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if the body has reached the membranous portion of the urethra, it can be removed by pressing it forwards through the rectum, while the curve of the urethra is diminished by traction of the penis. The cases wherein an instrument breaks in the urethra may be easily managed in this way with patience and presence of mind.
When the foreign bodies have reached the bladder, they are extracted with greater difficulty the longer and thinner they are. After they have remained in the bladder, too, they become incrusted, and are more difficult of removal, especially when the bladder has been rendered irritable. It is a matter of great difficulty to seize them in the longitudinal direction, but the extractor of Luer is admirably adapted for regulating the direction in which the body shall be removed, and with its aid, our difficulties are reduced in these cases to the discovery of the foreign body.
II. On the Treatment of Hernia by Electricity. By Dr. CLEMENS. (Deutsche Klinik, 1858, No. 34.)
In the first of a series of articles upon applied electricity, the fruits of ten years' investigation, Dr. Clemens gives an account of his employment of it in the treatment of hernia. He commenced its use in 1850, by endeavouring to produce a diminution in the size of the hernial apertures in a case of large double inguinal hernia. One of the poles of the battery, a massive metallic knob, was introduced deep into the canal, pressing a flap of skin inwards, and a moderately strong galvanic stream, increased daily, was passed along this during 6 minutes. At the end of a week the hernia protruded less easily, and the apertures had become narrower. When the examination was made before and after each séance, a great difference was always found in the accessibility and size of the sac-an observation since repeated hundreds of times. The application of the galvanism also has the good effect of increasing the peristaltic movements, which in becoming more energetic effect a favourable change in the position of the intestines, by altering the situation of the portion which had so long remained opposite the aperture, and had consequently become relaxed. A more complete evacution of the contents of the canal is also brought about. The impaired vitality of the intestine, of the hernial canal, and of the abdominal Coverings is always renovated through this application of electricity. When the hernia is recent, no means of treatment is so certain and so exempt from all danger; and even when the hernia long has protruded it has often been returned under the influence of the galvanic stream or the electrical flask. Dr. Clemens has usually preferred friction-electricity to galvanism, as its operation is more rapid and its effects are more energetic. Among twenty-seven patients so treated, none have complained of the least unpleasantness; but, on the contrary, they have found many inconveniences disappear under its influence, and especially obstinate constipation. In very sensitive persons diarrhoea may follow an energetic séance. When a hernia has been recently produced, as by a fall, lifting, &c., the success of the method is often surprisingly rapid, and in marked contrast with the slow progress of treatment by trusses, &c. A double hernia thus produced was cured without any bandage in twenty séances, and has remained so now for two years-the treatment only commencing a week after
Dr. Clemens states that for large hernia, which can only be kept up imperfectly by any ordinary truss, he has contrived a galvanic truss, which operates with remarkable efficacy. It is constructed of copper and zinc plates, or pieces of copper and silver money, having felt or leather interposed, which is kept moistened by the saline solution necessary for the excitement of the pile. He again dwells upon the importance of exciting peristaltic action, not only in hernia, wherein it may often prevent strangulation being produced, but in
various other affections due to a sluggish movement of the intestine. In numerous experiments upon animals, in which powerful shocks were employed, no ill effects resulted from the increased intestinal action produced.
III. Isolated Fracture of the Last False Rib. By M. LEGOUEST. (Gazette des Hôpitaux, 1859, No. 17.)
This rare form of fracture of the ribs occurred to a soldier, aged forty-five, who while playing fell with his side against the corner of a table. Violent pain, an imperious desire to cough, and difficulty of breathing revealed the nature of the accident. Examination detected the exact seat of the fracture to be at the junction of the middle with the posterior third of the last false rib. Crepitation was plainly felt at this point, but this was at some distance from that at which he had been struck. The corner of the table had forced the moveable end of the rib inwards and backwards, and the fracture had taken place in consequence of the excessive bending thus produced. No bandage was here applied as in ordinary fracture of the ribs. Such a bandage, having in view the limiting thoracic respiration and the rendering it abdominal, is useful in fracture of the true ribs (except the seventh), but is injurious in fracture of the false ribs. In point of fact, in the space comprised between the base of the transverse process of the first lumbar vertebra and the point of the last false rib, the circumference of the diaphragm is attached by an aponeurotic arch, one end of which is fixed to the base of the first lumbar vertebra, and the other to the lower edge of the last false rib; the remainder of the anterior circumference of the muscle rising up to be inserted into the cartilages of the false ribs and the seventh sternal rib. Wherever by inducing abdominal respiration the contractions of the diaphragmn were rendered more energetic, the patient's sufferings were only increased; and he was left to his own instincts, which very soon taught him the manner he could breathe with least inconvenience.
IV. Case of Spontaneous Fracture of the Femur, with Consolidation. By M. ROBERT. (Gazette des Hộp., No. 18, 1859.)
A porter, aged fifty, of small stature but robust constitution, and in good health, with the exception of having suffered for about two years from pains of the lower limbs, supposed to be rheumatic, was quietly descending a staircase when he felt a cracking in the right thigh, and fell down; the fall being induced by the fracture and not the reverse. After two months and a half treatment the fracture, situated just below the trochanter, had completely consolidated, there being an abundance of callus, and shortening to at least the extent of four centimetres, giving rise to considerable lameness.
M. Robert, commenting upon the case, observed that, as far as he knew, it was unique. Every one is aware that the bones are sometimes spontaneously fractured when they are the seat of serious disease. In the case related by Dupuytren of a lad who had fractured the humerus while throwing a stone, a hydatid in the medullary canal was found to have reduced the bone to a mere shell. Tubercular deposit in the medullary cavity would be expected to produce the same effect; and cancer induces also the absorption of the osseous tissue. M. Robert has himself met with four examples of fracture of the humerus or femur in this disease. The cause in such cases giving rise to the fracture would likewise prevent its consolidation. In explaining the occurrence of this accident in the present case, M. Robert has recourse to the hypopothesis of syphilitic disease, inasmuch as the man about twenty years ago suffered from chancre, but has never since had any symptoms of constitutional
syphilis. He states that he has seen other examples of apparent cure, in which the individuals, remaining fifteen or twenty years without any consecutive manifestation, have still, after such a lapse of time, exhibited evident signs of syphilitic cachexia. Syphilis appearing at so late a period, gives rise to indeterminate accidents which cannot be classed among those which are manifested in the secondary and tertiary periods. These ultimate accidents may be almost designated as those of the plus-tertiary period, and they always are observed affecting either the osseous or fibrous tissues.
[The occurrence of fracture from muscular contraction independently of the cancerous diathesis, is not so rare an occurrence as M. Robert seems to suppose. We would refer him to Dr. Van Oven's case, related by himself to the Medico-Chirurgical Society; to the collection of cases published by Dr. E. Gurlt, in the Deutsche Klinik, Nos. 25-29, 1857; and to cases related by Mr. Henry Smith, in 'Medical Times,' vol xxxvi. 1857.]
V. On Calculous Diseases in Hungary. By PROFESSOR BALASSA.
This article is the substance of a reply made by Professor Balassa, of Pesth, to a circular asking for statistical information, issued by Professor Gross, of Louisville, U.S. Owing to the absence of rural hospitals in Hungary, Professor Balassa observes, almost all the cases of stone which occur in Hungary are brought to Pesth for treatment; and in his clinic at the hospital, he has treated, in the twelve years 1843-55, 135 cases. The ages of these patients were as follow:
The employments and conditions of these patients were as follow:-Peasants, 82; artisans, 39; tradespeople, 7; employés, 2; landowners, 2; students, 2; teachers, 1.
Thus calculous affections are met with in the Pesth clinic with by far the greatest frequency in the young, inasmuch as out of a total of 135 cases, 100 of the patients had not reached their twenty-sixth year; and when it is added that in most of the cases the disease had long existed, its origin must be referred to a still earlier age. Moreover, during the twelve years there were also forty-nine children treated for stone in the Pesth Children's Hospital. So, too, the immense proportionate prevalence of the disease in the peasant (60-74 per cent.) and in the artizan (28.889 per cent.) classes is to be remarked. These classes, indeed, almost exclusively furnish the examples of the disease occurring amongst the young, as the author's private practice has taught. him. Dr. Ivanchich, too, in his statistics of 100 cases of stone, comprises 33 natives of Hungary, but only 2 of these are as young as eighteen. The conclusion is, then, that stone prevails especially among the young of the poorer classes; and this leads us to consider some of the influences that are at work in its production. The nature of the diet and mode of life can alone explain these differences. It is the custom in Hungary to feed children when weaned, or even while suckling, upon the same articles of diet as are
• Medical Times, vol. 26, p. 652. 1852.
employed by adults, and while these in the wealthy classes may be nutritious and digestible, among the poor they consist of unwholesome matters, as fruits, vegetables, pork, and bacon. The latter, then, are fed with a diet that is difficult of digestion, and containing by far too large a proportion of the carbonaceous element; and the importance of this statement will be seen when the chemical constitution of the calculi has been considered.
For various reasons, the author has only been able to preserve 83 calculi in his cabinet, but all these have been carefully examined, and he furnishes the details of the results. 63 of the calculi were of homogeneous composition, and in 20 the nuclei and external portions were of different composition, The general result is, that while uric acid was the most frequent constituent, it was not the most frequent chief constituent, for while it was found more or less in 72 calculi, it constituted the chief portion of these only in 23. The oxalate of lime was the chief constituent, for it formed the chief mass of 20 calculi of homogeneous composition, and formed the nuclei in 12 out of the 20 stones of non-homogeneous composition. It is evident, then, that the formation of stone in Hungary is much due to the richness of the urine in the oxalates-i.e., in the carbonaceous combinations furnished by the defective aliment employed. Of the 20 stones having nuclei of different composition to the surrounding parts, in 12 these consisted of oxalates and in 8 of urates. It is owing to the prevalence of these in the urine that the first impulse to the formation of calculi is given, while their enlargement much depends upon the presence of phosphates. These were present either as a chief or partial constituent in 45 calculi. These considerations lead to the conclusion that the most effectual means of preventing the formation or recurrence of calculi would be to act upon the oxalic or uric acid formations of the urine.
Of the 135 cases, 13, on account of disease of the urinary organs or the condition of the entire economy, were deemed unsuitable for operation. Some of the 122 operations were performed under very unfavourable circumstances, in consequence of the presence of chronic disease of the urinary organs.
Of the 122 cases operated upon, 92 were submitted to lithotomy, and 30 to lithotrity. Of the former, 11 patients (11.95 per cent.), and of the latter 5 (16.66 per cent.) died. Among the 11 fatal lithotomy cases, there were 5 individuals who suffered from severe chronic disease of the kidney, and 1 who died of typhus during an epidemic. There were, therefore, only 5 cases in which death took place in from the second to the fifth day, from inflammation of the bladder or peritoneum, consequent upon the operation. This reduces the strict mortality from the operation to 5:43 per cent. Among the 5 fatal lithotrity cases, in 1 death was due to phthisis, in 2 to old suppurative nephritis, and in 1 to recent nephritis, this last and one other death being alone directly referrible to the operation, i.e., 6.66 per cent. Rectal fistula and urinary infiltration were never met with in any of the lithotomy cases. The difficulty in extracting the stone was considerable in many cases on account of its size, and in several of these inflammation of the bladder and peritoneum was set up, this proving fatal in 5 instances. Irritation and inflammation of the bladder frequently also followed lithotrity, leading to considerable delay in the repetition of the operation.
With the exception of 7 cases, the stone was always removed entire. The largest calculus measured two inches five lines in diameter, in 5 calculi the diameter was above two inches, and in 24 between one and one and a half inch. The heaviest, removed from a boy ten years old, weighed one ounce and a half and ten grains, and the lightest seventeen grains. In 8 patients there were two stones, and in 1 three. In 2 children union by the first intention took place, and they left between the eighth and tenth day. The other patients were discharged between the twenty-first and sixtieth days. Relapse occurred in 2 instances after lithotrity, and in 1 after lithotomy.
Of the whole 135 cases nly 1 occurred in a female, upon whom lithotrity was performed.
As to the mode of performing lithotomy, Professor Balassa makes an aperture into the bladder with a convex scalpel sufficiently large to admit the index finger of the left hand, and then enlarges it by means of a straight probe-pointed bistoury or Heister's knife. He lays great stress upon the wound being made sufficiently large, and in cases of voluminous calculi frequently makes a bilateral incision. After bleeding has been arrested by the injection of iced water (performed while the fingers maintain the wound of the bladder open), some small strips of oiled linen are carried along the index finger to the wound in the bladder (especially when extraction has been difficult), in order to prevent the urine penetrating the swollen edges of the track of the incision. They are removed after two or three days, and the author attributes the nonoccurrence of infiltration principally to their employment.
VI. On Colouring the Lips by Tattooing after Cheiloplasty. By Professor SCHUH. (Wien Medicinische Wochenschrift, 1858, No. 47.)
Two years since Professor Schuh performed cheiloplasty in the Vienna Clinik, upon a girl in whom one-half of the nose, together with the vomer and the whole of both lips, were wanting. The flaps for the lower lip were supplied from the region of the lower jaw and the neck, and that for the nose from the forehead, while the skin of the arm was employed for the upper lip. The connexion of the flap with the arm was divided on the tenth day, and all went on well, excepting that the new upper lip, at its lower edge, owing to the cicatricial process, was covered with corion. The red lip-colour was wanting to give the mouth an agreeable appearance; and Professor Schuh determined to endeavour to imitate this by tattooing. He first of all tried cochineal as a colouring material, but this produced a too pale red, and he then had recourse to cinnabar, which gave rise to a surprisingly natural colour.
The following is the procedure: the cinnabar is made into a thin paste with water, and the limits within which the pigment is to be applied are traced with a pen and ink, in imitation of the direction of the natural redness of the lips. For forcing the pigment into the organic substance, a bundle of sharp-pointed pins is employed, each pin being wound round with waxed silk from its head to within four lines of its point. Ten or twenty such pins are tied into a bundle with thread, dipped into the colouring substance and repeatedly forced two or three lines deep into the lip. The margin marked by the ink is first to be coloured, and then the other portion, dipping the points into the pigment again as this is wiped off. Only a slight bleeding ensues, and the pain is very little, in consequence of the diminished sensibility of transplanted parts. Any of the pigment remaining on the surface should be left there until next day, and if any part is found to be less red than the others this can be easily remedied.
How long this redness will remain unchanged must be determined by further experience. In Professor Schuh's case it had become nowise paler at the end of a year and a half; and he believes that the introduction of the process of tattooing into the field of plastic surgery is not to be despised.
VII. On Adhesive Plaster in the Treatment of Fractures of the Lower Extremities. By Drs. GILBERT and SHRADY. (American Journal of Medical Science, April, p. 410; and New York Journal, March, p. 238.) Dr. Gilbert, as the result of a multiplied experience, now extending over many years, states, that of all the means which have been devised to effect