Chapter 14

In the Revue Medicale is a case, in which pomegranate succeeded in discharging three ells of tænia; but the patient broke off the worm in attempting to extract it with too much violence. This circumstance recalls us to the consideration of Dr. FRANK'S communication. He recommends much caution in the extraction of those portions of tænia, which have remained partly in the intestine; and says that Dr. CAGNOLA proposed touching the extruded portion with prussic acid, in hopes of killing the whole animal by means of this violent poison. Dr. GARLEKE adopted this plan on an extruded portion of four inches in length, and in one hour afterwards the _whole animal came away dead_. Dr. F. suggests, that the electric shock might weaken the tænia, so as to cause it to let go its hold, and thus be unresistingly extracted. BRERA recommended that the worm should be tied with a piece of silk. In this manner, it is retracted into the bowel, but begins to descend again not long afterwards. He dissuades from any attempt at forcible extraction, which excites the most distressing sensations in the bowels, and causes the risk of bringing on convulsions.

We are informed by Dr. FRANK, that a surgeon of St. Petersburg succeeded by passing the worm through a canula, and the canula through the sphincter ani muscle, so as to obviate the resistance caused by its contraction. In this manner, he easily succeeded in withdrawing the tænia _whole_, which is always desirable.

The writer of this article succeeded in removing many pieces of tænia from a female, by means of the tincture of black hellebore, given in doses of a teaspoonful for another object. The patient has since been affected with the same symptoms, and took to-day, Oct. 19th, in doses of [Symbol: ounce]iss, repeated every hour, sixteen ounces of a decoction of the rind of pomegranate fruit, (none of the cort. rad. being procurable); after which she took a dose of castor oil. It is said, we know not on what authority, in a French journal, that this preparation possesses the same powers as the root. It may be so; but this patient had no discharge of the tape worm, after swallowing the whole of this very astringent decoction, and following up the plan by taking [Symbol: ounce]iij of ol. ricini.

Perhaps the tænia had been effectually destroyed before. She has seen none of the joints for 18 months. The accounts, however, of the expulsion of tænia by the bark of the root, are so encouraging, that we have much pleasure in recommending it to the notice of the medical public in this country.

FOOTNOTES:

[18] Ed. Med. and Surg. Jour.

[19] Ed. Med. and Surg. Jour. July, 1821.

[20] Dict. des Sciences Medicales.

[21] There can be no particular benefit derived from the distillation. The simple mixture of the materials, above indicated, is all that is necessary. CHABERT'S remedy is therefore easily prepared.

[22] Lond. Med. Repos. April, 1825.

ARTICLE X.--_Researches Physiological and Pathological, instituted principally with a View to the Improvement of Medical and Surgical Practice._ By JAMES BLUNDELL, M. D., Lecturer on Physiology and Midwifery at the United Hospitals of St. Thomas and Guy. London, 1824, pp. 146, 8vo.

Dr. BLUNDELL is the author of some celebrated experiments on the physiology of generation, and the transfusion of blood. The work at present under consideration consists of physiological observations and experiments, the substance of a paper read before the Medico-Chirurgical Society of London, in the year 1823, and not heretofore published; of experiments on a few controverted points, respecting the physiology of generation; and lastly, of some remarks on the operation of transfusion.

The first part seems intended to ascertain what degree of lesion, or losses by extirpation, the body may sustain without inducing death; and thus, to open a way for improvements in surgery, by rendering the surgeon not only more bold and fearless, but more frequently successful in his attempts to preserve life, or counteract the inconvenient effects of disease and accidents. We shall make a short analysis of the first paper.

In four experiments, Dr. B. removed the left kidney of the rabbit, by incision on the outer edge. Ligatures were applied to prevent bleeding.

Two died; one in 60 hours, the other in 4-1/2 days: both of inflammation. One recovered, and lived 5 or 6 weeks, and then died. The 4th also recovered, but died in 5 or 6 weeks. On examination, a sac was found (in place of the kidney) filled with a semi-fluid substance, resembling custard, p. 4.

In seven rabbits, removed the spleen. One recovered permanently, and one lived six months. p. 5.

In five rabbits, opened the abdomen, and punctured the fundus of the bladder with a lancet. Three of them recovered entirely. p. 6.

In two rabbits, cut off one-fourth of the bladder with scissors, having applied a ligature first. One died in seven months; the other still lives in good health.

Into the peritoneum of four rabbits, threw [Symbol: ounce]i of human urine; then washed it out by injecting tepid water. One died of collapse in less than 24 hours, and two of inflammation, in 60 and 19 hours respectively. The fourth is now (12 months) in good health. p. 7.

In seven, injected [Symbol: ounce]xi decoct. quercûs into the peritoneum. Only one recovered.

Dr. B.'s inferences from the foregoing experiments are:

1st. "Large apertures into the peritoneum of the rabbit, do not immediately induce a dangerous prostration, of strength." p. 9.

2ndly. "Large apertures into the peritoneal sac of the rabbit, are not necessary, nor perhaps generally, productive of fatal inflammation."

3dly. "In the rabbit, the kidney, the spleen, and a large piece of the bladder may be extirpated, without necessarily causing death; though death under the first operation is probable." p. 10.

4thly. "When the abdomen is laid open, and parts are removed from it in the rabbit, the first danger arises apparently from collapse; the second from general inflammation; and the last from chronic disease." (Vide experiments.)

5thly. "The rabbit's abdomen is very tender, probably no less so than that of man." See exper.

6thly. "Success in abdominal operations on the rabbit, furnishes a presumption in favour of success in similar operations on the human abdomen; and, therefore, from these experiments, we may infer, _presumptively_, that moderate openings into the human peritoneum will not necessarily, nor even generally prove fatal from inflammation or otherwise; and further, that certain viscera or parts of viscera, not essential to the welfare of our structure, may be removed from the belly, without necessarily, or even generally, producing death. The extirpation of the kidney must be highly dangerous; but there is a presumption in favour of the successful removal of the spleen, the ovaries, or even of large pieces of the bladder." p. 11, 12.

Dr. B. having stated the foregoing results and inferences, proceeds by relating instances of severe injury sustained by the _human_ body, without being followed by death. These are confirmatory of his inferences from the experiments on rabbits. The instances given are--an os uteri torn off; extensive laceration of the uterus and rectum in labour; four uteri extirpated on account of chronic inversion, (p. 13.) One of these last under his own care. It was removed by a wire, and came off in 11 days, without one bad symptom, (p. 14.) Rupture and laceration of the abdominal coverings, four fingers' breadth, the bowels hanging out, (p. 14.) Two spleens removed; one in a soldier after the battle of Dettingen, who recovered without inconvenience afterwards; the other in a Mexican, whose case is related by Dr. O'BRIEN, in his Inaugural Essay, Edinb. 1818, (p. 15.) Three cases of rupture of the dropsical ovary. Two cases of opening into the abdomen, for the extirpation of dropsical ovaries, (p. 18.) Five cases of laceration of the uterus by natural efforts. Four of the women died, but in the fifth, Dr. BLUNDELL turned and delivered, after the child had escaped into the peritoneal sac, and the woman recovered, (p. 20.) Cesarian operation, three times by friend of Dr. HAIGHTON; once successfully, (p. 22.)

Dr. B. says, "From these (facts) few as they are, I feel conscious that no certain inference can yet be drawn; though _presumptive_ inferences certainly may, and they seem to me to be the following:

"1st. Small wounds, as tapping, hernia, &c. do not induce fatal peritonitis; and therefore the vulgar opinion that inflammation in a spot of the peritoneum will almost invariably diffuse itself over the greater part of it, is probably unfounded.

"2nd. Extensive divisions of the peritoneum are not necessarily fatal by inflammation or otherwise, and _probably_ not generally so.

"3d. That the womb, spleen, and ovaries, may be removed in the mode mentioned, without necessarily, and, _presumptively_, without generally destroying life.

"4th. That the gravid uterus may be torn open; the child may escape into the peritoneal sac; the os uteri may be torn off: not indeed, so far as these cases may be relied on, without great danger, but twice, in seven instances, without death. p. 28.

"5th. The peritoneum and abdominal viscera will bear more injury than the British surgeons seem disposed to admit.

"6th. That the above observations on the human abdomen, are in unison with those drawn from observations on the rabbit; and that observations made on the brute have more correspondence with those on the human being, than is generally believed."

Dr. BLUNDELL next remarks, that the facts related create a suspicion that a bolder abdominal surgery would not be unattended with success, and recommends the following operations to "_consideration_ merely, and not to practice, except in otherwise desperate cases."

1st. "When the Cesarian section is performed, divide or remove a small piece of Fallopian tube, so as to prevent the danger of reimpregnation, without destroying the sexual propensity. The need for a second operation might thus be certainly prevented, without scarcely increasing the danger."

2ndly. "Extirpation of healthy ovaries."

3dly. "The extirpation of the ovarian cyst in scirrhus, combined with dropsy, or in simple dropsy." He remarks, "This operation will, I am persuaded, ultimately come into general use; and if the British surgeons will not patronize and perform it, the French and American surgeons will." p. 26.

4thly. "The removal of a large circular piece of the cyst in ovarian dropsy, when the sac itself cannot be extirpated."

5thly. "The removal of the cancerous womb, when the ulceration first makes its appearance. Might not the womb be taken out above the symphysis pubis, or through the outlet of the pelvis?" &c. 27.

6thly. "Extirpation of the puerperal uterus." He suggests the removal of the whole womb after the Cesarian section, in order that the smaller might take place of the larger and more formidable wound through the uterus--but says expressly, "No operation perhaps can be more unpromising, shall I say more unjustifiable, in the _present state of our knowledge_; but I thought it proper to mention it." &c. p. 28.

7thly. "Should the bladder give way into the peritoneum," he asks, "Why should we not lay open the abdomen, tie up the bladder, discharge the urine, and wash out the peritoneum thoroughly, by the injection of warm water?" p. 28.

8thly. - - - - -

9thly. Injection of astringents into the ovarian cyst or peritoneal sac, unjustifiable.

10thly. "In cases of strongly characterized introsusception," why not make an opening into the peritoneum; and "pass the small intestines, fold by fold, through the fingers." Dr. B. has repeatedly done this in the dog and rabbit, without producing death, or extensive and dangerous inflammation.

11thly. In the rabbit, he has tied an abdominal artery, and carried the end of the ligature with a broad needle out through the back, opposite to the place of the vessel. This ligature can come away, and is a better mode than to leave it hanging out at the abdomen, or entirely among the bowels, where it forms a sac of puriform matter, and to appearance lays the foundation of chronic disease. p. 30.

Dr. BLUNDELL closes this paper by saying, that since the substance of it was read before the Medico-Chirurgical Society in 1823, Dr. RITZIUS, a Swedish physician, had informed him in London, "that the complete removal of the cancerous womb had been, to his personal knowledge, performed on the Continent five times. All the patients recovered from the operation," &c. "The womb was removed through the outlet of the pelvis." p. 36.

Since we read Dr. BLUNDELL'S recommendations to the new operations, we have been astonished to notice in the Ed. Med. and Surg. Journal, July, 1825, that a German surgeon had actually treated a case of ileus in the manner recommended by Dr. B. It is from Hufeland's Journal of Feb. 1825. After it was ascertained that an immoveable introsusception existed--

"The patient was placed on a convenient table. We examined accurately the situation of the hardening, (_which marked the diseased part_), and determined on opening the abdomen at the outer edge of the right rectus muscle, about two inches above the navel. After dividing the integuments with a common scalpel, and making a small opening in the peritoneum, I introduced my finger, and with a blunt pointed scalpel divided the peritoneum, so as to make it correspond with the external opening, which was between two and three inches. I then besmeared my hand with oil, and carried it into the abdomen, in order to feel for the indurated part. Scarcely had I introduced my hand, than an attack of the pain came on, and a portion of the intestines was protruded through the wound, which was immediately replaced by my assistant. On continuing the examination, I discovered in a transverse portion of the ileum, a foreign substance, just where the hardened intestine was to be felt. I drew the intestine out, in order to examine it more minutely. The intestine was neither inflamed nor expanded, but it contained in its cavity a soft coherent and compact mass, which at its upper part was somewhat compressed, and thus felt harder than the rest. So far as I could follow this part of the intestine, this contained matter was to be felt: I also here immediately detected an intus-susception, but in spite of all my efforts I could not reach the commencement of it, so as to bring it out. Two modes of proceeding were open to me, in order to remove the intus-susception; either to make a transverse incision in the integuments, from the right to the left side, or to open the intestine itself. The last mode seemed to me the most adviseable, both because the patient was already very much exhausted, and because the operation would be sooner completed. The intestine was opened at the end of the discovered intus-susceptio, and immediately a part of the strictured intestine came into view. I introduced my finger into the opening in the intestine, which was made about two inches in length, and gradually pushed the intus-suscepted part back from the right to the left side, whilst I gently drew that part of the intestine which contained the intus-susceptio towards me. By this means I fortunately succeeded in unfolding the tangled intestine, which amounted to two feet in length. There was not the slightest trace of inflammation, nor any thing unnatural to be discovered in the part; there was merely a round worm, which was situated in the upper part of the intus-susceptio. The intestine was brought together by means of six spiral stitches, after the manner of the glover's suture, and the end of the silk was allowed to hang out of the external wound in the abdomen."

The sutures were removed on the 8th day. On the 14th day, the man was cured, and continues well up to the date of the account.

ARTICLE XI.--_An Inquiry into the Nature and Treatment of Diabetes, Calculus, and other Affections of the Urinary Organs._ By WILLIAM PROUT, M. D., F. R. S. _From the second London Edition, published in 1825; with Notes and Additions_, by S. COLHOUN, M.D. Philadelphia, Towar & Hogan, 1826; pp. 308.

A very acceptable service has been done to the medical profession in this country, by the present republication of Dr. PROUT'S work on affections of the urinary organs. The American physician will now have it in his power, at a reasonable cost, to possess one of the best treatises on this interesting subject. From the known accuracy of Dr. PROUT as a chemist, and his reputation as an accurate observer of nature, much new light was naturally expected as the result of his observations. Nor indeed have these high expectations been disappointed. After a careful perusal of his work, we have formed the highest opinion of his powers, both as an original thinker, and experimental inquirer.

Dr. PROUT begins his treatise with some introductory remarks on the composition of the urine, and on urinary derangements generally. After giving a comparative tabular view of the composition of the blood, and healthy and diseased urine, he proceeds to notice in succession, their principal constituents. As albuminous urine is of frequent occurrence in dropsical complaints, and its presence regulates in some degree the practice proper to be pursued, the following characters, given to it by Dr. PROUT, should be well understood.

"Albuminous urine, on being exposed to a temperature of about 150° becomes opaque, and deposites this principle in a coagulated state. The precipitate varies considerably in its appearance in different instances. Sometimes it is of a firmer character, and similar to that formed by the serum of the blood, from which, in this case, it may be supposed to be derived; at other times it is very delicate and fragile in its texture, and somewhat resembles curd, when it may be supposed to be of chylous origin. In some instances, the effects of heat upon albuminous urine are increased by the addition of nitric acid. But the most delicate test of albuminous matter in general is dilute acetic acid, and the prussiate of potash." p. 6.

Dr. PROUT combats very successfully the opinion, generally entertained by chemists, that the power of healthy urine to redden litmus depends on the presence of free lithic acid.[23] That this power cannot depend upon lithic acid uncombined, is made evident to Dr. P. by its sparing solubility; it requiring, according to our author, 10,000 times its weight of water to dissolve it, or six times as much as is stated by Dr. HENRY. The reddening power of the urine is attributed by Dr. PROUT to the presence of lithate of ammonia, and superphosphate of ammonia: the former of which, contrary to what might be expected, is found capable of reddening litmus, and of remaining in solution with the latter, without decomposition.

The following interesting remarks are made by Dr. PROUT on the effects of muriatic acid, in precipitating lithic acid gravel:

"The muriatic acid, in combination with soda and potash, occurs both in the blood and in the urine; thus appearing to pass through the kidneys unchanged. This acid and its compounds formerly appeared to be of less importance in a pathological point of view than any other similar principles existing in the urine: but since the unexpected fact has been ascertained, that muriatic acid in a free state exists abundantly in the stomachs of animals during the process of digestion, I have attended a little more closely to the appearance of this principle in the urine, and am disposed to believe, in consequence, that it is the cause of the precipitation of lithic acid gravel from the urine more frequently than any other acid. I do not mean to say, that it is the _immediate_ cause of the precipitation of this acid; for in most instances, it acts like all powerful acids do under similar circumstances, namely, by liberating the weaker acids, which are thus enabled to act in their turn, and separate those having still weaker affinities than themselves. Thus, in the present instance, the muriatic acid may be supposed to separate the lactic, while the latter precipitates the lithic, &c. If this opinion be well founded, as I believe is the case, the muriatic acid may be considered of very great importance, not only in a pathological, but a physiological point of view; for if the muriatic acid, found in the urine in such instances, be supposed to have its origin in the digestive organs, we see at once the reason why the deposition of gravel is so liable to be influenced by the derangements in general, and more especially by the acidity, of the stomach."

"The muriatic acid may be shown to exist in the urine by the white curdy precipitate insoluble in nitric acid, which is formed, when the nitrate of silver is added to it, after the sulphuric and phosphoric acids have been removed by the nitrate of barytes or lead." pp. 20 and 21.

After finishing these introductory subjects, Dr. PROUT proceeds to the consideration of the diseases of the urinary organs themselves; which he divides into functional, mechanical, and organic. Under functional diseases, we have _first_, those, in which principles _soluble_ in the urine are morbidly deranged in quantity or quality, embracing three chapters; and _secondly_, those affections, in which principles _insoluble_ in the urine are morbidly deranged in quantity or quality, comprising six additional chapters. Under the first subdivision, the first chapter is on the affections, characterized by albuminous urine; the second, on diseases, in which an excess of urea is the characteristic symptom; and the third, on diabetes.

The diseased derangement, consisting in an excess of urea in the urine, has not been particularly noticed by any writer before Dr. PROUT, who believes that it has probably been confounded with that form of diabetes, called diabetes _insipidus_. The state of the urine and symptoms in this species of urinary derangement are thus described by our author:

"The average specific gravity of the urine seems to be a little above 1.020, and occasionally to vary from 1.015 to 1.030. Most generally it is pale, but occasionally it is high coloured, and exhibits somewhat the appearance of porter, more or less diluted with water; and this variety in appearance not unfrequently takes place in the urine of the same person. When first voided, it reddens litmus paper. For the most part, it is entirely free from sediment, except the mucous cloud of healthy urine; and the only remarkable property which it appears to possess, is that of containing abundance of urea; so that on the addition of nitric acid, crystallization speedily takes place. From the quantity of urea present, it is very prone to decomposition, and soon becomes alkaline, especially in warm weather.