ciiatto, esq., vvochenschr., 52.) interesting foreign operations...1859.3 quarterly report on...

QUARTERLY REPORT ON SURGERY.

By Joiin Ciiatto, Esq., M.R.C.S.E.

I. On Foreign Bodies in the JJretlira and Bladder. By Professor Pitiia. (Wien. Mcdicin. "VVochenschr., 1858, TsTos. 50, 51, 52.)

Tiie immediate cause of this communication was an interesting case, in which, on account of the introduction of foreign bodies into the bladder, the operations

1859.3 Quarterly Report on Surgery. 265

of lithotomy and lithotrity were successively performed oil the same individual. He was a soldier, aged thirty-four, who came into the hospital in consequence of a piece of lead-pencil about three inches long, and pointed at either end, having slipped into the bladder while he was trying to pass it, as a substitute lor a bougie. He had suffered excessive torment for a week, and the pencil (which was found divided into two parts) was removed by the lateral incision. He did very well. In two years he returned to the Clinic suffering froin intense cystitis, brought on from the presence of a piece of sealing-wax which had entered the bladder during his manipulation with it. The patient protested against the repetition of lithotomy, which, indeed, would have hardly been advisable in the inflamed condition of the bladder, and it was resolved to have recourse to lithotripsy. He was brought under the influence of chloroform with great difficulty, and never to an extent sufficient to subdue the irritability of the bladder, which instantly rejected the smallest quantities of water which were thrown into it. The preliminary injection of the bladder had therefore to be dispensed with. The foreign body was seized with the greatest ease, and not to pursue the details, was crushed and entirely removed in the course of three seances, at intervals of two or three days. The patient completely and rapidly recovered. This case is very interesting, from the fact of there being no means of anticipating the amount of resistance which wax that had lain in the bladder for four weeks would offer; and further, by showing that lithotripsy may be safely performed, notwithstanding violent general reaction and the greatest irritation of the bladder, producing complete intolerance of the presence of any water whatever. Hitherto one of the most received axioms has been not to undertake the operation in an empty bladder. It may surprise some that the narcosis was not pushed to the extent of appeasing this irritability of the bladder, but repeated experience has shown that the highest doses of anaesthetic agents will not effect this. The case is also interesting as exhibiting an example of the unexpected

slipping of foreign bodies into the bladder having occurred twice in the same individual. This accident has not excited the attention its frequency and importance demands. If experience upon this point were collected, surprise would be excited at the extraordinary character of various objects found in the urethra and bladder,* of some of which it would be difficult to explain how they could be forced through the urethra, to say nothing of their slipping into the bladder. But even with respect to the commoner objects, most of which have some resemblance in shape or size to the catheter, such as pen-holders, pencils, glass tubes, metallic rods, pieces of wood, &c., one can scarcely con- ceive how, once introduced into the urethra, they should escape from the fingers and slip into the bladder. This may be intelligible enough as regards the straight, short, female urethra, but not so as to the male urethra, whose long curved canal is traversed with difficulty by a well-oiled catheter in inexpert hands. Some have sought for an explanation in a suction-action or a peristaltic movement of the urethra, but ample experience in introducing instruments does not favour this view. On the contrary, a powerful expelling influence is often exerted by the urethra, the instrument being forcibly ejected when it has reached the neck of the bladder, this resistance being in fact met with more or less in the widest urethrse. The walls of the canal are naturally closely applied to each other, and its entire mechanism is directed so as to favour the passage from within outwards, and not the reverse of this.

Demarquay has furnished this natural explanation, that the entrance of the body takes place at the period of erection, and especially of ejaculation. The urethra is then elongated, its walls are expanded and smooth, and its canal is gaping and well lubricated, while its curvatures are diminished. The penis in relaxing forces the body deeper inwards, and the efforts of the person to pre-

* See a paper by M. Denuce : Brit, and For. Med.-Chir. Bev.,YOl. xx. p. 264.

266 Chronicle of Medical Science. [July,

vent the occurrence by forcing back the penis, in order to shorten it, only add to the mischief. This seems the most rational explanation, for in fact these cases usually occur in onanists, who in order to induce ejaculation, penetrate deeper and deeper into the urethra, having already blunted the sensibility of the anterior portion. In the performance of catheterism, too, we sometimes find, in spite of the greatest slull, the passage of the instrument is obstructed. Presently, the repeated attempts induce erection, and the instrument at once passes on. Sometimes the catheter glides at once to the membranous portion, where it meets with insurmountable resistance. Believing that there must be a fold or a stricture, or that a faulty direction has been observed, we seek to withdraw the instrument. This, however, is impossible without violence, so fast and immovably is it held; and now a phenomenon which astonishes the inexperienced is observed?viz., the spontaneous deeper penetration of the instrument, as if propelled by some unseen power, a circumstance which has

probably given rise to the suction theory. It is, however, a mere mechanical effect of the elastic return of the penis (after having been forcibly drawn forwards), during which the muscular walls, closely embracing the instrument, are also carried backwards. So strong may this spasmodic action of the muscles be, that nothing but rude force will overcome it, unless we wait for minutes or hours, until the spasm subsides. It may play the chief part where foreign bodies slip into the bladder during erection, at all events detaining them in the membranous portion of the urethra; and it will be the more certainly brought into action the more pointed and irritating the body be, especially .as the state of erection increases the irritability of the urethra. It is well known that catheterism after coitus or pollution is much more difficult, and that in such case a seizure of the instrument most readily takes place, even in patients accustomed to the operation?a fact of some importance in the treatment of stricture.

Tor the removal of foreign bodies of a roundish shape from the urethra, such as beads, beans, calculi, &c., Professor Pitlia has long been in the habit of using delicate long-bladed forceps (Kornzange), which can be easily manoeuvred with one hand, while the fingers of the other fix the foreign body from behind. Several such forceps of different lengths and widths should be at hand, in order to choose from in particular cases. When the body is seated very deeply, as at the neck of the bladder, the instrument should have a gentle catheter-like curvature given to it; and such an instrument the author finds admirably adapted for the removal of fragments from the urethra after lithotrity. When the foreign bodies are too voluminous, they should be first broken up by means of Segalas' urethral brise-pierre, and when not capable of being broken, they must oe removed by the button-hole operation, the wound in these cases

always readily healing, even when situated in the perineum. In the case of

sharp, pointed bodies, such as needles, awls, and the like, special manipulation is required. When a needle, e.g., is still in the region of the penis, we must ascertain by the touch its exact position, and then by pressure on the blunt end, force the point through the walls of the urethra, until it can be seized

by a forceps. Pins should be thrust through in the same manner, and so manoeuvred that the head is directed towards the mouth of the urethra, and then removed by an urethral forceps. When the needle is implanted lower down in the urethra, we must act in the same manner with the fingers placed in the rectum. In bodies having yielding stems and blunt points, such as hair- pins, these procedures are impossible, and for the removal of such, an instrument contrived by Matthieu, of Paris, answers admirably. Leroy has modified the instrument, so that it now resembles the brise-pierre a, pignon. Smooth, cylindrical bodies, such as needle-cases, pen-holders, bougies, &c., soon pass into the bladder. Before this they may usually be removed with ease, pro- viding their progress backwards be at once prevented by compression. Even

1859.] Quarterly Report on Surgery. 267

if the body has reached the membranous portion of the urethra, it can be removed by pressing it forwards through the rectum, while the curve of the urethra is diminished by traction of the penis. The cases wherein an instrument breaks in the urethra may be easily managed in this way with patience and presence of mind. When the foreign bodies have reached the bladder, they are extracted with

greater difficulty the longer and thinner they are. After they have remained iu the bladder, too, they become incrusted, and are more difficult of removal, especially when the bladder has been rendered irritable. It is a matter of great difficulty to seize them in the longitudinal direction, but the extractor of Luer is admirably adapted for regulating the direction in which the body shall be removed, and with its aid, our difficulties are reduced in these cases to the discovery of the foreign body.

II. On the Treatment of Hernia by Electricity. By Dr. Clemens. (Deutsche Klinik, 1858, No. 34.)

In the first of a series of articles upon applied electricity, the fruits of ten years' investigation, Dr. Clemens gives an account of his employment of it in the treatment of hernia. He commenced its use in 1850, by endeavouring to pro- duce a diminution in the size of the hernial apertures in a case of large double inguinal hernia. One of the poles of the battery, a massive metallic knob, was introduced deep into the canal, pressing a flap of skin inwards, and a moderately strong galvanic stream, increased daily, was passed along this during-6 minutes. At the end of a week the herniac protruded less easily, and the apertures bad become narrower. When the examination was made before and after each stance, a great difference was always found in the accessibility and size of the sac?an observation since repeated hundreds of times. The application of the galvanism also has the good effect of increasing the peristaltic movements, which in becoming more energetic effect a favourable change in the position of the intestines, by altering the situation of the portion which had so long remained opposite the aperture, and had consequently become relaxed. A more

complete evacution of the contents of the canal is also brought about. The

impaired vitality of the intestine, of the hernial canal, and of the abdominal coverings is always renovated through this application of electricity. When the hernia is recent, no means of treatment is so certain and so exempt from all danger; and even when the hernia long has protruded it has often been returned under the influence of the galvanic stream or the electrical flask. Dr. Clemens has usually preferred friction-electricity to galvanism, as its operation is more rapid and its effects are more energetic. Among twenty-seven patients so treated, none have complained of the least unpleasantness; but, on the contrary, they have found many inconveniences disappear under its influence, and especially obstinate constipation. In very sensitive persons diarrhoea may follow an energetic seance. When a hernia has been recently produced, as by a fall, lifting, &c., the success of the method is often surprisingly rapid, and in marked contrast with the slow progress of treatment by trusses, &c. A double hernia thus produced was cured without any bandage in twenty seances, and has remained so now for two years?the treatment only commencing a week after the accident.

Dr. Clemens states that for large hernia, which can only be kept up imper- fectly by any ordinary truss, he has contrived a galvanic truss, which operates with remarkable efficacy. It is constructed of copper and ziuc plates, or pieces of copper and silver money, having felt or leather interposed, which is kept moistened by the saline solution necessary for the excitement of the pile. He

again dwells upon the importance of exciting peristaltic action, not only in hernia, wherein it may often prevent strangulation being produced, but in


various other affections due to asluggish movement of the intestine. In nume- rous experiments upon animals, in which powerful shocks were employed, no ill effects resulted from the increased intestinal action produced.

III. Isolated Fracture of the Last False Rib. By M. Legouest. (Gazette des Hopitaux, 1859, No. 17.)

This rare form of fracture of the ribs occurred to a soldier, acred forty-five, who while playing fell with his side against the corner of a table. Yiolent

pain, an imperious desire to cough, and difficulty of breathing revealed the nature of the accident. Examination detected the exact seat of the fracture to he at the junction of the middle with the posterior third of the last false rib. Crepitation was plainly felt at this point, but this was at some distance from that at which he had been struck. The corner of the table had forced the moveable end of the rib inwards and backwards, and the fracture had taken

place in consequence of the excessive bending thus produced. No bandage was here applied as in ordinary fracture of the ribs. Such a bandage, having in view the limiting thoracic respiration and the rendering it abdominal, is useful in fracture of the true ribs (except the seventh), but is injurious in fracture of the false ribs. In point of fact, in the space comprised between the base of the transverse process of the first lumbar vertebra and the point of the last false rib, the circumference of the diaphragm is attached by an aponeurotic arch, one end of which is fixed to the base of the first lumbar vertebra, and the other to the lower edge of the last false rib; the remainder of the anterior circumference of the muscle rising up to be inserted into the cartilages of the false ribs and the seventh sternal rib. Wherever by inducing abdominal respiration the contractions of the diaphragm were rendered more energetic, the patient's sufferings were only increased; and he was left to his own instincts, which very soon taught him the manner he could breathe with least incon-

IY. Case of Spontaneous Fracture of the Femur, toith Consolidation, By M. Robert. (Gazette des Hop., No. 18, 1859.)

A porter, aged fifty, of small stature but robust constitution, and in good health, with the exception of having suffered for aborut two years from pains of the lower limbs, supposed to be rheumatic, was quietly descending a staircase when he felt a cracking in the right thigh, and fell down; the fall being induced by the fracture and not the reverse. After two months and a half treatment the fracture, situated just below the trochanter, had completely con- solidated, there being an abundance of callus, and shortening to at least the extent of four centimetres, giving rise to considerable lameness. M. Robert, commenting upon the case, observed that, as far as he knew, it

was unique. Every one is aware that the bones are sometimes spontaneously fractured when they are the seat of serious disease. In the case related by Dupuytren of a lad who had fractured the humerus while throwing a stone, a hydatid in the medullary canal was found to have reduced the bone to a mere shell. Tubercular deposit in the medullary cavity would be expected to pro- duce the same effect; and cancer induces also the absorption of the osseous tissue. M. Robert has himself met with four examples of fracture of the humerus or femur in this disease. The cause in such cases giving rise to the fracture would likewise prevent its consolidation. In explaining the occurrence of this accident in the present case, M. Robert has recourse to the hypo- pothesis of syphilitic disease, inasmuch as the man about twenty years ago suffered from chancre, but has never since had any symptoms of constitutional


syphilis. He states that he has seen other examples of apparent cure, in which the individuals, remaining fifteen or twenty years without any consecu- tive manifestation, have still, after such a lapse of time, exhibited evident signs of syphilitic cachexia. Syphilis appearing at so late a period, gives rise to indeterminate accidents which cannot be classed among those which are mani- fested in the secondary and tertiary periods. These ultimate accidents may be almost designated as those of the plus-tertiary period, and they always are observed affecting either the osseous or fibrous tissues.

[The occurrence of fracture from muscular contraction independently of the cancerous diathesis, is not so rare an occurrence as M. Robert seems to sup- pose. We would refer him to Dr. Van Oven's case, related by himself to the Medico-Chirurgical Society ;* to the collection of cases published by Dr. E. Gurlt, in the 'Deutsche Klinik, Nos. 25-29, 1857; and to cases related by Mr. Henry Smith, in

' Medical Times, vol xxxvi. 1857.]

V. On Calculous Diseases in Hungary. By Professor Balassa. (Wien. Medicin. Wochenschr., 1858, Nos. 25 and 26.)

This article is the substance of a reply made by Professor Balassa, of Pesth, to a circular asking for statistical information, issued by Professor Gross, of Louisville, U.S. Owing to the absence of rural hospitals in Hun- gary, Professor Balassa observes, almost all the cases of stone which occur m Hungary are brought to Pesth for treatment; and in his clinic at the

hospital, he has treated, in the twelve years 1843-55, 135 cases. The ages of these patients were as follow:

Prom 1 to 7 years 21

? 8 ? 15 ? 32

? 16 ? 25 ? 47

? 26 ? 50 27

? 51 ? 60 ? 6

? 61 ? 70 ? 2

135

The employments and conditions of these patients were as follow :?Peasants, 82; artisans, 39; tradespeople, 7; employes, 2; landowners, 2; students, 2; teachers, 1.

Thus calculous affections are met with in the Pesth clinic with by far the greatest frequency in the young, inasmuch as out of a total of 135 cases, 100 of the patients had not reached their twenty-sixth year; and when it is added that in most of the cases the disease had long existed, its origin must be referred to a still earlier age. Moreover, during the twelve years there were also forty-nine children treated for stone in the Pesth Children's Hospital. So, too, the immense proportionate prevalence of the disease in the peasant (60'74per cent.) and in the artizan (28*8S9 percent.) classes is to be remarked. These classes, indeed, almost exclusively furnish the examples of the disease occurring amongst the young, as the author's private practice has taught him. Dr. Ivanchich, too, in his statistics of 100 cases of stone, comprises 33 natives of Hungary, but only 2 of these are as young as eighteen. The conclusion is, then, that stone prevails especially among the young of the poorer classes; and this leads us to consider some of the influences that are at work in its production. The nature of the diet and mode of life can alone explain these differences. It is the custom in Hungary to feed children when weaned, or even while suckling, upon the same articles of diet as are

* Medical Times, vol. 26, p. 652. 1852.


employed by adults, and -while these in the wealthy classes may be nutri- tious and digestible, among the poor they consist of unwholesome matters, as fruits, vegetables^ pork, and bacon. The latter, then, are fed with a diet that is difficult of digestion, and containing by far too large a proportion of the carbonaceous element; and the importance of this statement will be seen when the chemical constitution of the calculi has been considered. For various reasons, the author has only been able to preserve SB calculi in

his cabinet, but all these have been carefully examined, and he furnishes the details of the results. 63 of the calculi were of homogeneous composition, and in 20 the nuclei and external portions were of different composition, The general result is, that while uric acid was the most frequent constituent, it was not the most frequent chief constituent, for while it was found more or less in 72 calculi, it constituted the chief portion of these only in 23. The oxalate of lime was the chief constituent, for it formed the chief mass of 20 calculi of homogeneous composition, and formed the nuclei in 12 out of the 20 stones of non-homogeneous composition. It is evident, then, that the formation of stone in Hungary is much due to the richness of the urine in the oxalates?i.e., in the carbonaceous combinations furnished by the defective aliment employed. Of the 20 stones having nuclei of different composition to the surrounding parts, in 12 these consisted of oxalates and in 8 of urates. It is owing to the prevalence of these in the urine that the first impulse to the formation of calculi is given, while their enlargement much depends upon the presence of phosphates. These were present either as a chief or partial constituent in 45 calculi. These considerations lead to the conclusion that the most effectual means of preventing the formation or recurrence of calculi would be to act upon the oxalic or uric acid formations of the urine.

Of the 135 cases, 13, on account of disease of the urinary organs or the condition of the entire economy, were deemed unsuitable for operation. Some of the 122 operations were performed under very unfavourable circumstances, in consequence of the presence of chronic disease of the urinary organs.

Of the 122 cases operated upon, 92 were submitted to lithotomy, and 30 to lithotrity. Of the former, 11 patients (11'95 percent:), and of the latter 5 (16-6G per cent.) died. Among the 11 fatal lithotomy cases, there were 5 individuals who suffered from severe chronic disease of the kidney, and 1 who died of typhus during an epidemic. There were, therefore, only 5 cases in which death took place in from the second to the fifth day, from inflammation of the bladder or peritoneum, consequent upon the operation. This re- duces the strict mortality from the operation to 543 per cent. Among the 5 fatal lithotrity cases, in 1 death was due to phthisis, in 2 to old suppurative nephritis, and in 1 to recent nephritis, this last and one other death being alone directly referrible to the operation, i. e., 6'GG per cent. Rectal fistula and

urinary infiltration were never met with in any of the lithotomy cases. The

difficulty in extracting the stone was considerable in many cases on account of its size, and in several of these inflammation of the bladder and peritoneum was set up, this proving fatal in 5 instances. Irritation and inflammation of the bladder frequently also followed lithotrity, leading to considerable delay in the repetition of the operation. With the exception of 7 cases, the stone was always removed entire. The

largest calculus measured two inches_ five lines in diameter, in 5 calculi the diameter was above two inches, and in 24 between one and one and a half inch. The heaviest, removed from a boy ten years old, weighed one ounce and a half and ten grains, and the lightest seventeen grains, in 8 patients there were two stones, and in 1 three. In 2 children union by the first intention

took place, and they left between the eighth and tenth day. The other patients were discharged between the twenty-first and sixtieth days. Relapse occurred in 2 instances after lithotrity, and in 1 after lithotomy.


Of the whole 135 cases nly 1 occurred in. a female, upon whom lithotrity "was performed.

As to the mode of performing lithotomy, Professor Balassa makes an aperture into the bladder with a convex scalpel sufficiently large to admit the index finger of the left hand, and then enlarges it by means of a straight probe-pointed bistoury or Heister's knife. He lays great stress upon the wound being made sufficiently large, and in cases of voluminous calculi frequently makes a bilateral incision. After bleeding has been arrested by the injection of iced water (performed while the fingers maintain the wound of the bladder open), some small strips of oiled linen are carried along the index finger to the wound in the bladder (especially when extraction has been difficult), in order to prevent the urine penetrating the swollen edges of the track of the incision. They are removed after two or three days, and the author attributes the non- occurrence of infiltration principally to their employment.

"VT. On Colouring the Lips by Tattooing after Cheiloplasty. By Professor Schuh. (Wien Medicinische "VVochenschrift, 1858, No. 47.)

Two years since Professor Schuh performed cheiloplasty in the Vienna Clinik, upon a girl in whom one-half of the nose, together with the vomer and the whole of both lips, were wanting. The flaps for the lower lip were sup-

}>lied from the region of the lower jaw and the neck, and that for the nose rom the forehead, while the skin of the arm was employed for the upper lip. The connexion of the flap with the arm was divided on the tenth day, and all went on well, excepting that the new upper lip, at its lower edge, owing to the cicatricial process, was covered with corion. The red lip-colour was wanting to give the mouth an agreeable appearance; and Professor Schuh determined to endeavour to imitate this by tattooing. He first of all tried cochineal as a colouring material, but this produced a too pale red, and he then had recourse to cinnabar, which gave rise to a surprisingly natural colour. The following is the procedure: the cinnabar is made into a thin paste with

water, and the limits within which the pigment is to be applied are traced with, a pen and ink, in imitation of the direction of the natural redness of the lips. Por forcing the pigment into the organic substance, a bundle of sharp-pointed pms is employed, each pin being wound round with waxed silk from its head to within four lines of its point. Ten or twenty such pins are tied into a bundle with thread, dipped into the colouring substance and repeatedly forced two or three lines deep into the lip. The margin marked by the ink is first to be coloured, and then the other portion, dipping the points into the pigment again as this is wiped off. Only a slight bleeding ensues, and the pain is very little, in consequence of the diminished sensibility of transplanted parts. Any of the pigment remaining on the surface should be left there until next day, and if any part is found to be less red than the others this can be easily remedied. How long this redness will remain unchanged must be determined by

further experience. In Professor Schuh's case it had become nowise paler at the end of a year and a half; and he believes that the introduction of the process of tattooing into the field of plastic surgery is not to be despised.

VII. On Adhesive Plaster in the Treatment of Fractures of the Lower Extremities. By Drs. Gilbe&t and Shkady. (American Journal of Medical Science, April, p. 410; and New York Journal, March, p. 238.) Dr. Gilbert, as the result of a multiplied experience, now extending over

many years, states, that of all the means which have been devised to effect


extension and counter-extension in fractures of the lower limbs, the application of adhesive plaster is by far the best. He refers to several cases in proof of this, which lie has published in prior volumes of the

' American Journal,' and in the present number gives the particulars of three additional cases.

Dr. Shrady, speaking of the practice of the New York Hospital, gives the following account _ of the mode of treating fracture of the thigh there:? " When a patient is admitted, there being generally a good deal of swelling present, the limb is placed upon the double inclined plane, until this has sub- sided. Then he is prepared for the application of the straight apparatus. The first step consists in the preparation of a double band of adhesive plaster, about three inches in breadth, which is cut long enough to extend from below the point of fracture on either side of the limb, forming a loop underneath the foot, a sufficient distance from the sole to allow of the introduction of a square block. This block is a little broader than the foot, and serves to prevent the

pressure of the adhesive bands over the ankles, and also affords a firm point to which is attached a short cord for extension. The adhesive strap is applied smoothly to the sides of the limb, and a bandage over it, leaving the loop free, extension being in the meantime kept up by an assistant. The body belt and

perineal strap are next adjusted, after which the coaptation splints are applied in the usual manner around the seat of fracture. Then the upper end of the

long splint is placed in a pocket of the body-belt, the limb drawn down as far as possible, and kept extended by means of a stout cord over the foot-piece ; this cord is attached to a ring in a large wooden screw, which plays through the block standing out from the internal surface of the splint. Next, the

inside splint, extending from the groin to the malleolus, is applied; pads of blanket being stuffed in on either side, to adapt the splints to the inequalities of the limb. The last step consists in binding the splints together. Three

strips of bandage are passed at equal distances from each other behind the limb; and their ends are brought forward between the limb and the splints, carried over the anterior edges backward over the outside of the apparatus, crossed behind, and finally brought forward around the whole again, and tied in front. By this arrangement a sling apparatus is made for the whole limb, at the same time that the splints are nicely secured to each other. The

extending force is regulated by means of the screw in the block. This block, I should say, slides in a fenestrum, being secured at any part by a screw arrangement, by which means the proper distance between it and the foot can be regulated, in order to have the full advantage of extension." The results obtained by this treatment may be judged of from the fol-

lowing statement of 74 cases, which involved the shaft of the femur, exclusive of either extremity. These cases were taken in the order of their occurrence.

In 19 of the 74 there was no shortening, and in 55 it averaged less than three- quarters of an inch. The ages ranged from three to sixty-four. There were

57 patients more than, and 17 less, than twelve. Of the 57 there was no

shortening in 13 cases ; but in the remaining 44, it was a fraction over three- quarters of an inch. Of the 17 under twelve, there was no shortening in 6, and in the remaining 11 it averaged less than half an inch."

VIII. On the Secale Cornutum in Disturbance of the Accommodation-power of the Byes. By Professor Willebrand. (Graefe's Arch, fur Ophthalmologic, B. 4, Ath. 1, s. 341.)

fa

When local hypersemia is dependent upon a laxity of the walls of the blood- vessels, advantage attends, Professor Willebrand of Helsingfors, states, the

employment of secale cornutum. He was induced to use it in these cases by the expectation that a means which acts so specifically upon the unstriped

1859.] Quarterly Report on Midwifery. 273

uterine muscular fibre must excite some power over the analogous structure of the arteries, and which its haemostatic action proves, in fact, that it does. During his investigations he soon became struck with the fact that the heart of persons employing it soon underwent contraction in all its dimensions, and that even within the first twenty-four hours?a circumstance which he has frequently verified since. The first case that came under his care was an

example of exophthalmos, accompanied with enlargement of the thyroid gland and hypertrophy of the heart. After a few weeks' use of the secale the hypertrophy of the heart and thyroid, as well as the projection of the eye, much diminished. The patient, however, left off the medicine, and the exophthalmos returned worse than ever. Since that period he has employed the secale in various cases in which increasing the contractility of the muscles of the blood- vessels or other tissues seemed to be indicated. It was found of especial advantage in a disturbed state of the accommodation-power of the eye, especially induced by over-taxing the organ on small objects with an insufficient amount of light. Children from some of the schools have furnished the author with many instances, and they have always been relieved by the secale. He relates a case in which impaired vision was always brought on by sewing or reading, and wherein the signs of some amount of chronic congestion were visible. Relief rapidly followed, and when the affection recurred some months after, it was as speedily relieved. He has also found the secale of great use in several eases of acute or chronic inflammation of the eye, and especially in blepharitis and the pustular conjunctivitis of children, the case proving much more rapid, and relapse being much less rare, than when local means alone are relied upon. No benefit has been derived from it in granular conjunctivitis and trachoma.

Proceeding upon the theory of its stimulant action upon the vaso-motoric

nerves, the author has extended the employment of the secale to other local disturbances of the economy; and, as already observed, he has had frequent occasions of observing its transitory influence in hypertrophy of the heart, without having any reason to believe that it is of any permanent utility in affections of this organ, the heart always returning to its former size soon after the use of the secale lias ceased. In many cases of both chronic and acute

hyperemia it has proved of great service, and especially in cases of galac- torrhea, and in indurations, tumefactions, and catarrhal affections of the uterus. Also, it has been very useful in enlarged spleen from intermittent fever, and when large doses of quinine have failed. It is especially indicated in the cases of relapsing intermittent depending upon enlarged spleen. In erysipe- latous affections, it has often done good service applied externally as a cata- plasm. The author formerly gave ten grains ter die, but now gives but five, combining it with magnesia, or, when chlorosis is present, with iron.

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