Dr. Henry Kennedy on the Use of Issues. 31

ART. II.--Cursory Remarks on the Use of Issues; with Cases. By Henry Kennedy, A. B., Licentiate of the King and Queen's College of Physicians, and the Royal College of Surgeons, Ireland ; one of the Medical Officers of St. Thomas's Dispensary.

[Read before the Obstetrical Society.]

REMEDIAL agents may be divided into two great classes: those which are capable of producing marked changes and effects in the animal economy, such as bleeding, purging, mercury, &c.; and those of which the effects are by no means so constant, and where, of course, a degree of uncer- tainty must ever attend their administration, such as tonics, diaphoretics, and nervous medicines. Amongst the former class may, I think, be fairly placed issues, to which, in what follows, I would very briefly direct the attention of the meeting.

The use of issues has been long recognized in practical medicine: the very earliest records of medicine we possess take notice of them. Nor is this so much to be wondered at, when we recollect how frequently Nature herself forms them, and evidently for the purpose of relieving the system.~ It would probably be quite within bounds to say that the great majority of persons are at one period or other of their lives indebted to natural issues for the preservation of their health. One might even go farther, and say that all the ordinary excretions of the body are nothing but healthy issues, by means of which materials are got rid of, which, retained, would be injurious to the system. But it is only of those states of the system in which some morbid outlet forms that I am at present speaking. Some might at first view be ink clined to question the frequency of those issues which form of themselves, or might even doubt whether such act as issues at all: but if any one inquire closely into the matter I think they will satisfy themselves that Nature formed them

32 Dr. Henry Kennedy on the Use of Issues.

with an express object in view. As an example of what [ mean, Iwould mention the very common occurrence of a purulent discharge from the ears during childhood; or the still more common occurrence of some form of eruption, ge- nerally of the nature of porrigo, on the head, or some other eruption over the body. Or if we look to more advanced life, we have examples enough in the existence of heemor- rhoids~ subject at times to bleeding; or to epistaxis; or to the existence of a chronic bronchitis; or here, as in child- hood, to the formation of a spot of some kind of eruption, which now, however, is more apt to form on one of the lower limbs. That all these act more or less as drains to the sys. tern, appears to myself to be self-evident. This view is con- firmed too by the great obstinacy which any of these affec. tions present to treatment, more particularly when they have existed for any considerable period; and above all, by the fact, which probably every one I have the honour of address. ing is well aware of, namely, that their hasty cure is ever attended with risk, death being by no means an uncommon result. Did the occasion call for it I could myself detail a number of instances where serious results followed the sud- den cure of the affections I have alluded to; but the fact is so well known as to require no farther notice here.

Of the various diseases in which issues have been used it is not my intention to speak. It may, I think, be very fairly questioned, however, whether there are not other dis- eases in which they may be used with good effect. Before concluding this Paper I shall detail three cases, in which, as far as I am aware, they are not generally employed, and yet in which the result was very striking. I may allude here, too, to a case, with the notes of which I have been favoured by my friend Dr. Travers: the case was brought before the Pathological Society by Dr. Stokes.

A man, oct. 39, of temperate habits, two years previous to applying for relief, was attacked suddenly with severe

Dr. Henry Kennedy on r Use of Issues. 83

pains in the lower par t of back, and in the region of the false ribs. The pain ultimately became fixed about the eighth dorsal vertebra. No treatment was of any avail, till issues were opened on either side of the spine. This mea- sure was adopted in consultation with Mr. Smyly and Dr. Cusack. Immediately on a discharge taking place the pa- tient experienced the most marked relief, which continued for several months 9 when he became affected with spasmodic cough and dyspnoea, botli of which were much increased by any exertion, or even by standing unsupported. When he used crutches, or leaned forwards, he got relief. There was also now dysphagia, though slight. Shortly after this phy- sical signs were detected in the chest, which all but con- firmed the opinion that thoracic aneurism existed. These symptoms, curious to say, soon after declined in a very marked degree. The chest became clear on percussion, the Soufllet could not be heard, and the pulse returned to the left wrist. In this way he remained the entire winter, free from suffering, except when the dlseharge from the issues be- came scanty. In tlle succeeding spring, however, the dys- phagia returned with great severity, and the patient sunk, partly from starvation, and partly from some slight bronchial affection. On examination of the body an aneurism of the arch of the aorta, where it becomes the descending aorta, was found. The aneurism was of large size, and the artery close to it much diseased. Four of the vertebrae correspond- ing to the tumour were eroded.

Now in this case the effects of the issues were very striking, and yet very few would guess what the disease turned out to be. Who is there that in such a diseasewould anticipate such a beneficial effect from the establishment of issues ? and that it did depend on them is clear from the de- tails of the case. With such a case as this before one's mind it requires v$xy little reflection to carry the principle farther : thus it strikes me as being in the highest degree probable

VOL. XXVltI . NO. S~. F

34 Dr. Henry Kennedy on the Use of Issues.

that in cases of ovarian dropsy, the establishment of an issue would prevent the increase of the disease. Again, in those cases of cancer of the breast, in which surgeons differ so much as to the propr ie ty or not of its removal, from the

well-grounded fear of its return, it appears to me that it

would be a very rational proceeding, after the part had been removed~ to establish an issue. Possibly these ideas may

have been acted on by others, but I am not aware of any thing of the sort having been done.*

During last session I had the honour of bringing before

this Society a case in which all the symptoms of hydroce- phalus were exceedingly ~,ell marked : the case ultimately got

well, and, as I believe, because the boy had had an issue in

his arm for some time before the attack. Two children of the

same family had died previously of the disease. I t was also

mentioned, of two families, in each of which several children had died, one after the other, of water on the brain, but in which the use of issues in the succeeding children had tile effect of averting the disease. Such facts as these, of which probably most present may have known similar ones, appear

to me to put in a very strong light the great advantage which

is likely to arise from a judicious use of issues.

In what manner issues act it is not very easy to determine. The i r effects seem to be out of all proportion with the amount of discharge ; otherwise we might be inclined to sup- pose that the system, by their means, got rid of morbid mat- ter, which, if retained, would prove injurious. Possibly this

may be true in part, but it is really curious to observe what a

very trifling discharge, as regards quantity, will suffice to re-

lieve the system: any one who has seen a case of phthisis

complicated with fistula must have observed this; or the

* Marsha l l Hall , I believe, has recommended an issue in encys ted dropsies .

The F r e n c h surgeons a re in t he habi t , a f ter r emoving a cancer , o f leaving the

w o u n d open for some t ime. This , however , would not a t all answer the end in

view. To afford a reasonable p rospec t of success the dra in should be pe rmanen t .

Dr. Henry Kennedy on the Use of Issues. 35

still more trifling discharge which takes place from a single spot of tetter situated on the front of the tibia, and which appears in itself sufficient to ward off apoplexy or paralysis, judging from the results if suddenly cured. It would appear, however, as if the formation of so small a quantity of pus as a drachm in the twenty-four hours is quite enough at times to strain, as it were, the constitution. So much is this the case that care should always be taken to see that the issue is not producing an undue effect, and thus is adding to the mischief it was intended to remove. Here, as in every thing else connected with medicine, a proper judgment must be exercised, and the practitioner must be guided by the pecu- liar circumstances of each individual case.

While alluding to the formation of artificial drains for the cure of disease, it must not be forgotten that objections stand in the way of their general use. In many minds a strong dis- like exists to the very name of an issue, and they would ra- ther submit to any thing else than this. Again, issues are chronic remedies, if I may use such an expression ; they have to be continued weeks, months, years ; and besides, they re- quire daily attention. For these reasons, then, it is very probable that objections will still continue to be urged against them, no matter what benefit might be expected to arise from their use.

I t would be very easy to prolong these remarks, but for the present I shall content myself by detailing very briefly three cases, in each of which the insertion of an issue was followed by very marked benefit.

Case I . - -Five years since, a young lady, aged, at that time, six years, was put under my care. I was informed that fi.om two years of age she had been subject to swellings forming in different parts of the body ; on the lower limbs, the wrists, one elbow, but, above all, in the neck. This lat- ter part was literally seanmd from ear to ear. Though these swellings were always forming in one part or other of the

36 Dr. Henry Kennedy on the Use of Issues.

body, still they were particularly troublesome in the spring- time of each year : no matter what treatment was adopted

they always went on to form abscesses, and ultimately to

burst ; and in this way it was that the neck had become so disfigured. She had had very good advice, and in the pro- per season had been sent to the sea-side for the bathing:

but still there had been no change for the better. A glance

was enough to tell any one that the patient was of the strongly-marked strumous diathesis. She had light hair,

blue eyes, and a very fine clear skin ; and her disease was evidently one of the hundred forms under which scrofula exhibits itself, when it affects the external parts of the body. Reflecting on all that had been done for the patient without benefit, I came to the conclusion that something which was

capable of producing a decided change in the constitution

was the only means likely to get rid of such an affection as has been described. Wi th this impression I advised an issue to be put in the arm, and having got Mr. Carmichael's sanc- tion to it, this was done. For about one year after this there was at times a tendency in some of the glands to swell, but

none of them ever went on to suppurate ; and for the last

four years there has been a steady improvement in every re_

spect. Any one who had seen the neck at the two intervals

would scarcely have believed that such a change for the bet- ter could have taken place. It is scarcely necessary to add that other means besides the issue were at tended to.

This case appears to me to afford a very striking example of the good eflhcts of the plan of treatment which it is the

object of this Paper to direct attention to. It is the more

worthy of notice, that the plan succeeded after other means had failed: and that though there had been more or less discharge going on from the beginning of the complaint, still it was insufficient to relieve the system, till the artificial drain

was established. T h e case, too, would lead one to expect that beneficial results would arise in many analogous cases; and

Dr. Henry Kennedy on the Use of Issues. 37

cases of this description are very common. In the particular one which has been detailed, there is, I think, every reason- able hope that the patient will ultimately recover perfectly.

CAsv. I I . - - I t is now nearly six years since I was asked to prescribe for a boy who had been labouring for some time

under asthma o f a very severe form. He was then seven

years old; of a full, plethoric habit, high complexion, and

well-marked sanguineous temperament. An examination of

the chest did not discover any cause for the complaint ; but

when the attacks were unusually severe there appeared to

exist bronchitis affeeting every part of the mucous mem- brane : I say appeared, for at times the bronchitis went off as rapidly as it had come on. T h e boy's breathing was

always of that kind which is described by the word thick: but it was at night that the fits of dyspncea were the most

severe, and on several occasions they were so violent, that it was not expected tile boy could survive them. Th o u g h the actual cause of the disease was unknown, still the parents soon came to learn what would aggravate the fits: thus it was found that any indiscretion in diet (and the boy was at an age and under circumstances where this was very likely

to occur) was sure to increase or produce them ; or any, even

the slightest, exposure to wet or damp weather. This pa- tient, like the last one, had been put under a variety o f treat-

ment: the only thing which appeared to be of any service was change of air, but even this had lost its effects when I saw him. After examining him very closely 'it struck me

that possibly his disease was owing to worms : there did not appear to be any state of the lungs sufficient to account for

the attacks of dyspncea, and the intermitting nature of the

bronchitis, I knew, often went hand in hand with their pre- sence. Under this impression the boy was put on a course of medicine suited for the expulsion of worms, and he was also directed to get an emetic when the dyspncea became se- vere. This plan was persevered in fo rmore than a month,

38 Dr . Henry Kennedy on the Use of Issues.

but with no effect in the way of relieving the disease, nor were any worms seen. I then determined on trying an issue, and one was put in the arm. It had scarcely begun to dis-

charge before the boy got relief, and with the single ex- ception of one attack, which occurred about a year after the

issue had been put in, and which the parents told me was

not a severe one, he has remained free ever since, now a pe-

riod of more than five years. He has grown very much. I

need scarcely add, that when it is thought advisable to dry

up the issue, it will be done with great caution. In this case I am quite at a loss to explain the benefit

which arose from the use of the issue. W h en I determined on it I knew it could do no harm, which, as the late Mr.

Colles used to say, was an important rule to adhere to in me-

dicine, and there was a possibility that it would produce such

a change in the boy's constitution as would, in the end, afford him relief. I t appears, however, to have acted sooner than any change could in reason be expected to occur: a single pea only was used, and the benefit was manifest within a month. I t is possibleit may have caused some change in the bronchial mucous membrane, but this is mere conjecture.

This case was an example of one of those in which the quan-

tity of discharge was out of all proportion with the relief

afforded.

T h e third and last case to be detailed occurred in a grown-up female, and, as such, may be fairly brought under tile notice of this Society.

CAsE I I L m I n the month of March, 1843, a servant ap-

plied at St. Thomas 's Dispensary for relief. She was labour- ing under lupus, affecting not only the nose, but spreading

over the greater part of the face. She was about 30 years of age, and was otherwise healthy. She stated it had com- menced on one side of the nose, from which spot it had gra- dually spread, and that it had existed now upwards of two

years. As it usually is~ the disease was best marked on and

Dr. Henry Kennedy on the Use ~ Issues. 89

about the nose ; in fact, on the cheeks and forehead it was of a different character. It might be described here as being of the nature of tubercular lupus ;-the entire skin was thick- ened and red, and it had lost its natural supple feel; be-

sides this, a number of hard tubercles could be felt almost

in every d i r e c t i o n ; a n d though no ulceration had taken

place over them, still in several places there was an appear-

ance of ugly cicatrices, disfiguring the entire countenance. She was directed a course of Plummer's pill, and to bathe the face assiduously with lukewarm water. This plan was pursued steadily for some time, but without any benefit, and

she was then directed to take the solution known under the name of Donovan's solution. This also was persevered in,

and continued till her health began to suffer. I t was then given up, and an issue was put in the arm, the bathing being

directed to be continued. In the course of a month a mani- fest improvement had taken place; the skin generally had

assumed a more healthy appearance, and the tubercles had manifestly lessened in size. I t is enough to add, that the issue was kept in seven months, when it was discontinued,

all trace of the disease having disappeared. As a matter of

precaution, however, she was again directed another course

of the solution. She has since then continued quite free of

the disease. The use of the issue in this instance was not my own

idea, but I am' unable to state where I learned i t ; nor, from want o f time, have I been able to ascertain whether it be a

plan of treatment recommended in any of the standard works

on diseases of the skin. I think it may be asserted, how-

ever, that it is not one in common use in such cases. The ease detailed appears to me a very strong one in proof of the

efficacy of this particular line of treatment. Every one knows

the extreme obstinacy of many diseases of the skin, and par- ticularly those which appear on the face and head. Some forms of porrigo, as also that form of ulceration which has

40 Mr. Donovan on the Properties of Cod-Liver Oil.

been described by Dr. Jacob, afford but too well-marked examples of this. The number of young females, too, wllieh one sees disfigured by the more common form of lupus, is very considerable. In all these eases I cannot help thinking that an issue would form a most important part of the treat- ment; further experience, however, can only determine this point.

In conclusion, then, I would repeat again, that it appears highly probable there are a number of diseases in which issues might be used with advantage, but in which they have not yet been employed. From the general feeling against their use, however, it will always be advisable to try th.e more ordinary forms of treatment in the first instance.

P. S.--In the discussion which arose after the reading of tile Paper, Dr. Churchill alluded to some instances he had seen of laryngismus stridulus, in which issues succeeded in arresting the attacks, after every other mean~of treatment, including change of air, had failed. An equally strong tes- timony in their favour, and in the same disease, was likewise given by my friend, Surgeon Neville, of Brunswick-street.

ART. III.--Seeond Communication on the Preparation and Medicinal Properties of Cod-Liver Oil. By M. DON0VAI% Esq.

IN the seventeenth volume of this JournalI inserted a communi- cation relative to the preparation and medicinal effects of cod-liver oil, and pointed out the circumstances to be at- tended to in order to procure it in a state fit for exhibition as a remedy. According to that process I prepared a large supply for the use of the Profession : it has been extensively tried, and it has sustained the character attributed to it by physicians of eminence in various countries of Europe.

In the time of Dr. Percival, of Manchester, this oil was so largely employed in the hospital of the town, that nearly