2
122 in London ; and though the weights she bears are excessive, there has been no return of the disease, nor have there been any bearing-down pains. She continues in perfect health. Mrs. M- had laboured under the severe effects of an extensive prolapse of the womb since the birth of her last child, a period of seventeen years. She stated that she was unable to walk, or in any way to gain a livelihood, and that she was only free from pain when lying down. On examination, the uterus was found altogether external to the vagina. It was much enlarged, thickened, and indu- rated, and around the os, and upon different parts of the vagina, were several small ulcerations. Pessaries of various forms had been used to support the womb, but without effect. Mr. James Lane saw the patient with Mr. Norton, and it was determined that the operation which Mr. Lane had per- formed on several occasions should be adopted. On the following Wednesday Mr. Norton removed an el- liptical piece of the mucous membrane about three inches and a half in length, by two in breadth, from the vesical wall of the vagina. The cut margins were then brought together by means of ten silver-wire sutures, and the uterus returned to its normal position. The bowels were confined by opiates till the sixth day, and then relieved by castor oil. The vagina was syringed daily with warm water, and after eight days the sutures were removed. Fourteen days after the first operation, Mr. Norton re- moved by a horse-shoe incision rather more than an inch of the mucous membrane of the posterior and lateral walls of the vagina, including the cutaneous margins of the four- chette. The denuded surfaces were now approximated as in the operation for ruptured perineum, and were firmly fixed by means of silver-wire quilled sutures. The pro- jecting lips were more evenly adapted by a second row of wire sutures somewhat deeply placed. As on the previous occasion, the bowels were quieted by opiates throughout the week. The quilled sutures were removed after forty- eight hours, and the others in seven days. On the removal of the quilled sutures a few drops of pus exuded, and the parts around showed some little redness and induration, but these symptoms were relieved by a bread-and-water poultice. Within a fortnight after the second operation the patient left the hospital entirely cured. LONDON HOSPITAL. THE USE OF CARBOLIC ACID. AT this hospital, Mr. Maunder has employed carbolic acid under various circumstances, -in the treatment of large chronic abscess, in acute abscess of bone, after the removal of mammary tumours, in incised operation wounds, (as, for instance, hernia and ligature of the arteries), and as a dressing after amputations, both primary and secondary. The most important and interesting case in which Mr. Maunder used the drug was one of ligature of the left com- mon carotid artery, in a private patient, the subject of three surgical aneurisms. The ligature having been soaked in a strong solution of acid, was cut short, a weak solution was poured into the wound, and all the sponges and instruments employed in the operation were dipped in the acid solution. The wound was closed over the ligature, and thick pads of lint saturated with carbolic oil were adapted to the wound, and the outer pad was occasionally moistened with the oil. Six days subsequent to the operation the wound was dressed with carbolic putty, when neither swelling, nor redness, nor secretion was observed. The wound closed over the ligature, and in less than a month the patient went to the seaside. Mr. Maunder is of opinion that carbolic acid tends to prevent and arrest suppuration, to prevent decomposition in abscess cavities, to prevent local inflammatory action, and general inflammatory or traumatic fever. Thus, he thinks, the healing process is expedited, and the dangers of accident and operation wounds greatly diminished. WESTMINSTER HOSPITAL. THE USE OF CARBOLIC ACID. MR. HoLT finds carbolic acid, as applied in accordance with the directions given by Mr. Lister, a very valuable remedy. He has tried it in a large number of cases, and although it does not always succeed, he believes this is more from failing health on the part of the patient than from any defect in the remedy. In the main, however, it can be relied upon. Indolent, deep abscesses, sinuses, unhealthy ulcers, and such like, are much benefited by its application, and in recent operations, if the directions are thoroughly carried out, it certainly promotes immediate union. GREAT NORTHERN HOSPITAL. RETENTION OF A FARTHING IN THE FOOD PASSAGE OF AN INFANT FOR SIX MONTHS. A CHILD seventeen months old was brought to this hos- pital in June last, having, it was said, managed to swallow a farthing. It did not, however, show signs that any article so unsuited to digestion had been taken. The house- surgeon, Mr. P. D. Hopgood, prescribed as much solid food as possible, and small doses of castor oil, but the farthing was not forthcoming, and the patient disappeared. A few days ago, however, the child was sick after taking an un- usually heavy meal, and in the midst of the vomited matter a green mass was seen, which was the farthing, much covered with verdigris. The mother said that the child had seemed to suffer occasionally from pain, had coughed a little, and lost flesh. Where was the farthing during these six months ? Provincial Hospital Reports. LIVERPOOL SOUTHERN HOSPITAL. FRACTURE OF THE SPINE WITH DISPLACEMENT; REDUCTION BY MEANS OF PULLEYS; RECOVERY. (Under the care of Dr. WOLLASTON.) J. M a clerk, aged thirty-six, while in a state of in- toxication, walked over one of the pier-heads, and fell on to the river bed below, a distance of about forty feet. In this state he remained for four hours, until he was roused by feeling the advancing tide. He was hoisted up by ropes, and brought to the hospital. On admission, Nov. 18th, 1868, he was unable to stand, and complained of intense pain from the toes of both feet up to the hips, and also of a feeling of stiffness in the back. On examining the back there was considerable ecchymosis of the lower portion of the dorsal region, and the eleventh dorsal vertebra was displaced, and protruded fully an inch and a half from its normal position. No cre- pitus could be felt. Hyperæsthesia of the lower extremities existed in a most marked degree, a breath of air, or a touch of a feather, causing the most excruciating agony. Without any stimulus paroxysms of pain came on every three or four minutes, commencing at the base of the toes. There was neither paraplegia nor priapism. Treatment.—The patient being placed on a mattress on the floor, chloroform was administered to its full extent. The shoulders were then securely fixed, and the pulleys ap- plied to both thighs. During extension, the hand, placed over the projecting portion of the spine, felt the displace- ment gradually disappear, but without crepitus or jerk. Hot water bottles were applied to the feet, a dose of tinc- ture of opium given, the catheter passed, and the patient directed to remain on his back. Nov. 19th.-Has passed a restless night, the attacks of pain being most intense, and with only short intervals. Although he has been tossing from side to side, no dis- placement has occurred, but a slight ° dip " is felt at the seat of injury. One-third of a grain of morphia was in- jected into the calf of one leg, and the legs elevated on pil- lows ; catheter passed. Towards evening, as no relief was experienced, the injection was repeated in the other leg, and with immediate benefit. Temperature: upper ex- tremity, 97°; lower, 985°. Pulse 98. 20th.-Feels better, and has slept for some hours; pain in feet and legs not so intense, unless touched; abdomen tympanitic, and he is unable to pass flatus; little or no

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Page 1: LIVERPOOL SOUTHERN HOSPITAL

122

in London ; and though the weights she bears are excessive,there has been no return of the disease, nor have there beenany bearing-down pains. She continues in perfect health.

Mrs. M- had laboured under the severe effects of anextensive prolapse of the womb since the birth of her lastchild, a period of seventeen years. She stated that shewas unable to walk, or in any way to gain a livelihood, andthat she was only free from pain when lying down.On examination, the uterus was found altogether external

to the vagina. It was much enlarged, thickened, and indu-rated, and around the os, and upon different parts of thevagina, were several small ulcerations. Pessaries of variousforms had been used to support the womb, but withouteffect.

Mr. James Lane saw the patient with Mr. Norton, and itwas determined that the operation which Mr. Lane had per-formed on several occasions should be adopted.On the following Wednesday Mr. Norton removed an el-

liptical piece of the mucous membrane about three inchesand a half in length, by two in breadth, from the vesicalwall of the vagina. The cut margins were then broughttogether by means of ten silver-wire sutures, and the uterusreturned to its normal position. The bowels were confined

by opiates till the sixth day, and then relieved by castor oil.The vagina was syringed daily with warm water, and aftereight days the sutures were removed.

Fourteen days after the first operation, Mr. Norton re-moved by a horse-shoe incision rather more than an inch ofthe mucous membrane of the posterior and lateral walls ofthe vagina, including the cutaneous margins of the four-chette. The denuded surfaces were now approximated asin the operation for ruptured perineum, and were firmlyfixed by means of silver-wire quilled sutures. The pro-jecting lips were more evenly adapted by a second row ofwire sutures somewhat deeply placed. As on the previousoccasion, the bowels were quieted by opiates throughoutthe week. The quilled sutures were removed after forty-eight hours, and the others in seven days. On the removalof the quilled sutures a few drops of pus exuded, and theparts around showed some little redness and induration,but these symptoms were relieved by a bread-and-waterpoultice.Within a fortnight after the second operation the patient

left the hospital entirely cured.

LONDON HOSPITAL.THE USE OF CARBOLIC ACID.

AT this hospital, Mr. Maunder has employed carbolicacid under various circumstances, -in the treatment oflarge chronic abscess, in acute abscess of bone, after theremoval of mammary tumours, in incised operation wounds,(as, for instance, hernia and ligature of the arteries), and asa dressing after amputations, both primary and secondary.The most important and interesting case in which Mr.Maunder used the drug was one of ligature of the left com-mon carotid artery, in a private patient, the subject of threesurgical aneurisms. The ligature having been soaked in astrong solution of acid, was cut short, a weak solution waspoured into the wound, and all the sponges and instrumentsemployed in the operation were dipped in the acid solution.The wound was closed over the ligature, and thick pads oflint saturated with carbolic oil were adapted to the wound,and the outer pad was occasionally moistened with the oil.Six days subsequent to the operation the wound was dressedwith carbolic putty, when neither swelling, nor redness,nor secretion was observed. The wound closed over theligature, and in less than a month the patient went to theseaside. Mr. Maunder is of opinion that carbolic acid tendsto prevent and arrest suppuration, to prevent decompositionin abscess cavities, to prevent local inflammatory action,and general inflammatory or traumatic fever. Thus, hethinks, the healing process is expedited, and the dangersof accident and operation wounds greatly diminished.

WESTMINSTER HOSPITAL.THE USE OF CARBOLIC ACID.

MR. HoLT finds carbolic acid, as applied in accordancewith the directions given by Mr. Lister, a very valuable

remedy. He has tried it in a large number of cases, andalthough it does not always succeed, he believes this is morefrom failing health on the part of the patient than from anydefect in the remedy. In the main, however, it can be reliedupon. Indolent, deep abscesses, sinuses, unhealthy ulcers,and such like, are much benefited by its application, and inrecent operations, if the directions are thoroughly carriedout, it certainly promotes immediate union.

GREAT NORTHERN HOSPITAL.RETENTION OF A FARTHING IN THE FOOD PASSAGE OF

AN INFANT FOR SIX MONTHS.

A CHILD seventeen months old was brought to this hos-pital in June last, having, it was said, managed to swallowa farthing. It did not, however, show signs that any articleso unsuited to digestion had been taken. The house-

surgeon, Mr. P. D. Hopgood, prescribed as much solid foodas possible, and small doses of castor oil, but the farthingwas not forthcoming, and the patient disappeared. A fewdays ago, however, the child was sick after taking an un-usually heavy meal, and in the midst of the vomited mattera green mass was seen, which was the farthing, muchcovered with verdigris. The mother said that the child hadseemed to suffer occasionally from pain, had coughed alittle, and lost flesh. Where was the farthing during thesesix months ?

Provincial Hospital Reports.LIVERPOOL SOUTHERN HOSPITAL.

FRACTURE OF THE SPINE WITH DISPLACEMENT; REDUCTION

BY MEANS OF PULLEYS; RECOVERY.

(Under the care of Dr. WOLLASTON.)J. M a clerk, aged thirty-six, while in a state of in-

toxication, walked over one of the pier-heads, and fell on tothe river bed below, a distance of about forty feet. In thisstate he remained for four hours, until he was roused byfeeling the advancing tide. He was hoisted up by ropes,and brought to the hospital.On admission, Nov. 18th, 1868, he was unable to stand,

and complained of intense pain from the toes of both feetup to the hips, and also of a feeling of stiffness in theback. On examining the back there was considerableecchymosis of the lower portion of the dorsal region, andthe eleventh dorsal vertebra was displaced, and protrudedfully an inch and a half from its normal position. No cre-

pitus could be felt. Hyperæsthesia of the lower extremitiesexisted in a most marked degree, a breath of air, or a touchof a feather, causing the most excruciating agony. Withoutany stimulus paroxysms of pain came on every three or fourminutes, commencing at the base of the toes. There wasneither paraplegia nor priapism.

Treatment.—The patient being placed on a mattress onthe floor, chloroform was administered to its full extent.The shoulders were then securely fixed, and the pulleys ap-plied to both thighs. During extension, the hand, placedover the projecting portion of the spine, felt the displace-ment gradually disappear, but without crepitus or jerk.Hot water bottles were applied to the feet, a dose of tinc-ture of opium given, the catheter passed, and the patientdirected to remain on his back.Nov. 19th.-Has passed a restless night, the attacks of

pain being most intense, and with only short intervals.Although he has been tossing from side to side, no dis-placement has occurred, but a slight ° dip " is felt at theseat of injury. One-third of a grain of morphia was in-jected into the calf of one leg, and the legs elevated on pil-lows ; catheter passed. Towards evening, as no relief wasexperienced, the injection was repeated in the other leg,and with immediate benefit. Temperature: upper ex-

tremity, 97°; lower, 985°. Pulse 98.20th.-Feels better, and has slept for some hours; pain

in feet and legs not so intense, unless touched; abdomentympanitic, and he is unable to pass flatus; little or no

Page 2: LIVERPOOL SOUTHERN HOSPITAL

123

pain at seat of injury; tongue coated ; great thirst, andconstant vomiting. Ordered iced milk ad limb. injection ofmorphia repeated ; catheter three times a day. The urineis loaded with mucus, and slightly ammoniacal. Tempera-ture : upper, 97.6° ; lower, 93.4°. Pulse 96. Respirations20.21st.-Feels easier; still sick. A turpentine-and-oil

enema was given last night, and repeated this morning, butwithout effect. To discontinue the morphia, and take onlysoda water and milk, with ice. Temperature : upper, 99-20;lower, 96.8°. Pulse 98. Respirations 18.22nd.-About the same; bowels acted, but he is not

aware of it; vomiting still continues ; towards eveningpain more severe. Hypodermic injection repeated ; ordereda purgative. Temperature: upper, 998°; lower, 964°.Pulse 90. Respirations 18.23rd.-Bowels freely moved, and patient expresses him-

self as feeling much better; hyperæsthesia diminishing ;no sickness ; tongue clean ; complains of a feeling of numb-ness in lower extremities. Temperature same as yesterday.28th.-Going on well; a little vomiting this morning,

which was relieved by an enema ; urine very alkaline.Ordered dilute nitro-hydrochloric acid, chop, and a pintof ale ; placed on a water bed, as there is a tendency tosloughing over the nates; spine firmly strapped with em-plastrum Robirans.

Dec. 4th.-He has daily continued to improve. The hy-peræsthesia has disappeared, with the exception of a littleat the outer side of each leg. Has passed urine to-day forthe first time since the accident. Has been sitting up inbed, and only complains of what he calls a "galvanic"sensation in the legs. Bowels obstinate, requiring the ad-ministration of purgatives.23rd.-Got up to-day, and was able to move about

the ward with assistance. Legs feel rather numb.From this date he rapidly -improved, and was able towalk about without assistance; the legs regained theirproper feeling, and his only complaint is a slight feeling ofstiffness in the back when he stoops to pick an object fromthe floor.On January 1st he was discharged cured, with only a very

little thickening at the seat of injury.Dr. Wollaston remarks :-This case is interesting in

many respects. Of course there was extensive fracture ofthe spine, for we cannot think it possible for simple disloca-tion to exist in this portion of the column; and it shows thenecessity for having recourse, at an early period, to thosemeasures that will as far as possible remove all pressurefrom the cord. In this case we may fairly infer, judgingfrom the amount of deformity, that the pressure musthave been very great, though probably no actual rupturetook place. What the consequences might have been hadthis pressure been allowed to continue, we can easilyimagine. Knowing the fatal result of many of these cases,and the distressing nature of the suffering, both to thepatient and to those in attendance, we think it justifiable-in most if not all such accidents-to follow some such treat-ment as that recorded in this instance. The sickness, whichwas a prominent symptom in the early stage, was probablypartly due to the chloroform; but also in some measure, wethink, to the use of the subcutaneous injection of morphia,.a result we have frequently seen follow the use of the drugwhen exhibited in this manner.

Reviews and Notices of Books.Clinical Lectures on Diseases of the Liver, Jaundice, and Ab-

domii-tal Dropsy. By CHARLES MURCHISON, M.D., F.R.S.London: Longmans. 1868.

THERE was a want in medical literature of a new workon Diseases of the Liver,-clinical in its character, compre-hensive in its treatment of the subject, yet free from detail,and conveying information in a clear, concise style, whichwould render it easy to read and to remember. This wanthas been ably supplied by Dr. Murchison, whose work-con-sisting largely of lectures which have appeared in THE

LANCET—cannot fail to take its place at once as a standardauthority on the diseases of which it treats.The grand characteristic of these lectures is their essen-

tially clinical nature, the principal objects kept in viewbeing accurate diagnosis and successful treatment. The

descriptions of symptoms bear the impress of extensiveand close observation at the bedside; and the remarks ondiagnosis show, in addition to this, great discriminatingpower.The first six lectures are devoted to enlargements of the

liver, which are divided into painful and painless ; and theremaining six to contractions, jaundice, fluid in the peri-toneum, hepatic pain, gall-stones, and enlargement of thegall-bladder. Every disease considered is illustrated by anumber of interesting and carefully reported cases.

Dr. Murchison divides abscess of the liver into two

varieties—pyæmic and tropical; the former usually manyin number and small, the latter generally single, and oftenattaining a large size. He does not agree with Dr. Buddin considering true tropical abscess to be due to purulentabsorption from the ulcerated colon in dysentery, while hepoints out that pycentic abscess may as often follow ulcera-tion of the intestine in India as in this country, and conse-quently be more frequent there on account of the prevalenceof dysentery.He recognises two forms of jaundice, one in which there

is a, mechanical impediment to the flow of bile into theduodenum, and another in which no such impedimentexists. In opposition to Budd and Harley, he believes thatthe bile pigment is formed in the liver as well as the biliaryacids. In support of this view he adduces the experimentsof Miiller, Kunde, Lehmann, and Moleschott, who have re-peatedly extirpated the liver of frogs, and have invariablyfailed to find a trace of either acids or pigment in the blood,urine, or tissues. He also brings forward cases in whichthe secreting tissue of the liver has been for the most partor entirely destroyed, and no bile secreted, yet without anyjaundice being the result. His theory of the production ofjaundice is the following :-He believes that in health aportion of both the biliary acids and pigment is absorbedinto the blood, and then transformed into products whichare eliminated by the lungs and kidneys. But in certainmorbid states this normal metamorphosis does not takeplace, and the absorbed bile circulates with the blood, andstains the skin and other tissues. Jaundice may also

result from too much bile being absorbed to undergo thenormal transformation. In this case there is an excessivesecretion of bile, usually combined with constipation, whichprevents its being carried off by the bowels.At the present time, when there is so much discussion

concerning the action of mercury, what Dr. Murchison hasto say on the subject will be read with interest. Mercuryand allied purgatives," he says, "probably produce biliousstools by irritating the upper part of the bowel, and sweep-ing on the bile before there is time for its absorption. Irri-

tating articles of food will often produce the same effect.Calomel is of unquestionable utility in congestion of theliver; but if it acted, as is usually argued, by stimulatingthe liver to increased secretion, it might be expected toincrease the congestion rather than diminish it. It is quitepossible, however, that the irritation of the duodenum bypurgatives may be reflected to the gall-bladder, and causeit to contract, and that the evacuation of this viscus mayaccount in part for the increased quantity of bile in thestools."

Dr. 3,lurchison’s book, it cannot be doubted, will have theeffect of lighting up many dark places of practice, and con-veying clear conceptions of diseases of the liver where allhad been vagueness before. There is a widespread tendency