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that the fracture is an impacted fracture of the cervix, thenyou may with tolerable confidence predict complete union anda sound limb; but if you have reason to believe that it is a frac-ture within the capsule, you must give a very guarded opinion,promising to do your best, but that you cannot honestly saythat your endeavours will be crowned with success. You must

acknowledge the imperfection of your art and the uncertaintyof the result. You may also add that such fractures haveunited, when properly treated, as you intend to treat the casebefore you. Of course the age and constitutional power of the

patient will be an essential element in favour or against theprobability of union. The two extremes may be thus put:Fracture within the capsule in a very old and feeble personscarcely ever unites ; fracture without the capsule in a strongand healthy person must be very badly treated if it does notunite.

Fractures within the capsule may generally be distinguishedby the fact of a fracture existing being almost unequivocal;by the signs of shortening ; easy production of crepitus afterreducing the limb by traction to its normal length; by theeversion of the foot; by the age of the patient being greaterusually than in the instance of the impacted form. It is truethat inversion of the foot does occur in the impacted, as inthe case just related, but still it is not so frequent.

In impacted and extra-capsular fracture the symptoms areoften obscure, as I have already shown, so much so as even todeceive well-educated surgeons into the belief that there isdislocation and no fracture. The foot, instead of being everted,is not unfrequently inverted, and all attempts to turn it in-wards give rise to excruciating pain. The shortening is scarcelyperceptible. Locomotion is not impossible. Patients can oftenstand and walk, and raise the limb in bed as they lie upon theback.In the complete fracture within the capsule the limb looks

like a paralysed limb, flabby, powerless, and immovable, withits whole expression altered.Remember, gentlemen, that these observations are far from

exhausting this important subject-it is inexhaustible. I hope,however, that I have told you enough to excite you to lose noopportunity of studying these cases, and when you see them" make a note of them;" trust not to unaided memory.

LecturesON THE

PROGNOSIS AND TREATMENT OFCERTAIN ACUTE DISEASES,

WITH

SPECIAL REFERENCE TO THE INDICATIONSAFFORDED BY THE GRAPHIC STUDY

OF THE PULSE.

Delivered at the Royal College of Physicians of London.

BY FRANCIS E. ANSTIE, M.D. LOND.,FELL. ROYAL COLL. OF PHYSICIANS,

SENIOR ASSISTANT-PHYSICIAN TO THE WESTMINSTER HOSPITAL.

LECTURE II.

MR. PRESIDENT AND GENTLEMEN,—I have now to discuss asubject that has been the theme of very keen controversies,and which I should certainly not care to agitate afresh, unlessit were possible to present to your consideration facts that arereally new, and appear to tend towards a solid and perma-nent settlement of the matters in dispute. The present lecturewill be devoted to a consideration of the indications which mayserve to guide us in employing or abstaining from the use ofalcohol in acute disease.

I suppose we are all by this time somewhat weary of thefruitless declamation and recrimination on this topic which havebeen so plentiful of late years. On the one side we have beenfavoured with constantly reiterated remonstrances against the.., indiscriminate" use of alcohol in acute disease-remon-strances whose undoubtedly excellent intention has been un-

fortunately defeated by their entire vagueness, and the singularunanimity with which their authors have abstained from sug-gesting any means by which a just "discrimination" might beeffected. On the other hand, the party which favours a greaterfreedom in the use of alcoholic stimulants in acute disease has

of late years contented itself, for the most part, with rebuttingthe sweeping charge brought against it of employing a merelyroutine treatment, and with challenging the accuracy of thealarming statements that have been made as to the fatal ten-dencies of the practice which it advocates.

Professing myself a disciple of the latter school, and firmlybelieving that the opinions of Dr. Todd, its most distinguishedleader, have been unjustly dealt with since his death by gen-tlemen who had never understood his principles, I neverthelessadmit that Dr. Todd’s powerful advocacy of alcoholic medica-tion in acute disease needed to be supplemented by a more pre-cise code of practical directions than he had time to elaborate;and, as one of his pupils, I take some shame to myself that solittle has yet been publicly done in this direction. It is, un-fortunately, impossible, in reopening this subject, to confineoneself to the record of bedside observations on the effects ofalcohol in acute disease; it is necessary to tax your patience bya preliminary review of the evidence obtained, so far, as to thephysiological action of this substance; the more so as I havemade some fresh researches into this subject, which lead toresults that are novel and even startling.Two distinct varieties of misleading popular prepossession

have helped to confuse the discussion on the propriety of em-ploying alcohol in acute pyrexial diseases. I mean, of course,in the decidedly pyrexial stages, since no one disputes itsutility in the stage of mere exhaustion.The first of these misconceptions is the result of à priori

reasoning. In its rudest form it is nothing but a purely meta-physical prejudice; a mode of thought which looks on acutediseases as a kind of concrete devil that enters into a man-adevil which lashes out with horns and hoofs when one stirs itup with things called " stimulants," and requires to be soothedwith "demulcents" and "sedatives," and debilitated with" sudorifics," before its awful rage will subside. It needs onlyto express such an idea as this in words to expose it in all itsnaked absurdity and anachronism ; yet it is certain that not afew minds still unconsciously cling to this bugbear of theimagination. It need only be mentioned here to be at oncedismissed. A yet more common fallacy of à priori reasoningis this: it is argued that alcohol is a heating substance (every-one knows how it warms one’s stomach) ; that pyrexial dis-eases appear to become dangerous in something like the directratio of the excess of temperature above the normal grade ; -,and that therefore the administration of alcohol in cases dis-tinguished by a highly elevated temperature must produce adirect aggravation of existing perils. There is only one littleflaw in this argument-namely, that the major premise hap-pens to be not merely incorrect, but the direct reverse of thetruth ! Alcohol, as has been abundantly proved by the ad-mirable researches of Dr. Sidney Ringer, does not elevate butreduces bodily temperature, when given in even the largestnon-intoxicative doses, except in the case where temperatureis already below the normal standard. There can be no doubtof the correctness of this observation, which I have repeatedlyverified. And it simply annihilates three-fourths of the de-clamatory reasoning which has been expended by some of themore unreserved opponents of the alcoholic treatment of acutepyrexia.The other kind of misconception which has confused the

controversy rests upon a more respectable basis, since it is theoutcome of laborious and, as many persons suppose, unim-peachable researches into the physiological behaviour of al-cohol in the animal organism. A large number of physiologists

believe that it has been proved that alcohol is simply a nar-cotic poison; that it is not at all transformed within the body,but merely lingers in the tissues and organs for a certain time,paralysing nerve-function, arresting tissue-change, and spoilingthe blood; and finally being altogether cast out of the organism,by the different emunctories, in a totally unchanged form.

I shall not occupy your time with a discussion of the well-known doctrines of Liebig and his disciples, which for manyyears had been pretty generally accepted. Nor shall I tracethe new and opposite opinion through all its stages of growth.It will be enough if we investigate with care the conclusionsof that remarkable volume of researches in which Messrs.Lallemand, Duroy, and Perrin claimed to have finally de-stroyed every pretension of alcohol to the rank of an aliment,

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and to have demonstrated its entire elimination, as an un-changed poison, from the organism.’ *

I find considerable difficulty in speaking with that modera-tion which is so desirable in controversy of this clever butmost misleading work. It is not merely that its chiefconclusions appear to me unwarranted, but that the book isreally studded with errors, both of observation and inference.The principal features in it which we shall have to considerare these. The authors claim to have proved-

1. That alcohol is copiously eliminated by the kidneys,skin, and breath, in an unchanged form, when taken in anydose.

2. That this elimination probably goes on for at least forty-eight hours.

3. That no products of the oxidation of alcohol can at anytime be detected either in the tissues or the secretions.

4. On the contrary, that unchanged alcohol can be found inconsiderable quantities (especially in the nervous centres and theliver) many hours after the ingestion.

5. That no approach to a quantitative estimation of the eli-minated alcohol can be expected, because the distillation of anyfluid containing alcohol involves enormous waste of that substanceowing to its great volatility.

6. That taking into account the positive evidences of largeelimination, the fact that large quantities of excreted alcoholnecessarily elude observation, and the non-discovery of anyoxides of alcohol, a reasonable certainty is established that allthe alcohol is eliminated in an unchanged form.

Of these propositions I shall assume Nos. 3 and 4 to be cor-rect, although the former of them is open to considerabledoubt. Propositions 1, 2, and 5 will be shown to be so

strikingly incorrect as to offer no support whatever to the con-clusion expressed by Proposition 6.That alcohol is copiously eliminated, when taken in any

dose, by kidneys, skin, and lungs, is asserted by Lallemand,Duroy, and Perrin, -on the following grounds :-Alcohol wasgiven, in various doses, to dogs and to men. (The dogs in-variably had intoxicating doses, t a circumstance which, as willbe hereafter shown, vitiates the whole result.) In a very fewinstances an inconsiderable amount of actual alcohol was re-covered, by distillation, from the collected urine of the wholeperiod of recognisable elimination. But in the bulk of theexperiments the only evidence obtained was the action of thevapour of urine, of the breath, or of the skin, upon the chromicacid test. This test is made by dissolving one part of bi-chromate of potash in 300 of pure concentrated sulphuric acid.Alcohol deoxidises it, changing it rapidly from deep-red brownto emerald green, by the formation of oxide of chrome. No

attempt was made by the French observers to determine

exactly the quantitative indications of the test.To the whole series of experiments, and the inferences built

upon them, objections have been already made both by M.Edmond Baudot and myself; these may be read at length inmy work on Stimulants and Narcotics,+ but I shall not detainyou with any detailed account of them, because the resultsobtained by my recent inquiries are of much greater import-ance. I had already shown that the chromic acid test was ofsuch extreme delicacy that the reactions obtained by theFrench observers might have been caused by the most minutequantities of alcohol; and that, in fact, the 1 h of a grain ofabsolute alcohol is enough to change one cubic centimetre ofthe test rapidly to a characteristic emerald green.In my latest inquiries, I was determined that the accuracy

of every process should be established by an independent andthoroughly capable witness. I therefore, after full reconsidera-tion of the subject, obtained the assistance of my colleague,Dr. A. Dupre, whose ingenuity and very great skill in analyticalchemistry are well known, and who fortunately is thoroughlyfamiliar with the subject of elimination of medicinal substances.Dr. Dupré satisfactorily established the moderation, and,indeed, the under-statement, contained in my previous esti-mate of the delicacy of the chromic acid test; and we thenproceeded, separately and conjointly, to a repetition of my ex-periments. I shall not now recite the experiments which Ihave made to determine whether other volatile organic mattersbesides alcohol are capable of producing the same effects onthe test as alcohol, because, as will be seen presently, theresults of my latest observations are such as to render this in-quiry quite superfluous.In commencing our observations on elimination of alcoholDu role de l’Alcool et des Anesthesiques dans 1’Organisme. Paris, 1860.t The quantities ranged from 90 to 300 grammes.1: Stimulants and Naacotics, their Mutual Relations, &c. London: Mac-

millan. 1864. ,

by the kidneys, I requested Dr. Dupré to determine whetherit were possible to distil fluids containing alcohol in an appa-ratus of manageable size, so as to recover the alcohol withoutso much loss as would be of serious consequence in formingan estimate. Readers of the work of Lallemand, Duroy, andPerrin, cannot fail to remember that these authors assert, inthe strongest manner, that the great volatility of alcohol mustalways prevent a just estimate of small quantities by thismeans. I confess that I always distrusted this argument; andmy own first very simple experiments on this point perfectlyastounded me by the utter discrepancy of their results withthe statements of the French observers. For instance, I tooka sample of urine from a child who never drank alcohol: Idistilled a portion, and found that the distillate gave no reac-tion with the chromic acid test. I then took another sample ofthe same urine-two ounces,-and mixed with it one minim ofspiritus vini rect. I distilled this in a common little portablestill (such as you can get at Griffin’s) with no sort of precau-tion, the receiver being a wide-mouthed bottle with no guard.Nevertheless, the distillate (half an ounce) reacted stronglywith the chromic acid test, when added to it in equal bulk; infact, it acted with a vigour little short of that shown by a,mixture made (for comparison) of one minim of sp. vin. rect.with half an ounce of water. Much staggered by this result,I requested Dr. Dupr6 to examine the question. He distilledin succession, in a similar apparatus to that employed by me(quite unprotected), various mixtures of alcohol and water, withthis result, that scarcely ever was more than i per cent. of thetotal alcohol wasted. He now repeated the experiments, takingcare that all the joints of the apparatus were made air-tightwith caoutchouc corks &c., and using as a receiver a two-ouncebottle with a caoutchouc cork, penetrated by the tube of thestill, and also by a safety or escape tube, bent upon itself ::

in the bend of this tube was placed a small quantity of mer-cury. By this simple precaution the passage of air throughthe apparatus was of course somewhat retarded; and it wasnow found, in repeated operations, that not more than Tl75õ partof the alcohol, in any mixture subjected to distillation, was lost.All our subsequent operations on urine have therefore beenconducted in an apparatus guarded precisely in this way; andwe have had the satisfaction of knowing that the recovery of(practically speaking) all the alcohol in any sample of urinewas not merely certain, but easy. Tho process adopted forurine was as follows :-Two ounces of the (mixed) urines passedduring any definite period were taken, and made alkaline withpotash; some tannin was added in the retort, to prevent.splashing over;* and the distillation was commenced. Aboutone-third was distilled over; this was acidified with sulphuricacid, and again distilled, till almost a quarter of an ounce was.driven over: this fluid was submitted to the test.

Dr. Dupre and I then made a number of experiments onourselves with full non-intoxicant doses of various French andGerman wines. In every case the experiment was not com--menced till the urine had become free from any traces of elimi-nation of the last dose of alcohol which had been taken, andthe bladder had been carefully emptied. Doses of differentkinds of wine, containing one ounce of absolute alcohol in eachexperiment, were taken, and some urine was passed hourly sub-sequent to the dose, until a point was reached at which thedistillate of the urine last excreted gave no reaction with thetest. At a very early period Dr. Dupr6 convinced himselfthat no such quantities of alcohol would be recovered as couldbe estimated by the alcoholometer, or by the formation of aninflammable liquid; it therefore became desirable to esti-mate the value of the chromic acid solution, so as to-render it a reliable quantitative colour-test. After a large num-ber of experiments with different mixtures of alcohol andwater, we arrived at fixed results. We found that a mixtureof one grain of absolute alcohol with one ounce by measure ofdistilled water immediately produced a very deep emeraldgreen, when one cubic centimetre of it was added to an equalbulk of the test; that a mixture of half a grain to the ounceproduced a lighter green, when added in the same way; andso on down to a mixture of only one-tenth of a grain to theounce, which still produced a change in the test-liquid quitedistinguishable from the effect of mere dilution. Standardcolour-tests were therefore always freshly prepared, as a meansof estimation; and in this way it has been found possible toestimate with great accuracy a total elimination of alcohol by

* I convinced myself that in my earlier distillations I had been misled intoassuming the presence of more alcohol than was really contained in parti-cular samples of urine, from insufficient precautions against splashing. Idid not then know that the urea and other organic matters, when once theyhave been exposed to high temperature, act on the test with an energy equalto that of alcohol itself Splashing therefore involves serious error. equaltwo that of alcohol itself. Splashing therefore involves serious errof.

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the kidneys not exceeding one-tenth of a grain. The accuracyof the quantitative application of the chromic acid test, whenused with the precautions which I have described, has for-tunately been tested quite recently by comparison withanother analytic process, by which very minute quantities ofalcohol can be estimated-namely, the plan of oxidation toacetic acid, by boiling with solution of chrome-alum ; and theresults of the two methods closely agree. I shall say nothingof the latter process here, because my friend Dr. Dupre willshortly publish some remarks on its application to the detec-tion of small quantities of alcohol in organic fluids.Having thus provided ourselves with a highly satisfactory

method of estimating the amount of renal elimination of alcohol,we proceeded to make a large number of experiments, which itwould be impossible for me to detail here at length. I may,give you the result of two consecutive ones by Dr. Dupre,made with different kinds of wine, the dose in each case con-taining one ounce of absolute alcohol. In the first case (Rhinewine) elimination ceased within four hours after the dose had,been taken: the total amount of alcohol excreted was estimatedat two-fifths of a grain. In the second experiment (claret)elimination only lasted one hour, and the quantity of alcoholexcreted was too small to be estimated. It would weary you,and occupy space which I cannot spare, to recite the many ex-

periments made by Dr. Dupré or myself, or by both of usjointly. Every kind of wine, spirit, and beer has been triedby me, and always with the same result. If not more thanone ounce or one ounce and a half of absolute alcohol has beentaken by me, the total amount of renal elimination never by- any possible chance has exceeded half a grain.

After this it need scarcely be said that the theory of Lalle-mand, Duroy, and Perrin, so far as concerns elimination bythe kidney, totally falls to the ground. It is not merely.exaggerated, it is chimerical. And to those who are familiarwith the subject, it will be evident that this virtually settlesthe question as to the elimination of the whole, or even a prin-cipal portion, of moderate doses of alcohol in an unchangedform; for it has always been stated that the largest proportionof the gross elimination must be performed by the kidneys.Nevertheless, to place the matter beyond doubt, I have madenumerous examinations as to skin and lung elimination.As for excretion by the skin, the following is the method

-which I have finally adopted :-A quantity of wine, brandy,or whisky, equal to one ounce of absolute alcohol, is takenimmediately before retiring to bed. A portion of skin on thefront of the trunk, equal to 250 square inches, or about one-- tenth of the total superficies of the body, is covered with apiece of oiled silk, which is carefully plastered down at the edges,so as to be practically air-tight. Heavy bed-clothes are piledup, so as to ensure copious transpiration. In the morning(about ten hours after the dose, a period amply sufficient toinclude all the skin elimination) the oiled silk is removed, andits moist surface, as well as the surface of the skin beneath it,rapidly mopped with a clean sponge containing a very little.distilled water. The fluid is quickly wrung out into a wide-mouthed glass bottle, and made up with distilled water to one- ounce. This fluid is then reduced by distillation to a verysmall bulk, and tested with the chromic acid. On the firstoccasion in which I tried this experiment, it was estimatedthat the total transpired fluid contained not more than one-thirtieth of a grain of alcohol, and I have never seen indica-tions of any larger quantity in subsequent experiments. Morethan once no reaction whatever has been obtained. Nor canit be supposed that any considerable quantity of alcohol

escaped in the form of vapour. Supposing no waste, and sup-posing, on the other hand, that the rest of the surface of thebody transpired alcohol with equal freedom, the calculationwould be one-third of a grain of total skin elimination; but, infact, the probabilities are that it is considerably less.

It seems almost ludicrous, now that the kidneys and skinhave been proved to eliminate only such minute fractionalproportions of moderate doses of alcohol, to ask whether thelungs may possibly eliminate as much as 400 grains of absolutealcohol. Let us inquire, however. The result of Dr. Dupre’sand my own observations is that lung elimination is of verybrief duration after moderate doses ; usually it does not lastmore than one hour, and there is no likelihood that it ever lastsmore than three or four hours. Let us say four hours, how-ever-that would be a period including about 3600 expiratorymovements ; we must then suppose that one-ninth of a grainof alcohol, on the average, is discharged at each expiration. ButI find, on the contrary, that it requires at least 60 expirations(in the height of the eliminating period) to colour two cubiccentimetres of the test, through which the breath is made to

pass, to the shade which is produced by the addition of an equalbulk of water containing one-sixtieth of a grain of alcohol. Takenat a strict average, that might theoretically admit of the sup-position that one grain of alcohol was eliminated in four hours;but this would be on the hypothesis that the rate of excretionwas uniform for that period ; whereas, in fact, it rapidly de-creases after the first fifteen or twenty minutes during whichit is perceived. There is no need to follow the calculation anyfurther. It is obvious that elimination of unchanged alcoholby the lungs, after a moderate dose, is merely infinitesimal inamount. Even if we suppose that a considerable proportion ofthe alcohol is wasted (one-half would be an extravagantlyliberal computation), there is no possibility of believing thatmore than a fraction of a grain can be accounted for in thisway, except, perhaps, in the case of forced respiration fromviolent exercise, &c.

After the evidence which has now been adduced, I thinkyou will allow that there is ample reason for an unqualifiedrejection of the theory of total elimination as far as regardsthe case of moderate doses of alcohol. For myself I may saythat I have been for the last twelve years an investigator ofthe action of alcohol, and ever since the appearance of thework of Lallemand, Duroy, and Perrin, I have been more or lessconstantly engaged in testing their statements ; and the resultof my inquiries has been a constantly strengthening convictionof the radical unsoundness of their theory as applied to mode-rate quantities of alcohol. I believe I am now fairly entitledto consider that it is disproved beyond further question ordispute.We have next to inquire- whether elimination occurs in any

greater degree when narcotic or intoxicative doses of alcohol aretaken.

CLINICAL PAPERS ON THE SURGERY OFCHILDHOOD.

BY THOMAS SMITH, F.R.C.S.,ASSISTANT-SURGEON TO ST. BARTHOLOMEW’S AND THE CHILDREN’S HOSPITALS.

NÆVUS.

(Concluded from page 126.)

Peculiarities of treatment necessitated by certain localities.THERE are certain parts of the body where the general rules

applicable to the treatment of the different kinds of neavusmust be modified so as to suit the peculiar requirements of thepart. I shall now refer to those parts where special treatmentis either advisable or necessary.

The scalp and forehead.-Here neevi may be sometimes ad-vantageously treated by pressure constantly maintained bymeans of a piece of lead, or a small coin, stitched into an elasticsilk band, or by means of any other device for exercising pres-sure that may suggest itself to the surgeon. It is a somewhatwearisome means of cure, and can only be successfully carriedout with the assistance of an intelligent mother or nurse, whomust be able to readjust the apparatus when displaced.Navi over the fontanelle should be more cautiously treated

than elsewhere-i. e., injection or perchloride setons, if used,should not penetrate very deeply. I have treated many inthis situation successfully, but should always prefer to waituntil the fontanelle be either quite closed, or at all events untilossification had taken place beneath the nsevus.The only case of nasvus that has died under my hands, in

consequence of an operation, was one situated in this region,where death occurred from sloughing after the introductionof perchloride setons.Face.-lt is well that you should be reminded that the treat-

ment ofnsevi in this region by the injection of perchloride ofiron has more than once been followed by instant death.In the London Medical Gazette of 1837 the following case is

reported by Mr. Paget, of Leicester :-A child, aged two years,suffered from a mixed nsevus, as big as half an orange, overthe right upper jaw. The growth was principally subcutaneous.On two occasions the nsevus was pierced with a lancet, and amixture of one drop of nitric ether with fifteen of nitric acidwas injected. As this produced no effect, on the next occa-sion a small quantity of liquor ammonias was injected, thesolution being so diluted that it could be smelt without itspungency being disagreeable. The instant that this fluid wasinjected, the child had one slight convulsion and was dead.