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He then goes on to show, from numerous statistical facts, that when diphtheritis attacks the air-passages, the extent of mischief is nearly if not quite as great as that which is met with in the idiopathic inflammatory croup of this country; and hence, that there is as great prospect of success in the latter case as in the former. That this prospect is not a visionary one, Dr. Fuller proves by collecting all the recorded cases in which tracheotomy has been performed in croup in this country. These amount to 23, including the author's own 7 cases; and although in all of them, without exception, the operation was deferred until the last stage of the disease, when suffocation was imminent, yet in 9 cases it was successful. (Since the appearance of Dr. Fuller's paper, 5 additional cases have been published by Mr. Spence, of Edinburgh, 3 of which were successful.)* Dr. Fuller concludes, that (even allowing that death was an unavoidable result in all the fatal cases), no practitioner would be justified, except under some peculiar circumstances, in withholding the chance afforded by the operation.
2. At what stage of the disease ought the operation to be undertaken? The author does not approve of the early performance of the operation recommended by Messrs. Bretonneau and Trousseau, and observes :
"As long as it appears possible to save life without operative interference, so long I maintain we ought to withhold the knife; but directly it becomes obvious that our remedies have failed, and that life will be sacrificed if the trachea be not opened, that moment we ought to urge upon the parents the immediate performance of tracheotomy. Each minute that is lost afterwards is so much against the patient's recovery."
3. Whether the existence of certain symptoms or other circumstances ought not to cause us to hesitate in recommending its performance? Pulmonary complications, Dr. Fuller admits, would counter-indicate the operation; but he insists that, from the peculiar circumstances of the case, neither by a physical examination of the chest, nor by the most careful observation of the general symptoms, can we arrive at a certain conclusion as to the condition of the lungs. He adds:
"If the patient has been out of health prior to his attack of croup, if his illness has been preceded by pneumonia or severe bronchitis, if he is suffering from any exanthematous or other disorder ; and further, if he is in such a position of life that his parents are unable to secure for him proper skilful attendance day and night, the operation ought not to be recommended, however promising it might otherwise appear. For, under such conditions, it must almost certainly prove fatal.”
4. Whether any, and what, medical treatment is necessary after an opening has been made into the trachea ? The author observes that the operation merely admits air, and does not arrest the disease; and hence that those remedies, calomel and antimony, which are usually considered useful before the operation, must be steadily persevered in afterwards. Except in the diphtheritic form of the disease, and in those varieties which follow measles, scarlatina, or other of the exanthemata, he objects, both on theoretical and practical grounds, to the administration of stimulants, as being not only unnecessary, but positively injurious.
The paper concludes with some useful suggestions as to the construction of the trachea tubes. These are recommended to be larger, shorter, and less curved than those in common use, of uniform diameter throughout, and with the outer tube constructed of two flattened blades, which can be immediately expanded by merely pushing in the inner tube between them.
· V. Some Observations on the Anatomy and Pathology of the Adult Prostate, founded upon Fifty Preparations of the Organ Dissected by the Author. By HENRY THOMPSON, F.R.C.S.—These observations have reference to the following heads:
* Edinburgh Medical Journal, Feb. 1858.
1. The frequency with which enlargement of the prostate occurs in advanced age. Contrary to the current opinion, which has been advocated by Sir Everard Home, Sir Benjamin Brodie, and others, Mr. Thompson, from an examination of his fifty cases, arrives at the following conclusion :
may, then, be regarded as established by the facts before the Society, that enlargement of the prostate, so far from
being a change natural to old age, is an exceptional condition. And it may further be regarded as highly probable, that a slight tendency thereto, almost, if not quite, unrecognisable during life, may occur in about one out of three individuals after fifty years; and that a marked enlargement may be found in one out of eight, rarely, however, before sixty years of age.”
2. On the weight and size of the healthy adult prostate. The various measurements of the organ are given with considerable minuteness; and the prevailing and average weight are stated to have been found the same, the latter being 4 drachms and 38 grains.
3. On the nature of a part called “the third” or “middle lobe.” The author confesses that he has not been able to detect a portion of the healthy organ in this situation, sufficiently defined by form or position to entitle it to the distinctive appellation conferred upon it by Sir Everard Home, and thinks that the term "posterior median portion” is more applicable to the thin laminæ of the organ lying above and below the urethra. The occasional appearance of a distinct lobe in this situation, he considers to be a result of disease, as was long ago asserted by Morgagni.
4. On the existence of distinct tumours in the prostate. The existence of distinct tumours, either embedded in, or projecting from, the substance of the prostate, Mr. Thompson thinks is more common than is generally believed. From an analysis of his own cases, and of seventy specimens of enlarged prostate in the Museum of the College of Surgeons, he shows that these tumours are more frequently than otherwise the essential element of the pathological condition generally known as hypertrophy of the prostate. Three sorts of these tumours are described-viz., 1. A simple fibrous tumour ; 2. a tumour containing, in addition to fibres, some of the glandular structure of the prostate imperfectly developed; and 3. A tumour composed of the ordinary structures of the prostate fully developed. The latter springs from the posterior median portion, and has its own special ducts. A striking analogy is stated to exist between these tumours and those of the uterus.
5. On the existence of minute" concretions,” their mode of production, and their relation to the formation of prostatic calculi
. Minute concretions, the largest about the size of poppy seeds, were detected in the prostatic ducts of every one of the fifty cases; and the author concludes that their existence is a necessary result of the performance of natural functions on the part of the prostate. The structure of these concretions, and the manner in which they may be converted into prostatic calculi, are carefully described.
VI. On Disarticulation of the Scapula from the Shoulder-joint. By JAMES SYME, F.R.S.E.—The operation described in this paper adds another to the many new operations, with which the distinguished Edinburgh Professor has already enriched the practice of surgery. The operation was performed on a female, nearly seventy years of age, on account of a large cerebriform tumour of the “scapula.” The wound healed favourably, and in no long time the woman could use her arm so freely, that she declared it was in no respect inferior to the sound one. The patient herself, however, gradually became weaker and more emaciated, and ultimately died, fully two months after the operation. The author appends to the history of the case some valuable practical remarks; and observes, that although it would have been more satisfactory if the patient had lived longer, yet the progress of the case was sufficiently advanced to show-1stly. That the entire scapula may be disarticulated from the shoulder-joint, without a loss of blood to any great extent. 2ndly. That the wound resulting from this operation does not necessarily occasion an excessive amount of discharge. And 3rdly. That the arm which remains is not a useless appendage, but a serviceable limb.
VII. On a New Method of Operating for Impermeable Urethra. By JAMES SYME, F.R.S.E.-Mr. Syme commences by pointing out the error of those who have attributed to him the opinion, that in no case is the urethra impermeable to instruments. All that he has asserted is, that the nature of a stricture is inconsistent with impermeability; and he has never denied, that in consequence of wounds or sloughing, the urethra may become completely obstructed beyond the fistulous opening, so as to be impermeable both by urine and instruments. Every practical surgeon knows full well the distressing nature of these cases, and how embarrassing and uncertain in its results is the ordinary operation of cutting upon the point of a catheter passed down to the seat of obstruction. Mr. Syme proposes the following mode of procedure in such cases :—To introduce into the bladder through the fistalous opening-which, if necessary, might be dilated-a staff like that used in lithotomy, but with the groove on its concave instead of its convex side ; then to insinuate through the urethra, as far as possible, the guide director employed for dividing strictures by external incision; and while the staff, confided to an assistant, is supported by a finger of the operator on the perinæum or in the rectum, to push the director onwards in the direction it ought to take, if the canal were free, so as to pass through the obstructing texture, enter the groove, and proceed into the bladder. The case might then be treated as in the ordinary operation for stricture by external incision. We shall be glad to hear the results of some of Mr. Syme's cases treated in the above manner.
VIII. Case of Double Talipes Varus, in which the Cuboid Bone was partially Removed from the Left Foot. By SAMUEL SOLLY, F.R.S.-For an account of this case we must refer our readers to the original paper.
IX. On Forcible Extension and Rupture of the Uniting Medium of Partially Anchylosed Surfaces. By BERNARD E. BRODHURST.-In cases of partially anchylosed joints, the author proposes this plan of treatment as less hazardous and more efficient than resection of the joint. "He commences by first dividing subcutanequsly the tendons likely to interfere with the extending process; seven or eight days after, the patient being under the influence of chloroform, he proceeds to rupture the adhesions by forcible flexion and extension of the limb. Afterwards, passive motion is practised daily on every second day. The history of eight cases in which this practice was pursued, is given : three, of partial anchylosis of the knee ; four, of the hip; and one, of the elbow. In all of these cases the result appears to have been favourable.
X. On Scirrhus of the Male Breast. By J. L. Milton, Esq.-The paper contains an account of a case observed by the author. The patient was a man, aged fifty-eight, and the case terminated fatally, about a year after the first appearance of the tumour, no operation having been attempted. It is to be regretted that no account is given of the structure of the tumour, except that it was pronounced by Mr. Quekett to be scirrhus. The author has also collected, apparently with much industry, between 50 and 60 other cases of scirrhus of the male breast.
XI. Analysis of Fifty-two cases of Epilepsy observed by the Author. By EDWARD H. SIEVEKING, M.D.-The author, without any attempt to theorize upon the disease, records a few valuable facts, the result of his own observation. These are classified under the following heads:
1. Sex.-Of the 52 cases, 24 were females and 28 males. From this it would appear that the male sex is somewhat more liable to epilepsy than the female.
The same result is arrived at by referring to the number of deaths from epilepsy in England and Wales, as recorded in the Registrar-General's Reports for seven years (1848 to1854 inclusive). Out of 12,878 cases, 6,729, or 52.26 per cent., were males.
2. Age.—Of the 52 cases, 36 were from infancy to the age of twenty years; 8, from twenty-one to forty; and 8, from forty-one to fifty-five years. Dr. Sieveking also confirms the observations of Tissot and Esquirol, that it is only at the period of puberty that the male exhibits a greater tendency to epilepsy than the female.
3. Causes.-In 16 cases a definite cause was assigned ; in 6 only could an hereditary taint be traced.
4. Premonitory Symptoms.- These existed in 27 out of the 52 cases. The various characters of these symptoms are enumerated; but they were never described by the patient as a puff of wind, or an aura': in its verbal sense.
5. Individual Symptoms. Headache was observed in 33 of the 52 cases. Of these, it was constant in 19; before the fits, only in 4 cases; and after the fits, only in 10 cases. Biting the tongue occurred in only 17 cases. In 19 cases the urine was tested for albumen, which was found temporarily present in one, and permanently in a second ; in 14 cases it was examined for sugar, which was not found once.
6. Results of Treatment. The number of apparent cures was fifteen; and it was observed that the curability of the disease bore an inverse ratio to its duration before treatment. Some remarks follow on the various plans of treatment pursued in the different cases. The author expresses bis disbelief in any specific for epilepsy, but thinks we must be guided by the following indications: to remove local congestion by counter-irritants, to promote the healthy action of the secernent organs, and to give tone to the constitution by vegetable and metallic roborants, as well as by suitable regiminal measures.
XII. A Case of Disease of the Heart, with great Dilatation of the Auricles. By W. 0. MARKHAM, M.D.-In this very interesting case, the following signs were observed during life :
“At a point about an inch and a half or two inches from the right edge of the sternum, and in the fifth intercostal space, a pulsation was observed, synchronous with the ventricular systole. This pulsation was visible along a space of about three-quarters of an inch: it communicated a strong thrill to the finger placed upon it, and likewise forcibly raised the finger. The stethoscope placed over it, transınitted to the ear of the observer à loud, prolonged, rough murmur."
The pulsation was quite distinct from that of the apex, which could be felt quite in the left lateral region of the thorax. During life an opinion was expressed that the pulsation was aneurismal; but after death it became manifest that the pulsation, the thrill, and the long prolonged bruit, took their origin from the right auricle, which reached away far to the right of the sternum. That tricuspid regurgitation did not cause the pulsation, seemed indicated by the perfect condition of the tricuspid valves, and other circumstances. “Hence, then, it would seem that we must place the pulsation, the thrill, and the murmur, to the account of the blood rushing into the auricle from the venæ cavæ during its diastole."
The patient was a man, aged sixty-nine. Twenty-four years before his death, his life had been despaired of on account of extensive dropsical effusions; and fifteen years before, he had been told that the dropsy and painful symptoms from which he suffered were the consequences of disease of the heart. The case then demonstrates the extraordinary degree of deviation from the healthy state of the heart with which a long life may be compatible.
XIII. Case of Intense and Long-continued Photophobia and Blepharospasm, Relieved by the Inhalation of Chloroform. By WILLIAM MACKENZIE, M.D. Glasgow. The patient, a female, aged twenty-two, had suffered from photophobia and rigid compression of the eyelids for sixteen years without intermission, and had been admitted into the Asylum for the Blind as one hopelessly deprived of sight. At intervals of three or four days she was put seven times under the influence of chloroform, but never to the extent of complete insensibility. Each administration produced a decided diminution of the symptoms; and after the seventh application she opened her eyes fully, and saw every object around her. The improvement was permanent.
XIV. On the Effects of Twelve Weeks' Residence in Bulgaria during the Months of June, July, and August, 1854, on the subsequent Health of the British Army in the Crimea. By WILLIAM AITKEN, M.D.-It will be recollected that at the commencement of the late Russian war a large body of our troops was stationed in Bulgaria for many months, previous to their embarkation for the Crimea. Cholera there raged among them to a fearful extent; and those who escaped its deadly ravages were subjected to influences of the most debilitating nature. Depression of spirits from inaction and from the suddenness and fatality of the attacks of disease among their comrades, long drills, bad tents, great alternations of temperature, malaria, and bad food-all contributed to "use up" the strength of the men.
It became, then, an interesting question to determine the amount of disease and mortality among these troops after their arrival in the Crimea, as compared with that among the troops which had been transported direct from England. Dr. Aitken has, with this object, divided the Crimean army into two bodies: the troops which had previously served in Bulgaria he designates exBulgarian, the others simply Crimean.' He then proceeds, by a series of elaborate analyses of the Army Returns, to investigate the prevalence of, and mortality from, different classes of disease in these two divisions. As regards the prevalence of different diseases, he shows that the admissions for fevers, scurvy, pulmonary affections, and many other diseases among the ex-Bulgarian troops, greatly exceeded those among the Crimean. To these, cholera and other enteric diseases presented a remarkable antithesis, the admissions for these affections being greater among the Crimean troops. This apparent anomaly, the author observes, is in a measure explained by what we know of these diseases. During the Bulgarian campaign, the more susceptible among the troops had already suffered from them; and fewer, therefore, were in a condition to become affected by them in the Crimea. The mortality from the different diseases, as the percentage of deaths calculated in the number of admissions, Dr. Aitken has ascertained to have been invariably greater amongst the ex-Bulgarian forces: in this respect cholera and dysentery proved no exceptions.
The residence in Bulgaria appears also to have exercised a prejudicial influence over the results of the surgery of the war. Thus
“ The ratios of the deaths per cent., in the Crimea and at Scutari, on the total admissions for wounds and injuries, were 19.1 per cent. amongst the ex-Bulgarian troops, and 137 per cent, amongst those who had served in the Crimea only."
XV. Further Observations on the Use of the Speculum in the Diagnosis and Treatment of Uterine Diseases. By ROBERT LEE, M.D., F.R.S.-Dr. Lee is well known as a most determined opponent of the use of the speculum-vaginæ for any affection whatsoever. In a previous volume of the Medico-Chirurgical Transactions,' he has published a collection of 220 cases in which the speculum and caustic had been employed by other practitioners, and we have now the details of 80 more, making in all the overwhelming number of 300. Dr. Lee argues with his usual energy, that in all these cases the introdnction of the speculum was unnecessary, injurious, or immoral. “The speculum” (he says) "emanated from the syphilitic wards of the hospitals of Paris, and it would have been better for the women of England had its use been confined to those institutions!” We quite agree with Dr. Lee, that the speculum is an instrument which has been, and