467

sented numerous granular masses. Pericardium healthy.Mitral valve covered with a thick mass of vegetations, to

which coagula were adherent. Spleen large, congested at oneend, and firm, the section showing a mass of minute extravasa-tion. The kidneys contained several fibrinous masses in variousstages; their structure full of minute extravasations.

UNIVERSITY COLLEGE HOSPITAL.

EMBOLON IN THE CEREBRAL ARTERIES, PRODUCING HE-

MIPLEGIA, IN A CASE OF DISEASE OF THE HEART

FROM RHEUMATISM ; RECOVERY.

(Under the care of Dr. P-4,RKEs.)THE symptoms of impaired nervous power in the following

case are very different from those which are usually encounteredin paralysis depending upon sanguineous effusions or softening ofthe brain; for the attack occurred suddenly, whilst the patientwas in the hospital, and every vestige of the palsy had disappearedon the fourth day, leaving behind morbidly-acute sensation inthe right ear. Now, in cases of even very slight congestionof the brain, a patient may not lose consciousness, and mayhave a temporary paralysis; but it is seldom that the symptomsso totally disappear in the short time mentioned in the presentinstance. For a week he now had slight recurring attacks ofparalysis every morning on the left side of the body; it thenbecame persistent, and he finally left the hospital improved.The case was suspected to be one of embolon; and althoughthe symptoms are not very clear, we include it in the samecategory with the others.The following notes are a brief abstract from the hospital

books furnished us by Mr. W. Murray, the physician’s assis-tant:-

Charles S-, aged thirty-six; has been subject to attacksof rheumatism, and has, during the paroxysms, had cardiacaffections. About May lst, 1858, he began to feel weak andlanguid, and suffered frequently from praecordial pain. OnJune lst, 1859, he was admitted into hospital, in rather a weakstate, with considerable pain at the epigastrium and uneasi-ness after eating. The chest is barrel-shaped, with slightbulging in the cardiac region; the lungs are healthy; theheart’s area of dulness is too large; a murmur with first soundis heard at the base, of greatest intensity over the second rightcostal cartilage; another murmur with first sound is heardloudest at the apex; (aortic obstruction and mitral regurgi-tation diagnosed;) no diastolic murmurs.June 3rd, 1859.-Eight A.M.: He was seized with pain in

the head, loss of power in the limbs, and loss of speech. Whenthe physician’s assistant saw him, he was lying on his right.side, with the legs drawn up; speech very difficult; counte-nance very anxious, and bathed in a cold perspiration. Themouth was drawn to the left side; right eyelids partially para-lysed ; pupils contracted equaly; sees best with the right eye,and hears best with the right ear; dysphagia; fluid returningthrough the nares; total loss of sensation and motion of theright arm; no rigidity; the left arm unaffected; loss of sen-sation, &c., of the right side of the chest; the lower extremitiesunaffected; the urine passed freely; healthy. He was ordered- calomel with croton oil.6th.-Every symptom of paralysis has disappeared; in fact,

the right ear is too sensitive.14th.-Has had each morning a short attack of paralysis on

the right side.18th.-The right side quite perfect; the left arm has become

slightly paralysed; and the left ear has become affected.From this time he improved, and left the hospital in July,

with his urine slightly albuminous.

ST. BARTHOLOMEW’S HOSPITAL.

EMBOLON IN THE CEREBRAL ARTERIES, FOLLOWED BY

HEMIPLEGIA , EXTENSIVE MITRAL VALVULAR DISEASEFROM RHEUMATISM ; IMPROVEMENT.

(Under the care of Dr. FARRE.)WEEN the infarctus occurs in the brain, it is said to usually

occasion yellow softening ; but the rapidity of the functionaldisturbance, as in the following case, simulates an attack ofapoplexy. Here, however, although the symptoms perhaps do

not differ from a case of cerebral haemorrhage or acute soften-ing, the attack was followed by hemiplegia without loss of in-telligence or of speech, and slow improvement is going on.

From the state of the mitral valve, it is probable there will bea recurrence of the mischief at a later period. A case has beenrecorded by Schiitzenberger, in which numerous slightly at-tached irregular vegetations were present on the mitralvalve, and many also were found loose in the cavity of the

ventricle.I Henry S-, a butcher’s boy, aged sixteen, a delicate-looking and spare lad, was admitted on the 20th of March,1860. It appears that two years ago he had an attack of acuterheumatism, for which he was confined to bed for some weeks;all the joints of his body were affected, but he made no com-plaint of pain or uneasiness over the region of the heart. He isblind of the right eye from an injury received during child-hood. At seven o’clock on the morning of admission, he wascarrying home to his master some meat from market, when hesuddenly staggered, and was obliged to catch hold of the rail-ings for support. He became utterly helpless, was then con-veyed to the hospital, and placed under Dr. Farre’s care. 011his admission, it was discovered that he had hemiplegia of theleft side, with some rigidity of the leg, but not of the arm; ;there was no loss of intelligence nor of speech. The carotidswere acting most powerfully, with great pulsation in the neck.On examining the heart, the organ was found to be hypertro-phied, with a direct systolic murmur, and a double murmurwas heard with both sounds over the aorta. There was, besidesthese symptoms, a good deal of pain in the head. He was atonce blistered at the nape of the neck, six leeches were appliedbehind the ear, and three grains of calomel were ordered atnight.March 22nd.-The pain in the head has gone, although the

pulsations in the carotid arteries are still strong. He wasordered half an ounce of the infusion of digitalis three times 0,day. This not only diminished the excessive action of theheart, but next day permitted of some movement of the affectedleg, and on the 26th the rigidity had completely disappeared.The infusion of digitalis was now reduced to two drachms,with twenty minims of tincture of hyoscyamus three times aday. The patient now began to improve, and on the 2nd ofApril he took the compound cinchona mixture, with two grainsof iodide of potassium, three times a day.

April 6th. -When standing up he can move the affected leg.9th.-Great pulsation in the vessels generally, but particu-

larly in those of the arm, which beat with a thrilling sensation.The digital arteries beat as strongly as an ordinary radialartery at the wrist. Besides his other treatment, he is havingelectricity applied every second day with considerable benefit.16th.-Slowly improving. Ordered a mixture containing

quinine three times a day.23rd. -Can walk a little without assistance, and is otherwise

much improved in his general health. He can move both hisleg and arm very much better; the leg can be drawn up in bedsbut he cannot grasp with the affected arm. There is still adouble friction sound, and a double valvular murmur. Thepulse is that clearly indicating regurgitant mitral valvular dis-ease. His intelligence is perfect. The galvanism is appliedthree times a week, and the quinine mixture is continued.May 7th.-Heart symptoms as before; is sitting up, and

walks with considerable dragging of the affected leg; hisstrength is much increased. Treatment continued, with wine.

Medical Societies.MEDICAL SOCIETY OF LONDON.

MONDAY, APRIL 30TH, 1860.DR. GARROD, PRESIDENT.

ECZEMATOID ERUPTION FOLLOWING THE USE OF

CHLOROFORM.

MR. J. F. CLARKE inquired if any Fellow of the Society hadobserved an eczematous eruption follow the inhalation ofchloroform ? A lady under the care of Mr. Curling and him-self had inhaled chloroform previous to an operation for fistulain ano. About three days afterwards the entire surface of thebody was covered by a red papular eruption, attended bygreat irritation, but no other marks of constitutional disturb-ance. There was no sore-throat, and the tongue was natural.The eruption soon assumed a scaly character, the scales being

468

thrown off in very large quantities. The process of " peeling"

continued for three weeks, at the end of which time the sur-face had assumed its natural appearance, with the exception ofthe skin on the calves of the legs and some isolated patches inother parts. It was at first supposed that the patient hadcontracted scarlet fever, but the absence of constitutionalsymptoms, and the peculiar character of the eruption, weresufficient to set aside this view.

Dr. HYDE SALTER had not seen any eruption follow the useof chloroform, but he had observed in one case a general ery-thematous eruption supervene on the use of iron.Mr. DE MÉRIC read a paper on

I1 JECTIONS OF TRISNITRATE OF BISMUTH IN

GONOBBHQBA.

The author premised that he would confine his remarks to thetherapeutics of the disease; but incidentally stated that truegonorrhoea, contained a contagious principle which might becalled a special poison, whilst another kind of urethral dis-charge existed which was a mere hypersecretion. Mr. deMeric gave the broad characters of the two forms, and thenrelated a series of experiments which he had made at the RoyalFree Hospital as to the efficacy of injections of the trisnitrateof bismuth. He had refrained from using the injections in theinflammatory stage; and had principally prescribed them inchronic cases, whether these had followed the acute period, orhad been at the outset of the chronic painless character. Nointernal medicines had been given, and the proportions em-ployed for the injections had gradually been carried from halfa drachm to a drachm of the insoluble salt per ounce of water.A special register of the cases had been kept, from which itappeared that, out of 140 patients who had used the injections,a great number were still under treatment, and a good manyhad attended irregularly, so that positive results were obtainedonly in 52 cases: out of these, 36 patients had been noted as cured;5 as much better; and 11 as not improved at all. The cures—Yiz., the cases in which the discharge completely ceased-were obtained in twenty-two days, on an average; the partialcures took place on an average of twenty days; and the un-successful cases remained under the bismuth treatment fortwenty-five days on an average, being then put, with goodresults, on the copaiba-and-cubebs mixture. Mr. de Mericnext alluded to some cases in private practice; to the proportionof swelled testicle, buboes, and other complications which hadbeen observed in the hospital cases; to the symptoms ob-served during the use of the injections; to the risk of stric-tures, &c. &c.; and concluded by stating that he was by nomeans wishing to extol the use of the trisnitrate of bismuth ingonorrhoea, though he considered it very useful, especially ingleet; but that his object, in instituting the experiments, hadbeen to test the value of a remedy which had been highlylauded in Paris, *

Mr. J. F. CLARKE would have wished that the author hadspecified how long the disease had lasted, and what treatmenthad been used, before the injections of bismuth had been begun,and also that something had been said of the temperament ofthe patients. He (Alr. Clarke) recollected a great authority,who had distinctly stated that gonorrhoea, would, when inflam- ’,matory symptoms had subsided, get well of itself. ’

Dr. HARDIXG inquired what might be the modus operandi ’

of the bismuth when injected, whether it was thought to fur-nish merely a coating, or whether it possessed any specific in-fluence.

llr. HENRY SMITH made some remarks touching the urethralsponge which Mr. de Meric had shown when speaking of causticapplications to the urethra. He (Mr. Smith) stated that theinstrument was of his invention.

Mr. BRYANT thought the injections of bismuth should not beused in common cases, and considered that the saline treatmentor copaiba was sufficient without injections. Tannin had beenvery successful in his hands, and had the advantage of yieldinga very clean injection. He would, however, try the bismuthin chronic cases, and did not believe, especially from investiga-tions of his own, that stricture was so frequently a sequel toinjections as had been alleged.

Mr. MILLER expressed his belief that we might do withoutinjections, and rely upon the use of internal remedies.The PRESIDENT said that the action of the bismuth was well

known to be very beneficial in pyrosis, and that analogy wouldthus lead to view its employment favourably in gonorrhoBa.

Mr. DE MÉRIC briefly replied to the observations made, andclearly dissented both from the authority who said that gonor-

* See the two articles of M. Caby, in the Bulletin de Thérapeutique, vol. Iv.,1RKR rm 19’.Iinfl MO

rhcea would get well of itself, and from those who had statedthat stricture frequently followed upon the use of injections.Herein he was glad to be supported by Mr. Bryant’s expe-rience. He (Mr. de Meric) did not think that bismuth pos-sessed any specific influence, and mentioned that 1B1. Caby’spatients passed urine more easily with the coating of bismuththan without it. The author congratulated Mr. Smith on theinvention of the urethral sponge, and wished to be understoodas having undertaken the bismuth experiments principally inorder to test the value of these injections, the latter havingbeen highly recommended at Paris. He did not think theywould drive other injections from the field, but that in chronicand tedious cases the bismuth would be found very useful.

At a former meeting, -

Alr. HENRY SMITH read a paperON THE PATHOLOGY AND TREATMENT OF PAINFUL

ULCER OF THE RECTUM.

He first made some observations upon the simpler forms ofulceration met with about the anus, describing that conditionoccurring in persons who neglect cleanliness, or who have suf-fered from gonorrhceal discharges. These cases are, for the-most part, simple sores seated outside the verge of the anus,and may be readily cured by careful ablution, and the use ofastringent lotions. The true painful ulcer, or fissure of the anus,is situated within, and upon, the sphincter ani, and is notvisible, except when the most careful examination is made,and then it appears to be simply a crack; whereas, in reality,when the part comes to be carefully exposed, the morbid con-dition is found to consist of an ulcer, varying from the size of asplit pea to a fourpenny-piece or larger, varying also in shape.There is generally a small external pile covering the seat of thisulcer, which is, in nine cases out of ten, met with at the pos.terior verge of the anus. Women are more liable to the affec-tion than men. As regards its pathology, the author was ofopinion that the disease was originally produced by some irri.tation excited at the point affected by some retained fa3cal orother matter, and as the disease was frequently found associatedwith haemorrhoids, and an external tumour was in many in.stances seen to be, as it were, overlapping the ulcer, he was ofopinion that the morbid process might be the effect of the reten-tion of the irritating matter from the mechanical impedimentoffered by the small tumour in question. The increase andpersistence of the disorder were due to the periodical action ofthe sphincter. The symptoms, although so very peculiar, werevery liable to be overlooked, or to be referred, especially inwomen, to disorders of other organs, particularly of the womb,and very gross maltreatment had been the result. One case inparticular was mentioned by the author, where a lady had beenconfined to the house, and had undergone prolonged treatment,.the real nature of the disease not being discovered.The treatment which should be adopted in the more simple

cases, where the disease had not long existed, and where theulcer could readily be exposed, was the application of causticand astringent lotions. A persevering use of these remedieswill cure many cases; but when the symptoms are excessivelysevere, and the ulcer cannot be brought well into view, anothermode of treatment is to be adopted. The principle uponwhich the surgeon acts in the treatment of these cases is thesame which teaches him the use of the swing splint in fracturedlimbs or diseased joints; the employment of a common splintapplied to the forearm for wrist-drop, or the division of thelevator palati muscle, as recommended by Mr. Fergusson, priorto the uniting of the edges of a cleft palate-that of placing thepart in a state of complete rest. It was upon this soundprinciple that Boyer, either consciously or unconsciously, acted,when he recommended the complete division of the sphincterani for the cure of this painful disorder. A modification of thesame plan is now chiefly practised, and Mr. Smith was amongstthose who adopted the limited incision as originally recom-mended by Mr. Copeland. It was considered by some surgeons-that the simple division of the ulcer did not include any of thesphincter, but the author was inclined to agree with Mr. Carl-ing, that in most cases where this limited incision only wasmade, some of the fibres of the sphincter must of necessity bedivided; and hence the almost instantaneous and perfect relief.The author practised the operation by introducing a narrow-bladed straight knife upon the finger previously introduced intothe bowel, and then cutting from within outwards. Severalcases were related where the most admirable results followedthe employment of this simple operation.An animated discussion followed, in which Mr. I. B. Brown,

Dr. Rogers, Mr. H. Lee, Mr. Price, and Mr. Gay, took part.