111 placed in a half-bent position upon a quilt. The patient had shortly after admission an opiate draught, which was repeated at night. On the following day she complained of a sense of weight and dull aching in the limb since the subsidence of the effect of the chloroform. The countenance was good; the pulse natural; and the tongue clean. To allay the pain, the author prescribed five grains of the compound soap-pill, to be taken every hour until its abatement. She was not relieved till she had swallowed seven of the above pills at the above intervals. On the fourth day, after removing the sutures and cleansing the wound, some discoloration was perceived at the under border of the flaps, together with an erysipelatous blush ’, extending about eight inches up the surface of the leg; the pulse was 108; the tongue was clean and moist; she had slept well from a dose of opium, and the bowels had been relieved by aid of castor oil. A streak of nitrate of silver was drawn round the erysipelatous blush above men- tioned. A more liberal diet than before was ordered. On the eighth day a considerable portion of the wound had sloughed. Mr. Ure directed the morbid surface to be dressed with solu- tion of chloride of soda diluted with water. Before the lapse of twenty-four hours the sloughing had ceased; the edges of the wound looked clean, and the pulse, which had previously risen to 120 beats in the minute, was reduced to 96. Nothing could be more remarkable than the prompt effect of the dilute solution of chloride of soda in arresting the gangrenous process, which threatened to destroy the flaps of skin in totality, and produce denudation of the bones. By the eleventh day the surface of the wound presented healthy granulations, and the quality of the matter secreted was materially improved. By the aid of nutritious diet, a moderate allowance of wine and porter, together with quinine, and one of the preparations of opium, convalescence advanced steadily. The sore occupy- ing the centre of the stump is nearly cicatrized. There is now an excellent cushion of integument, both at the posterior or heel-part, and also in front. The patient is in good health and spirits, sits in an easy chair during the day, with the limb resting on a hassock, and will be able to leave the hospital in the course of eight or ten days. The author was disposed to ascribe the sloughing in the present case to the violence done to the soft parts at the time of the accident. It is by no means easy in the instance of railway injuries to determine at once the exact amount of damage inflicted. He deems the operation one which ought to be resorted to wherever admis- sible. It is superior to amputation at the lower third of the leg, because attended with less risk of danger to the patient, and because affording a more serviceable limb. He had been informed by Mr. Gray, of Cork-street, the ingenious constructor of artificial limbs, that by means of a properly adapted foot, the individual is enabled to walk, run, get up and down stairs, just as well as with a natural one, and that in six weeks after the wound is cicatrized the artificial foot may be adjusted and worn. The solid cushion obtained from the heel, with its cellulo-adipose lining, forms an admirable support for the weight of the body, and one which, instead of becoming wasted and attenuated by continued pressure, acquires, on the contrary, increased firmness, and power of resistance. Mr. OBRE exhibited a very ingenious- INSTRUMENT FOR INJECTING THE LACRYMAL SAC. The extreme difficnltv, if not impossibility, of introducing fluid into the lacrymal sac, in cases of chronic inflammation, with Anel’s syringe, passed through the puncta, induced Mr. Obre to have a silver canula constructed, the same shape and size as the sound of Gensoul, to which is attached a small vulcanized india-rubber bag, about the size of a uut, into which the injecting tluid is introduced. The canula having been passed through the nasal duct bv the inferior meatus, slight pressure of the thumb on the india-rubber bag propels fluid. No more difficulty is found in passing this instrument than the ordinary sound, a little practice soon overcoming any difficulty. It is necessary there should be a canula for either nostril; the india-rubber bag is made to screw on either as required. Mr. Obre stated he had not brought this instrument before the notice of the profession until he had first given it a, fair trial and proved its utility. It is made by Mr. Coxeter. The diagram below will represent the invention. At the next meeting of the Society, Feb. 2nd, Dr. King Chambers will read a paper " On a Peculiar Form of Cardiac Disease." WESTERN MEDICAL AND SURGICAL SOCIETY. FRIDAY, JANUARY 20TH, 1854.—DR. WILSON, President, in the Chair. Dr. BARCLAY read a paper on- DROPSY IX ITS RELATION TO TREATMENT. He commenced by alluding to the high mortality of this disease, and stated that the only disease which at all approached it in this respect was phthisis. He drew his conclusions and care- fully illustrated his views from the Medical Registries in St. George’s Hospital during the years 1851, 1852. He then re- stricted the term dropsy to anasarca and ascites, considering that as hydrothorax, hydrocephalus, &c., when not presenting themselves as mere isolated portions of general dropsy, are practically found only as the result of infiammation, they should be classed accordingly. Although the distinction be- tween anasarca and ascites is generally clear, yet in many cases both forms are present, but a little care will generally discern the primary form. The morbid states giving rise to ascites are much more fatal than those associated with anasarca, more than two-thirds of those admitted with the latter form being discharged from the hospital cured or relieved, while less than one-third of those affected with ascites reap the like benefits ; 9 but here we should bear in mind that many anasarcous patients. return again and again to the hospital to be relieved of the same set of symptoms. Though the actual frequency of, and consequently the actual number of deaths from anasarca, is far greater than from ascites, yet the ratio of mortality in the latter form is exactly double that in the former. With regard to anasarca, though by far the greater number of cases. ! are associated with disease of either kidney or heart, yet cer- ; tain cases will compel us to attribute the disease to some other cause. During the two years alluded to, nearly one-fourth of these cases could not be accounted for. The most frequent association of this disease is disease of the kidney, with or with- out disease of the heart; next comes disease of the heart itself But though these lesions are apparently so evident a cause for serous effusion, yet upon further analysis of these cases, there will be found by no means such a direct connexion between the disea.se and symptom, except where both organs were impli- cated. This assertion is borne out by the fact that in the two years before mentioned but few cases of diseased kidney, and still fewer of diseased heart, presented no other malady of sufficient importance to find a place in the register of disease; and to every one conversant with disease, the pale face of albuminuria, and the dusky hue of impeded circulation, point out something beyond the mere change of structure—some change in the blood itself-to be one of the necessary associations of dropsy. We found also that 63 per cent. of the patients labouring under disease of the kidney, and 42 per cent. of those with disease of the heart have at the same time been affected with anasarca, and that in some cases the only other complication found was bron- chitis with emphysema. All which facts go to prove that disease of the heart and kidney may go on for years without causing any dropsv, until the mucous membrane of the lungs becomes congested, and that serous accumulation follows. The explanation then is found in the obstruction that takes place in the circulation through the lungs, and secondarily in the effects of a chronic bronchitis on the constitution. Next to bronchitis, phthisis stands as a cause for dropsy, its degree probably being regulated by the amount of night sweats, which draw off to a certain extent the serous accumulations.
Transcript
111
placed in a half-bent position upon a quilt. The patient hadshortly after admission an opiate draught, which was repeatedat night. On the following day she complained of a sense ofweight and dull aching in the limb since the subsidence of theeffect of the chloroform. The countenance was good; the
pulse natural; and the tongue clean. To allay the pain, theauthor prescribed five grains of the compound soap-pill, to betaken every hour until its abatement. She was not relievedtill she had swallowed seven of the above pills at the aboveintervals. On the fourth day, after removing the sutures andcleansing the wound, some discoloration was perceived at theunder border of the flaps, together with an erysipelatous blush ’,extending about eight inches up the surface of the leg; thepulse was 108; the tongue was clean and moist; she hadslept well from a dose of opium, and the bowels hadbeen relieved by aid of castor oil. A streak of nitrate ofsilver was drawn round the erysipelatous blush above men-tioned. A more liberal diet than before was ordered. On theeighth day a considerable portion of the wound had sloughed.Mr. Ure directed the morbid surface to be dressed with solu-tion of chloride of soda diluted with water. Before the lapseof twenty-four hours the sloughing had ceased; the edges ofthe wound looked clean, and the pulse, which had previouslyrisen to 120 beats in the minute, was reduced to 96. Nothingcould be more remarkable than the prompt effect of the dilutesolution of chloride of soda in arresting the gangrenous process,which threatened to destroy the flaps of skin in totality, andproduce denudation of the bones. By the eleventh day thesurface of the wound presented healthy granulations, and thequality of the matter secreted was materially improved. Bythe aid of nutritious diet, a moderate allowance of wine andporter, together with quinine, and one of the preparationsof opium, convalescence advanced steadily. The sore occupy-ing the centre of the stump is nearly cicatrized. There is nowan excellent cushion of integument, both at the posterior orheel-part, and also in front. The patient is in good healthand spirits, sits in an easy chair during the day, with the limbresting on a hassock, and will be able to leave the hospital inthe course of eight or ten days. The author was disposed toascribe the sloughing in the present case to the violence doneto the soft parts at the time of the accident. It is by nomeans easy in the instance of railway injuries to determineat once the exact amount of damage inflicted. He deems the
operation one which ought to be resorted to wherever admis-sible. It is superior to amputation at the lower third of theleg, because attended with less risk of danger to the patient,and because affording a more serviceable limb. He had beeninformed by Mr. Gray, of Cork-street, the ingenious constructorof artificial limbs, that by means of a properly adapted foot,the individual is enabled to walk, run, get up and down stairs,just as well as with a natural one, and that in six weeks afterthe wound is cicatrized the artificial foot may be adjusted andworn. The solid cushion obtained from the heel, with itscellulo-adipose lining, forms an admirable support for the weightof the body, and one which, instead of becoming wasted andattenuated by continued pressure, acquires, on the contrary,increased firmness, and power of resistance.Mr. OBRE exhibited a very ingenious-
INSTRUMENT FOR INJECTING THE LACRYMAL SAC.
The extreme difficnltv, if not impossibility, of introducingfluid into the lacrymal sac, in cases of chronic inflammation,with Anel’s syringe, passed through the puncta, induced Mr.Obre to have a silver canula constructed, the same shape andsize as the sound of Gensoul, to which is attached a smallvulcanized india-rubber bag, about the size of a uut, intowhich the injecting tluid is introduced. The canula havingbeen passed through the nasal duct bv the inferior meatus,slight pressure of the thumb on the india-rubber bag propelsfluid. No more difficulty is found in passing this instrumentthan the ordinary sound, a little practice soon overcoming anydifficulty. It is necessary there should be a canula for eithernostril; the india-rubber bag is made to screw on either asrequired. Mr. Obre stated he had not brought this instrumentbefore the notice of the profession until he had first given it a,fair trial and proved its utility. It is made by Mr. Coxeter.The diagram below will represent the invention.At the next meeting of the Society, Feb. 2nd, Dr. King
Chambers will read a paper " On a Peculiar Form of CardiacDisease."
WESTERN MEDICAL AND SURGICAL SOCIETY.
FRIDAY, JANUARY 20TH, 1854.—DR. WILSON, President, inthe Chair.
Dr. BARCLAY read a paper on-DROPSY IX ITS RELATION TO TREATMENT.
He commenced by alluding to the high mortality of this disease,and stated that the only disease which at all approached it inthis respect was phthisis. He drew his conclusions and care-fully illustrated his views from the Medical Registries in St.George’s Hospital during the years 1851, 1852. He then re-stricted the term dropsy to anasarca and ascites, consideringthat as hydrothorax, hydrocephalus, &c., when not presentingthemselves as mere isolated portions of general dropsy, arepractically found only as the result of infiammation, theyshould be classed accordingly. Although the distinction be-tween anasarca and ascites is generally clear, yet in many casesboth forms are present, but a little care will generally discernthe primary form. The morbid states giving rise to ascites aremuch more fatal than those associated with anasarca, morethan two-thirds of those admitted with the latter form beingdischarged from the hospital cured or relieved, while less thanone-third of those affected with ascites reap the like benefits ; 9but here we should bear in mind that many anasarcous patients.return again and again to the hospital to be relieved of the
same set of symptoms. Though the actual frequency of, andconsequently the actual number of deaths from anasarca, isfar greater than from ascites, yet the ratio of mortality in
the latter form is exactly double that in the former. Withregard to anasarca, though by far the greater number of cases.
! are associated with disease of either kidney or heart, yet cer-; tain cases will compel us to attribute the disease to some other
cause. During the two years alluded to, nearly one-fourth ofthese cases could not be accounted for. The most frequentassociation of this disease is disease of the kidney, with or with-out disease of the heart; next comes disease of the heart itselfBut though these lesions are apparently so evident a cause forserous effusion, yet upon further analysis of these cases, therewill be found by no means such a direct connexion between thedisea.se and symptom, except where both organs were impli-cated. This assertion is borne out by the fact that in the twoyears before mentioned but few cases of diseased kidney, and stillfewer of diseased heart, presented no other malady of sufficientimportance to find a place in the register of disease; and toevery one conversant with disease, the pale face of albuminuria,and the dusky hue of impeded circulation, point out somethingbeyond the mere change of structure—some change in theblood itself-to be one of the necessary associations of dropsy.We found also that 63 per cent. of the patients labouring underdisease of the kidney, and 42 per cent. of those with disease ofthe heart have at the same time been affected with anasarca, andthat in some cases the only other complication found was bron-chitis with emphysema. All which facts go to prove thatdisease of the heart and kidney may go on for years withoutcausing any dropsv, until the mucous membrane of the lungsbecomes congested, and that serous accumulation follows.The explanation then is found in the obstruction that takesplace in the circulation through the lungs, and secondarily inthe effects of a chronic bronchitis on the constitution. Nextto bronchitis, phthisis stands as a cause for dropsy, its degreeprobably being regulated by the amount of night sweats,which draw off to a certain extent the serous accumulations.
112
In other cases, anæmia goes to prove that some state of theblood is an essential element in the occurrence of dropsy. I
In regard to cardiac disease, valvular lesion is the mostcommon cause of dropsy, and hypertrophy the least so, whichshows that the production of dropsy depends upon some failureof the vis à tergo, a view borne out bz- a careful analysis of the ’,various cases. In mitral disease the danger does not depend ’,upon the loudness of the murmur, but upon the feebleness ofthe pulse, and in aortic disease dropsy seldom occurs untilregurgitation is established. An increased circulation alone,too, is barely a cause of dropsy, unless some obstruction existsto the circulation of the blood, or there be an abnormal ten-dency to transudation of serum. Bronchitis, whether due tocongestion of the lungs, from mitral regurgitation, or from
exposure to cold, is one of the diseases which act in thismanner. A similar (but a more fatal) result is seen in obstruc-tion to the circulation through the liver, and in all these casesthe other causes which of themselves originate dropsy maycome into play. With regard to valvular disease, we mustbear in mind its detection at an early period, while alterationof the size of the heart only becomes manifest after it hasacquired a certain degree of intensity, which fact, though itmay have much effect upon the numerical relations of thelesions, still is of little importance, as the dropsy never
occurs in an early stage of either form of disease. He then re-marked,-
1. That a systolic murmur may co-exist with dropsy andyet have nothing to do with its production, the cause beingsimply an anæmic condition of body.
2. That hypertrophy of the heart may be masked by em-physematous lungs, leading one to the supposition that eitheratrophy or dilatation of that organ existed.
3. That a mitral murmur may be covered by a turbulentaction of the heart.
4. That cases occur in which regurgitation through themitral valves depends upon hypertrophy, a condition leadingto no error, as the results are the same whatever the cause ofthe regurgitation.The relation of kidney disease to dropsy was then discussed,
in which he stated that each stage of the disease was markedby a peculiar state of the urine. In the early stage the urineis generally clear and free from albumen, though this conditionof the secretion sometimes is found in advanced stages of thesame disease, which must make us careful in our examinationsof the urine, and in forming our suspicions as to the degree ofrenal change. In the congestive stage, albumen is present,and in acute cases of dropsy, as after scarlatina, it is found insmall quantities only in comlexion with an abundant supply oflithates. In the hæmorrhagic stage, the albumen is most
abundant, but will be found to bear no relation to the bloodpassed. Diseased kidney acts in the production of dropsy intwo ways-by suppression of urine, and by causing a drain ofalbumen and salts from the body, in consequence of which theblood becomes impoverished, and when disease of the heart ispresent it is not difficult to see this morbid state act withincreased energy in company with albuminuria. In ascitesthere is more obscurity, and though the dropsy may arise fromobstructed circulation through the liver, it may also happen ifthe mutual balance between absorption and secretion of theperitoneal surface be destroyed. But the dropsy may be dueto some general disease of the svstem, and be associated withanasarca, in which case some distinct cause will be found forthe latter. A diseased state of the peritonæum, including in-flammation and malignant conditions of that membrane, mayalso cause ascites, and as either may be associated with renalor cardiac disease, it is clear that all such cases are connectedwith and dependent on some obstruction to the onwardcurrent of the blood. As dropsy seldom depends upon themorbid state of any organ alone, but generally in connexionwith some functional disturbance of it for the time being,these superadded causes are amenable to treatment, thoughthe original one may not be. In simple uncomplicatedanasarca (as after scarlatina) we have simply to counteract thesuppression of urine, but in other cases ’B’B e must improve thetonicity of the blood and system generally. When the kidneysare congested and effusion is an immediate result, we shoulduse the intestines and the skin as our channels for the dis-charge of the serum rather than the kidneys. In complicatedcases, we often have irritation to soothe and inflammation tosubdue before the dropsy be attacked. In chronic bronchitis,in connexion with these cases, we must attend to the generalhealth, rather than use expectorants. The heart must bemodified by digitalis, and the blood improved by iron, and thekidneys excited by vegetable salines and buchu, rather than
by more powerful diuretics. Purgatives are doubtful remedies,and promise most good in ascites.The discussion which followed embraced the subject of
acupuncture in cases of dropsy, which was strongly recom-mended by some members present.The society then adjourned until February 3rd.
MEDICAL MEETING AT CROYDON,TO MEMORIALIZE LORD PALMERSTON ON THE SUBJECT OF "THE
COMPULSORY VACCINATION EXTENSION ACT."
I consequence of the difference of opinion which has arisenbetween boards of guardians and the medical profession on thesubject of this Act, meetings have been held in many parts ofthe country for the purpose of petitioning Parliament for a re-vision of some of the clauses of the Act; and with that viewa meeting of the medical profession of Croydon and its vicinitywas held at the Town Hall, on Thursday evening, the 19th inst.,which was convened by the following circular, issued by Mr.Berney. the chairman of the Vaccination Committee :-
I "Croydon, Jan. 14,1854.I "My DEAR SIR,—Having been requested, as chairman ofthe Vaccination Committee, to convene a Meeting of our pro-fessional neighbours, for the consideration of the vaccinationquestion, which has just now an additional interest on accountof Lord Lyttelton’s contemplated modification of the Act, mayI beg the especial favour of your presence at the Town Hall, onThursday, January 19th, at seven o’clock in the evening pre-cisely, that we may derive the mutual advantage of professionalexperience and counsel.
" The almost entire unanimity displayed by the practitionersresident here, and those in our immediate vicinity, leads me tohope and believe that the same adhesion to correct and soundprinciples will manifest itself at the forthcoming meeting, andthat nothing but professional engagements will prevent yourattendance ; more especially as it is no longer a question withboards of guardians, but a means of enabling Lord Lyttelton toarrive at a conclusion as to what the profession considerbeneficial for the population at large, and satisfactory to them-selves. " EDWARD BERNEY.
" P. S. -If inconvenient to attend, please to forward, undercover to me, your views and opinions."
Letters were received in favour of the objects of the meeting,and expressive of regret for their unavoidable absence, from thefollowing gentlemen :-Messrs. Alexander Brown, (Streatham;)Alfred Brown, (Wandsworth ;) Bird, (Croydon;) Gilbert,(Sydenham;) Hassell, (Wandsworth;) C. Holman, M.D.,(Reigate;) Holt, (Bromley;) Leese, (Norwood;) Martin, (Rei-gate ;) Sargeant, (Reigate;) Ridge, (Putney;) and Thompson,(Westerham;) but there were present Messrs. Bottomley,Boulger, M. D., (Bletchingley;) E. Berney, Clever, A. Car-penter, Careless, {Beckenhaxn;) Gore, M.D.; Hubbert, Henley,Markwick, Roper, Sutherland, Stilwell, (Epsom;) Shorthouse,M.D., (Carshalton;) Richardson, (Mortlake;) and Westall,(Croydon.)Mr. E. BERNEY, in opening the business of the meeting, said
that they had been convened by a circular, to take into con-sideration the provisions of the Public Vaccination Act, which,in his opinion, required some modification, and was, as at pre-sent framed, thoroughly inefficient and unworkable. To thecredit of the medical gentlemen then present, not one of themhad tendered themselves for the vacant office of public vacci-nator. With that short preface, he would conclude by proposingthat Mr. Edward Westall do take the chair. The propositionhaving been seconded, was carried unanimously.
Mr. WESTALL, on assuming the chair, expressed his opinionthat Mr. Berney would have filled the chair more ably thanhimself, inasmuch as he had acted as chairman of the Vaccina-tion Committee, and, as such, had taken the initiative in theirproceedings. A memorial has been prepared, which suggestedthat the working of the Act should be placed under the controlof the Registrar-General, and that every legally-qualinedmedical man should he a vaccinator. The chairman concludedby calling upon Mr. Berney to read the memorial addressed toLord Palmerston, and the resolutions proposed to be submittedfor the approval of the meeting.
Mr. BERNEY said that the resolutions were, of course, opento modification; he would now read the memorial :-
" To the Right Honourable the Lord Viscount Palmerston,M.P., Her Majesty’s Principal Secretary of State for theHoane Department.
, "We, the undersigned medical practitioners of Croydon and
