see people when they are sinking from mortification of any other part; there can be no doubt of the nature of the disease.

GLASGOW ROYAL INFIRMAHY.

CASES WITH OBSERVATIONS. By WILLIAM DAVIDSON, M.D. Senior Physician to the Infirmary."

1. The first case detailed by Dr. Davidson is one of chronic pleurisy. Paracentesis was performed between the 6th and 7th ribs on the left side. Twenty pounds (apoth. weight) of serum were evacuated. It had a yellowish colour, was nearly transparent, adhesive, almost solidified by heat and nitric acid, and had a specific gravity of 1016. The fluid re-accumulated, and a small grooved needle was inserted into the left pleural cavity, near the cicatrix of the former opening, and, a large cupping-glass being applied over it, forty ounces of reddish-coloured serum were drawn off. Next day a small trocar was inserted by Dr. Lawrie, and twelve pounds (apoth. wt.) of serum were drawn off by cupping-glasses. The patient subsequently died.

Dr. Davidson makes some remarks on the mode of performing the operation. "The operation for empyema is not very frequently performed, for on the one hand there are the difficulties of the diagnosis, and even when the signs are pretty clear, there may be some doubt about the state of the lung; and on the other, the danger of exciting a pleuritic inflammation A plan, therefore, which may tend to remove or lessen any of these objections is worthy of consideration. The chief danger of the operation arises from the admission of air into the pleural cavity, and this cannot be avoided by the ordinary method, and if the stethoscope be applied to the chest during the evacuation of the fluid, atmospheric air can be heard entering its cavity with a noise similar to that produced by emptying a bottle nearly filled with water. To obviate this result, it occurred to me that the fluid might flow through the channel of a grooved needle, with the exhausted cupping-glass placed over it; this I accordingly tried, as stated in the report, and it succeeded perfectly, but the quantity of fluid being very great, it was necessary, in the second trial, to use a small trocar. One practical difficulty occurred with the canula, but not with the grooved needle, viz. its liability to slip from the opening, when the cupping-glass was applied, which is obviated by previously tying it around the chest by a piece of narrow and very thin ribbon. The cuppingglass employed was curved, and capable of containing about two pounds of fluid, and it was exhausted by a piece of ignited lint, which had previously been dipped in alcohol. Very little air, as far as could be ascertained, entered the pleural cavity, and it is a good practical rule to hold the finger over the mouth of the canula, during the changing of the glasses, which ought to be frequently done, as it lessens the duration of the operation, by causing the fluid to flow in a full stream, whereas, without the aid of an exhausted cupping-glass, it would do so very slowly. The same plan of operation I have frequently adopted in opening chronic abscesses, even in the knee-joint, without any subsequent irritative fever or inflammation, and in one or two cases, even in cachectic constitutions, there has been no re-accumulation of matter, when firm bandaging was afterwards had recourse to."

In another case, the operation was conducted exactly as described in the former, and the narrow piece of ribbon employed was completely successful in

* London and Edinburgh Journal of Medical Science, No. 11.

retaining the canula. A few bubbles of air got admission into the pleura, which is inferred, as stated in the report, from the metallic tinkle, which was heard two or three times. This may, he thinks, be obviated, by withdrawing the cuppingglass whenever the fluid ceases to flow in a stream, and applying another one.

2. Rubbing Sound in Pericarditis.

W. A., aged 15, of delicate and rather unhealthy constitution, was seized, on the 10th April, 1841, with a slight shivering, some pain in left side of chest, slight dyspnea, cough accompanied with a slightly acceleratrd pulse, hot skin, and furred tongue. On the following day the chest was examined, but nothing was discovered abnormal, except a pretty general bronchitis. On the 16th, he complained of rather acute pain in the cardiac region, accompanied with dyspnea, the pulse being 100, moderate in strength and regular. On percussion, the whole of anterior chest was found clear, except the right submammary region, which was slightly dull, and a dry subcrepitation was heard there with the stethoscope. The sounds of heart were rather loud, the impulse being pretty strong, and a rubbing sound was heard accompanying its action, about an inch below nipple, and a little to its right. This rubbing sound was tolerably distinct even during respiration; but in order to be sure that it was not connected with this process, the patient was desired to hold his breath, when it was most distinctly recognised as accompanying the motions of the heart. Although I listened to it very attentively on several occasions during the three or four days that it was discoverable, I was unable to connect its precise similarity to any other friction sound with which the generality of inen are familiar. It certainly was not like the creaking of leather, but if I were obliged to give an expression to my perceptions, I would say that it resembled somewhat the sound produced by the friction of one piece of woollen cloth against another. This friction sound, as already mentioned, only continued for a few days, and after that period, there was distinct and extended dulness of percussion in the cardiac region, accompanied with palpitation, irregular pulse varying from 120 to 130. On the 6th May, his symptoms were the following-urgent dyspnea; palpitation on the slightest movement; pulse 130, irregular, intermittent, weak; frequent cough; expectoration-a greenish, tenacious mucus; dulness of percussion in cardiac and both submammary regions; action of heart, weak, irregular; dry subcrepitation in right submammary, and in part of left submammary regions, accompanied with considerable fulness in the intercostal spaces of left chest and epigastrium, with cedema of the lower extremities. He lived nine days after this period, but the symptoms did not differ materially from those now mentioned. His treatment consisted of antimonials, purgatives, calomel and opium to salivation, leeches to the cardiac region, repeated vesicatories, diuretics, and, towards the close of his disease, anodynes.

Inspection. Inferior lobes of both lungs were red, congested, and slightly crepitant, bronchial tubes were reddened, and they contained an opaque somewhat tenacious mucus.

Pericardium was enormously enlarged, extended beyond sternum a considerable way towards right side, and covered completely the lower half of left lung. On laying it open, about three pounds of thin whitish pus, mixed with whitecoloured flakes of lymph, were evacuated. The internal surface of pericardium was whitish, rough, and covered with numerous patches of lymph and adherent flocculi. The heart was large, very flaccid, rather displaced or twisted to the right side, to which its apex pointed almost directly. Its pericardial covering was almost completely coated with patches of lymph, and rough fibrous vegetations. The valves and internal membranes of heart appeared to be quite normal. No other morbid appearance was discovered in the chest or abdomen. The head was not examined.

3. Diagnostic Symptoms of Malignant Disease of the Liver. The symptoms of the disease during life are involved in still greater obscurity than its pathology, and, in the early stages, our opinions must be little better than conjectural. The general symptoms of gastric and hepatic derangement are not to be depended on, for they are common in other affections of the liver; and Cruveilhier states, that the enlargement of this organ, and the elevations on its surface, are the only pathognomonic signs. In the majority of cases that I have witnessed, pain, frequently of a severe kind, was experienced in the right hypochondrium or epigastrium, and the termination of the disease was more rapid than in other hepatic affections. If, then, the liver be found considerably enlarged, distinctly nodulated-if the disease be accompanied with severe pain in the hepatic or epigastric regions-if it be somewhat rapid in its progress, and if the features of the patient have a very cachectic or sunken appearance; then there can remain very little doubt of the malignant nature of the affection.

CLINICAL REMARKS BY DR. MARSHALL HALL, ON THE USE
OF SETONS.*

Many years ago, I was consulted by Mr. Doubleday, of Blackfriars Road, in the case of a young married lady, who had suffered from peritonitis after her first accouchement.

This peritonitis appeared to be confined to the pelvic region. Its acute character had been subdued, but tenderness, with tumidity, and difficulty in voiding the bladder and rectum remained. I made a careful examination. A distinct hardness was felt under the pubes, extending to one side, I think the left. Оп examination per vaginam and per rectum, a similar hardness was found occupying the lower part of the pelvis. I imagined this hardness to consist in coagulable lymph, effused from the inflamed peritoneal surfaces of the pelvis, producing the symptoms by its pressure on the neck of the bladder, and on the

rectum.

We strictly regulated the diet and the intestines, and inserted an ample seton over the induration. Slowly and gradually that induration, with its attendant symptoms, became diminished, and eventually disappeared.

Several years after this, I was consulted in the case of the sister-in-law of this patient, under very nearly similar circumstances. The same remedy was followed by the same happy result.

A year ago, I was consulted by Mr. Burford, in the case of a gentleman of sixty, who had become affected with pain, tenderness, and tumidity of the abdomen. On a careful examination, a distinct hardness was felt, in the midst of the general tumidity, occupying the region of the caput cœcum coli. We regulated the diet and the bowels, administered mercury, and inserted an ample seton. The mouth became affected, and the seton discharged copiously: the hardness and the other symptoms gradually, but at length, entirely disappeared.

A similar case occurred a year ago, in the person of a gentleman of forty, a patient of Mr. Squibb, in Orchard street. A strict regimen was enjoined, the bowels regulated, and an ample seton was inserted. The induration, which in this case occupied the space between the false ribs and the ilium, on the left side, gradually disappeared.

Two years ago, I was consulted by Mr. P- a barrister, affected with pneumonia of the midele and upper lobes of the right lung. A seton was in

* London and Edinburgh Journal of Med. Science, No. XI.

serted, and Mr. P— went to Madeira. On his return, the physical signs and the symptoms of the pneumonia had disappeared.

I have still more recently treated a case of pneumonia of the upper portion of the right lung, in consultation with Mr. Beane of Peckham. A seton was inserted, and in six weeks a most decided amendment in the physical signs, the symptoms, and the general health occurred. Since that period, the patient has continued to improve, and now no dulness on percussion, or other sign of disease, is perceptible.

In a variety of cases of acute or chronic, local or limited internal inflammation, I have had recourse to the seton, and uniformly with the most marked success; so that, I think, we may look upon the remedy as almost specific in such cases. It is unnecessary to enumerate them. But hepatitis and nephritis belong to them in an especial manner, and I would suggest this remedy as likely to be of service, (if any remedy can,) in the case of albuminous urine. In one such case the urine was more albuminous after cupping. I imagined the effect arose from the mechanical violence inflicted, and recommended the cupping to be performed above and below the precise region of the kidneys. Under the use of this remedy, the albumen diminished, and even ceased for a time.

These and other cases, then, induce me to think, that there can be little doubt of the real efficacy of the seton in chronic inflammation. The object is to demonstrate this in some measure, and then to notice briefly, farther applications of the remedy. I do not pretend to suggest anything new, but rather to enforce what is old. The efficacy of setons, when appropriately applied in the nucha, (for they are frequently employed very uselessly,) is well known. The proper cases are inflammation and congestion. But the case to which I would particularly draw attention is that of disease of the spinal marrow, with paraplegia, or paraplegic spasm.

In this case, issues are generally inserted. They appear to me far more painful, far less manageable, and far less efficacious than ample setons. They have also, I am persuaded, been generally applied below the real seat of the disease. I was consulted a few weeks ago by a gentleman from Manchester. With partial loss of power, he had loss of sensation in the lower extremities; the numbness extended to a line just above the sacrum. Issues had been applied on each side of this line. They might, with equal efficacy, have been applied to the foot! I need not say that the spinal nerves proceed, for some distance, from above directly, rather than obliquely, downwards, and that the seat of the disease is at or ABOVE their junction (insertion or origin,) with the spinal

marrow.

Bearing these two principles in mind, then, viz. that ample setons afford a more efficacious counter-irritation than issues, and that they ought to be applied higher along the spinal column than has been usual, I think we have a new mode of treatment for this formidable class of diseases.

These setons should, besides, be larger than usual. They should be threefourths of an inch in breath, and extend through two inches in length, be inserted on the level with and above the supposed seat of the disease, (the anatomy being consulted.) and be four or six in number, two or three being instituted on each side of the spinal column. Acting on this principle, 1 had, five days ago, the pleasure to receive the most satisfactory account of a patient affected with paraplegia, whom I had seen at Lohan, in Essex, in consultation with Mr. Gross.

I repeat, and beg to conclude by repeating, that I believe counter-irritation applied along the spine has failed, because it has been applied below the seat of the disease; and that, to be efficacious, it must be both more efficient in itself, and applied with greater regard to the anatomy of the spinal marrow and nerves. The precise spot for their application must be left to the well-informed

practitioner. I need scarcely remind my reader, that the persistence, or cessation, of all reflex actions, will determine whether our remedies should be applied above or below the origin of the cauda equina, above or below the last dorsal vertebra.

We are great advocates for setons too. We confess we have not used them so broad nor so many at a time as our friend Dr. Hall. But perhaps he is right. The difficulty would be, in some cases, to induce patients to submit to their introduction.

We have tried setons in three or four cases of albuminous urine. They were bad cases certainly, and the effect was not encouraging.

MR. WILDE ON THE SCHOOL OF OPHTHALMIC SURGERY IN VIENNA.

Mr. Wilde gives an interesting sketch of this celebrated School in the last number of our Dublin contemporary.* We shall extract some passages from it.

State of Surgery in Austria.—It is remarkable, that while ophthalmology is, and has, for so many years been cultivated with such marked success in Austria, the general practice of surgery is in a state so low, that one of the grades of those licensed by its universities and lyceums to practise that branch of the healing art, is compelled by law to keep a barber's shop, whose interior may be learned by a glance at Teniers' graphic illustration of a Dutch surgery.

Barth the first Teacher of Ophthalmology in Austria.-Barth war born in the island of Malta, in 1745, and studied medicine at Rome, and afterwards at Vienna. When but eighteen years of age, he was appointed Professor of Anatomy to the University under Störk, the successor of Van Swieten. The anatomical school of the Austrian capital acquired considerable renown at that period, from possessing the valuable microscopic preparations of Ruysch, Lieberkühn, and Albinus, purchased by Van Swieten for the University; they were committed to the keeping of Barth, and the opportunities they afforded him for studying minute anatomical structure were eagerly laid hold of, and tended in no little degree to his future advancement.†

This tradition is current in Vienna; a lady attached to the court of the empress becoming blind, was pronounced amaurotic by the medical advice called in; her malady continuing to increase, the Baron Wenzel was sent for, and at once declared it to be cataract and operated on it with success. So amazed was Maria Theresia, at this display of Austrian surgery, that she forthwith established a special lectureship of ophthalmology, and Joseph Barth was the first that filled this chair, in 1773; and in 1776 he was appointed oculist to Joseph the Second. He was a most expert extractor, and there are still living several who have witnessed his operations-the invention and use of Beer's knife (that now so generally adopted) is in a great measure due to him for although his was longer in the blade, and somewhat broader toward the handle, yet it was upon an enlarged scale the same. The objections to it, of its pricking the nose from the great length of its point, and its not cutting itself out (as it is termed) with

*Dub. Journ. Nov. 1841.

Several of these most beautiful preparations still remain in the University museum; those of Lieberkühn in particular, now in the keeping of Professor Berris, are, notwithstanding all our modern improvements, some of the finest injections in existence; they are only equalled by those of our esteemed friend, Professor Hyrtl, of Prague.