359

died, but the hemorrhage was

stopped by pressing a piece of lintinto the wound and the artery was

not tied.

The introduction of extraneous

bodies into the wound to suppresshemorrhage is wrong in compoundfracture, as they produce too muchirritation and do not effectuallyanswer the proposed object. It is

better in some cases, in which youhave great difficulty to secure the

vessel at the wound, not to be twitch-

ing and pulling and continually ir-ritating the wound, and frequentlyto little purpose, but to cut down at

once on the artery, in its course tothe part. Jf, for example, theposterior tibial artery should be

wounded just below the middle ofthe leg, where it is deeply coveredby muscle, it should be cut down

upon, higher up, and secured. Mr.

Hey sawed through the fibula to

get at the posterior tibial from theouter part of the leg ; but I shouldrecommend it to be secured from

the inner side of the leg by makingan incision between the gastroc-nemii and the tibia, and then cut-

ting through the fascia coveringthe deep muscles.

I have only known one instanceof the femoral artery being dividedin compound fracture, and I thoughtit right to amputate immediately;the hemorrhage was but slight, but

as the artery and vein were bothtorn through I considered there was

very little chance of saving thelimb.

In two cases of division of the

brachial artery by fracture, ampu-tation became necessary. In one

of these cases I amputated evenwhilst the gangrene which had

taken place in the lower part ofthe arm was extending, but asthis arose only from local injuty,the patient did perfectly well.

I shall not have time to-day togo through the difficulties which

yet remain to be described ia the

treatment of these acidents, and Ishall therefore leave them until we

next meet; of which time, however,I will give you proper notice. ,

REVIEW.

Observations on the History andTreatment of the Ophthalmiaaccompanying the Secondary

.Forms of Lues Venerea. ByTHOMAS HEWSON, Esq. Sicr-geon to the Pleath Hospitaland County of Dublin ,Infir·mary, c., §’c., 8vo. pp. 117.London, 1824.The diseases of the eye have of

late years, both in this country andon the continent, received a consi-derable share of attention from well-educated surgeons, and the conse-

quence is, that at no former periodhave these affections been so well

360

understood as they are at present.The various complaints of the eye

used to be exclusively confined tothe care and management of cer-tain individuals who styled them-selves ‘ oculists,’’ and were not sup-

posed to belong to the province ofthe general surgeon. Some ofthese individuals in their genera-tions acquired great notoriety, andmany, we have no doubt, also ac-

, quired great skill in the perform-ance of those operations which

required little else than manual

dexterity to enable them to operatewith success, but with very few

exceptions it is to men who havemade disease in general their studythat we are indebted for all thathas been done towards the improve-ment of this branch of medical or

chirurgical science. The reason ofthis is obvious :-if the eye werean organ independent of the otherorgans of the body, and the dis-eases attacking it of a totally dif-ferent nature from those which at-tack other parts, then might theoculist have some claim to a know-ledge of their nature and treatmentsuperior to that possessed by thegenerality of surgeons. But, onthe contrary, as the diseases of the- eye are in a large proportion of,cases intimately connected withconstitutional derangement, and

require to be treated on the samegeneral principles as other com-

plaints, it will be found that hewhose observation of disease hasbeen most extended and accurate,and who has acquired the greatestprecision in the use of remedies forits relief, is the individual bestfitted by his habits and experienceto elucidate the -diseases of any

particular organ. This assertionholds good as far as it relates to aknowledge of the diseases of the

eye, and the employment of meansfor their cure, with the exceptionof operations, the performance ofwhich depends on manual skill;for there can be little doubt thatWENZEL could extract a cataractas well as any surgeon of the pre-sent day. Whilst manual dexte-

rity, however, is within the reachof every surgeon who will take thepains to acquire it, the oculist cannever be depended on as a safe andjudicious practitioner, as long as hedeprives himself of the assistanceto be derived from a knowledge ofdisease in general, and for thisreason we wish to see the complaintsof the eye form a part of theeducation of every surgeon.The subject of the volume before

us is on inflammation of the eyesfrequently occurring after syphilis,and commonly known by the nameof " syphilitic iritis," for which ourauthor substitutes that of "venerealophthalmia." We must object inlimine to the term Venereal OpA-thalmia on account of its vague-ness, and because it conveys to a

person unacquainted with the dis-ease no idea of its real seat, whereasIritis recalls to the mind the

particular part in fault, and if itcan be proved to have arisen fromthe action of the venereal poisoncall it Syphilitic Iritis. But Mr.HEWSON says, "this term wouldseem to limit the disease to theiris," and moreover adds, ’’_ that itgives an inadequate idea of a com-plicated series of symptoms." Whenany part of the eye is’ inflamedafter syphilis, and supposed to beproduced by it, the iris is the mem-brane generally affected, or at leastat its commencement, and thus thereason why the complaint is calledSyphilitic Iritis ; as for this namegiving all adequate idea of a com.

361

plicated series of symptoms, our

comprehension is so dull as not to

perceive how a more adequate ideacould be afforded by giving to the

complaint a name which is so in-definite that it does not even alludeto the part affected, except in com-mon with every other part of the

eye, whether in an unsound stateor not. No term by which a dis-ease is called, however correct, cangive an accurate idea of its symp-toms, unless a person is previouslymade acquainted with them eitherfrom observation, reading, or oralinstruction, but a vague appellationto a complaint may, for the time,mislead those really conversant

with it, and create in the minds ofthe uninformed false conceptionsrespecting its nature and treatment.For instance, Venereal Ophthal-mia means an inflammation of the

eye occurring after syphilis, vene-real ophthalmia (iritis) is only to becured by mercury. A person might,just after an attack of syphilis,have a slight inflammation of theconjuncti va,requiringonly very sim-ple means for its removal; allow theterm Venereal Ophthalmia, whatwould be the inference drawn by aperson unacquainted with the com-plaintrespectlnglts treatment. Hereis inflammation of the eye (of whatpart ?) occurring after syphilis, con-seq uently it is venereal ophthalmia;venereal ophthalmia is only to becured by mercury, therefore mer-cury is to be given. This wouldbe the chain of reasoning in themind of a person adopting Mr.HEWSON’S term, and if acted

upon in practice, in such a case asthe one alluded to, we need scarcelysay what would be the result. Mr.HEWSON, in answer to our objec-tion, may ask how this mistake canpossibly arise, when he has laid

down with care the symptoms ofvenereal ophthalmia, which will befound not to include those of simpleinflammation of the conjunctivaalone ? if so, we reply, why use aname which implies that an affec-tion of this as well as other partsmay be a consequence of syphiliswhen they really never are. Toreturn from the digression intowhich we have been led, the workbefore us is a treatise on syphilitic-,iritis, and the main object of it is.to show the importance of distin--

guishing between inflammation ofthe iris which arises from, or, to

avoid all dispute, after syphilis, andthat which is idiopathic and not,depending either on a syphilitic ormercurial action, a point which wedo not conceive to be of much im--portance, as we shall presently haveoccasion to observe when speaking-of the treatment of this complaint.-The symptoms of iritis in the mildform are an unpleasant sensationabout the eye, slight intolerance oflight, dimness of the humours, azone of red vessels round the cor-nea, and a change of colour in theiris itself ; when the complaint isof a more severe nature, in addi-tion to the above symptoms, thereis considerable pain in the su-

perciliary ridge, and frequentlythroughout the whole of the head,inflammation of the conjunctivaland sclerotic coats, adhesions of theiris to the capsule of the lens, andconsequently an inverted and puck-ered state of the pupillary margin,tubercles of lymph on some parts ofthe iris, pain in the globe of theeye, and dimness of sight; the ge-neral health also suffers in propor-tion. The complaint may be eitherin the mild or severe form at thecommencement; if it be mild it

may be easily removed, but if neg-

362

lected it soon runs into the second

stage. If the disease begins in thesevere form, the chance of cure-islessened unless attacked early, andit frequently comes on after syphilis;in this case it is generally accom-panied with some eruptions on theskin of the papular or scaly kind,and pains- of the limb which are

of an intermitting character. Thegreat difference, however, in syphi-litic and idiopathic iritis consists inthe degree [of severity with whichthe former comes on, and the quick-ness with which it proceeds to theeffusion of adhesive matter; andthis may be easily explained bythe greater degree of constitutionalderangement which exists or hasexisted, without seeking for thecause in the action of the venerealvirus. Some people have an irre-sistible propensity to account for

simple phenomena by hidden andmysterious causes, or if they be atall involved in obscurity to add tothe difficulty of the question by astill more difficult explanation; tosolve the igno tunz per ignotius ap-pears to be their chief delight;and of this error, or rather bad taste,M-r. HEWSON has been guilty.Idiopathic iritis is generally mild,because it often occurs in personswhose constitutions, have not beenbroken up or health deranged byprevious disease or long courses ofmedicine; but the syphilitic iritisarises after a complaint that dis-orders the health in no slight de-gree, and after medicine which

always leaves the body in an irrit-able state. Now if Mr. HEWSONhad recollected these simple cir-

,cumstances, the severity of the

syphilitic iritis might have beenreadily accounted for without en-tering into any controversial dis-

putes on the syphilitic or mercurial

actions contributing to produce it.In one part our author has the fol-lowing observations on this verypoint, without its ever having oc-curred to him that the state of theconstitution might in some degreecontribute towards the differencebetween syphilitic and idiopathiciritis." Some facts have led me to believe,

that where the constitutional symp-toms are most distinctly and stronglymarked, and are attended with mostgeneral disturbance, in the same pro-portion will those attending the oph-thalmia be violent and severe; and, onthe other hand, where the former arefew, and feebly developed, so will thelatter be slow and insidious in its

progress, and mild in its symptoms."P. 24.

As Mr. HEWSON has laid con-siderable stress on the necessity ofdistinguishing between idiopathiciritis and that which occurs after

syphilis, a person is naturally ledto suppose that the one requires amode of treatment different fromthe other; and this supposition isour author’s justification for’dwell-ing on this point. Our experienee,however, is at complete variancewith Mr. HEWSON’S opinion onthis subject, for we have found allforms of iritis yield to the- constitu-tional use of mercury; and findingthis medicine a sufficient remedyfor the cure of the complaint, wefee no reason for giving up a safeand certain measure for otherswhich are uncertain, and thereforedangerous, just in proportion as

their efficacy is not to be dependedon. On this subject we find thefollowing observations:" Before concluding, I cannot avoid

adverting to a point on which I amcompelled to differ from Mr.TRAVERS,*

*’ Vide Travers on Iritis, in SurgicalEssays, by Astley Cooper and B.Travers, part i. page 78.

363

iiam0y, that all forms of iritis, whe-ther primary or secondary, simple orspecific, require the constitutional useof mercury for their cure without ex-

ception.’ It appears to me, on the’other hand, from the effects that I al-most daily see attending it, that theconstitutional use of mercury shouldin general be confined within as nar-Tow and as precise limits as possible;and with respect to the class of affec-tions to which the preceding remarkrefers,.! believe that there are- manyamongst them in which the constitu-tional use of mercury might with greatadvantage be dispensed with. For ex-

ample, a considerable number of casesof idiopathic iritis are found to dependon a disturbed state of the digestiveorgans; and where this is observed,mercury will be most useful whengiven only in such combinations, andto such an extent, as is calculated torestore these organs to their healthyfunctions. Many cases; also, of iritisare connected with some morbid ex-citement or action about the bra;n orits membranes; and here, likewise,other remedies and modes of treatmentmust be adopted besides the constitu-tional use of mercury, which wouldoftener, perhaps, be more likely to doinjury than service. The practicewhich I have long thought to be. mostprudent, and have found to be mostsatisfactory, is to confine the constitu-tional use of mercury, in a great mea-sure to cases truly syphilitic, and inall others to employ it for the most

part only as an adjunct with other re-medies, and principally directing itsaction to the gastric organs." P. 63.

In this quotation two points arelaid down; first, that the consti-tutional use of mercury should in

general be confined within as nar-row and as precise limits as pos-sible ; and, secondly, that mostcases of idiopathic iritis may becured without mercury. With re- I’

spect to what is stated respectingthe care and precision required inthe use of mercury we entirelyagree, and are perfectly aware thatno medicine has been so indiscrimi-

nately employed. But on perusingsome of the cases contained in this

volume, we are sorry to see thatthe use of mercury was not con-fined by Mr. HEWSON within asnarrow limits as it might havebeen. The following case, we

think,- may serve as a pretty goodillustration of this:

"Dec. 24tb, 1813. Mary Goulding,a widow, aged 27, complains of acutelancinating pain in the ball of the righteye, and can distinguish no object withit. There appears considerable exter-nal inflammation; the aqueous hu-mour is very turbid; and the pupil canbe but indistinctly seen, and is irregu-lar and inverted at its inferior margin,where a small round whitish tubercleis observed attached to it, and whichprojects into the opening of the pupil.There is a copious flow of tears, andshe cannot bear the admission of theweakest light. A papular eruptionappears about the face, forehead,shoulders, and limbs; has severe head-aches, pains, and weakness in thelimbs, and night sweats. On the 24thof last June, she took a child to nurse,which was covered with an eruption,and had sore lips ; it lived only a fort-night. A small sore remained on theside of the nipple, which she founddifficult to heal. In about six weeksor two months after, she began to loseher health, and to suffer from painsabout the limbs, and night sweats. Tothese succeecled the eruption, and theeye has been affected for about threeweeks. Ordered pills and frictions." Jan. 3d, 1814. Symptoms about

the eye considerably relieved; the ap-proach of light gives no pain; the pupilcomes clearly into view, and there isbut little trace of the tubercle that wasattached to it; vision improved; con-stitutional symptoms less troublesome;mouth slightly affected. Medicines tobe continued."

"January l0th. Eye completely re-covered ; pupil has resumed its naturalshape and appearances’; has now veryuseful sight in the eye, but not quiteso good as formerly; constitutionalsymptoms have almost disappeared;ptyalism has been pretty severe for thelast ten days. Treatment afterwardscontinued, to secure the constitution."P. 70.

The length of time the mercury

364

was continued is not stated, nor

against what fiend the constitutionwas to be secured is not said ; butthere is another case given at page95, where the mercury was ex-

hibited from the 3d of February tothe 14th of March, and afterwardscontinued for the removal of theconstitutional symptoms. In thesecases there does not appear to havebeen any necessity for the quantityof mercurv that was taken.

As far as regards the practica-bility of curing idiopathic iritiswithout mercury, we will not go sofar as to say that it may not be

done, but extensive observation hasdemonstrated that mercury is a

certain, and if properly adminis-tered a safe, remedy; therefore wesee no reason for trying any other,whose efficiency is not to be reliedon. Mr. HEWSON himself givesmercury in idiopathic iritis, , butwith a view only to restore the se-cretions. The beneficial effects ofmercury in iritis may arise from its’action on tne secretions, out certain

it is that every form of iritis will

yield to its use. Where mercuryhas been exhibited in large quan-tities just before the iritis comes on,great care and management will3)e required in its employment forthe cure of iritis; and this point,which is of the greatest import-ance, has been totally overlookedby our author. No circumstancein the treatment of iritis requires igreater attention than this; " incases where age," says a writer onthis subject, " or the existence ofother diseases, or the already ex-cessive use of mercury has greatlyenfeebled the powers of the system,it must be used, if ventured uponat all, very sparingly, or with in-termissions, and the system mustbe supported by every admissible

means, both of nourishment andmedicine, during its employment.""The mode in which the mercury isgenerally administered for the cureof iritis is in the form of pills orpowders, composed of three grainsof calomel and a third of a grainof opium, and this is given twice orthree times a day, according to theseverity of the complaint. Mer-curial frictions are sometimes sub-stituted for the internal exhibitionof this medicine ; local depletion isnot often required. The extract ofbelladonna is now generally em-ployed in all stages of this com-plaint, and with the most decidedadvantage; speaking of this, Mr.H. says,- .

The solution of the extract of bel-ladonna is recommended, and verygenerally employed, in all stages ofthe disease; but if used whilst themorbid symptoms are in any degree ofactivity, it seems to create very uneasysensations about the entire eye. Ithink, therefore, that it should not beresorted to until the acute symptomsare in some measure on the decline."P. 62.

The disadvantage attending theuse of belladonna, as mentioned byMr. HEWSON, is not to be com-pared with the benefit it produces.The common consequence of iritisis adhesion of the iris to the cap-sule of the lens, occasioning cor-responding opacities of the cap-sule ; suppose that the adhesionstake place in a contracted state ofthe pupil, what will be the resultwhen the inflammation subsides-asmall fixed irregular pupil and ob-structed vision; whereas if the bel-ladonna had been used the adhe-sions would have formed in a

dilated state of the pupil, and thevision ultimately be much less im-paired. The consequences of iritis

Vide Tcavers on the Eye, p. 298.

365

when it is improperly managed,are, closure of the pupil, and oc-casionally, though seldom, the form-ation of an abscess in the deeperseated parts which generally ter-minates in the destruction of the

organ. It is very common, afterthe disappearance of the tuberclesof lymph, to see a fissure or cicatrixin that part of the iris where theyhave been situated. Iritis in themild form may be overlooked by a Ipractitioner, but there are few dis-eases with which it may be con-founded.We must confess that the volume

before us does not answer our

expectations ; we know the authorto be a well-informed surgeon,and that his opportunities of ob-serving disease have been nume-rous and extended, and thereforehad anticipated from his pen a

meritorious production. But wefind in the work little that hasnot been stated by others, andeven that not expressed in the bestmanner. Accompanying the workthere are some coloured engravingsby Mr. S’i’wART, which, like mostperformances from this artist, arewell done, with the exception that I

the colouring is a little too high. ’

FOREIGN DEPARTMENT.

ANALYSIS OF FOREIGN MEDICAL

JOURN ALS.

REVUE MEDICALE.—JULY.

The most interesting articles inthis Number are-Report of thediseases observed in the clinicalwards of Professor RECAMIER, atthe - Hotel Dieu, during the secondquarter of this year-Reflectionson a cyst developed in the brain,

in consequence of a fall-and ob-servations on rupture of the heart,by M. A. L. J. BAYLE.

Diseases observed at the HotelDieu, in the Clinical Wards ofProfessor RECAIIER, in the

I months of April, May, and

j June, of this year; by L. MAR-I TINET.

During this quarter there havebeen no complaints which could beregarded as epidemic, and, if we

except the cases of peri pneumoniawhich attacked almost exclusivelythe men in the month of April, noone organ has been particularly af-fected ; indeed, the patients admit-ted laboured under affections of thebrain, chest, and abdomen : thus,there were cases of cerebral affec-tion, among which an hydatid’ofthe brain was observed; pulmo-nary catarrhs, chiefly chronic; of

phthisis, organic diseases of theheart, inflammations of the stomachand intestines ; cancers of the sto-mach, rectum, and uterus; metritis,rather a large number of chronici rheumatisms, a few cutaneous in-flammations, and several other dis-eases which only occurred once,and which are marked in the tablebelow. The acute complaints werenearly in the same proportion asthe chronic, fifty of the former toforty-eight of the latter ; and themortality just the same, being ele-ven of the first to ten of the second.

REPORT.

Fevers .. 2Inflammation of the Cerebellum 1

Softening of the Cerebrum. 2

Hydatid of the Cerebrum . I

Epilepsy IParaplegia ...1Pulmonary Catarrhs , . 12Peripneumonies 12