probable that there may be various degrees of infection. The distinction between cholera "germ" and cholera "infecting matter" must be noted. The cholera germ stands in the same relation to the infecting matter as the seed does to the fully developed plant. In order to carry out a rational investigation of the specific infecting matter an exact study of the local and seasonal conditions of cholera epidemics is absolutely necessary, for it is only thus that one can find where and when this infecting matter is to be sought with any prospect of success. The differences in the local and seasonal occurrences of cholera are at present the only substantial grounds for inferring the existence of a specific cholera germ and infecting matter. Exact statistics of the local and seasonal movement of cholera are indispensable. (Vide the tables concerning Bavaria in the Bavarian Report, p. 50.) Closer examinations of isolated cholera places disclose that even in these more limited areas as great differences exist in the local conditions (proportionately) as in entire countries and provinces. (Examples of such are given in his article on Lyons, p. 464, and in Pfeiffer's article on Weimar in "Zeitschrift für Biologie," part iii., p. 189.) Whatever has hitherto been advanced against the view that the soil exercises an essential influence on the spread of cholera epidemics has proved untenable on closer examination; in illustration of which refer to pages 91 and 98 in the Bavarian Report on Kienberg, and to the remarks of Dr. Sutherland on the condition of the soil at Gibraltar and Malta in the Sanitary Reports. The seasonal disposition to cholera consists, in my opinion, in a certain degree of humidity combined with warmth of the soil. Refer to the article on Lyons, pp. 465-468. Note the definition of "ground water" in pp. 468,469; also a description of the influence of the rain season in Calcutta, Bombay, and Agra, in pp. 469-477, as well as the remarks on the influence of the Rhone on that portion of Lyons which is situated on alluvium, p. 484. Here I may also allude to the evidence establishing the connexion which existed between the ground water and ileo-typhus in Munich. When the former was at its lowest level, the latter raged the most. (Vide article on the subject, with diagram.) Individual predisposition consists, in my opinion, as a rule, in a proportionately excessive amount of water in the tissue of organs, and a deficiency of albumen. This subject is treated at length in the "Zeitschrift für Biologie," part ii., pp. 92-97.) In illustrating these views, the Professor entered at some length into a demonstration as to the grounds on which they are founded. In doing this he showed practically the method of estimating the percentage of the porosity of gravel, clay, and solid stone. He also showed the methods which he employs in ascertaining the temperature of the soil, and the level of the ground water. ON THE NUTRITIVE VALUE OF DIFFERENT BY BARON LIEBIG. Ir has been said that if man could live on air and water, there would be an end at once of the notions master and servant, sovereign and subject, friend and foe, hatred and affection, virtue and vice, right and wrong, &c., and that our political commonwealth, social and family life, our intercommunication, trade, commerce, and industry, art and science,-in short, all that makes man what he is, would not be if he had not a stomach, and were not subjected to a natural law which obliges him daily to take a certain quantum of nourishment. It is therefore worth while to answer the question why in reality man eats and drinks, and what the substances are which, received in the body during a succession of years, have an influence on the duration of his might perhaps believe that by perseverance the habit could be got rid of. But hunger is the inner admonisher that tells us there is something wanting within the body, and that we must supply the deficiency. That we grow thinner from privation of food, that we are cold and our forces diminish, while on the other hand our weight and bodily powers are kept up, and even increased, by taking nourishment, are facts which everyone can observe in his own person. But what we do not comprehend is, that in spite of this renovation, our body does not remain as it was, but gradually dies away. What we know of life does not help us to comprehend death, which still remains an inscrutable mystery, The animal body is a warm body, which emits warmth continually, and the heat thus lost must continually be replaced. It is, moreover, like a machine which daily performs a certain amount of work. The heart, or the muscles of the heart, work on uninterruptedly to keep up the circulation of the blood; the muscles of the chest to keep going the respiratory organs; and those of the entrails to maintain the worm-like motion of the organs of digestion. These are daily performances with which our will has nothing to do, while the mastication of our food, the motion of our limbs in walking and running, or otherwise working with them, are all dependent on our volition. The animal body has often been compared to a locomotive, in which, by air, water, and fuel working together, warmth and force are generated. Indeed, air and water are necessary conditions for the generation of heat and strength in the animal body, and food therefore may in a sense be considered as fuel: it has, however, other purposes also. We all know how rapidly wear and tear ruins an engine; and that to put it in repair materials and work are necessary. The iron or copper which has to be renewed will not be replaced by giving the machine more fuel, and therefore an exterior human power the power of many workmen-must co-operate and must be consumed, to make up the deficiencies of the machine, and set all right again. Food does not serve to generate warmth and force only, as is the case with the steam-engine, but also to form and to increase the quickened parts of the animal body, and to reproduce those which are worn out. If we keep in view these different purposes which food serves, it will be easy for us to form a decided notion of the nutritive value of different sorts of food. Physiology teaches the blood, and that the component part of blood, which beus that all animated and plastic parts of the body arise from rial which serves for their construction. comes fluid when heated, and is called albumen, is the mate All the different sorts of food of man, as well as that of animals, contain, without exception, substances which are identical, or nearly identical, with the albumen of blood. This constitutes an entire group of substances found in plants, partly in solution in the juices, partly deposited in the seeds, and which are found in greatest quantity in the cereals. The albumen of the blood is formed from them; they are also name given them is albuminate. In the nutritive process, called constituent nutritive substances, because they furnish the material for the formation of all the plastic parts of the body. From other organic substances they are materially distinguished, having an abundance of nitrogen, and by con(casein) of milk; syntonin, the principal component part of the taining a certain amount of sulphur. The cheesy substance muscles; albumen, or that part of vegetable and animal juices which is soluble in heat; gluten of the cereals; vegetable casein in peas, beans, and lentils (legumin), all belong to the group of albuminates. The component parts of human food and of the fodder of animals which are free of nitrogen, such as fat, starch, sugar, sugar of milk, &c., are applied in the vital process, principally and in part exclusively-for the generation of warmth. They have been named respiratory substances, or warmthgenerating substances. The food of men and animals contains, besides, a third class of nutritive substances, known as nutritive salts. These are the substances which remain in the form of ashes when the articles of food are burned: phosphoric acid, potash, lime, magnesia, iron, common salt, are their chief elements. The albuminates and heat-giving substances are quite incapable of nourishing and of sustaining life if the nutritive salts are not present, and co-operating with them. Without the nutritive salts they do not give nourishment. The idea of a perfect sort of food must be associated with three conditions; it must contain a certain quantity of albuminates, and there must also be a certain proportion of heat-giving substances, If eating had no other end but to satisfy appetite, one and of nutritive salts. We may accordingly speak of meat, life. THE LANCET,] DR. WILKS ON THE SIGNIFICANCE OF MARKINGS ON THE NAILS. milk, and bread, in which these three conditions are united, as being food; but albuminates, starch, and nutritive salts are in themselves not food; they are only nutritive substances, as indispensably necessary for the vital process as air and water are, but each alone quite incapable of sustaining life. As food, air, and water are the means by which all occurrences in the organisation of the body, all its multifarious manifestations of vitality, are brought about, it must be clear that the state of the body which we term health depends on the right relation and co-operation of these three require ments. We easily comprehend the influence of excess in eating and drinking, and in other matters on the health of an individual, because everyone perceives that the capabilities of the organisation and of its parts, as with a machine and its parts, have their limits; and that by the act of overstepping these, which we call excess or debauch, the equilibrium to be preserved in the co-activity of all the different organs will momentarily or lastingly be disturbed. In the animal body there is only a certain amount of force generated daily, which the heart, the organs of digestion and respiration, the limbs, &c., require for, and consume in, their special work. By such excesses the normal state is disturbed, and when such disturbances happen frequently, a change takes place in the condition, and consequently in the capability for work, of one or other of the organs, and the body grows sick. In order to understand the influence of an irregular expenditure of force, we need only remember that when greatly fatigued we lose our appetite, and that when the stomach is in full activity the limbs are indisposed for performing hard work. Insufficient nourishment and fatiguing work during the period of growth stop the corporeal development of the individual. Far more difficult is it, even for the attentive observer, to perceive the injurious influence which bad air, or impure water, or an insufficiency of food, exercises on the health of the population, as here the injurious influence is made up of a number of scarcely perceptible disturbing causes. If the air and water teem with such pernicious influences,-if the air abounds in damp, carbonic acid, and organic matter in a state of suspension,-if the water abounds in matters which are in a state of decomposition,-if the nourishment be wholly unfitted for digestion, and for the support of the vital process, then the harmful effect is quick, and we are seldom deceived as to the cause of the disease which has arisen. If, however, the impurities in the air and the water be but trifling, and the nourishment merely deficient in quality, the injurious influence produced from one day to another will scarcely be perceived; but the effect is none the less sure. A state of sickness comes on sooner or later, which is ascribed to a number of chance derangements, but very seldom to the right cause. From a certain age life is a slow decay, a change in the composition of the substance of the organs, which at last unfits them for their work. The arrival of this period may be hastened or retarded; hastened if the nutrition be deficient, retarded if all the inward parts, as far as this is possible by human care, are kept in a proper condition. In consequence of an imperfect compensation for the force expended, a life may be shortened five, ten, or more years. The old peasant dies of his brown bread; he is perfectly healthy, he says, and there is nothing the matter with him, except that he is unable to support the bread. The lasting health of the individual depends on the right proportion of the different sorts of food in quantity and quality. This proportion differs in each one, for it is determined more immediately by the condition or the power of work of his inner organs, and also by the daily work to be performed by the limbs. Individuals whose organs of digestion, secretion, and respiration are weak need food different in quantity and in quality from that of persons in robuster health. For every stage of life a certain mixture of food alone is fitted; and what we all consider as a matter of course for the infant, is, strictly speaking, applicable to every period of life. The evil is that every one has not the free choice of what he will eat; but by learning what is especially suited to his wants, or what is hurtful for him, he may help to lengthen his life a short while. The daily work performed by an individual bears relation to the mass of his muscles, as this depends on his nutrition in relation to his food. Two individuals with muscles unequally developed, cannot perform daily the same amount of work. A badly-fed individual has little muscular formation, and requires less food than one well fed. With the same quantity of food which would keep the badly-fed individual up to his [JAN. 2, 1869. weight, the better-fed man, with greater muscular formation, would lose weight. The English railway contractors measure the capacity for work of their men by their appetite. (Dr. Lankester.) In consequence of work the muscles diminish; they are used up, and must be renewed daily by means of food, if the power for work is to remain the same. In experiments which Dr. Parkes tried with two perfectly healthy and strong men, he found that, after a walk of fifty-six and a half miles, performed in two days, the men being well fed on substances free from carbon, fat, starch, &c., one lost four pounds in weight, the other one pound and a half, and it took four days for the men, with the aid of abundant meat food, to regain their original weight. As both men had enjoyed heat-producing food in abundance, and as purposely all victuals were avoided which could possibly have caused the formation of muscle, the loss in weight could only have been produced by the diminution of the musculatory mass in the body. Had the loss of weight been caused by a loss or evaporation of water, the original weight would soon have been restored by drinking a few glasses of water; but the slow restoration of the lost weight, and the necessary co-operation of food, show that the formations which in their natural state had retained the escaping water, now no longer existed. In order that the muscular mass, or, what is the same thing, in order that the working powers of an individual may be kept up, it is absolutely necessary that in his daily food a quantity of albuminate be consumed sufficient to make up for what is lost. A greater amount of work is not to be attained, for a continuation, without a greater amount of food, especially not without a larger amount of albuminate in the nourishment taken. The badly-fed German workman wants in England and America a month's diet abounding in albuminates before he is able to compete with the English or American workman. We may compute, without risking to be far wrong, that a working man of 140 lb. weight, requires for his sufficient nourishment 130 grammes of albuminate (453) grammes equal 1 lb. English) daily. The English navvies who were sent out during the Crimean war to make the Balaclava railroad, and who astonished both English and French soldiers by the extraordinary amount of work they performed, consumed daily from 150 to 159 grammes of albuminate. The men in the Munich breweries consume on an average 165 grammes of albuminate per day. The amount of albuminate in the rations of the Bavarian and English soldier in time of peace is about 126 grammes, or 4 oz. in a dry state. According to the work, it is not at all indifferent in what form the working man enjoys the albuminates in his food; and in this respect the place which meat holds among the food of man has not been sufficiently appreciated by physiologists. (To be continued.) ON MARKINGS OR FURROWS ON THE NAILS BY SAMUEL WILKS, M.D., THE fact that the traces of a past illness may be found on the nails is probably known to many in the profession, as it is one with which I have been well acquainted for many years. Constantly meeting, however, with medical men to whom it is unknown, I take the liberty of bringing the subject before their attention, hoping that the experienced will pardon the intrusion for the sake of those to whom the fact is novel. I cannot at present lay my hands on works of reference, but I believe the subject has been alluded to by English and foreign authors. On taking up the book on "Skin Diseases" by the late lamented Dr. Hillier, I find the following casual allusion to it:-"Cross furrows are often seen on the nails. It has been suggested that these are due to an irregular growth of the nail from disturbances of health, the thinner portion being formed when the patient is out of health, and the thicker parts in the intervals." My own rarely resort to amputation of the arm for compound comminuted fracture opening the elbow-joint, and then only in cases in which the soft parts as well as the bones are damaged extensively and beyond recovery. In a comparatively healthy subject I should remove large fragments both of the humerus and of the bones of the forearm, rather than submit a patient to the terrible alternative of amputation. Of the seven cases referred to, two died: of these, in one instance the injury to the elbow was associated with a compound fracture of the skull; and in the second case-the patient being of a most desponding disposition-death resulted from pyæmia. The remaining five cases recovered with useful limbs; flexion and extension, supination and pronation, being secured to all in varying degrees. Some of these cases are recorded in the London Hospital Reports. New Broad-street, Dec. 1868. A MEDICO-LEGAL CASE OF INJURY TO BY THOMAS BUZZARD, M.D. LOND., ASSISTANT-PHYSICIAN TO THE NATIONAL HOSPITAL FOR THE PARALYSED distinct knowledge of the fact that the nails become altered in disease was obtained many years ago, when a non-professional gentleman observed the circumstance for himself, and was so much interested in it that he referred the matter to a distinguished natural philosopher. It was after a severe attack of diarrhoea, which caused almost as much prostration as Asiatic cholera, that he discovered a white line or depression at the roots of the nails. Having formed a pretty accurate idea of their rate of growth, he was convinced that the markings corresponded with the date of the illness. I may state that these marks are caused by a slight furrow, which is found more especially on the middle of the nail, and more distinct on that of the thumb. They point, no doubt, to a sudden arrest of the nutritive process during the time of the illness, and herein lies the interest of the observation. In cases of fever we know that the most profound changes take place in all the tissues of the body. In scarlet fever, for instance, the whole of the epithelial surface within and without the body is affected, and, as a result, we may witness a desquamation of the cuticle, falling off of the hair, and separation of the nails. When the fever is at its height, we can have then little doubt of the changes taking place in the tissues, and can feel no surprise that the nails show evidence of the former conflagration. As the patient recovers, and a new cuticle forms, and the hair begins to grow, the nail proceeds to shoot forward afresh, and it is not long before the latter exhibits a transverse furrow, indicative of EARLY in February last I was called in consultation by the previous illness. It is possible, therefore, to ascertain the date of the attack. Physiologists say that the thumb- Dr. Slight, of Brewer-street, to a foreign tailor, A. K—, nail grows its whole length twice in a year; and thus it fol-aged fifty, who had been knocked down three weeks prelows that if the furrow be found in the middle of the nail, viously by a van. He had received some scalp wounds at the illness occurred three months before. This fact may the back of the head, and bruises about the body, appathen serve for a limited period, like "foot-prints on the rently from the horses' hoofs; and was said to have been sands of time," as some additional proof of a previous serious stunned for a few minutes. I found him in bed, complainillness. For instance, a patient with cardiac disorder stated that he had had an illness three months before, and on his ing of pain about the left side of the head, and speaking in nails some transverse markings were found; also another a peculiarly slow and laboured manner. He had a quick suffering from phthisis said that his illness resulted from an pulse, and his head was hot. I was informed that he had inflammation of the lungs occurring a few weeks previously, been almost constantly drowsy, requiring to be roused and on his nails also some distinct lines were discovered. before he could reply to questions. He volunteered the inThat a severe diarrhoea could produce such a cessation of the nutritive process as to exhibit its effects on the nails is formation that objects frequently appeared double to him. a fact for which I should have been unprepared had it not There was no apparent paralysis of face or limbs. His been apparent to the eyes. It is one, however, of extreme symptoms appeared referable to concussion. interest. I have never made the subject one of accurate clinical observation; but if I can induce my clinical clerks to record a few cases, the readers of THE LANCET shall be furnished with the result. On April 16th and 18th Dr. Slight brought him to my house. His speech had then greatly improved, and he looked much better in general health. He walked lame, however, leaning heavily upon a stick held in the left hand, and dragging the right leg. The grasp of the right hand appeared very defective. There was no drawing of facial muscles. It ON PRIMARY EXCISION OF THE ELBOW. seemed that he left his bed a month after the accident; and JOINT. BY C. F. MAUNDER, SURGEON TO THE LONDON HOSPITAL. THE operation of excision of the elbow-joint for disease is a proceeding justified, no doubt, by the experience of every hospital surgeon. No operation of equal magnitude is attended by less fatal consequences, or by such happy results as the above. In almost every instance the surgeon can promise his patient something a great deal superior to a stiff elbow; while the latter condition usually results, after the lapse of a great expenditure of time and prolonged suffering, if the ends of the bones be not removed. So much for excision for disease. it was then noticed that his right leg gave way under him, and his right arm was deficient in power. Sensation being tested, we found that he denied feeling compass-points or pinches over the right upper and lower extremity. Now, if this were a case of spinal hemiplegia (which the total absence of facial palsy seemed to indicate), there should have been hyperæsthesia of the paralysed limbs, with anesthesia of the opposite side. This discrepancy, coupled with the damages against the owners of the van, threw the gravest fact that the patient was then bringing an action for doubts upon the genuineness of the symptoms. Before proceeding any further, therefore, I resolved to test, by a carefully-contrived experiment, the truth of his assertion that he had lost sensation in the right limbs; and as the means employed were, so far as I know, novel, I will describe them. The lower extremities being bared, I brought near them Stöhrer's induction machine, with its two wires and sponge directors connected with it. I attached, also, I am anxious to show that equally happy results may be to the box (not to the working portion) two other wires and insured by excision for injury-as in cases of compound sponges; and I gave one of these to the patient, directing comminuted fracture opening the joint. I am the more him to press the sponge on the outside of his left thigh, and desirous to do this because quite recently (vide THE LANCET the other to Dr. Slight, requesting him to apply it to the of Dec. 5th, 1868) the bone-ends forming the elbow-joint, same limb on a given signal. Meanwhile, the patient's and primarily excised, have been exhibited at the Medical whole attention being occupied with these pretended opeSociety of London, and this instance of primary excision rations on his left thigh (the unaffected one), I applied one was spoken of as a novelty in London hospital practice; of the real sponge directors to the right thigh, and, at the amputation of the limb having, as was supposed, been re-signal, clapped on the other to the same limb; thus directsorted to up to the present time. It has fallen to my lot to ing the most powerful current upon the skin of the paraperform primary excision of the elbow-joint in seven in- lysed thigh. At the same moment my assistant applied his stances; and most of my colleagues have also performed sponge. Watching the patient's face, we failed to discern this operation more than once. At the London Hospital we in it the slightest expression of consciousness that he was THE LANCET,] MR. R. B. CARTER ON THE PARALYTIC FORMS OF STRABISMUS. receiving a current, the pain of which is wellnigh insupportable. I then reversed the whole apparatus, applying the electric current to the left thigh. Upon this the patient started with a shriek of unmistakable pain, and nearly fell from his seat. The result of this experiment showed conclusively that, to the electric current at least, there was anæsthesia of the right thigh, and removed at once our doubts of the patient's credibility. Further examination confirmed this view. A thermometer left five minutes in each axilla marked 98.1° on the right side, and 97.9° on the left. Careful measurement showed that the right thigh, 6 in. above patella, was in. less than the left; and the right leg, 6 in. below patella, was in. less than the other. The arms were equal. Electro-motility was good everywhere except in the thumb muscles of the right hand. Asked to raise his right leg, the foot "dropped" as it was lifted from the ground. I should say here that the fingers of the affected hand were quite flaccid. On June 13th, measurement showed that the right upper extremity had wasted since last examined. The right arm, 6 in. above olecranon, was in. less than the left; the right forearm, 6 in. above lower end of ulna, in. less than the other. The disparity between the lower extremities had increased. The right thigh, 6 in. above patella, was now in. less than the left; the right leg, 6 in. below patella, in. less than the other. An important change, too, had taken place in the right hand. The middle, ring, and little finger were rigidly contracted upon the palm, and could not, by any exertion of force on my part, be extended. The tendons could be seen and felt projecting and hard in the palm. On November 20th, the patient walked freely, and there was no dragging of the right leg. The measurement of the thighs and legs was now found to be equal. The wasting of the right upper extremity had increased. The right arm was in. less than the left; the right forearm in. less than the other. The rigidity of the fingers was still more marked than at the last examination. Sensibility was much improved in the right limbs, but was still apparently defective. At the end of November the case was tried in court, and the plaintiff recovered damages, the testimony of Dr. Slight and myself being to the effect that the plaintiff was permanently disabled in the right hand. The man had been examined, on the part of the defendants, by two eminent surgeons, who were not called, and no opposition was offered to the medical testimony. The very careful examination to which this patient was subjected, and his gradual progress to recovery (except in the use of certain fingers), make it evident that he did not pretend his symptoms. The wasting of the limbs and the rigid contraction of the fingers he could not simulate. As regards the nature of the nervous lesion, one can only suggest the probability that blood was effused, a part of which became gradually removed by absorption, and a part converted into a cyst or hæmatoma, which encroached upon and destroyed a small portion of nerve-substance. Its exact situation, and whether, as is quite possible, there was more than one lesion, are points which necessarily remain doubtful. Green-street, Grosvenor-square, December, 1868. ON THE [JAN. 2, 1869. 7 latter case, where the strabismus was originally caused by hypermetropia, and where vision is much impaired, disfigurement alone will be present. In both, after the lapse of a certain time, we may find the eye almost fixed in an abnormal position: one muscle contracted and perhaps structurally shortened, and its antagonist so far paralysed that it will not respond at all to the influence of the will. However successfully we may then address remedies to the removal of the original cause of the paralysis, our success will be fruitless, because the natural balance of power between the opponents is too much disturbed for the weaker muscle to have any chance of reasserting itself; and if we divide the tendon of the contracted muscle, the paralysed one will yet be too feeble to bring back the eyeball to its proper position. Surgical ingenuity has been taxed to devise compound operations, by which the weakened muscle has been brought forward or shortened, and the contracted one divided or put back; but the results have seldom been satisfactory, and the last state of the patient has often been worse than the first. Some two or three years ago, Professor Moritz Benedikt, of Vienna, published on the effects of the direct galvanic current in paralysis of the ocular muscles; and my very rough translation of his paper appeared almost by accident, and without my having any opportunity of revising it, in the second volume of the Ophthalmic Review. Benedikt's results seemed to me capable of being improved upon, and I determined in the first suitable case to try a combination of tenotomy with faradisation. The A patient soon afterwards presented herself with complete paralysis of the right superior rectus. She was a respectable, middle-aged woman, the affection was of many years' standing, and I could not ascertain its cause. inferior rectus was strongly contracted, the cornea rolled down, the supra-corneal region of the sclerotic bulging forward from the loss of support, the diplopia very distressing, and the deformity extreme. Voluntary power of upward rotation was wholly lost. In order, in the first place, to test the electric contractility of the paralysed muscle, I obtained a pair of small rheophores, terminating in discs of not more than a line in diameter. These discs were covered with very fine white leather, well wetted. The upper lid being lifted, and completely controlled by a large retractor, governed by the left hand, the discs were applied to the supra-corneal region of the conjunctiva, as far back as possible, with the right hand, and about a line apart. When fairly placed, they were connected with the primary current of a Stöhrer's battery, in very feeble action. At first, the only effect produced was irritation of the fifth nerve, as shown by pain, lachrymation, and redness; but, after three or four applications of the current on successive days, some very slight effort of contraction in the weakened superior rectus became manifest. I then divided the tendon of the inferior rectus; and continued the use of the current daily. Day by day the paralysed muscle recovered strength; and, in about three weeks from the commencement of the treatment, the cure was complete, as well of the diplopia as of the deformity. The second case that came under my notice was one of hypermetropia, with extreme convergent strabismus of the right eye, the vision of which was so much impaired that there was no diplopia. The patient was a young man of TREATMENT OF THE PARALYTIC FORMS nineteen, a domestic servant; and his squint was a serious OF STRABISMUS. BY ROBERT B. CARTER, F.R.C.S., CONSULTING SURGEON TO THE GLOUCESTERSHIRE EYE INSTITUTION. THE forms of strabismus that depend not only upon contraction of one rectus muscle, but also upon paralysis of its opponent, have been long recognised as sources of much embarrassment to the surgeon. The paralysis is sometimes the primary affection, and sometimes, I believe, it is merely a secondary one, due to the enforced inactivity of a muscle that has been long overpowered by its antagonist. In the former case, the paralysis itself being often traceable to some rheumatic or syphilitic cause of pressure upon the motor nerve, and vision being unaffected, there will usually be much diplopia as well as much disfigurement. In the hindrance to his prospects in life. Paralysis of the external rectus appeared to be absolute; and the most complete possible tenotomy of the internal rectus, by Liebreich's method, was followed by little if any improvement in the position of the eye. The eyelids were then held apart as widely as possible, and the rheophores used for the former case were applied in the same manner to the conjunctiva covering the external rectus. Little by little, the weakened muscle responded to the current; and after a short period of treatment the squint was entirely removed. The patient was then instructed to exercise the eye daily by reading through a lens of short focal length; and it seems probable that he will ultimately regain useful vision. I have taken these two cases as types of different forms of paralytic strabismus; and the results obtained in them, and in others of a less marked character, induce me to believe that paralysis of a rectus muscle, due to any of its more frequent causes, is seldom beyond the reach of recovery by electric treatment. But in such paralysis, as indeed in some other forms, the contraction of the opponent is a formidable impediment to the functional restoration of the muscle that is weakened; and the anatomical relations of the recti tendons to the capsule of Tenon are fortunately such that an effectual tenotomy, if carefully performed, will not involve any loss of power likely to produce displacement in an opposite direction. It is always satisfactory to obtain some evidence of reaction to the current before the tenotomy is performed, because then eventual success may be considered certain; but there will be some cases in which the paralysed muscle will be too feeble to react until released from the tension of its antagonist. I am disposed to attach importance to the small rheophores, and to their application on the conjunctival surface, immediately over the affected muscle; so that "localised electrisation" may be practised after the manner of Duchenne. There can be no doubt that an induced or faradaic current is more generally applicable than the direct current to the cases under consideration, because less potent in its effects upon the optic nerve and retina; and, as a rule, for the same reason, I should use the primary induced current before having recourse to the secondary. The latter, as the more penetrating, may be used if the former should fail; but on account of the very superficial situation of the recti, only a small power of penetration will usually be required. Furthermore, since it has been shown that in some cases paralysed muscles will react to the direct current when they are insensitive to the induced, the former should in all cases be tried, but with due caution, as a last electrical resource, and prior to the performance of any operation for shortening the weakened muscle. Princes-street, Hanover-square, Dec. 1868. WHILST attention has of late been increasingly bestowed upon the mode of investigating and treating diseases of the ear, and great advance made in aural pathology, there can be little question that our present physiological knowledge of the more important parts of the organ of hearing, is neither comprehensive nor accurate. The space allowed me in THE LANCET will not admit of even cursory reference to the laborious researches and experiments on physiological acoustics pursued by German and other continental aural surgeons; it must, therefore, be presumed that my readers are somewhat acquainted with the results of their inquiries, as recorded in the several periodicals devoted to their spécialité. It is much to be regretted that more unanimity of opinion does not prevail; indeed, it is curious to observe how importantly one writer will modify the ideas of another investigator without himself arriving at more exact or satisfactory inductions. The somewhat contradictory and, at present, irreconcileable views entertained by both English and German physiologists in reference to the actions of parts within the tympanum and internal ear, seem to have suggested to the late learned President of the Medico-Chirurgical Society (Dr. Alderson) the following observations, which were consequent upon a discussion on the last paper ever presented by Mr. Toynbee, May 8th, 1866:- "He (the President) thought much more would be gained by the close study of physiology as introductory to pathological investigation. Whilst we were fully acquainted with the mode in which light was impressed upon the retina, and so communicated to the brain, notwithstanding that doubt still existed as to the true theory of the nature of light; yet, on the other hand, whilst the vibrations of the air were fully understood, very little that was positive had been ascertained as to the mode in which those vibrations were communicated to the brain."-Vide THE LANCET, June 16th, 1866. Under these circumstances, I have undertaken to en deavour to indicate, with as much perspicuity and brevity as are in my power, some of the more important offices which the various parts in the tympanum perform in transmitting sonorous vibrations to the fluid in the internal ear. The manner in which the terminal extremities of the auditory nerve spread out upon the delicate membranes of the labyrinth, receive the undulations of sound, and communicate their effects to the sensorium, has lately been elucidated by the minute dissections and microscopical investigations of Kölliker, Schultze, Henle, Czermák, Hulschke, and others, and will be subsequently adverted to. The advance in knowledge of the structure and functions of the labyrinth seems necessarily to lead to the conclusion that the great end and intention of the tympanum (its more immediate accessory part) are to modify, extend, and multiply the various sounds which are conducted through it; whilst by its position, form, communications, and contents, it acts as a protective organ, and renders the internal ear quite independent of the vicissitudes of atmospheric temperature. Incidentally I may remark that this last preservative office is not sufficiently regarded by aural surgeons in their therapeutical treatment. To relieve a catarrhal obstruction in the tympanum, I have frequently witnessed the introduction of cold air and lotions into its cavity, through the Eustachian tube catheter, both being, according to my views—in which I am glad to find myself supported by the eminent aurist, Dr. Von Tröltsch,-injurious rather than curative agents. If we put the pathological anatomy of the ear under strict examination, we shall, I think, be soon convinced that the greatest number of cases of deafness arise from disease of the cavity of the drum and its appendages. The hindrances to sound-conduction may be occasioned by simple mucous accumulation, by thickening of the lining mucous membrane (which is also a periosteum, and every inflammation of it therefore constitutes a periostitis) lessening the degree of motion in the chain of ossicles, and giving rise to adhesions between each other, or to the parietes of the tympanum. If these conditions be neglected, further morbid alterations will take place: rigidity of the whole ossicular chain, extending to the membrana tympani externally, and to the fenestra ovalis internally, causing the base of the stapes to become more or less fixed to its articulating surface, may result. This last affection, anchylosis of the stapes, which is so likely to supervene upon repeated attacks of aural catarrh, advances insidiously with the patient's age, until no vibrations are able to be transmitted to the vestibule by the ossicular course, and the tympanic air ceases to influence the labyrinthine fluid, in consequence of the necessarily fixed condition of the membrane and is frequently now, confounded with affections of the of the fenestra rotunda. This disease was always formerly, auditory nervous apparatus; and Dr. W. Kramer, at one period of his practice, estimated that his cases of nervous affections exceeded fifty per cent., whereas now, owing to our advance in pathological science, their frequency is reduced to four in a thousand. We cannot, however, yet quite credit theless, we assuredly may diagnose rigidity of the ossicles, such marvellously increasing powers of diagnosis. Neveror anchylosis of the stapes, by careful attention to the symptoms accompanying their progressive stages, by the history of the case, and by observing the degree of loss which the patient has sustained over, what I term, the power of adjusting the ear to receive certain vocal or other sounds. I shall subsequently point out that this power of adjustment results from the mode of attachment, position, and voluntary action of the stapedius muscle, affording to my conception a most close analogy to the ciliary muscle of the eye, especially when, as in predaceous birds, that muscle is inserted into osseous plates in the sclerotic, as strong and massive as are the crura of the stapes. To return to our more immediate subject. An accurate study of the functions normally performed by the tympanum and its contents, will therefore be the only safe guide in determining the exact locality of the diseased alteration. It is not my intention at the present time to enter upon a detailed anatomical or physiological description of the middle and internal divisions of the hearing apparatus. I am now simply desirous of throwing additional light upon certain important points which have hitherto escaped notice, or have not been sufficiently elucidated. * "Ohrenheilkunde der Gegenwart," p. 39. Berlin, 1861. |