Part 5

=The Pressure and Ligature Methods of treating Aneurism.=—In the course of a lecture on aneurism of the femoral artery Mr. Paget, adverting to these two methods, speaks of them thus: “Taking large numbers of cases of aneurism together, they are very nearly balanced, on the one side for pressure, and on the other for ligature. In favour of pressure there is the experience of the surgeons in Dublin. They seem to have a much larger number of aneurisms, especially of aneurisms of the popliteal artery, to treat than we have in England, and they have certainly a large amount of success. I have no doubt this is in part due to a well-arranged system, and to the house-surgeons and dressers acquiring a more special skill than we have yet achieved. On the other hand, there is the remarkable success attained by surgeons who have constantly practised, with great skill, the ligature. The success of Mr. Syme in the ligature of the femoral artery for popliteal aneurism has been so great that any one who might fairly expect to attain nearly the same measure of skill would undoubtedly follow the ligature rather than the pressure. I would prefer, however, to leave the subject open for your own observation, and say, endeavour to ascertain, as far as you may be able, which are the cases for the ligature and which are those in which pressure is more likely to lead to a good result. And in many cases in respect of which you are doubtful, pressure may be tried first and the ligature afterwards.” (See _Lancet_, April 24.)

=Treatment of Atonic Dyspepsia.=—Dr. Thorowgood, in a paper just published, refers to the existence of torpor of the colon as a complication in cases of this kind. In treating cases of dyspepsia occurring in those who work hard with their brains and have but little “tone” about the stomach and bowels, he is convinced that the more we refrain from the administration of purgatives the better. At one time he used to think that when the tongue was crusted a purgative could not be amiss; but to whatever degree this holds good with strong country people and over-fed townspeople, it does not apply to those who have feeble appetite and who work hard. In these cases he has seen an acid mixture or a chalybeate do more service in cleaning the tongue and promoting digestion than alkalies or aperients. If the colon be filled with scybalæ, the best evacuant is a table-spoonful of castor-oil in peppermint water. When the constipation takes on a less or more obstinate character, he uses a saline chalybeate in imitation of the saline chalybeate waters of Kissingen, Harrogate, &c. In addition he gives a zinc pill, with extract of henbane, at night. But he avoids the use of opium. (See _Lancet_, April 24.)

=Anaemia and Chlorosis treated by Nickel and Manganese.=—Dr. Broadbent lately read a paper before the Clinical Society (April 9th), in which, on the principle that chemical substances closely allied have similar action, he recommended manganese and nickel as substitutes for iron in the treatment of chorea. He recorded various cases, in some of which good results appeared to follow this method.

=Operation for Chronic Inversion of Uterus.=—At the meeting of the Royal Medical and Chirurgical Society, on the 13th of April, Dr. Barnes read a paper, in which he described a new operation for the relief of chronic inversion of the uterus. He gave the statistics of the different methods now in use. He stated that the ligature and excision were open to the double objection that, besides being very hazardous to life, success was only achieved at the expense of mutilating the patient. Forcible taxis was a violent and often fatal proceeding. Sustained elastic pressure had given remarkable results, but cases would occur where the constricted cervix uteri would resist simple pressure. He then described a case of inversion of six months’ standing, which had resisted elastic pressure kept up for five days, and in which he resorted to a plan then practised, he believed, for the first time, of making three longitudinal incisions into the os uteri, so as to relax the circular fibres; taxis then applied quickly succeeded, and the woman made an excellent recovery. He proposed, therefore, as the best proceeding where simple sustained elastic pressure fails, to make an incision on either side of the os uteri, and then to re-apply the elastic pressure, as being safer from the risk of laceration than the taxis. (See _British Medical Journal_, April 24.)

=A Presse-artère for Compression of the Arteries=, which may be found useful in some cases, has been described by Mr. B. Wills Richardson, of Dublin. The tubular _presse-artère_ which he has invented is intended only for immediate compression, but it was used with good result in the amputation of the fore-arm. The new instrument is composed of two parts. (1) A fine silver or a fine German silver tube. To the upper end of this tube a small milled button is soldered. The button facilitates the turning or screwing of the tube by the fingers of the surgeon. A female screw is formed upon the upper half of the inside of the tube. (2) A steel stem having two jaws at its lower end. These jaws are perfectly smooth on their opposed as well as on their outer surfaces, and free from any cutting edge. They are so arranged as to open and close parallel to each other. At the upper end of the stem there is a handle nut. It is hexagonal only in the present instrument; but, for recognition in wounds, the handle nut of the _presse-artère_ intended for large arteries should have some other form when more than one instrument is in use. The nut is fitted to the stem by means of a square mortise to prevent it from turning on the stem during the screwing or unscrewing of the tube. The handle nut is secured in its position by a smaller but screw nut. The upper half of the stem has a male screw cut upon it, and is adapted to the female screw on the inside of the tube. The inventor claims the following advantages for this piece of apparatus:—(1) The smallness of the space it occupies. (2) Facility of application and removal. (3) Accurate graduation of the compression by means of the fine screw arrangement. (See _Medical Times_, April 24.)

=Catgut in the Ligature of Arteries.=—In a communication to the _Lancet_, Professor Lister, after giving numerous pathological details, refers to the practical importance of catgut as a ligature. He states that by applying a ligature of animal tissue antiseptically upon an artery, whether tightly or gently, we virtually surround it with a ring of living tissue and strengthen the vessel where we obstruct it. This antiseptic animal ligature consists of catgut steeped in carbolic acid and oil. And with such a ligature Professor Lister says he should now “without hesitation undertake ligature of the innominate, believing it to be a very safe proceeding.” He thus expresses himself as to the necessary qualities of the ligature:—“The method which I have found to answer best is to keep the gut steeped in a solution of carbolic acid in five parts of olive oil, with a very small quantity of water diffused through it.” A larger proportion of the acid would impair the tenacity of the thread. If a mere oily solution is employed, the gut remains rigid, the oil not entering at all into its substance. But a very small quantity of water, such as the acid enables the oil to dissolve, renders the gut supple without making it materially weaker or thicker. And, curiously enough, the presence of this small amount of water in the oily solution gradually brings about a change in the gut, indicated by a deep brown colour; after which it may be placed in a watery solution for a long time without swelling, as a portion prepared in a simple oily solution does. This is a great convenience; for an oily solution is unpleasant to work with during an operation, and exposure to the air soon renders gut suppled with water rigid from drying. But when it has been treated in the way above recommended, it may be transferred to a watery solution at the commencement of an operation, and so kept supple without having its strength or thickness altered. “For tying an arterial trunk in its continuity, catgut as thick when dry as ordinary purse-silk will be found best. But for ordinary wounds, where, if one ligature happens to break, another can be easily applied, much finer kinds may be employed, and are convenient from their smaller bulk.” (See _Lancet_, April 3.)

=The Advantages of Tracheotomy.=—Mr. T. R. Jessop corroborates the views expressed in our last Number by Mr. A. E. Durham. He gives some very remarkable cases, showing the great usefulness of the operation. Indeed, one case was a veritable resuscitation of life. (Ibid.)

=Arsenic a Cause of Shingles.=—The very important problem as to whether arsenic, when continuously administered, is productive of shingles, is again discussed by Mr. Hutchinson. Mr. Hutchinson does not assert the fact to be more than a coincidence, but he relates several very interesting cases in which the prolonged use of arsenic was followed by shingles. (See _Medical Times_, April 17.)

=The Treatment of Diabetes.=—Dr. Basham records some cases of diabetes treated very successfully with alkalies and the phosphatic salts of ammonia, and he expresses an opinion very favourable to this method of treatment. The following is the prescription employed:—Phosphate of ammonia and carbonate of ammonia of each ten grains, aromatic spirit of ammonia half a drachm, water an ounce, added to the juice of a fresh lemon, and taken three times a day. This line of treatment was continued for four months, with the results tabulated below:—

Mean Sugar sp. gr. per oz. September (began phosphatic salts) 1037 18 grains. October 1040 18 grains. November (great increase of urates) 1036 6 grains. December 4th (large proportion of urea and urates) 1018 ½ grain. December 28th (urea and urates in excess, a large crop of crystals of oxalate of lime after cooling) 1024 Nil. January 26, 1869 (same as above) 1026 Nil.

(See _British Medical Journal_, April 10.)

=Silver-wire Ligatures for the Pedicle in Ovariotomy.=—Dr. Marion Sims calls attention to a recent case in which he performed ovariotomy, in order to explain his method of dealing with the pedicle. In the particular instance the walls of the abdomen were so thick, and the pedicle was so short, that it would have been impossible to secure it in the usual way by the clamp externally. In such cases he has always held that the pedicle is best secured with silver-wire ligatures and dropped back into the pelvic cavity. “If the pedicle be small, it is enough to transfix it with a double silver-wire and secure the two halves by firmly twisting the wires on opposite sides.” If it be broad, it requires a number of separate wires. This case required eight deep silver sutures for closing the external wound, care being taken to pass them through the divided edges of the peritoneal coat. A piece of lint, wet with carbolic lotion, was laid over the wound, and secured by a bandage, and a large compress of cotton wadding. The urine was drawn off for three days. There was no constitutional disturbance, and the patient was convalescent from the moment of the operation. (See _British Medical Journal_, April 10.)

=Perchloride of Iron in Post-partum Hæmorrhage.=—Mr. Hugh Norris corroborates the testimony of the various obstetricians who have spoken so favourably of this styptic. Injections of strong solution of the salt instantly arrest the hæmorrhage in this dangerous class of cases. He noticed also that the perchloride has a peculiar corrugating effect on the superficial muscular fibres, as well as on the mucous surfaces. He has noticed in less than five minutes after injection that the sphincter vaginæ, which had previously allowed the passage of the hand, became so contracted that it barely admitted a single finger. From this he concludes that one of its beneficial effects in these cases is the contraction of the muscular fibres of the uterus. He lays down the following conclusions in reference to this preparation:—(1) We possess no topical styptic in efficacy at all approaching the perchloride of iron; its effects being certain, perfect, and instantaneous. (2) In _post-partum_ hæmorrhages, a solution of this salt, applied in the form of an intrauterine injection, is of the utmost value both in immediately arresting the flow of blood and also in causing a permanent contraction of the recently emptied uterus. Its presence in the cavity of the uterus _post-partum_ is not only not injurious, but on the contrary, from its well-known antiseptic properties, may frequently be productive of positive benefit in more ways than one. Mr. Norris employs a saturated (?) solution of the perchloride. All clots must first be removed, and the long tube of the syringe should be introduced thoroughly into the uterus before injection. (Ibid.)

=The Cure and Prevention of Scurvy.=—In a paper in the _Lancet_, Mr. Archer Farr starts a doctrine which is yet, we think, to be proved, viz. that scurvy is not caused by the absence of certain alkalies and the presence of others. Indeed, he refers scurvy to the absence on ship-board of proper flesh-food, and he thinks that by supplying flesh in thoroughly good condition scurvy may be avoided. Lime-juice acts, he says, by taking the place of the gastric juice and digesting the food, and thus promoting the nutrition of the body (!). (See _Lancet_, March 27.)

=Treatment of the Vomiting of Pregnancy.=—Mr. John Harrisson recommends that in these cases hypodermic injection of morphia be tried. He gives the report of a very decided and serious case, in which nearly every conceivable remedy had been employed in vain. He then tried the subcutaneous injection of acetate of morphia, in doses of one-sixth of a grain, three times a day, and this instantly arrested the vomiting. (See _British Medical Journal_, April 3.)

Extracts from British and Foreign Journals.

=Carbolate of Soda as a Remedy for Itch.=—Dr. Zimmermann, of Braunfels, remarks that no one who sees much of itch will deny that we are without any remedy which acts with the certainty of a specific. In private practice, where we cannot readily obtain the proper baths, frictional manipulations, &c., cases are apt to be very inveterate. The popularity of petroleum and Peru balsam is due chiefly to their being neither very disagreeable nor very troublesome in the use; but petroleum has not justified its reputation,[12] while Peru balsam, which really is very valuable, especially in recent and in children’s cases, is unfortunately very costly. Zimmermann is inclined to hope that in carbolate of soda he has found a remedy that will cure scabies, _tuto_, _cito et jucunde_, though his experience is not yet sufficient for absolute proof. He employs a solution of 160 to 320 grains of the salt in about 7 ounces of water; this is to be well rubbed into the affected parts thrice daily. In two or three days every case of Zimmermann’s, even the inveterate ones, has been completely cured, and this without any annoyance or interruption of the patient’s ordinary business. There is no irritative erythema of any consequence from the frictions. Carbolate of soda may be used as a disinfectant and deodoriser; for this purpose 16 to 32 grains to 7 ounces of water is sufficient. (_Der Praktische Arzt. März._)

=On the Contra-indications of Anæsthesia.=—M. Gosselin considers that alcoholism renders patients very unfit for taking chloroform, and thinks that to all persons above 50 years of age, and given to intemperance, chloroformisation should be forbidden; or at any rate only applied with the greatest caution, and never for a long time together. Professor Nagel, of Vienna, has recently opposed this wholesale condemnation. In delirium tremens, chloroform narcosis is often very useful, especially where it is necessary to set fractures. The severest delirium, on which large doses of opium produce no effect, has been repeatedly calmed by chloroformisation in Nagel’s own practice. Alcoholism only so far contra-indicates anæsthetics, that in refractory subjects it is necessary to push the agent in such large doses that, even with the greatest care, there is a risk of asphyxia.

An even more positive contra-indication to chloroform is found by Gosselin in the case of stupor following severe wounds. No one will dispute that narcotisation is at first entirely out of the question; it only remains doubtful for how long a time after the injury it is unsafe to give chloroform for operative purposes. Gosselin is for total exclusion, since even after the apparent departure of stupor, a kind of concealed shock to the system may still exist, and would render anæsthesia dangerous. He also thinks that in recent dislocations, especially of the shoulder, chloroform is not only usually needless, but contra-indicated by the fact that the patient’s want of sensibility may permit such force to be used as may inflict severe injuries upon the nerve trunks; and even in old dislocations chloroform should not be used till other means have been tried. This contra-indication, also, is opposed by Nagel, who brings a large amount of experience to controvert it; it even happens, sometimes, that the muscular tone can be sufficiently relaxed for the reduction without any loss of consciousness. The chief contra-indication to chloroformisation which Nagel admits is the pre-occurrence of long-standing or considerable (arterial) hæmorrhage, and advanced age, especially if there be also heart or lung disease, vascular degeneration, emphysema, &c., also the fact that the operation might cause blood to enter the larynx; and in hernia, because of the tendency to vomit. He recommends the greatest care in giving it to refractory patients, who struggle, scream, and hold their breath. The danger of asphyxia increases every moment, and it is necessary to have ready the means of throwing in a stream of pure air or of oxygen, through the _nose_, sprinkling the patient with cold water at the same time. Nagel has also observed that the restlessness and oppression produced by half-felt pain in incomplete narcosis, and the consequently insufficient respirations, may produce an even fatal exhaustion. Narcosis should therefore be properly kept up as long as it is wanted. (_Der Praktische Arzt._)

[It is very necessary that we should study the opinions of foreign physicians and surgeons as to the dangers of anæsthesia. At the same time, I think it right to protest here that the cautions given even by Nagel, and still more those which Gosselin inculcates (with two exceptions), are to me inexplicable. At least they can only be understood upon the supposition that the means of inducing anæsthesia which are employed by these authorities are extremely inefficient and improper. A former very large experience of chloroform administration, some years ago, impressed me with the confident belief that if chloroform be given with proper care and with a Snow’s, or still better a Clover’s apparatus, there is really no danger whatever in its use, except in two cases—that of shock after severe injury, and that of delirium tremens. I cannot admit that a patient who is in a fit condition to undergo a surgical operation at all is placed in any worse position for supporting the shock of it by the fact that he has been chloroformised, if this has been skilfully done—the case of severe shock from injury always excepted.—F. E. ANSTIE.]

=Subcutaneous Injection of Mercury in Syphilis.=—Dr. A. Stöhr records a series of clinical observations on this method of treatment, which are very interesting. He considers that the subcutaneous injection of the bichloride is the most effective and direct means of producing the curative effects of mercury which has ever been applied. Stöhr employed the treatment for 96 patients; in almost all the cases it was carefully ascertained that no specific treatment had been previously adopted. His cases included a larger relative proportion of inveterate syphilis than those treated by Lewin in his researches, described by M. Bricheteau in the _Practitioner_ for March. Stöhr considers that the hypodermic method is not needed for the milder forms of syphilis. Old and obstinate cases, on the other hand, in which inunction or other forms of mercurialisation have been vainly tried, are particularly appropriate for a trial of the subcutaneous method. It is especially indicated in such cases as those of iritis and of dangerous laryngeal affections, in which it is important to produce a very rapid effect; also in severe and extensive syphilitic skin affections, in which inunction cannot be applied. Syphilis of the bones and periosteum, and syphilitic gummata, are but little influenced by hypodermic mercurialisation. In cases accompanied by severe marasmus, the hypodermic use of mercury is contra-indicated. It is also inappropriate to the treatment of those persons who have to be treated as _out_patients of a hospital. Stöhr employs a solution of corrosive sublimate in distilled water: he had at first tried a solution in glycerine, but this did not prove practically convenient. The dose ordinarily used was ⅛ of a grain; the daily employment of this only slowly produces ptyalism. When ¼ grain doses were used daily, the slighter symptoms of ptyalism never failed to occur by the third or fourth day, and the severer phenomena by the eighth or ninth; so that, with few exceptions, the administration of 2 or 2½ grains in this way produced such a strong development of salivation that the treatment had to be interrupted. (_Deutsches Archiv f. klin. Med._ V. 3 and 4.)

=The Treatment of Diabetes.=—Dr. Leube gives an elaborate report of two cases of diabetes in which he made the most careful daily observations of the quantity of water, of sugar, &c. He arrives at the following therapeutic conclusions:—Pure meat diet (with only _almond_ bread) was the most powerful means of reducing the sugar excretion. Of drugs which were tried, _arsenic_ had by far the most remarkable effect in reducing the sugar. Saikowsky discovered, some three years ago, that the continuous administration of arsenic for several days to animals entirely removed all glycogen from the liver; and that then neither puncture of the fourth ventricle nor curara poisoning would produce diabetes at all. Leube made the therapeutical application of the drug which these experiments suggest. He administered Fowler’s solution in doses equivalent to about ⅓ grain of arsenic daily. The effects were most striking during the period when the patients were taking a _mixed_ diet. With mixed diet, and without arsenic, the daily average of sugar was 570 grammes in one case; arsenic reduced it to 352 grammes, on the average of 79 day and night observations; and substantially the same result was obtained in the other case. The use of this drug would appear to promise results of real importance. (_Deutsches Archiv f. klin. Med._ V. 3 and 4.)