ROYAL FREE HOSPITAL,

672 seat and extent of sloughing continually noticed. In this man an incision was required on the left side, about the level of tlre crista ilii, and gave vent to a considerable quantity of darkcoloured foetid sloughy matter, while the whole space on

either side above Poupart’s ligaments, except in this particular situation,. does not, on the most careful examination, afford any indication of mischief, either in appearance or to the touch. In all these cases, the appearance of the part, diffused swelling, darkness of hue, and a boggy feel, indicate the place at which incisions are required. (The patient, since the above was written, has left the hospital, able to void his urine in a good stream through the urethra. Besides the incisions, which should be at once resorted to in cases of extravasated urine, the local treatment used in these patients consisted in the application of warm poultices till the sloughs were separated, and careful support of the scrotum, should that part be affected; afterwards, astringent lotions of sulphate of zinc were usually applied. As regards the general treatment, the patients at first are in a state of fever ; the skin is hot, the pulse very quick, tongue coated, often dry and brown, and in most cases the countenance wears an expression of agitation and apparent anxiety concerning their condition. Soon, however, the pulse becomes small, and the skin cold, or even clammy; this change probably accompanies the mortification which goes on in the parts through which the urine has been infiltrated. While the fever is present, the bowels should be unloaded by an enema, and Dover’s powder given to procure rest. Afterwards, when the low state comes on, the principal resources are stimulants with opium, until, with returning health, food is taken in sufficient quantity. The form of stimulant is not a matter of indifference ; brandy or gin is almost always resorted to by Mr. Quain. He states that he has long discarded port wine; it disagrees with most stomachs, particularly empty stornachs: He has repeatedly seen persons who had been low, and apparently sinking, revived, so to say, under the use of the simpler form of alcoholic drink. Alcohol is easy of digestion, and is therefore, on this ground, suited to the depressed state of these patients. It is food for respiration, and perhaps it is on this account, in addition to its stimulating influence, that the temperature of the patient becomes raised under its use; But these are reasonings à posteriori; after the fact has been ascertained, and the fact itself is the important matter in a practical point of view. utmost importance in these, and in some Opium is of other diseases affecting the urinary organs, allaying pain and the apprehensions about- themselves which these patients so generally. feel, and procuring sleep, of which they are nearly altogether deprived. The patients, whose cases are above noticed, took half a grain of muriate of morphia in a draught, or a quarter of a grain repeated at the interval of four hours. In the cases above noticed, the urine escaped from the membranous part (so named) of the urethra, and it very rarely occurs at- any other part. Occasionally, however, the urethra ulcerates in the erectile tissue of the penis, (corpus spongi osum,) and the urine escapes into that structure. A case wa, mentioned in illustration of the disastrous effects of extrava. sation of urine in this situation, and the evils of this form o: the disease were referred to the infiltration of urine and puf into a part- of vascular system.

high

the

ROYAL FREE

downwards over the neck and shoulder, and terminated by subdivisions which lost themselves in the skin covering- the scapula and clavicle. From the condition of the parts, it was very obvious that a cicatrix produced by the removal of a portion of the tarsal conjunctiva- would not of itself be a sum" ciently-powerful antagonistic force to those which kept up the ectropium ; but that some operation was required which should set free the lid by separating the adhesions of the skin to the malar bone, and, if possible, should give increase of surface to the skin of the cheek and corresponding side of the neck. This was accordingly done in the following manner, suggested by, but differing from, the operation of Dr. Ammon: A semilunar incision was made through the skin, commencing about an inch external to the temporal angle of the orbit, and carried around to a point about half an inch below the inner’angle, the lowest portion of the curve being just below the inferior edge of the malar bone. This flap of skin was carefully dissected from the subjacent textures to within a very short distance of the tarsal cartilage, when the eyelid A horizontal was readily restored to its natural position. fold of conjunctiva was then removed, the lid secured by adhesive plaster in its right situation, and the cut edge of the flap stitched to the tissue immediately below the orbit, leaving a wide gap to be filled up by new material. The conjunctival affection was treated by a ten-grain solution of nitrate of silver, and began to disappear ; but a stop was put to its cure by the partial return of the ectropium, which accrued upon the cicatrization of the new sore. The skin of the neck and the bands by which it was traversed now appeared to be the principal remaining obstacles to the complete restoration of the lid; and Mr. Gay suggested a similar operation to that performed on the face, which was, to embrace that portion of the skin which dragged mostly on the integuments of the face, and which would, at the same time, allow of the removal of the principal cellular band. This was cheerfully acceded to by the patient, and performed as follows:-A semilunar incision was made through the skin, commencing about an inch and a half behind the angle of the jaw-bone, descending to about midway between the clavicle and the jaw, and terminating just below, and about midway between, the symphysis and angle of that bone. This flap was readily dissected up, and the tense band at the same time completely cut away. The patient’s head was drawn towards the opposite shoulder, and confined by bandages in that posture ; the lower edge of the flap of skin was retained by ar suture at least two inches above its former site, thus leaving a large gap to be filled up, as in the former operation, by new granulation; the parts were covered with water dressing; and the patient was put to bed. The flap thus made consisted partly of sound skin, and partly of cicatrix; and although each portion was of the same thickness, whilst the former retained its vitality, the latter sloughed, a circumstance which gave rise to some anxiety, lest the extensive loss of skin thus occasioned, and the large surface for cicatrization, should rather aggravate than cure the deformity. The wound healed, and the eyelid, which, immediately upon the completion of the operation, had resumed its natural position, became again semi-everted. This partial ectropium did not, however, remain beyond a few days, after which, the lid began to restore itself; and after the lapse of a month from the last operation, its position and mobility were as perfect as before the accident, and the

patient discharged. The particulars of

HOSPITAL,

the

foregoing may present interest,of inasmuch they show, that, aggravated ectropium, from cicatrices, may be, they

GRAY’S-INN ROAD.

case

cases

WITH THREATENED LOSS OF VISION, AFTER SEVERE BURN; OPERATION; CURE.

some

as some are not

as

beyond the hope and prospect of remedy. They further show, that by repeatedly shifting circular A YOUNG woman, aged twenty-seven, epileptic, was admitted, flaps of skin, increased extent of surface may be obtained, and in May, 1845, under the care of Mr. Gay. Three n’onths by these means, the effects of most extensive contractions before, during a fit, she had fallen on the fire and burnt the may be successfully counteracted; and in cases where imside of the face and neck most severely. The wounds had portant organs are implicated in these cicatrices, and their almost healed, and a large cicatrix resulted, which had gra- functions thereby either impaired or destroyed, such measures, dually everted and so firmly drawn down’ the edge of the backed by favourable experience, may be fearlessly recomlower eyelid, that it could not in the slightest degree be mended.

ECTROPIUM,

restored

It is most desirable that

by means of pressure. Granular inflammation of the

portions

of skin selected for the

conjunctiva followed, and rapidly spread over the sclerotic formation of a flap for shifting should comprise as little as and exposed corneal portions, threatening a loss of vision, and possible of cicatrix; for the fresh arrangement of its vessels presenting so disagreeable an aspect, that the young woman renders it most prone to slough. In healthy skin, the arteries wished to subject herself to any treatment that might beenter its structureby comparatively a few large vessels, which likely to prove a remedy to the disease and deformity. The immediately anastomose most abundantly, and form a rich malposition of the lid was maintained partly by slight ad- capillary plexus, horizontal to the plane of the surface; hence hesions of the skin to the malar bone, partly by the dermal’ its vitality is maintained, although a large superficies of skin contraction, and partly by two tense and prominent bands, may be dissected from the subjacent tissue; but, in regard to which arose from the skin covering the lower jaw, tendedl a cicatrix, it must be very obvious that its vessels must be !

,

673 ,obtained from innumerable small arteries yielded to it from the textures below; and it is more than probable that the peculiarities of its structure, its failing to secrete healthy-epidermic cells, and its liability to slough on being dissected up, re9B1lt from the want of-as there cannot be the same necessity for-that free anastomosis of its capillaries within its own texture, which follows this peculiar disposition of its supplying

vessels.

I

NEWCASTLE-ON-TYNE INFIRMARY. CASES IN THE HOSPITAL PRACTICE OF DR.

WHITE,

PHYSICIAN TO

THE INFIRMARY.

Reported by Mr. CHARLES J. GIBB, House-pupil. ENDERMIC APPLICATION OF

CASE

MORPHIA IN NEURALGIC

I.-George B-, aged fifty-seven,

a

PAINS.

keelman, tall,

stout, rheumatic-looking, admitted April 2, complaining of a severe aching pain in the left hip, and posterior part of the

thigh, which is much worse at night, and frequently assumes lancinating character, darting down to the foot. This pain has been of twenty-nine years’ duration, but never so severe as lately. The patient is quite lame, and walks with difficulty; sleepless ; no complaint of thirst or fever ; whitish tongue ; bowels regular; has frequently taken medicine, but without much benefit. To have three grains each of blue pill, aloes, and acetous extract of colchicum, with five grains of Dover’s powder, every night: five grains of the iodide of potassium thrice a day, and a small blister to the most painful part of buttock, after which, the abraded skin to be sprinkled over with a grain of the acetate of morphia, every morning. 6th.-Pain considerably relieved; sleeps better; bowels a

free.

To continue.

lOth.-Says pain is almost gone; walks with very much less halt; sleeps well; appetite good; bowels free. To persist, and as the vesicated skin is dry, to re-apply the blister, and continue the morphia powder. 15th.-No pain for the last two days; blistered skin nearly well; bowels confined, and tongue furred, with slight thirst. To omit pills and iodide, and have three grains each of blue pill and aloes every night, and a dose of common purging infusion twice a day.

20th.-Feels himself well, and says he is a better man now than he has been for the last thirty years. Dismissed, cured. CASE 2.- Joseph C-, aged fifty-six, a joiner, pretty healthy-looking, and of swarthy complexion; admitted as an

out-patient March 3rd, with sharp stinging pains proceeding from the right buttock down the leg to the foot, which benumb and partially disable the extremity; sleeps well, pains being easier at night; ankle becomes oedematous towards the evening; health good; urine natural; bowels free; no thirst. Was cured when here nine years ago; remained well until about two years ago, when the pain returned, without any evident cause. To take two grains of blue pill and four of aloes every night, and the mixture and volatile tincture of guaiacum thrice a day; and to have a small blister on the hip, dressed every morning with a grain of the morphia. 8th.-Easier; bowels free. To continue. 16th.-Blistered skin has been dry the last few days; pain greatly banished ; guaiacum disagrees slightly ; bowels free. To repeat the blister and morphia, omit the medicines, and have a mixture with twenty drops of turpentine thrice a day, and a teaspoonful of castor-oil every night. 23rd.-Pain almost gone; skin discharges yet; no effects from the mixture ; -continues well in health. To go on with remedies. April 1st.—Pain completely gone for the last few days ; only slight heat of urine; bowels free. Dismissed, but to continue castor-oil for a short time. CASE 3.-Robert B-, aged forty-eight, a seaman, rather distressed-looking, admitted July 25th, with a severe aching pain, and soreness of the whole skull, not affected by outward circumstances, but frequently amounting to extreme pain; no tenderness of scalp; slight inflammation of throat from a cold; bowels confined; pulse quick, and system seems generally deranged. Has been ill, with varying intensity, for eight years; has not had syphilis. To take four grains each of blue pill and aloes every night, and a compound mixture of magnesia and rhubarb twice or thrice a day. 30th.—Feels " his body more free and light," but pain continues ; bowels freely open. To continue remedies.

Aug. 7th.-Is passing blood by the amis, and is alightly, purged; languid and oppressed state of the body disappexritrg; pain a little easier, except at intervals. To omit .pills, and continue mixture. 14th.-Pain as severe as ever; bowels regular; no more blood with motions after the omission of the pills. To continue the mixture and resume the pills. 17th.-Head in much the same state. To apply six leeches to the temples. 19th.-No easier; state of system considerably improved. To apply a small blister to each temple, and have the abraded skin sprinkled over with half a grain of morphia every morn-

ing.

25th.-Pain almost gone; tongue clean; pulse soft and rebowels free; appetite good. To continue. 29th.-Pain entirely gone; feels himself well, and wishes to leave. Dismissed cured. Remarks.-This mode of treating those pains which appear to depend principally upon nervous irritation, or, it may be, chronic inflammation, and are confined in their extent, has been extensively employed here, and in no cases has it been attended with any disagreeable effect; but, on the contrary, with the most surprising benefit in many, or, I might say, in most of those patients, who, from their condition, seemed to be suitable for its application. The pain is generally soon relieved, and a comfortable feeling of ease, with sometimes a little drowsiness, is experienced. In fact, in sciatica, or, indeed, in any case where the pain can be distinctly traced along the nerve, this plan is often the only one that affords even partial relief. The application must be used as near the trunk of the nerve as possible, particularly when the pain most nearly centralizes. It sometimes requires to be re-applied nearer and nearer the terminating branches, as the pain is gradually expelled. Hence, in sciatica, the buttock first, then the knee, and, lastly, the foot, sometimes in succession, require the vesication, and subsequent sprinkling on of the morphia. It is quite certain that this treatment has entirely succeeded when leeches, blisters, moxas, belladonna externally, and arsenic, iron, iodine, turpentine, and guaiacum, have entirely failed. Dr. White has had frequent opportunities of testing its power over pains situated about the upper parts of the body, and does not consider that the locality, as regards the contiguity of any of the most sensitive organs, or, indeed, of the sensorium itself, has much, or any, influence in heightening the constitutional effects of the drug, but he does, nevertheless, watch it then with great care, and uses the application, in such cases, with somewhat less freedom than when, by its narcotic touch, he endeavours to dispel a sciatic pain. The secretions and states of the different viscera are, of course, during its use, to be carefully examined and increased, or corrected when faulty. To Dr. Greenhow, of North Shields, I believe, the merit is due of first applying morphia endermically over the region of the stomach for pains in that viscus.

gular;

0

BIRMINGHAM LYSNC-IN-HOSPITAL. MEDICAL AND STATISTICAL REPORT.

By

J. M.

WADDY, M.D. Lond., M.R.C.S., Senior Surgeon

to the Hospital. BEFORE entering on the following statistics, it is well to remark, that as the benefits of the charity are limited to married women, many injurious complications of labour are, to a great degree, avoided; but the class of patients attended upon are, for the most part, poorly fed, clothed, and lodged, and many of them are employed in manufactories, and exposed to circumstances, of a moral and physical nature, extremely detrimental to their health and comfort. The early age at which some marriages appear to have taken place, will strike the reader; but the freedom of intercourse between young persons of both sexes employed in factories, especially at meal-times, and after work is over in the evenings, tends to the early development of sexual inclinations, and often induces early, ill-assorted, and compulsory marriages. These early marriages are extremely prejudicial to health,are embittered by constant disappointments, and are often associated with extreme poverty and wretchedness. No wonder, then, if in persons thus circumstanced, labour should often prove tedious, difficult, and dangerous, and the offspring weak and sickly, having, in birth, the germ of future ill-health and premature old age, and the promise of an early grave. The marriage of factory girls with apprentices, whose low wages are scarcely sufficient to procure subsistence for them-