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placement of the uterus in the autopsies of young virgin girls when the bladder was full. On the contrary, he had remarked its frequency when the bladder was empty.-Zeitsch. der K. K. Gesells. der Aertze zu Wien. March and April. P. 365.
MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH. December 6, 1854.-J. Y. SIMPSON, M.D., President, in the Chair. ANEURISM OF THE SUBCLAVIAN ARTERY WITH CONTRACTION OF THE PUPIL. By W. T. GAIRDNER, M.D.— The patient, a middle-aged man, was shown to the Society. Dr Gairdner remarked that he had no doubt that the aneurism involved the inner third of the left subclavian artery ; possibly also the adjoining portion of the aortic arch. The interesting fact connected with the case was the contraction of the pupil on the side corresponding to the aneurism. This was not an accidental coincidence, for the recent experiments of Budge and Waller showed that the pupil was under three distinct sources of nervous influence. The circular fibres which contract the pupil are supplied from the third nerve (oculomotor) and the fifth (trigeminus). The radiating fibres which dilate the pupil are supplied, according to Budge and Waller, by sympathetic filaments which pass from the ganglia of the neck and upper part of the thorax upwards into the skull and join the ophthalmic branch of the fifth (trigeminus) after it passes the Casserian ganglion. Hence stiinulating the sympathetic in the neck dilates the pupil, and cutting it causes permanent contraction of the pupil. These experiments further show that the whole of the sympathetic fibres which go to the pupil from the cervical ganglion are originally derived from the spinal cord in the lower cervical and upper dorsal region. If the cord be destroyed in this region, or if the emerging spinal nerves be cut near their roots, the effect on the pupil is the same as if the sympathetic nerve or its ganglia in the neck were destroyed, i.e., permanent contraction of the pupil follows. The portion of the cord involved in the motions of the iris is called by Budge and Waller the regio cilio spinalis. It extends from the fifth cervical to the sixth dorsal vertebra.
Mr Spence said that while the contraction of the pupil after division of the sympathetic in the neck had been very generally noticed in the course of Dr John Reid's experiinents, yet from the numerous sources of fallacy, he knew that Dr Reid at the time did not wish to attach undue importance to this apparently casual sequence.
Dr Struthers remarked that Dr Reid's experiments showed that compression or division of the sympathetic in the upper part of the neck in the cat and dog had an immediate effect on the pupil, causing its contraction. Whatever the explanation might be, there could be no doubt as to the fact. Dr Struthers had himself experimented on the cat with similar results. The explanation given that evening might be fair enough as a theory, but we must be careful in deducing physiological conclusions from these experiments. Observers had shown that, in the dog at least, the brachial nerves, and the part of the spinal marrow from which they arise, exerted a similar influence; and, besides, the results of various experiments were not uniform on different animals. The anatomical explanation, also, was not free from difficulty. The communication between the sympathetic and third nerve in the cavernous sinus was but a slight one, and was not constantly to be found, while it was the sixth or abducens nerve which formed the large and constant communication; but it was the third and not the sixth nerve which supplied the iris. In confirmation of the theory that the third nerve did not furnish the dilating power of the pupil, Dr Struthers had found that in paralysis of the third nerve, in which the pupil remains fixed in a somewhat dilated condition, the iris still retained its dilating power under the influence of belladonna. But this might be, independent of the nervous forces altogether, as we do not yet understand the mode in which belladonna acts on the iris in causing its dilation.
Dr Gairdner said that these experiments of Budge and Waller mere remarkable, as they tended to clear up the differences in Dr Reid's experiments, and especially those which related to the different results obtained in dogs and rabbits, and to which allusion had been made by Dr Struthers. Dr Gairdner suggested that a series of experiments should be made on his patient when the effect of various reagents on the pupil might be ascertained.
Two Cases OF ANEURISM UNSUCCESSFULLY TREATED BY COMPRESSION. BY JAMES MILLER, Esq.- The author was of opinion that the question as to the treatment of aneurism by compression was still sub judice, and must be settled by the production of facts, rather than by mere reasoning. As an advocate for this form of treatment, however, he held it to be necessary that all facts bearing on the question should be adduced, and, acting on this belief, he brought forward these cases of failure.
Case I. was one which Mr Miller had had under his own care in the Royal Infirmary. The patient was a shoemaker, aged forty-two, from Galashiels, and was admitted March 23, 1854. His general health was good, and the popliteal tumour was about the size of a hen's egg. Next day, Carte's compressor was applied on the femoral at its upper and lower portions. The pressure was moderate, and antiphlogistic regimen was enjoined. On the 27th, the upper compressor was reinoved, in consequence of the complaint of pain ; and on the 5th of April it was noted that there was much pain, swelling, ani ædema of the limb. A lump of lead, with an elastic band attached, as used in the Dublin hospitals, was now tried. August 1st, seventeen weeks since the commencement of the treatment, the tumour was harder and slightly diminished in size; pulsation was distinct. Flannel was ordered to be applied to the limb. The lead weights had up to this time been kept constantly applied above, and Carte's apparatus to the lower part of the limb. Aug. 3, the patient suffered much; anxious to have the artery tied. Carte's apparatus alone was now kept applied at night. Aug. 10, pressure was abandoned: the tumour was harder, but still pulsating, becoming caudate towards its head, and increased in size towards the inner side. Aug. 24, five months after admission, the artery was tied. The parts in its neighbourhood were found more matted together than usual. At 8 P.m., a slight thrill was perceptible in the tumour. There was sickness from the chloroform. Pain of the back was complained of. Aug. 25, the thrill was still less. Colchicum was given internally; and chloroform was applied locally to the back. Aug. 26, the thrill was scarcely to be felt; and on the 27th it was gone. Aog, 30, the thrill had returned ; and on the 15th September it was noted that the thrill was still present; the ligature was yet in the wound; it came away on the 18th. October 10, the tumour was at length silent, and diminished in size. The patient was dismissed on the 14th.
Case II. had been under the care of Dr Johnston of Montrose, and was admitted into the Montrose Infirmary, March 24, 1854. The tumour was about the size of a small orange, and had been first noticed in the previous July, and gradually increased in size. The pain at the time of admission was severe, the symptoms well marked. The health was good, and the heart sound. Low diet, etc., was ordered, and digitalis given internally. Carte's apparatus was applied at intervals, and soon another instrument alternately with it. Up to the 16th of August the tumour had become flattened and diminished in size to that of a walnut. The pulsation was weakened, but was still apparent. The health now began to flag, and on the 23d a ligature was applied. Slight pulsation was felt in the tumour on the 28th, but never returned. The ligature came away on September 14th; and on the 15th of October the patient was dismissed from the hospital. Dr Johnston attributed the successful issue to the fact of the pressure employed having developed the collateral circulation of the limb.
Mr Miller drew attention first to the fact of the pressure not having been easily borne. He believed that a still simpler method of applying it would yet be discovered. Secondly, careful watching was requisite during its application, as the patient, under the mistaken idea of expediting the cure, was apt by undue pressure to excoriate the parts and induce erysipelas. Any swelling of the limb, etc., demands attention, but cessation of the pressure appeared to juffice to dispel such dangers. Care to be taken that the pressure was not pplied too low down. Third, it was to be noted that the collateral circula. ion was much affected. In the first ca-e, the tumour first became harder, etc., and then pulsation appeared in it from the collateral circulation. In uch circumstances, Mr Miller would recommend instant application of the igature, and if this was not done, difficulties were met with afterwards, even f the artery was tied. As it was, in this case the pulsation continued for six weeks. In Dr Johnston's case, however, the collateral circulation gave no rouble after the deligation of the vessel. In future, if after long-continued pressure the collateral circulation increased greatly, Mr Miller would cease compression, and after an interval of rest would apply a ligature, without, lowever, any risk of gangrene su pervening. Fourth, as to the effect on comDressed parts. In the first case, pain was always complained of, and a hardless could certainly be felt. On dissection, the parts were found much conlensed, and difficulty was experienced in passing the needle, but this was to e avoided by cautious dissection. Fifth, after prolonged pressure, the state a which the system is, is one very favourable for a subsequent operation. n the first case, from accidental exposure while on the operating table, an ttack of lumbago came on. Lastly, Mr Miller pointed out the odd parallelism which existed between the two cases as to the dates of admission and of their eneral progress. These histories furnished the following arguments for and gainst the treatment by compression : Against. 1. The pressure was not rell borne. 2. The effect produced on the collateral circulation, and on the arts immediately subjected to the pressure was very troublesome in the first ese. 3. In both cases the plan failed after a trial of five months. For. 1. f compression can be maintained so long, it must be a comparatively safe rocedure. 2. The free collateral circulation induced was favourable to any Ibsequent operation, as there is less risk of gangrene of the limb. 3. The onstitution was better prepared for the operation by ligature, should that ecome necessary.
Mr Spence was an opponent of the treatment of popliteal aneurism by comression; but he felt that the Society and the profession were deeply indebted » Mr Miller for his candour in publishing these cases : and he only wished jat all the cases of this treatment had been as faithfully recorded, as he was onvinced that the question as to the respective merits of the operations in uestion would long ago have been set at rest. As to the increase of the coliteral circulation which Mr Miller deemed advantageous, he (Mr Spence) was i opinion, that it might become too free, and endanger the subsequent proress of the case. He did not think that much was to be gained by it; and we just remember, that in this disease the collateral circulation had a natural
ndency to increase. Gangrene, we must remember, also occurred after comression, and, in Mr Spence's opinion, was due more to over stimulation of the mb, than to any want of development of the collateral circulation which Mr (iller feared so much. This form of treatment, too, had always, to his mind, *esented one great danger, viz., that many who did not consider themselves NEW SERIES.-NO. I. JANUARY 1855.
capable of placing a ligature on the vessel would be tempted to try compris sion, a mode of treatment, as was well illustrated in the cases read that evening, which required very careful management. He felt convinced that the ligature was the simplest and safest method of procedure.
Dr J. D. Gillespie concurred in the remarks made by Mr Spence. Another danger which he (Dr Gillespie) thought incident to the treatment by corpression, was that of secondary bæmorrhage from the matting together of the parts, and the consequent difficulty of the dissection when the vessel ultimately required deligation.
Dr John Struthers remarked, that a considerable part of the blood of the collateral circulation was poured into the artery above the aneurism, Blog between the ligature and the aneurism. This also held true with regard to femoral and axillary aneurisms. The operation by ligature, therefore, stil allowed of a considerable current along the vessel at the site of the aneuris. The current was not stopped, but only very much retarded ; thus favouring coagulation. The principle involved in the two operations was thus very similar; but the results, as seen in Mr Miller's cases, were widely different, The advocates of compression had represented the danger of the operation by ligature as much greater than it really was, by an unfair use of statistics. These statistics had been made up from cases performed at a time when the operation was a bad one, before surgeons were alive to the importance of denuding only the smallest possible extent of the artery. Dr Struthers referred to Scarpa's directions as to the dissection of the vessels, viz., that the surgeon was to pass his thumb below the artery, unless he had very large thumbs, in which case he was to pass his forefinger instead. Now, this involved the laying completely bare an inch and a half, to two inches of the vessel. Although the operation of Scarpa was modified in accordance with the kind of ligature he used, the reference above still showed that in time past the importance of not disturbing the connections of the artery was ne: recognised. It was only in comparatively recent times, chiefly through the influence of Mr Syme, that surgeons had recognised the importance of cariu manipulation, in the later stages of the operation, as determining its ultimst? success. The results had been highly successful. Mr Syme relates upwards of twenty cases operated on with success. The operation, now-a-days especi: ally, was a mere trifle compared with the protracted suffering from continued compression,
Mr Spence reminded Dr Struthers that Hunter, in stating the object of his operation, distinctly declared that it was a mere slowing of the current, ac not complete stoppage, which he desiderated. He (Mr Spence) recognised, that the principle of the two operations was essentially the same; but the methods of putting it into execution were widely different.
Mr Miller was still of opinion that the establishment of a free collater circulation was attended with many advantages. Gangrene might, no doul be caused by over stimulation of the limb; yet that it might be directly pro duced by the ligature, he referred to a case which he had published. Association Journal, May 19th, 1854.) He (Mr Miller) agreed with in Spence that compression was not so suitable for employment in private as la hospital practice, where a staff of assistants could be obtained. As to the danger of secondary hæmorrhage, the parts in the first case was not so muc matted as he had expected ; and such a condition he regarded as no drawback other things being equal. He declared himself in favour of compression.
The President said, that the question was curious and interesting, why compression was so successful in Dublin, and so much the reverse in Edinburr It had been remarked that, as a general rule, the proportion of stout men vi less in the Irish hospitals than with us, the patients there being more spare Might there thus exist a difference in the respective coagulability of our and our neighbours' blood ? In a surgical work published the other day hi Guérin, he (Dr Simpson) had seen it stated that, of a hundred and fifty came
treated by compression, one in five had died. In his (Dr Simpson's) opinion, the previous preparation of the constitution during the compression was very important; and he for one, did he labour under the disease in question, would undoubtedly give compression a fair trial. Travers mentions that the success which a Dr Young obtained in the removal of cartilaginous bodies from joints was generally ascribed to his keeping his patients for two or three weeks in bed, until the bed-fever was over. Dr Simpson thought the treatment of aneurism without knife or ligature a fair problem yet to be solved ; and perhaps the difficulty would be solved by attacking the aneurism itself.
CASE OF CANCER SUCCESSFULLY TREATED BY EXTERNAL APPLICATION OF CaUSTIC. BY J. D. GILLESPIE, M.D.-A gentleman, aged seventy-nine, of a large robust frame, in 1847 received a slight abrasion of the heel, which speedily cicatrised, but the cicatrix soon after gave way and ulcerated. The ulcer dried up and left a hard warty substance in its place, which continued to increase. In 1851, it had assumed the appearance of a hard cancerous growth, fully half-an-inch in depth. By the advice of Mr Syme, caustic was applied. Erythema of the leg soon after set in and reached as far as the groin, and the tumour increased in size. A second attack of erythema occurred a few weeks after. The tumour continued to increase in size; the glands in the groin became enlarged; the general health began to be impaired, and the mental faculties were affected. It was in October 1851 that caustic had been first applied ; the tumour was then the size of a walnut, spongy, and occasionally bleeding. Chloride of zinc was had recourse to, and the tumour came away, but after cicatrisation had commenced, the tumour reappeared. The application was continued for a year with similar results, repeated hæmorrhages took place and the glands in the groin were permanently enlarged. Potassa fusa was applied on three different occasions, but the chloride of zinc was decidedly more efficacious. On September 18th, a year after the first application, chloride of zinc was tried for the twentieth time, and the tumour to the extent of three inches was destroyed; a part of the os calcis exfoliated. Two years have now elapsed, and there had been no tendency to reproduction. Dr Gillespie considered the case interesting, as it was just such a one which was occasionally vaunted by some quack as a victory gained over modern surgery, and this one certainly explained their socalled cures, and at the same time it was fraught with caution to the surgeon not to lose an opportunity of giving similar cases & trial with the caustic before dooming them irrevocably to the knife. - Professor Miller referred to cases of soft cancer of the breast where a cure was sometimes obtained by the diseased product sloughing en masse. He could corroborate the statement of Dr Gillespie with reference to the efficacy of the chloride of zinc; as a caustic it was thorough, and easily kept under command.
The following officers were elected for the ensuing year :
President : William Seller, M.D. ; Vice-Presidents : John Taylor, M.D., Samuel A. Pagan, M.D., Robert Omond, M.D.; Councillors : Alexander Zeigler, M.D., James D. Gillespie, M.D., J. Matthews Duncan, M.D., Andrew Wood, M.D., Archibald W. Dickson, Esq., James Miller, Esq., David Gordon, M.D., Daniel R. Haldane, M.D.; Treasurer : John Struthers, M.D.; Secretaries : William T. Gairdner, M.D., J. Warburton Begbie, M.D.
BIOGRAPHY OF THE LATE PROFESSOR EDWARD FORBES. SINCE the publication of our last number so many able sketches of the career of the late Professor Edward Forbes have appeared in the different newspapers and literary journals, that the chief incidents of his life, and the general tenor of his writings, must be familiar to most of our readers. We cannot, however, on this account, refrain from the melancholy satisfaction of