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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; artizans, 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. 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 reinarked. 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 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 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 dep nds 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
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 one 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 only 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 bi-lateral incision. After bleeding has been arrested by the injection of iced water (performed while the fingers maintain the wound of the bladder open), some sinall strips of oiled linen are carried along the index finger to the wound in the bladder (espec ally 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 non-occurrence of infiltration principally to their employment.
VI. On Colouring the Lips by Tattooing after Cheiloplasty. By Professor SCHUн. (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 extension and counter-extension in fractures of the lower limbs, the application of adhesive plaster is by far the best. He refers to several cases in proof of this, which he has published in prior volumes of the American Journal,' and in the present number gives the particulars of three additional cases.
Dr. Shrady, speaking of the practice of the New York Hospital, gives the following account
of the mode of treating fracture of the thigh there:-"When a patient is admitted, there being generally a good deal of swelling present, the limb is placed upon the double inclined plane, until this has subsided. Then he is prepared for the application of the straight apparatus. The first step consists in the preparation of a double band of adhesive plaster, about three inches in breadth, which is cut long enough to extend from below the point of fracture on either side of the limb, forming a loop underneath the foot, a sufficient distance from the sole to allow the introduction of a square block. This block is a little broader than the foot, and serves to prevent the pressure of the adhesive bands over the ankles, and also affords a firm point to which is attached a short cord for extension. The adhesive strap is applied smoothly to the sides of the limb, and a bandage over it, leaving the loop free, extension being in the meantime kept up by an assistant. The body belt and perineal strap are next adjusted, after which the coaptation splints are applied in the usual manner around the seat of fracture. Then the upper end of the long splint is placed in a pocket of the body belt, the limb drawn down as far as possible, and kept extended by means of a stout cord over the foot-piece; this cord is attached to a ring in a large wooden screw, which plays through the block standing out from the internal surface of the splint. Next, the inside splint, extending from the groin to the malleolus, is applied; pads of blanket being stuffed in on either side, to adapt the splints to the inequalities of the limb. The last step consists in binding the splints together. Three strips of bandage are passed at equal distances from each other behind the limb; and their ends are brought forward between the limb and the splints, carried over the anterior edges backward over the outside of the apparatus, crossed behind, and finally brought forward around the whole again, and tied in front. By this arrangement a sling apparatus is made for the whole limb, at the same time that the splints are nicely secured to each other. The extending force is regulated by means of the screw in the block. This block, I should say, slides in a fenestrum, being secured at any part by a screw arrangement, by which means the proper distance between it and the foot can be regulated, in order to have the full advantage of extension."
The results obtained by this treatment may be judged of from the following statement of 74 cases which involved the shaft of the femur, exclusive of either extremity. These cases were taken in the order of their occurrence. In 19 of the 74 there was no shortening, and in 55 it averaged less than three-quarters of an inch. The ages ranged from three to sixty-four There were 57 patients more than, and 17 less than twelve. Of the 57 there was no shortening in 13 cases; but in the remaining 44, it was a fraction over three-quarters of an inch. Of the 17 under twelve, there was no shortening in 6, and in the remaining 11 it averaged less than half an inch.
VIII_ On the Secale Cornutum in Disturbance of the Accommodation-power of the Eyes. By Professor WILLEBRAND. (Graefe's Arch. für Ophthalmologie, B. 4, Ath. 1, s. 341.) When local hyperæmia is dependent upon a laxity of the walls of the blood-vessels, advantage attends, Professor Willebrand of Helsingfors, states, the employment of secale cornutum. He was induced to use it in these cases by the expectation that a means which acts so specifically upon the unstriped uterine muscular fibre must excite some power over the analogous structure of the arteries, and in which its hæmostatic action proves, in fact, that it does. During his investigations he soon became struck with the fact that the heart of persons employing it soon underwent contraction in all its dimensions, and that even within the first twenty-four hours-a circumstance which he has frequently verified since. The first case that came under his care was an example of exophthalmos, accompanied with enlargement of the thyroid gland and hypertrophy of the heart. After a few weeks' use of the secale the hypertrophy of the heart and thyroid, as well as the projection of the eye, much diminished. The patient, however, left off the medicine, and the exophthalmos returned worse than ever. Since that period he has employed the secale in various cases in which increasing the contractility of the muscles of the blood-vessels or other tissues seemed to be indicated. It was found of especial advantage in a disturbed state of the accommodation power of the eye, especially induced by over-taxing the organ on small objects with an insufficient amount of light. Children from some of the schools have furnished the author with many instances, and they have always been relieved by the secale. He relates a case in which impaired vision was always brought on by sewing or reading, and wherein the signs of some amount of chronic congestion were visible. Relief rapidly followed, and when the affection recurred some months after, it was as speedily relieved. He has also found the secale of great use in several cases of acute or chronic inflammation of the eye, and especially in blepharitis and the pustular conjunctivitis of children, the case proving much more rapid, and relapse being much less rare, than when local means alone are relied upon. No benefit has been derived from it in granular conjunctivitis and trachoina.
Proceeding upon the theory of its stimulant action upon the vaso-motoric nerves, the author has extended the employment of the secale to other local disturbances of the economy; and, as already observed, he has had frequent occasions of observing its transitory influence in hypertrophy of the heart, without having any reason to believe that it is of any permanent utility in affections of this organ, the heart always returning to its former size soon after the use of the secale has ceased. In many cases of both chronic and acute hyperæmia it has proved of great service, and especially in cases of galactorrhea, and in indurations, tumefactions, and catarrhal affections of the uterus. Also, it has been very useful in enlarged spleen from intermittent fever, and when large doses of quinine have failed. It is especially indicated in the cases of relapsing intermittent depending upon enlarged spleen. In erysipelatous affections, it has often done good service applied externally as a cataplasm. The author formerly gave ten grains ter die, but now gives but five, combining it with magnesia, or, when chlorosis is present, with iron.
QUARTERLY REPORT ON MIDWIFERY.
BY ROBERT BARNES, M.D. LOND.
Physician to the Royal Maternity Charity, Assistant Obstetric Physician to the London Hospital, &o.
I. THE NON-PREGNANT STATE.
1. Case of Vesico- Vaginal Fistula. By HENRY THORP, M.D. (Dublin Quarterly Journal of Medical Science, February, 1859.)
2. Death through an Injection of Carbonic Acid into the Uterus. By M. SCANZONI. (Beiträge zur Geburtsk. tome iii., 1858; and Arch. Gén. de Méd., March, 1859.)
3. A Case of Chancre of the Uterus. By C. KOLLOCK, M. D. (Charleston Med. Journ. and Review, March, 1859.)
1. DR. THORP Contributes a practical paper on Vesico-Vaginal Fistula. He believes that the shield recommended by Bozeman has no advantage over the quilled suture when properly constructed and applied, and that the latter has the advantage of simplicity. The case he relates is that of a woman delivered of her second child, in March, 1856, after a tedious labour. A month afterwards a slough came away from just behind the neck of the bladder, leaving an opening of an oval form, through which a catheter passed from the urethra into the vagina; it measured an inch from before backwards, and three-quarters of an inch from side to side. The first operation was performed on the 30th of May, 1856. It was unsuccessful, but the opening was narrowed one-half. In August the actual cautery was applied, but the opening remained. In December, 1857, she was again delivered. A second operation was performed in July, 1858. The opening now was as large as at first. The operation was that of Dr. Hayward, of Boston, the object being to obtain extensive raw surfaces for immediate union, by separating the vagina from the base of the bladder to the extent of half an inch around the fistulous perforation-that is, splitting the vesico-vaginal septum into two laminæ, and so adjusting the fresh cut surfaces of the respective flaps, that when turned upon themselves and retained in contact by quilled suture, they shall adhere and unite by the first intention. Dr. Thorp thinks it essential that the needle should penetrate the vesico-vaginal septum, so as to enter about two lines in front, and crossing the area of the fistulous perforation, emerge at the same distance behind the line of division of the membrane into two flaps, and should in its course precisely hit off this angle anteriorly and posteriorly, so that the ligatures when tied shall cause the quills to press together the cut surfaces at their furthest point from the abnorinal opening-that is to say, at the divisional line already spoken of.
2. The observation of M. Scanzoni shows the hazard of gaseous injections into the uterus. In this case it had been determined to amputate the neck of the uterus in a woman who was pregnant, the pregnancy being masked by attendant circumstances. The father of the patient, bimself a physician, wished to practise for a few days injections of carbonic acid into the cavity of the neck, hoping by this means to produce a contraction of the vessels and to obviate the hæmorrhages which so often complicate amputations of the uterine neck. He tried a first injection with the aid of an elastic reservoir; but scarcely had two or three cubic inches of gas penetrated the gaping mouth of the neck, when the patient cried out that she felt air entering the abdomen, head, and neck. Immediately afterwards she was seized with general teta
nic convulsions; respiration became laborious and stertorous; the pulse rapid, small; the extremities grew cold, and death followed at the end of an hour and three-quarters. The autopsy revealed nothing but considerable pulmonary œdema. The uterus, much thinned, contained a four months' fœtus; it seemed that the hypertrophy, of which the body of the uterus is the seat in normal pregnancies, had been entirely expended on the neck. The mode in which death was caused is not clear; but the case suggests that extreme reserve should be used in resorting to injections of carbonic acid, whether for the purpose of producing anæsthesia or premature labour. [For the latter purpose it is altogether superfluous, surer and safe means existing.-R. B.]
3. Dr. Kollock's case adds an instance to the rare observations of uterine chancre. It occurred in a woman aged thirty-two. Two well-defined ulcers were observed-one on the parietes of the vagina, about an inch from the vulva; the other occupying the anterior lip of the uterus. They had every characteristic of the Hunterian chancre-greyish colour, excavated, with margins irregular and elevated; the vaginal discharge was puriform. In order to test this character, Dr. Kollock took pus from the chancre on the uterus, and inoculated both thighs. Genuine Hunterian chancres were the result. All were cured by the internal use of bichloride of mercury and the topical use of caustic nitrate of mercury.
1. On the Cervix Uteri in Pregnancy. By J. MATTHEWS DUNCAN, M.D. (Edinburgh Med. Journ., March and April, 1859.)
2. On the Normal Hypertrophy of the Heart during Pregnancy, and on its Pathogenic Importance. By Dr. LARCHER. Memoir addressed to the Academy of Medicine, 6th April, 1857. (Arch. Génerales de Médecine, March, 1859.)
1. Dr. Matthews Duncan discusses the prevalent notion as to the progressive shortening of the cervix uteri during pregnancy. With Stoltz and Caseaux, he shows the error of this doctrine. He says the length of the cavity of the cervix uteri undergoes little or no change during pregnancy; the evidence of this is based on the inspection of gravid uteri, and on vaginal examinations. He gives outline sectional views of four cervices of different stages of gestation, one taken from Coste, one from William Hunter, and three from dissection, which establish his proposition. With regard to the evidence from vaginal examination, Dr. Duncan cautions against being misled by the frequent obliteration of the vaginal portion of the cervix, this being only a fictitious, not a real shortening; he advises to measure the length of the cavity by gently intruding the finger through the external os uteri, as can generally be done in advanced pregnancy, in multiparæ, and frequently in primiparæ.
Dr. Duncan further affirms that, 2, the capacity of the cervical cavity becomes gradually greater as pregnancy advances; and this is effected by an increase of its diameter, or breadth, advancing from below upwards-that is, from the external to the internal os of the cervix. 3. The length of the vaginal portion of the cervix, or the amount of its projection into the vaginal cavity, generally diminishes as the uterus rises into the cavity of the abdomen. 4. The softening of the cervix uteri, already commenced superficially during the menstruation preceding conception, continues, and extends more deeply into the substance of the cervix, as pregnancy advances; and the process is generally completed two or three months before the end of utero-gestation. This softening is attended by a considerable increase of bulk. 5. In vaginal examinations during life, after the middle of pregnancy, the finger of the obstetrician feels the uterine cervix as if it were gradually shortened according as pregnancy still further advanced.
[Similar views to the above are advanced by Dr. Arthur Farre, in the article Uterus, 'Cyclopædia of Anatomy and Physiology;' and in the April number of the 'Edinburgh Medical Journal' is another sketch of the cervix of a gravid uterus, taken from a dissection forwarded to Dr. Duncan by Dr. Barnes.-REPORTER.]
2. The memoir of Dr. Larcher points out a most important physiological consequence of pregnancy. He affirms that, in the human species the heart is normally hypertrophied during the course of gestation. The proposition is so interesting that it is desirable to cite in detail the evidence upon which it is based M. Larcher was interne to the Maternité at Paris in 1826 and 1827. His observation bore mostly upon women aged from eighteen to thirty-five, and their number was so great as to present in turn every imaginable variety of temperament and organization. Some had been ill a long time before delivery, some for a