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ST. BARTHOLOMEW'S HOSPITAL. THREE CASES OF NECROSIS.?A CASE OF FIBROUS TUMOUR ON THE TONGUE

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734 Although carbolic or phenic acid, or phenic alcohol (in fact, the latter is the most appropriate name for this substance, as its properties are not those of an acid, but that of an alcohol), was discovered in 1834 by Runge. Still, it remained in nearly complete oblivion until 1841, when Laurent re-examined some of the chemical properties of this substance, and devised the following method of extracting it from certain coal-tar pro- ducts. His process consists in submitting the light oils of tar to a fractional distillation, and then treating with a concen- trated solution of potash the products, which distil at a tempe. ratnre between 320° F. and 392° F., separating the alkaline solution from the hydrocarbons which float on it, and then neutralising the alkali by an acid, which liberates the carbolic acid. Such was Laurent’s method of preparing carbolic or phenic acid, but pure carbolic acid was there in only small propor- tion ; it was, in fact, a mixture composed chiefly of different liquids similar in properties and composition to carbolic acid ; and although Laurent succeeded in obtaining solid carbolic acid, still the process devised by him was too expensive to answer on a manufacturing scale, and, besides, his method of operating was too complicated. In the year 1857, I was called upon to investigate the matter, and find a cheap and practical process for obtaining carbolic acid in considerable quantity, this substance being required to produce a variety of colours that had just been discovered as obtainable from it, and the manufacture of which still con- tinues. From that date up to 1864, myself and partners (F. C. Calvert and Co.) continued to make improvements in the purification of commercial carbolic acid until we succeeded in obtaining large quantities of an acid similar in properties to that obtained by Laurent in his laboratory. From this time I made many efforts to draw the attention of the medical profession to the really remarkable therapeutic properties of carbolic acid; but the tarry and sulphuretted odour which it still possessed was a serious obstacle to its application. I soon succeeded in overcoming this difficulty, and towards the end of the year 1864 our firm was in a position to deliver in considerable quantities carbolic acid deprived of sulphuretted compounds, and therefore fit for all medicinal uses. But I am glad to say that the series of improvements in the manufacture of pure carbolic acid, or phenic alcohol, did not stop there; for towards the end of last year I discovered a ’process which now enables me to present a product com. pletely deprived of all disagreeable odour and tarry flavour, and in fact as pure, though extracted from tar, as if it had been produced artificially by the help of the reactions recently discovered by Messrs. Wurtz and Kekule, based upon the direct transformation of benzine into carbolic acid, or by the well-known changes by which it may be obtained from salicylic acid or nitro-benzoic. This new phenic or carbolic acid, which crystallises in white prismatic crystals, which are usually sold in a white, hard, fused mass, is distinguished from Laurent’s in being soluble in 20 parts of water, whereas the latter requires 33. It is fusible at 106° F. instead of 93° F., and boils at 359° instead of 36’7° F. ; but it gives, like Laurent’s, the blue colour described by M. Berthelot, when mixed with ammonia; and to the solu- tion is added a small quantity of a hypochlorite; the same effect is also produced when you expose to the vapours of hydrochloric acid a chip of deal soaked in this pure carbolic acid. This acid is so pure, and so free from any objectionable flavour, that it should always be used as a therapeutic agent for all internal and dental purposes. The second quality of carbolic acid which is manufactured, and which is identical in properties to that first described by Laurent-that is to say, a white solid substance, having a fusing point of 93° F., as above stated--can be used with ad- vantage for all external applications, either medical or surgical, as its peculiar tarry taste is of no importance for such applica- tions. The third quality of carbolic acid which is now manufac- tured, and which will now be used extensively throughout her Majesty’s fleet, presents itself in white detached crystals, which have a fusing-point of about 81° F. This quality, when dissolved in from 50 to 100 parts of water, gives a perfectly colourless solution, which can be used with great advantage for antiseptic and disinfecting purposes in private dwellings, hospital wards, &c. Lastly, there is also a quality found in the trade which is a nearly colourless fluid, and is a mixture of cresylic acid with carbolic acid. This product, when diluted with 100 parts of water, or more, according to the required application, *can be used with great advantage as an antiseptic and disinfectant for all out-door purposes, such as cesspools, waterclosets, drains, &c.; and as this quality has been extensively used to prevent the spread of rinderpest during the cattle plague, and also the spread of cholera in Liverpool, London, and other large towns, its demand at times has been very extensive, and therefore great temptations have been held out to unscrupulous manufacturers of the article to offer to the public a fictitious mixture. To enable purchasers to protect themselves from fraud, the following test is supplied on the authority of Mr. W. Crookes, F.R.S.:- I Commercial carbolic acid is soluble in from 25 to 70 parts, or in twice its bulk, of a solution of caustic soda; while oil of tar is nearly insoluble. " To apply these tests- " 1. Put a teaspoonful of the carbolic acid in a bottle; pour on it half a pint of warm water; shake the bottle at intervals for half an hour, when the amount of oily residue will show the impurity. 11 2. Dissolve one part of caustic soda in ten parts of warm water, and shake it up with five parts of the carbolic acid. I I As before, the residue will indicate the amount of impurity. These tests are not given as having any pretension to scientific accuracy, but as affording persons who are desirous of using carbolic acid a rough and ready means of seeing whether or not they possess the right article." P. S.-I deem it my duty to call the attention of the medical profession to the fact that drying oils, like linseed oil, have the property of absorbing, with great rapidity, oxygen, and may thereby be the means of conveying oxygen to wounds, and thus produce irritation, if not inflammation. We therefore advise the employment of sweet olive oil only, or still better, of gly- cerine. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. ST. BARTHOLOMEW’S HOSPITAL. THREE CASES OF NECROSIS.—A CASE OF FIBROUS TUMOUR ON THE TONGUE. (Under the care of Mr. PAGET.) Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum ot dissectionum historias, tum aliorum, tum proprias collect as habere, et inter se comparare.-MORGAGNI De Sed. et CauB. Morb., lib. iv. Prooemium. SURGICAL interference on account of death of bone is pro- bably the most common of all operations. In some respects it is the most interesting. There is no condition in which sur- gical art may be more happily exhibited. Well-timed explora- tion may save months, nay, sometimes years of suflering; and if the question be asked as to the proper time for interference, there are probably few surgeons who would not agree that it is better to be too early than too late in our efforts to remove sequestra. Delay but too often surrounds the dead piece of bone with a dense growth of new osseous tissue, which renders extraction very difficult. We saw on Saturday last at this hospital three patients placed upon the operating-table in succession, each of whom had portions of dead bone which Mr. Paget wished to remove. The circumstances of each case differed. The first was an unhealthy-looking lad, of apparently four- teen or fifteen years of age. The lower part of the right leg and also his ankle were swollen and boggy, whilst over the outer malleolus were apertures through which pus was dis- charged. It seemed that five weeks previously this boy had broken his fibula just above the outer malleolus. The fracture was a simple one, and had been properly put up. The boy, however, instead of keeping quiet, had walked upon the broken limb, with the result of setting up some inflammatory action in the neighbourhood of the fracture. Suppuration had followed,
Transcript

734

Although carbolic or phenic acid, or phenic alcohol (in fact,the latter is the most appropriate name for this substance, asits properties are not those of an acid, but that of an alcohol),was discovered in 1834 by Runge. Still, it remained in nearlycomplete oblivion until 1841, when Laurent re-examined someof the chemical properties of this substance, and devised thefollowing method of extracting it from certain coal-tar pro-ducts. His process consists in submitting the light oils of tarto a fractional distillation, and then treating with a concen-trated solution of potash the products, which distil at a tempe.ratnre between 320° F. and 392° F., separating the alkalinesolution from the hydrocarbons which float on it, and thenneutralising the alkali by an acid, which liberates the carbolicacid.Such was Laurent’s method of preparing carbolic or phenic

acid, but pure carbolic acid was there in only small propor-tion ; it was, in fact, a mixture composed chiefly of differentliquids similar in properties and composition to carbolic acid ;and although Laurent succeeded in obtaining solid carbolicacid, still the process devised by him was too expensive toanswer on a manufacturing scale, and, besides, his method ofoperating was too complicated. ’

In the year 1857, I was called upon to investigate the matter, and find a cheap and practical process for obtaining carbolicacid in considerable quantity, this substance being required toproduce a variety of colours that had just been discovered asobtainable from it, and the manufacture of which still con-tinues.From that date up to 1864, myself and partners (F. C.

Calvert and Co.) continued to make improvements in thepurification of commercial carbolic acid until we succeeded inobtaining large quantities of an acid similar in properties tothat obtained by Laurent in his laboratory.From this time I made many efforts to draw the attention of

the medical profession to the really remarkable therapeuticproperties of carbolic acid; but the tarry and sulphurettedodour which it still possessed was a serious obstacle to its

application. I soon succeeded in overcoming this difficulty,and towards the end of the year 1864 our firm was in a positionto deliver in considerable quantities carbolic acid deprived ofsulphuretted compounds, and therefore fit for all medicinaluses. But I am glad to say that the series of improvements inthe manufacture of pure carbolic acid, or phenic alcohol, didnot stop there; for towards the end of last year I discovereda ’process which now enables me to present a product com.pletely deprived of all disagreeable odour and tarry flavour,and in fact as pure, though extracted from tar, as if it hadbeen produced artificially by the help of the reactions recentlydiscovered by Messrs. Wurtz and Kekule, based upon thedirect transformation of benzine into carbolic acid, or by thewell-known changes by which it may be obtained from salicylicacid or nitro-benzoic. ’

This new phenic or carbolic acid, which crystallises in whiteprismatic crystals, which are usually sold in a white, hard,fused mass, is distinguished from Laurent’s in being solublein 20 parts of water, whereas the latter requires 33. It isfusible at 106° F. instead of 93° F., and boils at 359° instead of36’7° F. ; but it gives, like Laurent’s, the blue colour describedby M. Berthelot, when mixed with ammonia; and to the solu-tion is added a small quantity of a hypochlorite; the sameeffect is also produced when you expose to the vapours ofhydrochloric acid a chip of deal soaked in this pure carbolicacid.

This acid is so pure, and so free from any objectionableflavour, that it should always be used as a therapeutic agentfor all internal and dental purposes.The second quality of carbolic acid which is manufactured,

and which is identical in properties to that first described byLaurent-that is to say, a white solid substance, having afusing point of 93° F., as above stated--can be used with ad-vantage for all external applications, either medical or surgical,as its peculiar tarry taste is of no importance for such applica-tions.The third quality of carbolic acid which is now manufac-

tured, and which will now be used extensively throughouther Majesty’s fleet, presents itself in white detached crystals,which have a fusing-point of about 81° F. This quality, whendissolved in from 50 to 100 parts of water, gives a perfectlycolourless solution, which can be used with great advantagefor antiseptic and disinfecting purposes in private dwellings,hospital wards, &c.

Lastly, there is also a quality found in the trade which is anearly colourless fluid, and is a mixture of cresylic acid withcarbolic acid. This product, when diluted with 100 parts of

water, or more, according to the required application, *can beused with great advantage as an antiseptic and disinfectantfor all out-door purposes, such as cesspools, waterclosets,drains, &c.; and as this quality has been extensively used toprevent the spread of rinderpest during the cattle plague, andalso the spread of cholera in Liverpool, London, and otherlarge towns, its demand at times has been very extensive, andtherefore great temptations have been held out to unscrupulousmanufacturers of the article to offer to the public a fictitiousmixture. To enable purchasers to protect themselves fromfraud, the following test is supplied on the authority ofMr. W. Crookes, F.R.S.:-I Commercial carbolic acid is soluble in from 25 to 70 parts,

or in twice its bulk, of a solution of caustic soda; while oil oftar is nearly insoluble.

" To apply these tests-" 1. Put a teaspoonful of the carbolic acid in a bottle; pour on

it half a pint of warm water; shake the bottle at intervals forhalf an hour, when the amount of oily residue will show theimpurity.

11 2. Dissolve one part of caustic soda in ten parts of warmwater, and shake it up with five parts of the carbolic acid.

I I As before, the residue will indicate the amount of impurity.These tests are not given as having any pretension to scientificaccuracy, but as affording persons who are desirous of usingcarbolic acid a rough and ready means of seeing whether or notthey possess the right article."

P. S.-I deem it my duty to call the attention of the medicalprofession to the fact that drying oils, like linseed oil, have theproperty of absorbing, with great rapidity, oxygen, and maythereby be the means of conveying oxygen to wounds, and thusproduce irritation, if not inflammation. We therefore advisethe employment of sweet olive oil only, or still better, of gly-cerine.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.

THREE CASES OF NECROSIS.—A CASE OF FIBROUS

TUMOUR ON THE TONGUE.

(Under the care of Mr. PAGET.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumot dissectionum historias, tum aliorum, tum proprias collect as habere, et interse comparare.-MORGAGNI De Sed. et CauB. Morb., lib. iv. Prooemium.

SURGICAL interference on account of death of bone is pro-bably the most common of all operations. In some respects itis the most interesting. There is no condition in which sur-

gical art may be more happily exhibited. Well-timed explora-tion may save months, nay, sometimes years of suflering; andif the question be asked as to the proper time for interference,there are probably few surgeons who would not agree that itis better to be too early than too late in our efforts to removesequestra. Delay but too often surrounds the dead piece ofbone with a dense growth of new osseous tissue, which rendersextraction very difficult.We saw on Saturday last at this hospital three patients

placed upon the operating-table in succession, each of whomhad portions of dead bone which Mr. Paget wished to remove.The circumstances of each case differed.The first was an unhealthy-looking lad, of apparently four-

teen or fifteen years of age. The lower part of the right legand also his ankle were swollen and boggy, whilst over theouter malleolus were apertures through which pus was dis-charged. It seemed that five weeks previously this boy hadbroken his fibula just above the outer malleolus. The fracturewas a simple one, and had been properly put up. The boy,however, instead of keeping quiet, had walked upon the brokenlimb, with the result of setting up some inflammatory action inthe neighbourhood of the fracture. Suppuration had followed,

735

abscesses had hurst, haemorrhage had taken place, and the boy’s health had suffered considerably. Mr. Paget introduceda grooved director into a sinus, and made a cut upwards forfive or six inches along the course of the fibula. This bone, onbeing exposed, was found dead in patches, varying in extent,the intervening portions presenting signs of ostitis. The ex-ternal malleolus was loose, denuded of cartilage, and dead.When this was removed, pus was found evidently exudingfrom the ankle-joint. Mr. Paget then made a vertical cut overthe inner malleolus, where there were evident signs of matter.When the joint was opened, a large quantity of creamy puspoured out. These signs of disorganisation made it only tooevident that amputation was the sole remaining chance for thelad. It was necessary, however, that this should be for themoment deferred, as neither the patient nor his friends hadbeen prepared for such a result. The wound was thereforefilled with lint steeped in perchloride of iron, and the boy re-moved. There had evidently been in this case inflammation ofbone, which had extended to the ankle-joint.The next patient was a man past middle age, who seemed

to have come in for more than his share of the common evils ofour lot. He had lost the left leg and the right eye. He statedthat Mr. Paget had removed the former five or six years agofor mischief which arose out of a scratch. Nothing more de-finite than this could be ascertained. He was now sufferingfrom necrosis of the lower jaw. His chin was enlarged ; theskin thickened, and presenting two or three sinuses whichwept a little matter. Mr. Paget, introducing a director throughthese, could feel bare bone, and, as it seemed probable that thiswas loose, he determined to try and remove it. He first ex-tracted one or two teeth, and endeavoured to get at the bonethrough the month ; but this was not practicable. He then

opened up a sinus under the chin, and getting hold of the deadbone with the sequestrum forceps, he tried to dislodge it; butby no effort could he accomplish this. It was a good illustra-tion, Mr. Paget remarked, of the difficulty-nay, impossibilitysometimes-of determining beforehand whether bone is looseor not. There is no rule in such cases. Separation may takeplace very rapidly, or be long deferred. On the whole, hethought it was the more rapid when the inflammation had beenmost acute. Such a case as this, he said, had not unfrequentlybrought dentists into most unmerited disgrace. Inflammationof bone and consequent necrosis had followed the removal ofteeth, and had been most erroneously attributed to this opera-tion. In all probability the loosening and decay of teeth whichhad necessitated their removal had themselves resulted fromthe inflammation of bone, instead of having caused it.A young man was now placed upon the table whose right leg

had been amputated in its upper third by Mr. Paget in Februarylast. A portion of tibia in the stump had died; and, two or threeweeks since, Mr. Paget had removed some of this dead bone,leaving, however, another part which was not yet loose. Onthe present occasion, having cut down upon the necrosed part,he succeeded in removing two small sequestra, which he hopedwere all that had to come away. The probability is that theman’s stump will heal now that the source of irritation is nolonger present.

The preceding patients had all been kept under the influ-ence of chloroform by Mr. Langton. To the next one nonewas administered. She was a girl, who, on putting out hertongue showed upon its dorsum, near the base and to theright of the mesial line, a tumour the size of a large pea orsmall bean. This was hard to the touch. It was variouslydiagnosed by some of the staff, who examined it with theirfingers, as calcified sebaceous tumour, shrivelled hydatid, orfibrous tumour. The last opinion proved to be correct. Mr.Paget seized it with forceps, and having divided it into halveswith a bistoury, it was easily turned out. It was white, dense,and fibrous in structure. Mr. Paget remarked that he hadonce before met with a similar case.

WESTMINSTER HOSPITAL.INJURY TO THE HEAD FROM A FALL; RECOVERY.

(Under the care of Mr. HOLTHOUSE.)IN the " Mirror" for Nov. 9th we published notes of a case

of injury to the head, under Mr. Holthouse’s care, in whichan ataxy of articulation resulted, and continued after the pa-tient’s general health was restored. In the present instanceit will be observed that slight symptoms of aphasia were appa-

rent, but gradually disappeared, the patient entirely recoveringfrom the injury to his head. There are points in the casewhich it is interesting to note. In the first place, it seemspretty certain that the man fell from exhaustion, and perhapsgiddiness-not from apoplexy, or there would have been moreor less persistent paralysis for a length of time. As regardsthe diagnosis of the lesion and its locality, it would seem pos-sible that there was a fracture extending from the right parietaleminence-the point struck-to the petrous bone of the sameside, giving rise to the hemorrhage from the right ear. Fromthe occurrence of aphasia, it is probable that the left anteriorcerebral hemisphere was damaged by contre-coup. There mayhave been bruising, slight laceration, and haemorrhage of its

posterior part, near to the Sylvian fissure. It is to be notedthat though the patient ate and drank well, and articulated toa certain extent, he could not protrude his tongue. This in-ability, which is rare in simple hemiplegia, is not uncommonin aphasia. Other interesting points in the case are, the pa-tient’s mental retrocession to childhood life, and the calls ofthis man of fifty-five for his mother. We saw a case of aphasiafrom softening the other day at the National Hospital forEpilepsy and Paralysis, where the patient, an old man, whenasked by Dr. Buzzard where he lived, gave as his address aresidence which he had quitted twenty-five years ago.

Alex. D-, aged fifty-five, was admitted into the West-minster Hospital on Jan. 4th, 1867, in a semi-conscious state,in consequence of a severe blow on the right side of the headeighteen hours previously. According to his wife’s account,he had suffered from chronic cough and dyspnœa for someyears, and on ascending the stone steps to his rooms he wasobserved to be much out of breath on reaching the top (onlyeight steps), and then to stagger and fall down heavily, strikingthe right side and back part of the head over the right parietaleminence. He lay where he fell, and, on being picked up,blood was flowing from a scalp wound about three quarters ofan inch in length, in the situation above described, and alsofrom the right ear, and it continued to flow from the latter fortwelve hours. For the first hour after the accident he wasrational, but after that he began to talk incoherently, andmade no rational reply to questions, but raved the whole ofthe night and was much excited. Half an hour after the acci-dent he had a very copious evacuation of the bowels, and aboutmidnight was slightly sick, vomiting chiefly a little frothymucus. On removing him from his room to come to the hos-pital, his nose burst out bleeding, and continued to bleed tillhis arrival there, when it ceased.When seen an hour after admission, he was lying on his left

side, with the knees drawn up, and breathing quietly ; skintolerably warm ; pulse small and feeble. There was no bleed.ing from the scalp wound or from the ear. When questioned,he answered, though not relevantly ; but when asked if hehad pain in the head, said " Yes." There was no unnaturalheat of the forehead. Ordered low diet.

Jan. 5th.-No disposition to coma, but rather to restlessnessand incoherent talking. When asked a question, always re.sponds, but the response is no answer, but not unfrequently" Yes," or some irrelevant ejaculation.6th.-Lying with his eyes open, and looking intelligent, but

talking a good deal to himself, chiefly about getting up. Hefrequently calls out "Mother," though his mother has beendead many years, and he is not in the habit of addressing hiswife thus. When spoken to, he still answers, or rather articu-lates something quite irrelevant to the question. When toldto put out his tongue, he opens his mouth, but will not, orprobably cannot, protrude it. His countenance does not ex-

press suffering or intra-cranial mischief. His skin is moistand warm, and he takes a moderate amount of nourishment.His pupils are in a medium state, and act under variations oflight. Pulse feeble, 78. He passes urine voluntarily, and hisbowels have not acted since his admission.

7th.-Passed a restless night, moaning, and getting up anddown in his bed. He lies indifferently on either side, butseems to prefer being on his back with the trunk slightlyraised and his head leaning against the wall. Though he stillanswers only " yes," or " oh dear !" to nearly every question,and cannot put out his tongue, he is evidently conscious ofwhat is said to him, and explains by his hand that he has painon the top of his head. His bowels acted well yesterday. Hemakes his wants known. Pulse 7S, soft and feeble. A blisterto be applied at back of neck.8th.-The blister rose well. He passed a better night, and

this morning is decidedly improved; the pain in the head isrelieved, and he answers questions rationally for the first time.Thus, on asking him if his head was better ,he said "’ "xes,

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