Part 62

To expedite the sloughing process, allay the unpleasant fetor, and promote the formation of healthy granulations, I know of no remedy that will answer so well as the nitric acid lotion. It should vary in strength, according to the exigency of the case, from four to twelve drops of the acid to the ounce of water, and a cloth wet with it should be constantly kept in contact with the affected part, taking care to wash it occasionally to rid it of the foul discharges with which it becomes from time to time impregnated. If necessary, a poultice can be placed over the rag. Under this treatment, particularly when aided by the liberal use of carbonate of ammonia, wine, brandy, and other cordials, I have often been astonished to witness the rapid changes that have taken place, in cases apparently of the most desperate character.—ED.

In this country no remedy is perhaps more frequently employed in the treatment of erysipelas than blistering. In my own practice I have constantly resorted to it for the last fourteen years, and in no instance has it disappointed my expectations. Not only do I consider it as perfectly free from danger, an objection which has sometimes been alleged against it, but I know of no measure so well calculated to afford prompt and effectual relief. My practice is to apply the blister directly to the inflamed surface, together with a small portion of the healthy skin, and to keep it on until it produces thorough vesication. The vesicles are then opened with a needle, and the part covered with a light emollient poultice or the warm-water dressings. In children, and persons of a nervous delicate constitution, or whose health has been previously much impaired, the blister must be removed in from three to six hours, otherwise serious local mischief may be induced. This treatment, although applicable to every species of erysipelas, is particularly valuable in the phlegmonous form, no matter where situated, whether in the face, eyelids, scalp, trunk, or extremities.

Another remedy which has been extensively employed in this country, is the mercurial ointment, first recommended to the notice of the profession by Dr. Dean and Dr. Little, of Chambersburgh, Pennsylvania. My own experience, however, does not enable me to offer anything in its favour. Indeed, if at all useful, it can only be so, it seems to me, in the milder forms of the complaint: in the more severe grades it should never be resorted to, as it is far inferior to blistering, or scarification, as practised by Mr. Liston. The ointment should be perfectly fresh, and be applied upon soft linen, at least twice a day. Professor Velpeau has recently recommended methodical compression by means of the roller, and from some cases which he has published in illustration of his method it would seem to be entitled to further trial.—ED.

Having pursued the above plan for a few weeks, and accustomed the patient to his confinement, the next object was to insure perfect rest to the diseased joint, the most essential item of the whole treatment. To this end, a carved splint, long enough to extend from the middle of the side of the chest nearly to the external malleolus, and sufficiently wide to reach nearly one-half round the parts into which it was to lie in contact, was adapted to the shape of the limb, carefully padded on the inside, and secured by two rollers, one of which was passed round the trunk, the other round the limb from the ankle to the top of the thigh. When the limb is much bent or distorted, it should by no means be forced into a straight position in the first instance; on the contrary, the splint should be angular, to accommodate itself to hollows and projections of the parts, and, as the cure progresses, another less crooked should be substituted. It is rarely that more than two splints are required, though Physick was sometimes obliged to use as many as three or even four in the same case. During the whole treatment the patient should lie upon a hair mattrass, and the apparatus kept steadily applied until all the symptoms of the disease have vanished, which is seldom under twelve months.—ED.]

Memoir on the General Characters of Rachitis, translated by Dr. T. W. Colescott, of Louisville, and published in the Western Journal of Medicine and Surgery, for January, 1841.

The alterations of the osseous tissue have been divided by Mons. Guerin, to whom we are indebted for the most able and elaborate account of this disease that has yet been furnished, into three stages. In the first, the bones seem to be saturated with a reddish, watery fluid; a considerable quantity of which is also interposed between their outer surface and the periosteum, on the one hand, and between the medullary membrane and their internal walls, on the other. At a more advanced period, this fluid is replaced by a sort of gelatiniform substance, that is particularly conspicuous in the situations here specified, becomes gradually organized and vascular, and ultimately adheres with great firmness to the parts with which it lies in contact. The periosteum is thickened and injected, the nutrient vessels are remarkably enlarged, and the medullary membrane is sensibly altered in its character; the changes which it has undergone being similar, though less in degree, to those of the fibrous envelope just mentioned. The lamellæ of the long bones, naturally so hard and compact, are a good deal softened, and the areolar structure greatly rarefied, many of the cells being more than double or even triple the natural size. Similar alterations are observed in the short and flat bones.

In the second stage, a peculiar spongoid substance is formed between the periosteum and the outer surface of the bones, varying from two to three lines, or upwards in thickness; and which, by the pressure which it exerts upon the lamellæ of the compact tissue, sometimes forces them inwards upon the medullary canal, thus greatly reducing it in size, or even entirely obliterating it. Simultaneously with these changes the bones are rendered so soft that they may be easily bent, cut, or even indented with the finger. In the third stage—that of resolution—the recently formed substance in the long bones, as well as in some of the flat and short, assumes a compact character, and becomes gradually identified with the pre-existing tissues, which at the same time regain their primitive solidity. Owing to the presence of this new matter, the bones are much larger than in the natural state, and their firmness—especially in the adult—resembles that of ivory. Hence the term eburnation is sometimes applied to this state of the skeleton.—ED.]

1. Popliteal 59 { at the groin 26 2. Femoral { { at other points 18 3. Carotid 17 4. Subclavian 16 5. Axillary in the arm-pit 14 6. External iliac 5 7. Innominata 4 8. Brachial 3 9. Common iliac 3 10. Anterior tibial 3 11. Gluteal 2 12. Internal iliac 2 13. Temporal 2 14. Internal carotid 1 15. Ulnar 1 16. Fibular 1 17. Radial 1 18. Palmar 1

In another table, constructed by Mr. Hodgson, and founded upon sixty-three cases, including, however, twenty-nine of the aorta and innominata, the results are as follows:—

Carotid 2 Subclavian and axillary 5 Inguinal 12 Femoral and popliteal 15.—ED.]

The disease is most commonly seated in the head of the tibia. It has been observed also in the scapula, as in the case mentioned in the text, the femur, wrist, and ankle. The male is more liable to it than the female, and it rarely makes its appearance until after the period of puberty. The cause of the disease has not been satisfactorily explained. In some cases it is produced by external violence, as a blow or fall; in others, especially when seated near a large joint, it is traceable to gouty and rheumatic affections.

The enlargement, even in its early stage, is tense and painful; being attended with distention of the superficial veins, swelling of the surrounding structures, and slight discoloration of the skin. In a short time a deep-seated pulsation, or throbbing, synchronous with that of the left ventricle, and similar to what is witnessed in some erectile tumours, may be perceived in the affected part. In the advanced stage of the malady the beating is accompanied by a sort of undulating movement, and is easily interrupted by compressing the main artery of the limb, between the tumour and the heart. The enlargement varies in size. In a case mentioned by Mr. Bell, it was more than nine inches in circumference, by upwards of six in length. In some instances, pressure applied to the tumour with the finger imparts a peculiar crackling sensation, not unlike that of dry parchment or an egg-shell. The soft parts around the disease are generally œdematous, the whole limb is apt to be swollen, and the motions of the contiguous joints are constrained and painful. Towards the last the general health always seriously suffers.

On inspection, the outer table of the bone is found to be considerably attenuated, in many parts destroyed, and in some so flexible and elastic as to be bent with the same facility as cartilage. Frequently the bone is extremely brittle, and may be crushed like an egg-shell. The areolar texture is partially absorbed, and the medullary canal filled with coagula, which are often arranged in concentric layers, as in old aneurismal sacs in other situations. The investing membrane in the immediate vicinity of the disease is thickened, as well as preternaturally dense and firm, and the vessels ramifying through the tumour are greatly enlarged.

The only effectual remedy for this disease, provided its location be favourable, is amputation. In the early stage relief may possibly be afforded by securing the main artery of the limb. Lallemand relates a case in which ligature of the femoral artery completely arrested an aneurismal affection of the head of the tibia; but this must be regarded as an exception to the general rule.—ED.]

Of the great number of serpents inhabiting this country, only two—the rattlesnake and copperhead—are known to be venomous. Both are very active in warm weather, are furnished with long teeth, and secrete an acrid, virulent poison, of a yellow-greenish colour, which is lodged in a bag or reservoir at the roots of two of the teeth of the upper-jaw. When this poison is fairly infused into a wound of the skin and cellular tissue, it often proves fatal in a few minutes; in other cases, the patient either recovers, or death does not occur until a later period.—ED.]

When a person has been bitten in one of his limbs by a venomous serpent, a ligature should be immediately applied, as tightly as possible, at a short distance above the wound, which is then to be carefully excised together with a portion of the surrounding structures. A cupping-glass is next applied, and after this has remained on for several hours, the sore is to be dressed with an emollient poultice or some simple unguent, or fomented with cloths wrung out of warm water and laudanum. The only internal remedy upon which the slightest reliance is to be placed, is arsenic, in the form of Fowler’s solution. It should be administered, as was first suggested by Mr. Ireland, an English surgeon, in doses of two drachms every thirty minutes until an ounce or upwards is taken, or until free vomiting and purging ensue.—ED.]

In obstinate cases of tertiary syphilis it may be necessary to exhibit along with this medicine the compound decoction of sarsaparilla, or some of the preparations of mercury, such as the proto-ioduret, deuto-chloride, or cyanuret. The first may be given in doses of from one-half a grain to a grain, the second, from one-eighth to a fourth of a grain, and the last, from one-sixteenth of a grain to a grain, twice or three times a day. How the iodide of potassium acts in producing its beneficial effects in the diseases in which it is now so extensively used by our French brethren, as well as by some of the practitioners of our own country, has not yet been explained. That it is a powerful alterant must be admitted, and that it greatly improves the condition of the digestive organs is equally certain.—ED.]

Of these cases only two occurred in the female. The age of the youngest was two years and a half; of the oldest, forty; seventeen were twelve years or under; nine from thirteen to twenty years; and seven, twenty-one or upwards. The seat of the wound giving rise to the disease, occupied, in fourteen cases, some part of the frontal region; in seventeen the parietal; and in two the occipital. In fourteen cases the brain was lacerated, and a portion of its substance discharged; in five it was wounded without loss; in one its surface was simply denuded; in ten there was no exposure; and in three its condition is not noticed. The dura mater was torn in twenty-one cases, and in another perforated; the cranium in all, except one, was broken into several fragments; and in twenty-four the scalp was more or less lacerated; in another it was pierced; in three there was no solution of continuity; and in five no mention is made of its condition.

The period of the appearance of the morbid growth from the occurrence of the injury varied in different individuals. In eleven cases it manifested itself prior to the sixth day; in fifteen between the seventh and twelfth; and in five between the twelfth and twenty-fifth. In one instance it did not begin until the eighth week: in another the time is not specified. The earliest period of its appearance was the third day, and that in two cases only; in more than three-fourths it commenced on or before the twelfth day. The average period was the ninth day from the accident.

In regard to the volume of the tumour, it varied from half an inch in diameter to a mass measuring six, by three and a half inches upon the surface, and two and a half in thickness. In twenty-two cases in which the dimensions are stated, the tumour in five was of the size of a hen’s egg; in eight it exceeded that magnitude; and in nine it fell short of it. The morbid growth was dissected only in eleven of the cases; in nine of these it consisted of cerebral substance, in which the cortical and medullary tissues were distinctly recognised, and in the other two it was composed of coagulated blood of a fibrous texture. In seven cases the tumour assumed a sloughing character; in five it yielded a fetid, sanious discharge; in one it bled freely on the slightest touch; in three it was enveloped by the pia mater; and in three others the surface was coated with a layer of clotted blood. In the centre of the largest tumour a cavity existed, filled with an ounce of limpid serum, and lined by a transparent, glistening membrane.

The general symptoms, indicative of disturbance of the vascular system, and of the cerebral functions, may be next considered. In twenty-three cases there was more or less excitement of the heart and arteries; in four none was apparent; and in the other six the symptoms are not stated. “In fourteen cases some one or more of the following symptoms of disturbance of the brain and nervous system were present: coma, delirium, pain in the head, general irritability, and insensibility. In six paralysis of the side of the body opposite to the injury was superadded to the preceding symptoms; and in two convulsions. Three cases were remarkable as presenting some striking exceptions to the general characteristics, and are, therefore, deserving of more particular notice; one of them, from the circumstance that there was no apparent shock to the nervous system, not even as the immediate effect of the injury, though its severity was so great that several fragments of bone and pieces of coal penetrated the brain, causing a discharge of three or four teaspoonsful of its substance. In another the patient remained in a state of complete insensibility and general paralysis for twenty-three days; the hernia appearing on the seventh day, and no inflammatory symptoms supervening. The third case exhibited a character of most frightful violence. Besides paralysis of one side, there were spasmodic actions of the muscles of the face and of all the limbs; nausea, retching, quivering of the eyelids, fixed eyeballs, strabismus, grinding of the teeth, alternate contraction and dilatation of the pupils, intolerance of light and sound, and other signs of the most alarming nervous commotion, often threatening to terminate life.”

Of the thirty-three cases in question, seventeen recovered, at a period varying from three weeks to four months; and sixteen terminated fatally, on an average, about the twenty-fourth day. More young persons recovered than old. Of the sixteen fatal cases, eleven were examined, and exhibited the following lesions: in eight the portion of the brain subjacent to the hernia was softened, pulpy, more or less disorganised, and sometimes intermixed with clots, while in the account of the other three no notice is taken of its condition. In eight other cases there were signs of acute inflammation of the arachnoïd membrane as indicated by thickening, opacity, adhesions to the dura mater, and deposits of lymph or pus. The portion of the dura mater around the opening through which the fungous mass protruded was thickened, black, and sloughy, in three of the eleven cases in question. In four the ventricles were filled with bloody serum; in one there was a large abscess in the brain full of pus, and lined with a false membrane. In one case a clot of blood was found between the dura mater and the cranium; in four the fracture extended through the base of the skull; and in one of these the edges of the osseous aperture, through which the hernia protruded, were rounded off by absorption.

In respect to the general treatment, it was uniformly antiphlogistic, consisting of the abstraction of blood by venesection and leeching, and the use of purgatives, proportioned to the urgency of the inflammatory symptoms. The local means employed were, excision of the hernial tumour, the application of the ligature, pressure, and caustics, either singly or together. In one of the cases that resulted favourably a spontaneous cure took place after copious hemorrhage from the morbid mass, excited by an accidental attack of vomiting. In another, after the ineffectual use of the nitrate of silver and other escharotics, the ligature was applied and gradually tightened from day to day; in five pressure alone was sufficient; in two the pressure was conjoined with lime-water; and in one with the nitrate of silver. In seven other favourable cases excision was resorted to, either once, or repeatedly, accompanied with pressure; in some dilute nitric acid—twenty drops to the ounce of water—lime-water, or nitrate of silver, were employed in addition. In the sixteen cases that terminated fatally the local treatment was, pressure alone in two; in five excision with pressure; in two the ligature; in one both ligature and excision; and in another escharotics. In five no mention was made of the local means.—ED.]

Essay on Cataract, translated by Dr. Bowditch, of Boston.

TABLE I.

From 20 to 29 years 5 patients 30 39 3 40 49 11 50 59 25 60 69 41 70 82 27 ——— 112

TABLE II.

From 1 to 10 years 14 patients. 11 20 16 21 30 18 31 40 18 41 50 51 51 60 102 61 70 172 Above 70 109 ——— 500