recognised, particularly the greasy feel when rubbed, are usually in accordance with the results obtained by chemical examination. The beer used by the inmates of St. Thomas’s Hospital being
brewed on the establishment, it is a matter of consideration that the hops selected should be of good quality, as there can be little doubt that the bitter principle in such a beverage is not the least important ingredient. Six samples of hops gave the following quantities of extract from the same amount of
vegetables
,
-
.
"
liquor :--
From this table it appears that the total amount of extract affords no correct key to the amount of salts or acids, although where much salts and acid are present, there is likewise a corresponding augmentation of residue. In none of these specimens could free sulphuric acid be detected. 3. Potassii Ioclidi.-Out of seven samples, each sent by a different dealer, only two gave no effervescence. 4. Potassae S’ulp7zcxs.-Contained a trace of chloride of potassium. 5. Potassae Carbonas.-This specimen contained ’686 per cent. of chloride of potassium. 6. Potassae Hydras.-A sample contained 6’99 per cent. of carbonate of potash. 7. Pulv. Potassce Bicurb.-A specimen lost 32’S per cent. by ignition, instead of 30 ’5, the theoretical amount. It contained ’19 per cent. of chloride of potassium. 8. Sodce Potas8io-l’art.-This salt lost by ignition 57’8 per cent. instead of 56.7. 9. Antim. Mw’ias.-This preparation gave, for half a fluid ounce, 92 grains of residue ; much iron was present, showing either thatimpure tersulphide of antimony had been employed, or a ferruginous metallic antimony was the material from which the solution had been made. This carelessness should be avoided. 10. Zinci Chlorídum.-Yielded a trace of oxide. This was the best specimen I have examined for some time. 11. Tinct. Fen.i S’e.suiclzloridi.-One ounce of one sample yielded 35’9 grains of sesquioxide of iron. On rejecting it another sample was returned, yielding 30’2 grains of sesquioxide. 12. Vinum Pi -Half an ounce yielded 17 ’4 grains of residue. 13. Vinum OpM.—The specific gravity was found to be ’990, half an ounce yielding 79 grains of residue. 14. Acidum Hydrocyanicum.-100 grains gave 9’98 grains of cyanide of silver-the proper quantity. 15. Clilo?,ofo2-2)i. -A sample had a specific gravity of 1’525. This seems too high, although no impurity was detected. Chloroform was first obtained in my laboratory, of the specific gravity 1’5 by my pupil Mr. James King, several years ago, an account of which was published at the time in THE LANCET. 16. Pulv. Scammon.-Of four samples, which all contained starch, only one was considered fit for purchase, although the starch should have been entirely absent. It is to be hoped that the frequent complaint that no genuine scammony is to be had in England may at last induce the importation of the genuine drug-especially now that our profession has gained a footing in Asia Minor. 17. Brown Diszclplaccte of Quinizze.-I have found the composition of this salt, as compared with the white disulphate, to be as in the following table : -
Brown Salt.
White Salt.
, -
The following table exhibits the equivalents of these specimens ; and is thus read-100 parts of No. 6 will go as far as 126’5 of No. 5, in giving flavour and preservative power to the
fermented
There was no difficulty in deciding which of these samples to be preferred. 2. Lemun-juice.-As the mode in which lemon-juice acts I believe to be the same as that in which succulent vegetables prove advantageous in scurvy and purpura-viz., by its containing those saline ingredients (chlorides, sulphates, phosphates of the alkalies, &c.), which are likely to be absent from the food when it is restricted in its derivation, I consider it important to determine the amount of the saline residue from a given quantity of lemon-juice. The results of my examination of£ lemon-juice I published many years ago and have given the " summary in my School Chemistry," in 1848. These samples yielded the following results from a pint of each:was
There is observable here a difference in the amount of water, which may be due to some alteration in the alkaloid itself. Frequent objections have been started to the use of this preparation by physicians, on the ground of its inferiority in a therapeutic point of view to the white salt. Before confidence can be placed in it as a medicine, it would be necessary to know its mode of preparation, since slight causes induce isomeric modifications of quinine, which are not known to possess similar physiological actions. April, 1855.
ON
SURGERY,
DELIVERED DURING
THE WINTER SESSION OF 1854-5.
BY JAMES
SYME, ESQ.,
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.
LECTURE XVIII. HYDROCELE.
affection regarding the treatment of which there has been, till within a comparatively recent period, great diversity of opinion and practice. The common treatment in this country was injection with port-wine, which, however, was so liable to unpleasant occurrences, that many surgeons ’ z’ were dissatisfied with it, and preferred other methods, such as incision, excision of the whole or a portion of the sac, and the seton. It was alleged that these methods, though more painful at the time, did not occasion so much subsequent suffering as the port-wine injection, and were nor attended with so much danger of sloughing of the scrotum, or even of death itself, which was known to have occurred occasionally, from the escape of the wine into the cellular substance. While the treatment was in this unsettled state, hydrocele was often e’hosen as the subject of thesis at graduation, which implied that it was one admitting of a great diversity of opinion. Since that time, however, a fluid has been introduced for the injection of hydrocele, which accomplishes the object with such certainty and safety as to have left no room for discussion, and the treatment of hydrocele may now be said to be as near perfection as can be supposed possible. After the treatment by injection had been first suggested by Munro, a Scotch army surgeon, various fluids were tried by others, and an admirable paper by Sabatier, in the Memoirs of the French Academy of Surgery, contains an account of experiments made with almost every conceivable fluid. When I was house-surgeon at this hospital there happened to be, at one time, twelve patients with hycrocele in the house together; and it was suggested by one of the surgeons that as it was a pity to use so much port-wine as would be requisite, cold water might be tried instead : this was accordingly done, with the effect of curing some of the patients, while others remained in the same state as before, and one died. Since that time cold water has not been used again here, but one surgeon tried insufflation of air with no very satisfactory results. The introduction of iodine, however, put It has been tried in various an end to all these experiments. forms, but in my own practice, I have been long satisfied that the pure tincture of our pharmacopoeia is the best ; about two drachms should be thrown in, without much regard to the size of the hydrocele. The curative effect of injection, whatever be the nature of the fluid, is to produce a degree of inflammation, attended with such a degree of lymphatic effusion, as to cause the obliteration of the serous cavity, or else so to change ’, its surface as to prevent the undue secretion of fluid. In the case of tincture of iodine, I believe obliteration is always produced. There is in the museum a beautiful specimen, sent there by myself, of a hydrocele in which the cure is in progress, and where thick bands of lymph are to be seen between the surfaces of the sac, with interspaces occupied by serous fluid. I have also dissected testicles after the cure was complete, and have always found the two surfaces firmly united. The advantages of this method of treatment are, that it is effectual with very little pain to the patient, and at the same time perfectly safe. I have been told that the injection of iodine into the cellular substance is not injurious; but I confess this is an experiment which I should not like to try. I recollect going to assist at the injection of a hydrocele with
HYDRoCELE is
an
I
port-wine in a patient who had been before operated on by of incision, on Mr. Benjamin Bell, by his favouriteendmethod of last century. My which he wrote a book towards the friend, who went to perform the operation, spoke exultingly of the superiority of injection over incision. He then drew off No. 1653.
1855.
fluid, and injected the port-wine; but, on attempting to draw it off, could not get a single drop to come away; it had been forced into the cellular substance, and excited so much inflammation as almost to kill the patient, who, I need not say, was not much impressed with the improvements of modern surgery as far as they concerned his case. For performing the operation, the best syringe is one which was, I dare say, familiar to all of you in youth-viz., a common sixpenny squirt, which holds just about the proper quantity, and fits accurately to the canula, on account of the softness of the metal of which it is composed. If you go to the shops, and ask for an instrument for injecting hydrocele, there will, perhaps, be shown to you a glass apparatus, with a metallic nozzle, and I know not what other niceties. This I would call the foppery of surgery, quite unworthy of gentlemen who have in view the single object of the effectual treatment of their patients; you wiU always find that the best workmen use the simplest tools. But while I speak thus of the syringe, I would recommend you to be very careful about your trocars; see that the trocar fits accurately to the canula, and that the margin of the latter does not project beyond the surface of the former, otherwise the sac is liable to be pushed before the canula, so as to impede the injection and endanger the testicle. You should always avoid using the instrument more than once or twice without its being sharpened. Before entering the trocar, reilder the sac tense by grasping it in the hollow of the hand, and take care to select for the puncture a part where tluctuation can be distinctly perceived; then push in the instrument till you feel that its point is free in the cavity, and, withdrawing the trocar, push on the canula a little further. Be sure you do not puncture where the testicle is; for the organ is by no means con. stantly pl’.,ced at the posterior and inferior aspect of the sac, but is so.netimes situated anteriorly. In examining for the position of the testicle, you are aided by the feelings of the patient, who experiences pain when it is squeezed, but none when the sac only is handled. I had a few days ago under my care a general officer, who hud been under treatment in India for hydrocele, and had suffered most excruciating pain during its injection, and afterwards took iodine internally to-an almost incredible extent, with the effect of greatly impairing an iron constitution, but without causing absorption of the -re-effused fluid. As the hydrocele presented no unusual character, I recommended a repetition of the injection, which he was at first very unwilling to submit to, through dread of repetition of the pain; but he at length made up his mind, and I performed the operation in the usual manner, and vrith the usual result. He called on me the day before yesterday, and said that he must admit there had been no pain from the operation. In this case the difference of suffering, and also of result, can, I think, be accounted for only by supposknj that the testicle had been injured in the first operation. The only other point to which I wish to direct your attention is, that some hydroceles present certain peculiarities; some are small and round, looking like a supernumerary testicle, the real one being usually placed below the sac, and, when evacuated, are found to contain a fluid, not clear and strawcoloured like that of an ordinary hydrocele, but colourless and slightly opalescent, owing to the presence of multitudes of spermatozoa, which are seen when a drop is placed under the microscope. The distinction thus established by the microscope has been supposed to be a reason for difference of treatment; but this I believe to be quite an error, as I have always found these spermatoceles, as they have been called, no less amenable to injection than the ordinary kind. You may recollect my showing you some time ago a good example of the fluid from one of these collections; in that case the sac was injected with iodine, and the cure was quite satisfactory. But whatever confusion the microscope may have caused in the treatment of this form of hydrocele, it has much more to answer for with regard to spermatorrhoea. It is not surprising, considering the excursive tendency of the animalcules in question, that they should occasionally leave their proper ducts, and pass out with the urine; and if a patient, who has been led to think that there is anything wrong in that quarter, unhappily has his urine examined microscopically, and learns that any of these long-tailed creatures are present in it, he readily believes there is something very far wrong; and I have known persons driven to the very verge of madness, if not to actual iasanity, on account of that which, I believe, would be found to happen with every one, if the urine were examined at proper times. Sometimes -the fluid is found between the vessels of the cord, and, in this case, which is more strictly called hydrocele of the cord, the tumour generally attains a larger size. This form of the disease has been also supposed less amen-
the
Lectures CLINICAL
5,
s
448 able to treatment by injection than common hydrocele ; but there seems to be no good ground for such a distinction. Not long ago I received a letter from a gentleman in London, he had a large hydrocele, which Sir Benjamin Brodie had told him was one of this last kind, and was therefore incurable; but having happened to learn that I did not regard any such difference as an objection, wished to know if I would undertake his case. I had no hesitation in complying; and he returned home completely relieved in less than a fort-
tails of four spermatozoa projecting from it, and many of the free spermatozoa had the remains of cell contents attached about their necks; lastly, many cells were present which were evidently destined for the formation of spermatozoa, the rudiments of which could often be more or less distinctly traced in their interior. These appearances show that the spermatic animalcule did not in this case enter the sac by penetration from without through its parieties, as has been supposed by some to occur in similar cases. ]
stating that
night.
INTERNAL DERANGEMENT OF THE KNEE-JOINT. [The patient having been brought into the theatre, Mr. Syme said :-] Many years ago, gentlemen, in reading the observations of You observe, this large tumour reaches quite up to the Mr. of Leeds, I was much struck with some cases menHey, groin, and thus presents features of a hernia rather than a tioned by him under the title Internal Derangement of the hydrocele. The first question to be determined in examining Knee-joint," in which the articulation was affected with some a scrotal tumour is, whether it is a swelling of the parts natuobscure injury, producing more or less lameness, and interrally contained in the scrotum, or whether it is produced by fering with the perfect motion of the limb, and remedied by the descent of a portion of the contents of the abdominal acute flexion, followed by sudden extension of the leg. From cavity. With regard to this point, the best criterion is the state that time I had been on the look out for such cases, without of the cord at the external ring ; if, on taking hold of it there, ever meeting with one, and though I never doubted Mr. Hey’s you find that nothing more is present than its natural con- accuracy, I could not but wonder that that of which he had seen stituents, you are sure that the tumour is not a hernia; and several examples should never have occurred in my practice. this I find to be the case in the present instance. It is fur- The other day, however, a case of this kind came under my ther evident, from the sensation communicated to the fingers, care, and you did not see it, I think it would be although that this is a collection of fluid; in fact, an ordinary hydrowrong if I omitted to allude to it; but before speaking of it, I cele, which I shall now proceed to inject. will read you the account given by Mr. Hey of one of his cases. [Having drawn off twenty-two ounces of straw-coloured " In 1784, the Honourable Miss Harriet Ingram, as she was lluid, Mr. Syme remarked:-] with a child, and making a considerable exertion, and playing When all the fluid has been removed, it is right to feel the herself forward, and stooping to take hold of the stretching testicle, which you could not do before, in order to ascertain child while she rested upon one leg, brought on an immediate if it is in a fit state for injection; a moderate degree of en- lameness in the knee-joint of that leg on which she stood. largement is certainly no obstacle to injection with iodine, The disorder was considered as a simple sprain, and a plaster which, on the contrary, appears to be the best means of pro- was applied round the joint. As the lameness did not diminish moting its diminution. in the course of five or six days, I was desired to visit her. [Mr. Syme then threw in about two drachms of tincture of Upon comparing the knees, I could perceive no difference, iodine, and having shaken the part well to ensure the diffusion of except that when the knees were placed in a state of complete the fluid over the whole surface of the sac, directed the patient, extension, the ligament of the patella of the injured joint who suffered little or no pain, to walk to his bed. He then re- seemed to be rather more relaxed than in that joint which had marked :—] received no injury. When I moved the affected knee by a At the time of the injection some pain, often very slight, is gentle flexion and extension, my patient complained of no felt in the part, and extending up the loins; in the course of pain, yet she could not perfectly extend the leg in walking, the day, the tumour begins to increase again; and, about the nor bend it in raising the foot from the floor, but moved as if third or fourth day, the swelling caused by inflammatory effu- the joint had been stiff, limping very much, and walking with sion is at its height. No treatment, however, is required, ex- pain. I thought it probable that the sudden exertion might in cept rest and moderate living for a few days, when the tumour some degree have altered the situation of the cross ligaments, gradually subsides, and ultimately disappears entirely. or otherwise have displaced the condyles of the os femoris with [After the injection, the fluid re-accumulated, being at its respect to the semilunar cartilages, so that the condyles might maximum about the fourth day, the integuments of the scrotum meet with some resistance when the flexor or extensor muscles being at the same time being slightly red and oedematous. A were put into action, and thereby the free motion of the joint few days later, the tumour having already considerably dimimight be hindered when the incumbent weight of the body nished, the patient left the hospital. pressed the thigh-bone closely against the tibia, though this On the 21st of April Mr. Syme brought before the class a derangement was not so great as to prevent the joint, when man, thirty-six years of age, affected with a large scrotal relaxed, from being moved with ease. To remedy this detumour of the left side, of nearly globular form, reaching rangement, I placed my patient upon an elevated seat, which up to the external ring, with the testicle at its lower and had nothing underneath it which could prevent the leg from anterior part as a distinct prominence, having the ordinary backward towards the posterior part of the thigh. being characters of that organ, while the rest of the tumour was I thenpushed extended the joint by the assistance of one hand placed obviously a collection of fluid; the vessels of the cord were to just above the knee, while with the other hand I grasped the be felt expanded over the anterior part of the sac. The patient During the continuance of the extension, I suddenly stated that it had commenced six years before as a small leg. moved the leg backwards, that it might make as acute an swelling immediately above the testicle, and had since conwith the thigh as possible. This operation I repeated tinued to increase. Mr. Syme, after pointingout its charac- angle once, and then desired the young lady to try how she could ters, said that it was evidently a hydrocele of the cord, but walk. Whatever may be thought of my theory, my practice that it was impossible before puncturing it to say whether it proved successful, for she was immediately able to walk were a spermatocele, or contained serous fluid like an ordinary without lameness, and on the third day after this reduction hydrocele. He also remarked that if the direction usually she danced at a private ball, without inconvenience, or regiven for puncturing hydrocele were followed in this case, ceiving any injury from the exercise."* there would be danger of wounding the testicle. He then The case to which I wish to direct your attention was that drew off, by canula and trocar, about a pint of nearly colour- of a young man, about thirty years of age, who came from less and slightly opalescent fluid, remarking that he had no the to consult me on account of stiffness and pain country doubt, from its characters, that it would be found to contain in the right knee, of four or five days’ standing. He had spermatozoa, since he had repeatedly met with as large tumours been for some years liable to attacks of this kind, but of this kind. Having emptied the sac completely, he threw in they had generally passed off quickly. His case differed about two drachms of tincture of iodine. The fluid re-accumu- from that of the young lady mentioned by Mr. Hey, inlated, so that on the third day after the injection the tumour asmuch as it was impossible to extend the limb completely, had again attained its former size, and at the present time even by external force, but, as in Mr. Hey’s case, there (April 24th) it has already begun to diminish again, and is was nothing to be felt wrong about the joint, except a loose but slightly tender to the touch. The fluid was examined cartilage in the pouch above the patella, freely movable, and microscopically by Mr. Lister, who found it to contain numerousi evidently having nothing to do with maintaining the derangespermatozoa, of which some presented their ordinary appear-ment of the knee. As movement of the joint to any considerunder the ance and lashing movements, while many were coiled up as if: able extent caused acute pain, I placed the just escaped from cells; others were distinctly seen in the influence of chloroform, and following Mr.patient Hey’s principle, interior of cells, some of which contained a single spermatozoon, ,
’ ’
others
as
many
as
three
or
four;
one
cell
was seen
with the
,
Vide
Hey’s Observations in Surgery, 1810, p. 336.
449 bent the limb to the full extent, and then attempted to extend it, but at first did not succeed in doing so completely; but after repeating the process several times, and shaking the limb in every direction, while the muscles were completely relaxed, I felt something give way in the joint, and then immediately found myself able to extend the limb completely, and the patient was from that time free from lameness. Mr. Hey speaks of some displacement of the crucial ligaments or semilunar cartilages as the probable cause of the lameness in these cases; the latter appears to me the more likely explanation; but, as Mr. Hey says, whatever may be thought of the theory, the practice proved successful.
FIRST
QUARTERLY METEOROLOGICAL
AND
CHEMICAL REPORT AT THOMAS’S HOSPITAL FOR 1855.
BY ROBERT DUNDAS
THOMSON, M.D., F.R.S. L.
PROFESSOR OF CHEMISTRY IN ST.
THOMAS’S
ST. &
E.,
HOSPITAL COLLEGE.
THE present quarter appears to have been the coldest on record since 1814; at that period the cold commenced about Christmas, 1813; whereas, in the present year, it began on the 10th of January. In 1814, the weather became warmer after the 21st of March; but, in 1855, the cold continued till the beginning of April. For three months the thermometer has been on some portion of almost every day near the freezing point,-the mean temperature of the whole quarter having only been 35°’4. The mean temperature of February was 300’8; with easterly and north-easterly winds. These winds also predominated during January and March. The greatest cold registered in England, with compared thermometers, was 00’8 at Berkhampstead. At other places it was 3°, 5°, 7°, and J0°. The lowest temperature at Elgin, in Scotland, in lat. 57°, as determined with compared thermometers by Dr. Geddes, was 3°. The effect of the protracted cold upon the aged has been very strikingly registered in the bills of mol" tality throughout the country-a result which must be perceptible in all cold countries, and which seems to render very old age, in regions where long winters exist, an impossibility, at least under the present laws of mortality. Persons in advanced life should, therefore, not emigrate to the more northerly states of North America or Canada, but seek a more tropical climate. This is a question deserving of attention by insurThe lowest temperature at St. Thomas’s Hospital ance offices. was 18°’S on the 18th of February, while the highest temperature was 54°’2 on the 21st of March. The barometer in January was high : on all the weeks considerably above the average. In all the weeks of February, with the exception of the last, below the average. In March also the pressure was below the average. The amount of water which fell in the form of snow was nearly an inch. Snow fell on eight days in January. The fogs have not been so dense as in the preceding year, which may be due, in some measure, to the low temperature of the river, and the resulting diminished evaporation. REPORT ON
CHEMICALS, &c.
1. the
Zop.s.—In consequence of the differences in the seasons, quality of hops varies greatly in different years. The general external characters by which hops are recognised, particularly the greasy feel when rubbed, are usually in accordance with the results obtained by chemical examination. The beer used by the inmates of St. Thomas’s Hospital being
brewed on the establishment, it is a matter of consideration that the hops selected should be of good quality, as there can be little doubt that the bitter principle in such a beverage is not the least important ingredient. Six samples of hops gave the following quantities of extract from the same amount of
vegetables
,
-
.
"
liquor :--
From this table it appears that the total amount of extract affords no correct key to the amount of salts or acids, although where much salts and acid are present, there is likewise a corresponding augmentation of residue. In none of these specimens could free sulphuric acid be detected. 3. Potassii Ioclidi.-Out of seven samples, each sent by a different dealer, only two gave no effervescence. 4. Potassae S’ulp7zcxs.-Contained a trace of chloride of potassium. 5. Potassae Carbonas.-This specimen contained ’686 per cent. of chloride of potassium. 6. Potassae Hydras.-A sample contained 6’99 per cent. of carbonate of potash. 7. Pulv. Potassce Bicurb.-A specimen lost 32’S per cent. by ignition, instead of 30 ’5, the theoretical amount. It contained ’19 per cent. of chloride of potassium. 8. Sodce Potas8io-l’art.-This salt lost by ignition 57’8 per cent. instead of 56.7. 9. Antim. Mw’ias.-This preparation gave, for half a fluid ounce, 92 grains of residue ; much iron was present, showing either thatimpure tersulphide of antimony had been employed, or a ferruginous metallic antimony was the material from which the solution had been made. This carelessness should be avoided. 10. Zinci Chlorídum.-Yielded a trace of oxide. This was the best specimen I have examined for some time. 11. Tinct. Fen.i S’e.suiclzloridi.-One ounce of one sample yielded 35’9 grains of sesquioxide of iron. On rejecting it another sample was returned, yielding 30’2 grains of sesquioxide. 12. Vinum Pi -Half an ounce yielded 17 ’4 grains of residue. 13. Vinum OpM.—The specific gravity was found to be ’990, half an ounce yielding 79 grains of residue. 14. Acidum Hydrocyanicum.-100 grains gave 9’98 grains of cyanide of silver-the proper quantity. 15. Clilo?,ofo2-2)i. -A sample had a specific gravity of 1’525. This seems too high, although no impurity was detected. Chloroform was first obtained in my laboratory, of the specific gravity 1’5 by my pupil Mr. James King, several years ago, an account of which was published at the time in THE LANCET. 16. Pulv. Scammon.-Of four samples, which all contained starch, only one was considered fit for purchase, although the starch should have been entirely absent. It is to be hoped that the frequent complaint that no genuine scammony is to be had in England may at last induce the importation of the genuine drug-especially now that our profession has gained a footing in Asia Minor. 17. Brown Diszclplaccte of Quinizze.-I have found the composition of this salt, as compared with the white disulphate, to be as in the following table : -
Brown Salt.
White Salt.
, -
The following table exhibits the equivalents of these specimens ; and is thus read-100 parts of No. 6 will go as far as 126’5 of No. 5, in giving flavour and preservative power to the
fermented
There was no difficulty in deciding which of these samples to be preferred. 2. Lemun-juice.-As the mode in which lemon-juice acts I believe to be the same as that in which succulent vegetables prove advantageous in scurvy and purpura-viz., by its containing those saline ingredients (chlorides, sulphates, phosphates of the alkalies, &c.), which are likely to be absent from the food when it is restricted in its derivation, I consider it important to determine the amount of the saline residue from a given quantity of lemon-juice. The results of my examination of£ lemon-juice I published many years ago and have given the " summary in my School Chemistry," in 1848. These samples yielded the following results from a pint of each:was
There is observable here a difference in the amount of water, which may be due to some alteration in the alkaloid itself. Frequent objections have been started to the use of this preparation by physicians, on the ground of its inferiority in a therapeutic point of view to the white salt. Before confidence can be placed in it as a medicine, it would be necessary to know its mode of preparation, since slight causes induce isomeric modifications of quinine, which are not known to possess similar physiological actions. April, 1855.