History midterm

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extent; there is no blood in the lungs; and the left side of the heart and arteries are empty; the serous, albuminous, and saline parts of the blood ooze through the different tis- sues, and are evacuated; the fibrine of the blood alone being found in the intestines. Now this must be owing either to the choleraic poison

having so chemically altered the blood that the oxygen of the atmosphere cannot act chemically upon it, and the venous blood remains in the pulmonary artery; or the choleraic atmosphere is of such a nature as to prevent the chemical combination of it with the blood of the individual in respira- tion. Unfortunately, Dr. Parkes had not the means of chemi- cally and pathologically examining the blood of his cholera patients; but the former position appears the most tenable, from the immediate good effect produced by injecting a solu- tion of albumen and salts into the veins, which, unhappily, does not last long enough to allow Nature to weather out the disease. When a case has reached this period, it is almost in-

variably fatal, for no absorption can take place, the venous system is full, and all medicine and nourishment introduced into the stomach must be useless. But may not the red globules of the blood become poisoned

and useless ? And if so, what use would the albumen-and- salts be, if there were no oxygen carries t

Reflecting on this subject since reading Dr. Parkes’ work, I have made up my mind, should nothing more be discovered respecting the pathology of cholera, and considering the failure of every other mode of treatment, that I will treat any cases verging into the stage of collapse, by first taking away as much blood as I reasonably can from a vein in the arm, (no easy matter,) and then immediately transfuse warm blood from the most healthy subject I can meet with; and keep up respiration as long as possible with a mixture of equal parts of oxygen gas and atmospheric air. Although this will not dislodge from the branches of the pulmonary artery the poisoned blood, it must give Nature a better chance of carrying on circulation and respiration, than by injecting merely albumen and salts, without any healthy red globules.

I think respiration may be carried on, in such cases, by using a modification of my friend Sibson’s mouth-piece, which he invented for the inhalation of chloroform: and oxygen gas can be kept ready prepared over water for a great length of time. The first, or premonitory stage of cholera, requires merely

common astringent remedies. The next stage, where the vomiting and purging are accompanied by cramps, seems to admit of two grand modes of treatment-viz., tartar-emetic, and acetate of lead with opium; together with various ex- ternal remedies, to relieve particular symptoms. In 1832, I only became acquainted with Mr. Hott’s (of Manchester) treatment by tartar-emetic, when the disease was subsiding; but all the cases I treated with it certainly recovered. In THE LANCET for the 16th of September, 1848, there is a valu- able communication from my friend Dr. C. Radclyffe Hall on this subject, well worth perusing; and I can add my testi- mony to the success which attended that mode of treatment.

I am not aware that the above method of treating the stage of collapse has ever been tried; but until the researches of those who are most conversant with pathological chemistry shall have decided what the nature of the poison of cholera is, any apparently rational mode of preserving life for a few hours cannot be deemed unworthy of notice. Rotherham. October 10th, 1848.

ON A RECENT CASE OF ASIATIC CHOLERA SUCCESSFULLY TREATED.

BY W. B. HART, ESQ., M.R.C.S., &c., Spitalfields. MARY ANN C-, aged eleven, residing at Wilson’s-place, Spitalfields, became the subject of malignant cholera on Thursday, the 5th inst., having been previously in good health, and free from diarrhoea or any other disorder of the bowels. Her parents state that they went out with their children,

including my patient, about eight o’clock A.M. on the above day, and in passing beneath the railway arch in Wheeler- street, they remarked the offensive effluvium arising from refuse matter which is there lying about in various nooks and corners. Upon their return home, the child was seized with vomiting and purging every half-hour. About eleven o’clock she began to complain of cramps, and to feel very low and faint, when the father administered some medicine which he had purchased at a chemist’s shop. The symptoms, however,

increased in severity. I was applied to, and saw her at half- past eight P.M. I found the extremities cold; no pulse to be distinguished at the wrist; frequent vomiting and purging; the stools consisting of watery, colourless fluid, with white flocculi floating in it, and possessing no faeculent smell; coun- tenance sunken and deathlike; voice weak and whispering, (vox cholerica.) She was quite sensible, and said she had not passed any water since the commencement ; complains of cramps in the back and arms; asks frequently for drinks, but generally vomits shortly after taking any. To take imme- diately the following draught :-Tincture of opium, ten minims; aromatic spirit of ammonia, half a drachm; essence of peppermint, twenty drops; chalk mixture, an ounce. Mix. Bottles of hot water to be applied to the feet and legs, and all parts that felt cold. The parts affected with the cramp to be rubbed with mustard. Half a gill of brandy, mixed with hot water, to be given directly, and a dessert-spoonful every half-hour. Weak brandy-and-water to be given whenever drink is asked for.

I saw her again in half an hour. The symptoms continuing the same, I ordered that she should take the following pill directly, and repeat every half-hour:-Powdered opium, half a grain; powdered capsicum, camphor, of each two grains; conserve of roses, sufficient to form a pill.-Eleven P.M.: No pulse at wrist; the pulsation of heart can scarcely be dis- tinguished ; the face and neck getting cold, and also all parts not in contact with warm applications; three evacuations from the bowels, about half a pint in quantity; had vomited once. A hot mustard poultice to be applied to the epi- gastrium. To continue the other remedies.

Oct. 6th, One P.M.ŇHas been purged once; has not vomited; the action of heart cannot be felt by the hand; appears mori- bund.-Three P.M.: I was agreeably surprised to find that re- action had taken place; the pulse had returned to the wrist, and was 130; the skin less deadly cold; face rather flushed; eyes half closed, and turned upwards; she is somewhat coma- tose ; can be roused by loud speaking and shaking, but soon relapses into insensibility; no vomiting, nor any evacuation from bowels. To discontinue the opiate and brandy, and to take sesquicarbonate of ammonia, three grains, in peppermint water, every two hours.-Eight P.M.: Less comatose; pulse 120; skin moist and warm; has had two motions, but coloured with bile, and of a faeculent smell.

7th.---Pulse 110; passed water for the first time at two o’clock this morning, and several times since; dozes a good deal, but is easily aroused; and sensible. The bowels became rather relaxed in the course of this day, but the evacuations were of a natural appearance. To take every four hours, mercury with chalk; compound ipecacuanha powder; of each, four grains. Continue the mixture. Since then she has been gradually improving, and is now convalescent.

I take this opportunity to acknowledge the kind assistance and advice of Mr. Liddle, of Alie-place, in the treatment of this case. Another child in this family, aged three years, was attacked

with this disease about the same time as her sister; the symp- toms were less severe; and she is now recovered. The mother, aged thirty-two, was also attacked on the 8th inst., and died in twenty-eight hours.

October. 1848.

CHOLERA AND ITS TREATMENT. BY HENRY MOON, M.D. Lewes.

WITH an enemy so formidable as the cholera, and which is steadily advancing in its well known course from east to west, we have reason to congratulate the nation that the government has made some preparations, however limited and insufficient they may be, to receive it. In a late number of THE LANCET there is an interesting case of cholera, very ably reported by Mr. Ford, of Pimlico, but which admits of the strongest doubt if it were cholera of the Asiatic kind. It is true there were many points in this poor man’s disease, which would go far to identify it with its more fatal neighbour, but the absence of the peculiar turbid whitish liquid, free from bile, which, sooner or later, is poured forth from the stomach and bowels, in every case of Asiatic cholera that has come under my own notice in this country, and in the severe epidemic which visited Canada in 1832, would induce me to classify it as an instance of the sporadic variety, aggravated by the unfavourable cir- cumstances with which the patient was surrounded. The treatment of cholera can only be empirical, so long as

the pathology of the disease is so imperfectly understood; and until some new light be thrown upon this mysterious subject,

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we must refer to experience alone, in the selection of those remedial agents which have been the most successful in the mitigation of its sufferings. The facts connected with carbon, as a remedy for Asiatic

cholera, recorded by Mr. Ritson and by Mr. Price Evans, are at least striking: they remind me of the course pur- sued by a celebrated quack at Montreal, in 1832, who combined charcoal, maple-sugar, and lard, in equal quantities: three table-spoonfuls of this compound were swallowed by his patients every two hours; they were also immersed in the hot ley of wood - ashes, and afterwards covered with warm blankets-this process was repeated until amendment took place. I can with confidence add my humble testi- mony to the efficacy of well applied frictions, and the hot bath. During the rage of this epidemic, it often happens that on first seeing the patient, he has not the power of deglutition, or if that should remain, the incessant vomiting and purging will render any internal remedy useless; in this condition, particularly, the hot bath, to be repeated as often as may be necessary, the whole body afterwards to be well rubbed with coarse woollen cloths by three or four persons even for hours together, has done more to allay the irritability of the internal organs, than any other means whatsoever; indeed, I have often seen these remedies, raise as it were from the dead, in the extreme stage of collapse and of apparent death, so often witnessed in this distressing and fearful disease. Lewes, Sussex, Sept. 5th, 1848.

ON A NEW PLAN OF TREATING OVARIAN

DROPSY, WITH A REVIEW OF THE VARIOUS MODES OF TREATMENT WHICH

HAVE BEEN ADOPTED FOR THE CURE OF THAT DISEASE.

BY E. J. TILT, M.D., &c., London, PHYSICIAN TO THE FARRINGDON GENERAL DISPENSARY, ETC.

II. SUR’GICAL TREATMENT-continued.

OVARIOTOMY.

WE have now passed in review those plans of treatment whereby it has been attempted to remove the contents of ovarian cysts; but it has been of late proposed to attack the complaint by a more radical plan of treatment-viz., the re- moving the cyst itself, as well as its contents. This operation has found favour with American surgeons, being well calcu- lated to suit the neck-or-nothing character of our transatlantic brethren. Dr. M’Dowal performed several operations of ovariotomy in 1809, and his example was followed by some of his countrymen. Under the sanction of a certain amount of undenied success, ovariotomy was imported to England, and first performed by Lizars in 1823. Since then, the operation has been frequentlyrepeated; and when we consider the apathy of the profession with respect to the treatment of ovarian disease, and the proverbial inutility of our efforts to cure this complaint, can we be surprised if many hailed the account of the first successful operation as the earnest of future success, and as positive assurance that the radical cure of ovarian dropsy had been at last discovered? a

This operation was performed by Dieffenbach in 1828, and several times afterwards by different German surgeons. The French, on the contrary, look upon it with almost unanimous feelings of astonishment and disapprobation. Auguste Berard was, I believe, the first in France to perform this operation, at L’Hopital de la Pitié; the patient died three days after; and THE LANCET of June last published the first case success- fully operated upon in the same country by Dr. Vaullegeard.

I say, advisedly, that this is the first case of ovariotomy per- formed in France, for L’Aumonier’s operation admits of no ex- cuse, and cannot be classed with those performed to remove volu- minous ovarian cysts. Those who will take the trouble to refer to the M4moires de la Societé Royale de Médecine, année, 1782, 4to, p. 296, will find that L’Aumonier made an incision four inches m length, to remove an abscess of the ovary from a woman twenty-one years of age, six weeks after delivery. Though success did follow such an extraordinary plan of treatment, still, if such cases are to be included in tables of operations for ovariotomy, then why not also include the case told by Wierns in his book, (de prestigiis,) of the sow-gelder who thought proper to remove the ovaries of his daughter to im- prove her morals. There are now about 150 cases recorded, so that we have con-

siderable data afforded us wherewith to form some opinion respecting the value of the operation, though insufficient for the final decision of the question. How, indeed, can we hope

to arrive at a fair average of the dangers and merits of ovariotomy, when we know that many unsuccessful cases have not been published ? Mr. Phillips states, that he has heard " particulars of five unpublished cases, of which at least three were unsuccessful; but I cannot (says Mr. Phillips) venture to publish them !" " As an honourable man should be equally ready to publish his unsuccessful cases, we may look for the authentic particulars hereafter. This opinion is confirmed by Dr. F. Bird, who says, it was " deeply to be regretted that the profession were unable to form any correct opinion on the subject, from motives that could not be too strongly censured. Unsuccessful operations had been most carefully suppressed,. while those in which a happier termination occurred, had been hurried into publicity even before the patient had been fully recovered, and whilst the ligature was still contained in the abdominal cavity. Within these last few weeks the abdomen of a patient had been laid open, in which no tumour was con. tained; in another example in which the operation had been performed, death had been ushered in with all the symptoms of strangulated intestine; in another, in which the abdominal section had been made, the patient had quickly died; yet were all these cases carefully concealed; while those in which recovery had taken place were made the subject of daily advertisement." Mr. Caesar Hawkins mentions as a notorious fact, that there

are many unsuccessful cases unpublished. In alluding to these statements, Mr. S. Lee adds-" I myself am aware of two cases, one in which no tumour was found, and the other died shortly after the operation, which cases have never been published, and of which I could obtain no authentic records."* I have also heard of a case where gastrotomy was performed, and no ovarian tumour found. The case is not published, and I am not allowed to publish it. If those gentlemen who hav& now often performed this operation, after careful selection of cases, and with undoubted skill and acknowledged success, would imitate the good example set them by Dr. Clay, and publish their cases, alike successful and unsuccessful, then, indeed, would the profession be able to arrive at something like a correct estimate of the value of this plan of treatment.

It was my intention to have published a new table of cases of ovariotomy, noting all the known operations performed up to the present date; but I must defer so doing until I bring out my work on ovarian diseases. Dr. Clay’s cases will then have been made public. Mr. Walne has announced bisinteni. tion of publishing his cases, and Dr. F. Bird has assured me of similar intentions. These gentlemen will probably not long delay the fulfilment of their promises. The imperfection of our data being premised, I will :first

adduce the conclusions that may be drawn from the table affixed by Mr. Lee to his valuable work on

" Tumours of the Uterus." I will afterwards give the results to be derived from the practice of those who have been in the habit of per" forming the operation. We find in the above-mentioned table, 118 cases wherein

the abdomen has been opened. We cannot call these eases of ovariotomy, for it was often impossible to extract the tumour. If we want to ascertain (as far as this document may allow) the value of ovariotomy, we must then deduct from these 118 cases of evisceration,-lst, the six cases in which no tumour was found; 2nd, those cases where there existed a tumour different from the one expected; 3rd, those cases where the tumour was really ovarian, but so adherent, that no operation could be performed to remove it. There will remain ninety-two cases of ovariotomy. Of these ninety-two cases, thirty-three were fatal, and fifty-nine were successful. The chance of recovery after this operation is, then, as fifty-nine to thirty-three; or, in round numbers, as two to one. Ovariotomy is, then, a most dangerous operation, almost as dangerous as hysteriotomy; for if we refer to Kayser’s valuable dissertation, " De Eventu Sectionis C,,2k-saria-," we find that out of 341 cases, the whole amount of cases on record, the recoveries were 127, or thirty-seven per cent., or nearly two recoveries in every five cases. If, on the contrary, we were to take the results afforded by the reports of lying-in hospitals, in which con. cealment is impossible, and failure is necessarily as notorious as success, we should find that of sixty-seven cases recorded in the above-mentioned dissertation, only fourteen recovered; or that the recoveries were only twenty per cent. instead of thirty-seven per cent., or one in five instead of two in five. If, when concealment is impossible, such be the amount of danger in hysteriotomy,-an operation which may be termed

* Dr. Ashwell, in the recently published edition of his work on "Diseases of Women," while dismissing, almost without observation, this operation, declares that he has painful reason to doubt the accuracy of many of the cases published, as attended ’with favourable results.