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At all events, it should be confined to partial trichiasis, and even here others besides the hairs in fault are generally destroyed.
All that has been said above relates to the upper lid. When the lower one is the seat of the affection, the ordinary excision of the skin will. suffice. Great care is, however, required, so that ertropion be not produced; and where the ectropion of the lachrymal point would be the consequence, it is better to remain content with the repeated extraction of the cilia, which in the lower lid are very slowly reproduced.
II. On lare-lip Operations. By M. GUERSANT. (Gazette des Hôpitaux, 1858, No. 24.)
“ The more operations for hare-lip I perforin,” M. Guersant observed, at the Society of Practical Medicine, “the more I am convinced, -1. That in operating for simple or double hare-lip, at any age, the result is almost always favourable ; 2. That the operation for complicated bare-lip, at whatever uge it may be undertaken, is only exceptionally successful; 3. That in the operation, whether for simple, double, or complicated hare-lip, we almost always fail when a complication supervenes in the shape of disease of the skin or other part.” He addel that he generally operated early, but waited for six weeks or two months after birth, being able by that time to judge whether the child is lively and well nourished, and also to have it vaccinated, and thus obviate a mischievous complication. In support of these opinions, it is to be observed, that some cases of simple hare-lip operations practised a few days after birth have failed because the infants, unable to nourish themselves, fell into a state of languor and died. Moreover, a considerable number of children die within the first two months, even without having undergone any operation. If this is true of the operation of simple bare-lip, it is still more so with regard to complicated hare-lip; for in the latter, the mortality is greater in the earliest period of life than it is in simple bare-lip. Moreover, having to undergo a more laborious operation, these infants lose inore blood; and as in some of them the operation has to be completed at several intervals, it is better to wait till they have attained the age of a year, when they are better able to support it.
Great care must be taken both before and after the operation as to the presence of other children who have or have just had any of the diseases of infancy, as hooping.coagh, scarlatioa, measles, &c.; affections likely to cause the failure of this, as well as of all other operutions performed on infants. A child, thirty-two months old, with a double hare-lip, had been vaccinated by M. Guersant a few days before he intended performing the operation, and was carried to the door of one of the wards in which scarlatina prevailed, in order to furnish lymph for some of the children in the ward. The next day it was operated upon on one side only; but two days after it exhibited scarlatina, union failed, and the child died.
For some time past, M. Guersant has employed separate points of suture, having found that they less easily cut through the lips of the solution of continuity than the twisted suture. In the above case, although union was prevented by the scarlatina, the two points of suture being divided at the end of a week, it was found that the lips of the wound had not been cut through by the double threads which were employed.
III. On Salication in Syphilitic Patients. By Professor SIGMUND. (Wien Medicin.
Wochenschr., 1858, Nos. 5 and 6.) During the last fifteen years Professor Sigmund has treated 8,983 syphilitic patients by means of mercury. All the various preparations have been tried, and it has been found that the oumber of cases of salivation have much decreased during the latter portion of the period, in consequence of the greater attention that has been paid to the cleansing of the patients' mouths with gargles, the due regulation of diet, &c.
1. What is the proportion of cases in which salivation occurred ?-Of the 8,983 mercnrialized patients, 520 exhibited it--viz., 139 among 4,792 hospital patients, and 381 among 4,191 private patients. This far smaller number occurring in lio-pital practice without doubt arises from the greater care taken of the patients, and especially from the attention paid to the month; and it has been found that in spacious, well-ventilated wards, supplied with careful purses, the occurrence of salivation may be nearly prevented altogether. At the tiine of the autbor's writing, 157 cases were under mercurial treatment, without salivation having occurred in any one of them,
2. What mercurial preparation is most liable to induce rapid and severe aaliration ?--The author marsliuls the different preparations, together with the numbers respectively treated and affected by these. Oar limits do not admit of these details, and we can only observe that calomel affected the mouth more frequently and more rapidly than any other preparation; while, united with cinnabar, and used in fumigation, it rapidly gave rise to excessive salivation. Blue pill, and especially mercurial ointment, which is the author's favourite preparation, acted far more mildly. Not only was there a much less proportion of cases of salivation observed in hospital than in private practice, whatever the form of mercurial employed, but these were almost all mild cases, the examples of excessive salivation being almost all observed in private practice.
3. What circumstances favour the production or the prevention of salivation ?- First among the individual circumstances in the attention paid to the state of the mouth and fauces, neglect in keeping this clean being the cause of 80 per cent of the cases of salivation. Due attention paid to this point will
, in nearly all cases, enable the mercurial treatment to be uninterruptedly continued. The preparation employed is an influential circumstance, as we have seen by the active operation of calomel. A loose, spongy, separated condition of the gums, and the presence of bad teeth, seem, cæteris par bus, to exert but slight influence. Anemia from ague, chlorosis or tuberculosis, does not seem to favour salivation; and even the lesser degrees of scorbutus have not occasionally prevented the use of mercury. Among the general circumstances favouring the production of salivation may be mentioned impure or defective air, insufficient warmth, and damp; and where these are combined with neglect of the mouth, the proportion of attacks of salivation become immense. Such cases are not unfrequently met with in private, as they may also be in hospitals when these are overcrowded during epidemic visitations. As a means of cleansing the mouth every conceivable substance has been tried in the Vienna hospital, and as the result of prolonged experience, alum, borax, chlorate of potass, tannin, or tincture of opium, are now only employed. Gargles composed of some of these must be used every hour, half or quarter hour, and the attendant must not merely direct the patient to use them, but see that he does so. We should not wait for the commencement of the salivation to employ these, but begin to use them at once as soon as we prescribe the mercurials. Internal medicines, without the use of gargles, are of no avail whatever, but in combivation with these, chlorate of potass or soda, or iodide of potas. sium, are u-eful.
4. Is salivation an essential sign of the curatire influence of mercury ?—Of the 8,983 syphilitic patients treated with mercury, 8,463 exhibited no salivation, and yet were just as permanently cured as those in which this occurrence took place. The author's multiplied and prolonged experience, indeed, enables him positively to state that salivation is neither a sign nor a condition of cure, and should, whenever possible, be prevented.
IV. Supra-Pubic Puncture of the Bladder. (Gazette des Hôpitaux, 1858, No. 59.) A discussion upon this operation recently arose at the Paris Surgical Society, on the occasion of the presentation of a memoir by M. Fleury, in which he stated that he had often performed the operation with success, and considered it a very easy one.—M. Boinet regretted that the author bad not stated whether his patient suffered consecutively from the adhesion of the bladder to the abdominal wall at the seat of puncture, and the consequent impediment to the functions of the organ.-M. Chassaignac could not admit the ill consequence said to result from these adhesions—such, indeed, not being observed in the case of the high operation for lithotomy, after which much more considerable adhesions take place. He did not, however, admit that puncture of the bladder was the simple operation it was stated to be by M. Fleury. When the abdominal parietes are very thin and the bladder is much distended, few precautions are necessary; but in very fat or very muscular subjects serious difficulties may arise. We have then to employ a very long trocar, and to plunge it in very deeply; and there is danger of wounding the opposite side of the bladder—an accident which occurred to M. Chassaignac himself -M. Robert considered puncture of the bladder as preferable to forced catheterism, and has had recourse to it seven or eight times. He does not fear the accidents attributed to the retention of the metallic canula in the wound. The substitution of a gum-elastic catheter for this is sometimes very difficult, owing to the contraction or deviation of the track made by the canula, and the attempts may give rise to paintul laceration and to infiltration. He therefore leaves in the canula for a fortnight, and then substitutes a caoutchouc tube. He observed, also, that the urine should not be allowed to run continuously from the canula. This should be plugged, and only opened every three or four hours, otherwise the bladder, contracting too readily upon itself, may abandon the canula.-M. Deguise could not understand how any difficulty could arise in introducing a catheter by the track of a canula that had remained in situ for eight days. For his own part, he introduced a catheter on the first day, and changed it on the third or fourth, and he never found any difficulty in so doing. He considered the operation a very easy one, providing that a preliminary incision be made down to the linea alba. He employs also a straight, in preference to a curved canula, the latter being liable to injore the bas-fond of the bladder or the prostate. The trocar is to be introduced horizontally, and a gum-elastic catheter is to be passed into the canula, immediately on the withdrawal of the stil tto, and to be fixed in situ when the canula bas been slid away upon it.-M. Haguier maintained that there were conditions which rendered this a very difficult operation, and among these is particularly the ascension of the prostate and bas fond of the bladder. When the bladder becomes much distended, it rises, like the uterus in pregDancy, above the superior aperture of the pelvis; and in complete retention the fluctuation felt through the rectuin, so much spoken of by authors, cannot be felt, because the bladder becomes raised to a point beyond the access of the finger. Under these circumstances the prostate may be wounded, and that when in nowise enlarged. This occurred to Ricberand, who was a great advocate of the operation, and very skilful in its performance. To avoid this accident the straight should be preferred to the curved trocar, and this should be passed horizontally above the pubes, instead of, as is usually directed, downwards and backwards. He seldom removes the canula before the seventh day, and has never known a straight instrument excite any irritation of the posterior wall of the bladder. He however takes the precantion of introducing a gum.elastic catheter into the canula and fixing it there, so that its smooth, rounded extremity, furnished with its lateral eyes, may project at least a centimetre beyond the vesical extremity of the canula.-M. Giraldès could not agree with M. Huguier in admitting this ascension of the bas-fond, the ease with which the organ may be punctured by the rectum showing that the relation of the parts is not changed. This rectal operation has very often been performed by Mr. Cock, of Guy's Hospital, who finds it of much easier execution than the supra-pubic puncture.—M. Lenoir has been struck with the facility with which some surgeons decide upon the performance of this operation. For his own part, although attached to the hospitals for twenty years, he has never had recourse to it but twice. He thinks it should be reserved for extreme cases, when the rupture of the bladder seems imminent. Then the bladder is very distended, and its puncture presents no difficulty. He entirely rejects the opinion of M. Huguier as to the ascension of the prostate. This gland is solidly fised, and if it sometimes extends above its ordinarily level, it is only because it has become hypertrophied. It is possible, that when it is greatly hypertrophied it might become punctured by a curved trocar ; but M. Lenoir never exposes himself to such an accident, because he never punctures the bladder for prostatic retentions. Such an obstacle being perinanent, there is no chance of re-establishing the natural course of the urine, and the patient is exposed to the inconvenience of a hypogastric tistula for the rest of his lite. In such a case, forced catheterism, by means of a conical instrument, is far preferable. It is an intra-urethral puncture through the prostate; and a fal-e passage, an intra-prostatic fistula, is produced that will fulfil the functions of the prostatic portion of the urethra. The operation completed, the conical catheter should be replaced by one in gum elastic—a practice much preferable to leaving in the metallic instrument.-M. Huguier added that although the anterior portion of the prostate is fixed by ligaments and aponeuroses which do not allow of its rising, its posterior part is in fact drawn up during distension of the bladder. The finger cannot then feel the globular or cylindrical fluctuation which has been described as one of the principal signs of retention; but this does not prevent a long anıl concave trocar, directed backwards and upwards, from reaching the bladder.-M. Chassaignac also admits this «levation of the posterior part of the prostate. He thinks the preliminary incision of the integuments, as recommended by M. Deguise, might give rise to infiltration; and he rejects puncture by the rectum as dangerous, because of the risk of penetrating into the recto-vesical cul-desac of the peritoneum.
V. Case of Ersection of the Entire Radius. By Dr. CARNOOIAN. (American Journal of
Medical Science, April, 1858.) Dr. Carnochan, the first surgeon who exsected the entire ulna, now records the first example of exsection of the entire radius. The patient was a struinous Irish labourer, twenty years of age, in whom disease of the fore-arm was set up consecutively to a severe blow. Believing the osteitis was confined to the radius, Dr. Carnochan resolved upon the excision of this bone in preference to the performance of arnputation. In the progress of the disease, the elbow-joint had become stiff, the fore-arm being fexed at an obtuse angle. Chloroform was administered, and the operation was performed with great care, especially at the lower part, in order to preserve uninjured the different tendons proceeding to the hand. The greatly-increased size of the
bone rendered its detachment more difficult, and the bony union it had contracted with the humerus had to be destroyed with the chisel. The shaft of the bone itself was also divided across the middle, in order to render its detachment at each end easier. None of the nerves or arteries were injured, the interosseous artery and two muscular branches alone requiring ligatures. The patient was discharged cured at the end of eleven weeks, and returning afterwards for some other slight disease, he was found to have so regained the use of his arin and hand as to be able to perform the duties of orderly in a surgical ward. The fore-arm remains flexed at a con enient angle, and the deformity is less than might be expected. The power of the hand is not quite so great as formerly, but its functions are otherwise uninjured. He can carry a bucketful of water without difficulty, and can write with ease. Flexion and extension at the wrist are performed readily, and the hand can be brought into the prone or supine, abducted or adducted condition. The radius removed was found to be much expanded over its whole extent, and weighed seven ounces and a half, the weight of a healthy radius being about two onnces.
VI. On Imperforate Anus and Rectum. By Dr. Gay. (Boston Medical and Surgical Jonr
nal, vol. Ivii., pp. 397 and 415.) Dr. Gay, on the occasion of relating a case of unsuccessful operation for imperforate anus, passed in review the principal cases on record. These-104 in number, he arranges under the following heads:-1. Imperforato anus, 16 cases, all op-rated upon, with 2 recoveries and 14 deaths. 2. Imperforate rectum, 26 cases and 19 operations, with 4 recoveries. 3. I'nperforate anus with abdominal opening of the rectum, 24 cases, 14 operations, with 9 recoveries. 4. Anus natnral, and rectum with abnormal opening, 3 cases, 1 operation, with recovery. 5. Imperforate anus and rectum, 25 cases, 23 operations, with 8 recoveries. 6. Imperfurate anus and absence of rectum, 8 cases, 4 operations, 1 recovery. 7. Ditto, with absence of colon also, 2 cases, no operation. Thus, in a total of 104 cases, there were 77 operated upon and 27 not operated upon. Recovery took place in 25, and death in 52 of the cases operated upon.
The general conclusion is, that as nothing can be expected from nature in the way of substantial relief, while several of the cases operated upon have furnished encouraging results, an operation should be recommended, unless other complications or conditions of the system contraindicate it. The undertaking this should not be delayed too long, lesť laceration of the intestine be produced. In place of employing a trocar, the author prefers making a free incision with a sharp-pointed instrument guided by the finger. The opening should, when possible, be made sufficiently large at first, as the tendency to contraction becomes much greater in subsequent operations. Where the obstruction is hard and firm, it should all be removed, if this can be done safely, as it frequently resembles cicatricial tissue. The main difficulty and labour consists in the after-treatinent, owing to the disposition of the parts to contract. During the operation, we should use the finger as a director, and when it can be done, dissect away with this the intestine from the neighibouring parts. A probe should also be introduced into the bladder.
VII. Case of Dislocation and Reduction of the Crystalline Lens. By M. MAHIEUX. (Moni
teur des Hôpitaux, 1858. No. 41.) The subject of this case, & farmer, aged sixty-five, had lost his right eye, twenty years since, from intense inflammation and evacuation of the humours. The left eye bad preserved its functions, when, fifteen mooths since, without obvious cause, vision began to be sensibly disturbed, ohjects being no longer so clearly perceived, and a veil seerning to conceal their apper part. This state of things continued a year, unaccompanied by pain or inflammation, when without blow or violence of any kind, a condition of nyctalopia suddenly came on, objects feebly illuminated could alone be perceived, and these when placed low down could not be seen at all. Objects, too, perceived in one position of the head were lost sight of in another. This condition bad continued four montlıs, obliging the patient to abandon his occupation, and of late it had been accompanied by congestion of the conjunctiva, giving rise to some amount of pain.
On examination, the lower part of the anterior chamber was found occupied by the opaque and quite movable lens, its upper border rising a little above the centre of the pupil. The tremor of the iris characteristic of synchisis was also present. A lens that had remained so long without undergoing diminution in size was not likely to undergo absorption, but although its extraction would not be difficult, it would be a serious operation to risk in a man who had lost one eye, and who still saw enough to gnide himself about. It was determined, therefore, to attempt the reduction of the lens, or rather its passage into the posterior chamber. The patient was laid on his back, and the sulphate of atropine was dropped several times into the eye, motion being imparted to the head from time to time, in order to direct the lens towards the centre the iris. This gradually passed into the posterior chamber, and when the patient stool up, the upper part of the lens was alone perceived in the lower hemisphere. Next day, the patient had recovered his vision completely, except that there were some muscæ volitantes observed. A bright light now favoured, in place of preventing vision. The report only comes down to a fortnight after the reduction, when the pupil was found to be normal in its action, the iris continuing tremulent.
VIII. On Hospital Gangrene. By M. Maurix. (Mémoires de Médecine Militaire,
toine xx., p. 368.) This paper is the result of M. Maupin's observations upon hospital gangrene as it appeared in the French army of the East, in which it committed frightful ravages. In reference to the conditions under which it may become developed, M. Maupin observes that overcrowding of patients has usually been considered a necessary condition of the productiou of the disease; but that at the hospital into which the Russian Embassy was converted at Pera, and which united every condition of salubrity-and among these ample space-gangrene broke out amongst the wounded officers seven days after the arrival of eight others who had been severely wounded, the wounds of the preceding occupants having been slight. Still, the gravity of the disease will generally be found to be proportion:te to the amount of vitiation the air has undergone. The disease may indeed arise even in the open air when there is a considerable agglomeration of wounded soldiers, examples of which occurred to the author in Algeria. Overcrowding may be only relative, and a given number of patients that in the time of peace may be advantageously treated in a hospital, will in the period of war give riso to hospital gangrene. Not only do the numbers of the patients, but the gravity of the cases and the constant succession of such cases, increase the hygienic exigencies. The rule is, then, that the wounded soldier requires space and air in proportion to the gravity of his wound; and when hospital gangrene is once set up in a ward, the dispersion of the subjects of it is a measure alike beneficial to themselves and the other patients. As long as the medium remains unchanged, the treatment is but tentative, and the results are uncertain.
In order properly to appreciate the instability of the results of treatment, we should bear in mind that, if epidemic hospital gangrene may be an essentially local affection, it is frequently during a campaign but the expression of a general modification of the economy, of a true intoxication, the energy of which, intimately dependent upon the salubrity of the locality, and the number and nature of the wounds treated therein, is increased or diminished, revived or extinguished, with the increase or diminntion of the number of the patients, witli their agglomeration or dispersion. Means which in isolated cases of gangrene may act heroically-as the actual cautery, sulphuric acid, perchloride of iron, and in milder cases, citric acid, carbon, iodine, &c., are in the epidemic form either powerless or only of temporary benefit. It is this which explains the differences of opinion that prevail on the treatment of this disease.
In respect to the local affection considered separately, we must recognise an acute and a chronic form, a distinction of importance as regards treatment. The acute form is denoted by the conversion of the tissues into a pulpous or pntrilaginous magma, and wbich, as soon as the destructive process is arrested, becomes detached through a series of eliminatory pro
The ulcerative is the chronic form of the disease. The putrilaginous forın is almost always primary, and is found almost exclusively in recent wounds; while the pulpous form, though often also primary, is also often met with in old wounds, and it does not pursne the same rapid and destructive course as the putrilaginons forin. The ulcerative form is almost always consecutive to the two other forms, appearing especially in the case of old wounds, or after amputations these have necessitated. In the putrilaginous and pulpous forms the most appropriate measures are those which hasten the separation of the parts affected, and stimu. late the reparative process. Of these, the actual cautery, sulphuric acid, and the perchloride of iron occupy the first rank. In an hospital in which there are at least 300 cases of hospital gangrene at the same time, the application of the actual cautery is made with difficulty, while, although it is just as painful as the other means, it does not adapt itself so readily to all the