of 2 /2
stone, and after neither sitting was the urine stained by a single drop of blood. At the time of operation Mr. Maunder explained the two methods of using the lithotnte, preferring that of Civiale as being likely to do less injury to the bladder than that of Brodie, in which latter, of necessitv, the blades of the instrument come in contact with that viscus. One hundred and fifty grains of benzoic acid, administered over a period of seventy-two hours, had removed the am- moniacal odour, and rendered the urine acid. WEST LONDON HOSPITAL, HAMMERSMITH. OBSTRUCTION OF THE BOWELS OWING TO SCIRRHUS OF COLON ; DEATH. (Under the care of Dr. SIMMS.) THE diagnosis here was from the first that the patient was afflicted with cancer, firstly, because of the asthma with which the illness began, there being no history of such attacks previously, either in the patient’s own case or in his family, and no evidence of heart or lung disease. The asthma, moreover, ceased entirely when the more serious mischief set in. Both lumbar regions were tender to the touch, and dull; but beyond this there was no indication whatever as to the seat of mischief. Amussat’s opera- tion was not tried, although it might have given a few hours’ relief, if successful, in a case in which the stricture was so far distant from the anus. The two operations dis- cussed were—puncture of the colon, which, by letting out faecal matter into the peritoneal cavity, would have been fatal; and an exploratory operation, which was not at- tempted, as the only warrant for it was the pain complained of in the umbilical region, where the patient believed the obstruction to be. A feature worthy of remark is that the stercoraceous vomiting, at one time so free as to lead to the suspicion of a communication between the colon and the stomach, was almost entirely arrested, and completely kept under, by subcutaneous injections, at first of morphia .and atropia, and afterwards of morphia alone. Neither the direct nor interrupted galvanic current availed, although a small passage was left; but their use increased the pains and tormina very much. IMr. W. P. Adams, house-surgeon, has furnished us with the notes. R. C-, aged forty, shoemaker, a thin man, with a sallow but not cancerous complexion, was admitted on March 23rd, with obstruction of the bowels. He had always had good health till three months since, when he had an attack of asthma. On March 16th, he was seized with sud- den pain in the abdomen ; the bowels had been relieved once on that day. He applied at the hospital, and was ordered a calomel- and - opium pill, which gave him no relief. He was accordingly attended at his own home by the house-surgeon, and was treated with purgative medicines and enemata, which failed to relieve him; and, as he was getting worse, he was admitted into hospital. He had some stercoraceous vomiting two days previous to his admission. States that he has always been very regular in his bowels, but three months ago he had an attack of constipation, which yielded to a few doses of purgative medicine. Admits having drunk rather freely in early life. No history of can- cer in his family. Condition on admission.-Has passed nothing by the bowels for a week. Pulse 84; tongue clean. Has vomited some faecal matter this morning ; the abdomen is distended; superficial veins enlarged ; outline of stomach, which is distended, well defined; abdomen tympanitic in iliac and umbilical regions; marked tenderness on pressure in left lumbar region; slight dulness in both flanks. Principal pain referred to umbilical region. No hernia to be detected in any of the usual situations; the rectum is quite clear and free from disease. No albumen in urine, which is of usual quantity, and passed without difficulty. Gums slightly ulcerated, and bluish, but without a defined line. March 23rd.-An enema of one pint of warm olive oil was given with a long tube passed up the rectum about six inches; it was not retained, and brought away nothing with it. To have one grain of extract of opium every six hours, and an enema of warm soap-and-water to be given night and morning. 24th.-Pu’se 108; tongue clean. Vomited a large quan- tity of faecal matter. Nothing has passed ; abdominal dis- tension increased. Five grains of calomel at night. 2Sth.-Passed some small round balls of hardened faeces, after enema this evening; not in much pain. 29th.-Pain very great. Pulse 108. Has vomited a great deal of faecal matter. 30th.-Vomited more faeces. Complains very much of the- feeling of distension. Omit the opium pill. Abdomen to be rubbed night and morning with a liniment composed of equal parts of belladonna liniment and chloroform liniment. To have five minims of tincture of belladonna every four hours. 31st.-Sickness still continues. Pulse 108; tongueclean. Nothing has passed. Tincture of belladonna to be increased to ten minims every four hours. April 1st.—Fæcal vomiting still occurs frequently, espe- cially after taking any food. Some more hardened fæces came away with the soap-and-water enema this morning. 3rd.-In great pain. Is vomiting large quantities of faecat matter. Abdomen tympanitic; some slight fluctuation; pulse 108. To discontinue the liniment, and also the tinc- ture of belladonna. To have a subcutaneous injection of atropine solution, with a quarter of a grain of hydrochlorate of morphia, every six hours. 4th. - Passed a good night. No sickness all day. Pulse 92. 7th.-Has been tolerably free from pain since last note, and has had no sickness; but nothing has passed the bowels. To have ten grains of calomel, three minims of cro- ton oil, one grain of extract of opium, and five grains of the compound extract of colocynth, to be made into three pills, one to be taken every four hours. 10th.—Pulse 100, weak. Patient begins to look very worn, and is getting much emaciated. No sickness. Had an, enema this evening of warm soap-and-water while in a warm bath, which brought away a small quantity of liquid, fseces. Has a subcutaneous injection whenever he is in very great pain. 13th.—Vomiting has returned. To have bismuth, five. grains, and compound tragacanth powder, ten grains, in half £ a teacupful of beef-tea, every six hours. The subcutaneous, injection to contain half a grain of hydrochlorate of morphia. Chloroform liniment to be rubbed into abdomen night and morninsr. 16th.-A little liquid fæces has come away to-day, and on. . the two preceding days. Pulse 96. No sickness. Galvanism applied to abdomen with a magneto-electric machine. Ab- dominal distension increases very much. 17th.-Much the same. An enema was given him this vening while in a warm bath. The tube was passed up fourteen inches. A few hardened lumps came away. 20th.-General condition the same. Pulse 80, feeble. To have the following mixture: iodide of potassium, ten grains; and an ounce of decoction of bark, twice a day. An enema of an ounce of castor oil and a pint of oatmeal was given him to-day, and a little hardened faeces came away with it. 24th.- Nothing has passed since the 21st, when some liquid faeces came away after an enema and warm bath. Patient seems very weak after the baths. Slept better last night. Had a subcutaneous injection of morphia, half a grain, Has been having morphia by the mouth since the 18th. The relief afforded by the subcutaneous injections is much greater than that by the morphia draughts. Mr. Teevan examined the patient to-day with a view to some operative interference, but was unable to localise the seat of obstruc- tion, and decided to wait. He suggested that half-drachm. doses of tincture of nux vomica should be added to the, iodide of potassium and bark mixture, and that galvanism should be applied with a Stohrer’s battery. 26th.—Patient weaker. Pulse 80, feeble. Galvanised him to-day, a tube connected with the battery being inserted in the rectum. Patient said that he could " feel the current working inside" him. It gave him great pain. 28th.—Abdominal distension very great. Pulse 80; tongue. clean ; no sickness; complains greatly of flatulence. Gal- vanised him again to-day. Says he cannot bear the pain caused by it. Is now having a grain of hydrochlorate of morphia injected subcutaneously, as any less quantity gives’ no relief. Generally has two injections in the twenty-four hours. A consultation was held to-day to consider the pro- priety of some operation being performed, and it was de- cided not to interfere.

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Page 1: WEST LONDON HOSPITAL, HAMMERSMITH

stone, and after neither sitting was the urine stained by asingle drop of blood. At the time of operation Mr. Maunderexplained the two methods of using the lithotnte, preferringthat of Civiale as being likely to do less injury to the bladderthan that of Brodie, in which latter, of necessitv, the bladesof the instrument come in contact with that viscus.

One hundred and fifty grains of benzoic acid, administeredover a period of seventy-two hours, had removed the am-moniacal odour, and rendered the urine acid.

WEST LONDON HOSPITAL, HAMMERSMITH.OBSTRUCTION OF THE BOWELS OWING TO SCIRRHUS

OF COLON ; DEATH.

(Under the care of Dr. SIMMS.)THE diagnosis here was from the first that the patient

was afflicted with cancer, firstly, because of the asthmawith which the illness began, there being no history ofsuch attacks previously, either in the patient’s own case orin his family, and no evidence of heart or lung disease. Theasthma, moreover, ceased entirely when the more seriousmischief set in. Both lumbar regions were tender to thetouch, and dull; but beyond this there was no indicationwhatever as to the seat of mischief. Amussat’s opera-tion was not tried, although it might have given a fewhours’ relief, if successful, in a case in which the stricturewas so far distant from the anus. The two operations dis-cussed were—puncture of the colon, which, by letting outfaecal matter into the peritoneal cavity, would have beenfatal; and an exploratory operation, which was not at-

tempted, as the only warrant for it was the pain complainedof in the umbilical region, where the patient believed theobstruction to be. A feature worthy of remark is that thestercoraceous vomiting, at one time so free as to lead tothe suspicion of a communication between the colon andthe stomach, was almost entirely arrested, and completelykept under, by subcutaneous injections, at first of morphia.and atropia, and afterwards of morphia alone. Neither thedirect nor interrupted galvanic current availed, although asmall passage was left; but their use increased the painsand tormina very much.IMr. W. P. Adams, house-surgeon, has furnished us with

the notes.R. C-, aged forty, shoemaker, a thin man, with a

sallow but not cancerous complexion, was admitted onMarch 23rd, with obstruction of the bowels. He had alwayshad good health till three months since, when he had anattack of asthma. On March 16th, he was seized with sud-den pain in the abdomen ; the bowels had been relievedonce on that day. He applied at the hospital, and wasordered a calomel- and - opium pill, which gave him norelief. He was accordingly attended at his own home by thehouse-surgeon, and was treated with purgative medicinesand enemata, which failed to relieve him; and, as he wasgetting worse, he was admitted into hospital. He had somestercoraceous vomiting two days previous to his admission.States that he has always been very regular in his bowels,but three months ago he had an attack of constipation,which yielded to a few doses of purgative medicine. Admitshaving drunk rather freely in early life. No history of can-cer in his family.

Condition on admission.-Has passed nothing by thebowels for a week. Pulse 84; tongue clean. Has vomitedsome faecal matter this morning ; the abdomen is distended;superficial veins enlarged ; outline of stomach, which isdistended, well defined; abdomen tympanitic in iliac andumbilical regions; marked tenderness on pressure in leftlumbar region; slight dulness in both flanks. Principal painreferred to umbilical region. No hernia to be detected in

any of the usual situations; the rectum is quite clear andfree from disease. No albumen in urine, which is of usualquantity, and passed without difficulty. Gums slightlyulcerated, and bluish, but without a defined line.March 23rd.-An enema of one pint of warm olive oil

was given with a long tube passed up the rectum about sixinches; it was not retained, and brought away nothing withit. To have one grain of extract of opium every six hours,and an enema of warm soap-and-water to be given nightand morning.

24th.-Pu’se 108; tongue clean. Vomited a large quan-tity of faecal matter. Nothing has passed ; abdominal dis-tension increased. Five grains of calomel at night.2Sth.-Passed some small round balls of hardened faeces,

after enema this evening; not in much pain.29th.-Pain very great. Pulse 108. Has vomited a great

deal of faecal matter.30th.-Vomited more faeces. Complains very much of the-

feeling of distension. Omit the opium pill. Abdomen to berubbed night and morning with a liniment composed ofequal parts of belladonna liniment and chloroform liniment.To have five minims of tincture of belladonna every four hours.

31st.-Sickness still continues. Pulse 108; tongueclean.Nothing has passed. Tincture of belladonna to be increasedto ten minims every four hours.

April 1st.—Fæcal vomiting still occurs frequently, espe-cially after taking any food. Some more hardened fæcescame away with the soap-and-water enema this morning.3rd.-In great pain. Is vomiting large quantities of faecat

matter. Abdomen tympanitic; some slight fluctuation;pulse 108. To discontinue the liniment, and also the tinc-ture of belladonna. To have a subcutaneous injection ofatropine solution, with a quarter of a grain of hydrochlorateof morphia, every six hours.

4th. - Passed a good night. No sickness all day.Pulse 92.7th.-Has been tolerably free from pain since last note,

and has had no sickness; but nothing has passed thebowels. To have ten grains of calomel, three minims of cro-ton oil, one grain of extract of opium, and five grains of thecompound extract of colocynth, to be made into three pills,one to be taken every four hours.

10th.—Pulse 100, weak. Patient begins to look very worn,and is getting much emaciated. No sickness. Had an,enema this evening of warm soap-and-water while in a warmbath, which brought away a small quantity of liquid, fseces.Has a subcutaneous injection whenever he is in very greatpain.

13th.—Vomiting has returned. To have bismuth, five.grains, and compound tragacanth powder, ten grains, in half £a teacupful of beef-tea, every six hours. The subcutaneous,injection to contain half a grain of hydrochlorate of morphia.Chloroform liniment to be rubbed into abdomen night andmorninsr.16th.-A little liquid fæces has come away to-day, and on. .

the two preceding days. Pulse 96. No sickness. Galvanismapplied to abdomen with a magneto-electric machine. Ab-dominal distension increases very much.17th.-Much the same. An enema was given him this

vening while in a warm bath. The tube was passed upfourteen inches. A few hardened lumps came away.20th.-General condition the same. Pulse 80, feeble. To

have the following mixture: iodide of potassium, ten grains;and an ounce of decoction of bark, twice a day. An enemaof an ounce of castor oil and a pint of oatmeal was givenhim to-day, and a little hardened faeces came away with it.24th.- Nothing has passed since the 21st, when some

liquid faeces came away after an enema and warm bath.Patient seems very weak after the baths. Slept better lastnight. Had a subcutaneous injection of morphia, half a grain,Has been having morphia by the mouth since the 18th. Therelief afforded by the subcutaneous injections is much

greater than that by the morphia draughts. Mr. Teevanexamined the patient to-day with a view to some operativeinterference, but was unable to localise the seat of obstruc-tion, and decided to wait. He suggested that half-drachm.doses of tincture of nux vomica should be added to the,iodide of potassium and bark mixture, and that galvanismshould be applied with a Stohrer’s battery.

26th.—Patient weaker. Pulse 80, feeble. Galvanisedhim to-day, a tube connected with the battery being insertedin the rectum. Patient said that he could " feel the current

working inside" him. It gave him great pain.28th.—Abdominal distension very great. Pulse 80; tongue.

clean ; no sickness; complains greatly of flatulence. Gal-vanised him again to-day. Says he cannot bear the paincaused by it. Is now having a grain of hydrochlorate ofmorphia injected subcutaneously, as any less quantity gives’no relief. Generally has two injections in the twenty-fourhours. A consultation was held to-day to consider the pro-priety of some operation being performed, and it was de-cided not to interfere.

Page 2: WEST LONDON HOSPITAL, HAMMERSMITH

10

29th.-Patient has slept but little. Says he feels lulledafter the subcutaneous injections, though they do not makehim sleep much now. Has passed about a teacupful ofliquid fæces this morning. Has had an assafoetida enemato-day.He gradually sank, and died on May 2nd.Examination forty-nine hours after death. - On opening

the abdomen a small quantity of serous fluid escaped.The whole of the intestines, both large and small, wereenormously distended with liquid faces, and in many placesthere were deposits of lymph upon them, matting themtogether. The rectum was quite clear, and free from anydisease; but in the descending colon, at a distance of six-teen inches from the anus, was an indurated ring of can-cerous tissue, springing from the coats of the bowel, andalmost occluding it. A small passage, about the size of a

goose-quill, was left. The intestines above the point of ob-struction were very much distended, but all below it weremuch contracted and empty. The lumbar and mesenteric

glands were enlarged ; liver small, and somewhat atrophied;stomach empty and contracted; thoracic viscera healthy.

Reviews and Notices of Books.A Handbook of Therapeutics. By SYDNEY RINGER, M.D.

Small 8vo, pp. 485. London: H. K. Lewis. 1869.

THis work is deserving of praise as a laborious compila-tion of much that has been written and said of the applica-tion of the commoner medicines in the treatment of disease.The reader must not expect to find in Dr. Ringer’s Hand-book any general exposition of the theory of the action ofmedicines. It is chiefly devoted to the practical side of thequestion. One fault that we must find with it in limine is,that the author seems but superficially acquainted with themany standard works on the subject in English. His treatiseis founded on the German work of Buchheim. He has, per-haps, intended to return the compliment which has beenpaid to us abroad. The most important work on thera-peutics which has appeared in Germany-that of ProfessorAlbers, of Bonn-is founded upon a well-known English.book, and is, in fact, in great part a mere translation of it.It would have been better, perhaps, if Dr. Ringer had con-tented himself with giving us a translation of Buchheim’swork. He would then, at least, have escaped the respon-sibility of fathering Buchheim’s errors. As a correct under-standing of the modus operandi of drugs is the only rationalexcuse for their employment in novel cases of disease, weare justified in placing theoretical therapeutics, as far asthey have been worked out, on a higher level than therandom results of empirical observation. An error in scienceleads to a misdirection of art. Men of the present day, whorike to know the reason for everything, are scarcely con-vinced by being told that a certain drug will cure a certaindisease. They wish to know how it is that this medicine

operates ; and when they understand that, and only then,they accept the fact of the cure as a logical conclusion doublyjustified. This book of Dr. Ringer’s leaves a void in ourminds by not attempting to show how it is that these medi-cines work out all the wonderful results which are detailedat such length. Thus, bromide of potassium is said to curealmost every one of the ills that flesh is heir to. How itcan cure them is not explained. And who can wonder that

we rest incredulous as to the facts paraded before us untilwe have tried the drug upon a large number of our patients- an experiment that may result in disappointment andconfirmed unbelief ? This medicine has its uses, which wedo not mean to gainsay; but it is not an all-healer, anelixir vitm, an aurum potabilz. This book of Dr. Ringer’swould involve any man who was not versed in the theory ofthe action of medicines in great bewilderment. It is founded,

we are told, on the German work of Buchheim ; but as itcomes to us in a quasi-original English shape, we have nochoice but to hold its English author answerable for itsmistakes of omission and commission.On page 33 we are informed that, when charcoal is given ’

internally, 11 a little finds its way into the blood and lymph-atic glands." On page 76 we read that acids possess the

power to check the production of acid secretions from glands,.and to increase the flow of alkaline ones ; while the reverseis the case with alkalies. On page 92 the statement is re-

peated. We should have supposed that none but the so-called homoeopathists would dream of prescribing acids forover-acidity, or alkalies for deficient secretion of an acidgastric juice. It is stated, on page 113, that magnesia onlyacts as a purgative by being changed into a bicarbonate bycarbonic acid gas in the intestines. Does Dr. Ringer doubtthat the secretion of the stomach is acid, and capable offorming the magnesia into a soluble salt, lactate or hydro-chlorate ? He seems quite unaware that it has been provedthat sulphate of magnesia and other salines will act aspurges when injected into the veins of any part of the body ;that when taken into the stomach they are absorbed there,and only pass out by the glands of the lower bowel afterperforming the circuit of the blood. As he fails to appre-hend the rationale of the action of eliminative medicines, sois he equally unaware of what has been done by English,American, and French therapeutic writers in clearing upthe action of the medicines which take effect upon theblood. His theory of the action of saline purgatives,.founded upon

11 Buchheim’s careful observations," was en-tertained, it is true, in the infancy of therapeutical science,but has been utterly exploded by recent and more carefulinquiries. This is nothing to the utter ignoring, in Dr..Ringer’s book, of the explanation which has lately beengiven of the action of quinia and other tonic medicines indisease. The hypothesis was put forward by Dr. Headland,many years ago, that these remedies were of use in supply-ing something which was wanting in the blood. It wasfound at that time that only a small proportion of thequinia taken as medicine was excreted from the body. Itwas supposed that the remainder was used in the mannerof food, as a 11 restorative" medicine. Since that time, BenceJones and Dupre have discovered in the healthy blood asubstance analogous to quinia; and two American phy-sicians have stated that this material is deficient in quan--tity in cases of ague and remittent and typhoid fever.Whatever doubt may still rest on the completeness of thischain of argument, it is at least the duty of a writer ontherapeutics to take some notice of it. It seems that Dr.Ringer has no knowledge of it. Nothing is said of it in thework of Dr. Buchheim.Our author must again be taken to task for his deficient

apprehension of the theory of the action of vegetableastringents. He states that gallic acid precipitates albu-men, which is not the case. Gallic acid is not an astringentexternally; it becomes astringent internally by combiningwith the elements of glucose and forming tannic acid. The-knowledge of this fact will enable us to avoid the mistakeswhich are sometimes made in prescribing, and which wouldnot have been authorised by Dr. Ringer if he had taken thepains to make himself better acquainted with English workson therapeutics.We must award our meed of praise to the industry-we

have much respect for the ability-of the Professor ofMateria Medica at University College; but we must warnhim that, if he wishes to escape the severer criticisms ofothers, he should devote in future some portion of his timeto a more careful study of the results of the labours of thosewho are older than he, in a rfield which he affects to regardas all but unploughe A and untrodden by his predecessors.