PROVINCIAL MEDICAL & SURGICAL JOURNAL. THE RETROSPECTIVE ADDRESS, DELIVERED AT THE SIXTH ANNIVERSARY OF THE KEADING PATHOLOGICAL SOCIETY. been present, (which was, however, rarely the case,) the saline aperients with occasionally a dose of castor oil, the Liq. Ammoniæ Acetatis, the Nitrate of Potass, and Carbonate of Soda, had been freely administered. By EDWARD WELLS, M.D., Physician to the Royal Where diarrhoea has existed, the Bicarbonate of Potass, Berkshire Hospital. (Continued from page 398.) VII. FEVER. On the 30th of September, 1846, Mr. Vines read a paper On the Epidemic Fever then prevalent in Reading Mr. Vines said his situation as surgeon to two large parishes in this town, as well as to the Reading Dispensary, independently of his private practice, had given bin more ample opportunities of observing this epidemic than could have been possessed under other circumstances. His observations were intended to include the period of the last twelve months, viz., from the Ist of September, 1845, to the 1st of September, 1846. The number of cases which came under bis notice during this period, amounted to 306. The smallest number of cases occurred during the months of January, April, and June, and the largest number The number of in February, July, and August. deaths within the same period amounted to twelve, and of these, the largest number was in the months of March, July, and August, which corresponds nearly to the periods of the greatest amount of cases. According to this calculation, the average proportion of deaths was about four per cent. With regard to the localities in which the fever prevailed, the most densely-populated neighbourhoods were not always the most prolific. Isolated cases have occasionally occurred in well-ventilated places, but in these instances a communication has been generally traced with individuals or The fever prevailed localities previously infected. most extensively and most severely at the east end of the town, along the river Kennet. Throughout the winter and early spring months determination to the pulmonary tissues was a marked concomitant of the disease, which Mr. Vines thinks is attributable to the mildness and damp of the winter, and the low situation of the Kennet. The fever throughout the year, was generally characterized by debility, or where acute symptoms set in, a rapid prostration of the vital powers has quickly succeeded. Hence bleeding or depletion of any kind has been scarcely warranted in the majority of cases. The wild, soothing, and supporting plan proved the most successful. Where constipation has No. 17, August 25, 1847. Gum Acacia, Sp. Etheris Nitrici, and Ipecacuanha, were given. The tenderness of the bowels rarely required leeches; blisters and mustard poultices were generally sufficient, with small doses of Hydrargyrum cum Creta frequently repeated. In no instance has calomel been given to affect the system. The pain of the head was generally relieved by a blister at the nape of the neck. In a few cases exhibiting a typhoid aspect, quinine, opiates, and port-wine, freely administered, were found of great utility. In conclusion, Mr. Vines stated that the effects produced in the present epidemic have been principally tissues of the respiratory and digestive organs have been in turn affected: at one time the lining membrane of the throat and fauces; at another, the bronchial membrane; and latterly, the gastro-intestinal canal has been more particularly the seat of the morbid process; and the extent to which these differenttissues have been diseased, has modified, in a certain degree, the severity of the fever, and produced such re-action on the nervous system, as tended materially to favourable or fatal results. upon the mucous membranes. The whole mucous Mr. Vines illustrated these views of the constitution of the epidemic by appropriate cases, which I regret not to have room for inserting. When Mr. Vines read this paper in September, the epidemic was at its intensity. His report, however, ceased with the first day of that month, after which time he found the fever to become more fatal; so that taking the cases from January, 1846, to January, 1847, the proportion of deaths in his practice was five per cent. upon the whole amount of cases. Upon examining the records of the Dispensary, with a view to ascertain the mortality of the late epidemic, I find that from June to December, (both inclusive,) 155 cases of fever were treated, of which fifteen, or about ten per cent., died. These cases were distributed through the seven months in the following manner, showing a progressive increase and diminution in their number:-June, 6; July, 21; August, 40; September, 48; October, 24; November, 7; December, 9. Sequele of Fever.-As a corollary to the above interesting account of our epidemic, I may mention, R that on the 3rd of March, 1847, Mr. Walford related | Suffice it to say, that the sanguine anticipations of the case of a child, which he had treated for fever in the first instance, but in the course of a few days the head symptoms became so prominent, that he began to doubt whether disease of the brain was not the primary affection. He daily expected the child to die, but diarrhoea with green stools set in, with relief to the head, and she afterwards got better. Some time afterwards extreme pain of the knee and hip came on, which could not be accounted for. The child still continued to suffer from the hip, with all the symptoms of morbus coxæ. Mr. Harrinson stated that the father of the child had suffered in the same way. Your reporter mentioned that during the late epidemic, a case similar in some respects to Mr. Walford's had fallen under his notice. A boy, five years of age, was convalescent from typhoid fever, when be complained of severe pain in the hip and knee, chiefly in the latter; he was quite unable to walk in consequence. Some incipient disease of the hip-joint was at first suspected, but by rest and tonics it had gradually and entirely recovered. Croup in Measles.-On the same evening also Mr. Walford exhibited the larynx of a child who had died of croup, which supervened some time after measles. The chordæ vocales were very much thickened. Mr. Walford considered the chief interest of the specimen arose from the connection between croup and measles. VIII. SURGICAL DISEASES. success, which Mr. May had from the first entertained, were satisfactorily proved to the members of this Society to have ensued from the operation. Perfect bony union had taken place, and the motion of the hand, which many had supposed irrecoverably lost, was already to a certain extent regained, and there was reason to hope would still be much improved. At our last meeting, (May 26th,) Mr. May stated that this case was still progressing very favourably, and that he had every reason to anticipate that the man would ultimately regain the entire use of the limb. I need not recall to your recollections that Brodie, in his recent lectures on Surgery, has uttered an anathema against this operation, which he says “no surgeon with a moderate share of prudence would perfom." It is therefore of the highest importance that its merits should be tested in the crucible of experience, and that each successful case and each failure should be recorded. Treatment of Burns.-The variety in the kinds of applications which have been recommended by surgeons to burnt surfaces, would lead one to supAbscesses in Scarlatina.-At the same meeting Dr. pose that they were not yet quite satisfied with Cowan mentioned the case of a lady who suffered from those in general use, and that there was still room scarlatina; abscesses formed in the legs, shoulders, for some suggestions with respect to them. Although and beneath the mamma, which were opened. She your reporter himself would venture to believe that was then in a satisfactory state. surgeons have been too much on the look out for specific effects in the various applications used in the treatment of burns, and that they should be rather treated on general principles, yet as he knows that great success has in many instances followed Mr. Bulley's plan of treating these cases, he has much pleasure in calling your attention to a paper on this subject, which was read before this Society on the 3rd of February, 1847. Mr. Bulley stated that he had introduced this mode of treatment to the notice of the profession, and that it had met with the approbation of all those of his medical brethren who had made use of it. Out of six cases of burns which had been brought into this hospital during the last six months, three died; the survivors were treated with the treacle dressing. The plan adopted is to steep cloths in a mixture of one part of treacle to two of water, and apply them over the burnt surface. Ile attributed the beneficial results of this mode of treatment to the prevention of those metastasis of inflammation to internal organs which were so liable to take place after severe burns. It should be applied warin, (at a temperature of 980.) He attributed its remedial power to fermentation which takes place in the treacle. He had found that anything producing cold renders the liability to metastasis greater. The proudest boast of modern surgery is, that it shines more in the skill, with which it preserves the injured parts of the body, than which it formerly displayed in their removal. This remark, perhaps, applies more truly to the extremities than to any other division of the human fabric. Limbs which some time back would have been doomed to immediate amputation, for compound fractures and other injuries, are now not only preserved, but rendered as serviceable as ever to their owners. Still it is too often found, even at the present day, that the non-union of bones after fractures drives patients to submit to the loss of a limb, in preference to keeping it as a useless and troublesome appendage. Any operation, therefore, which is calculated to overcome this difficulty, is well worthy of our attention, and I have much pleasure in bringing before the notice of this Society the following successful instance of such a result : - I may state, that on the 2nd of December last, Mr. burns of the arms, neck, chest, &c. They had been treated with the treacle dressing, and were then nearly Operation for Ununited Fracture of the Forearm.-F. Bulley had exhibited a patient who had had extensive On the 5th of August, 1846, Mr. May introduced to the Society the patient upon whom he had some time previously successfully operated by excision for an ununited fracture of the radius and ulna, healed. In the discussion on the subject, Mr. Vines mentioned An account of this case has already been published a case where a patient was suffering from rheumatic by Mr. May in the Medical Gazette; it will not, there- pains of the legs, and had been treated by eminent fore, be considered necessary to repeat it in this place. ' men in various ways without relief, when an old nurse ON FUNCTIONAL DISORDER OF THE LIVER. recommended the legs to be wrapped in flannel soaked in treacle for some days, which procured him complete relief. He therefore thought there was some sedative influence in the treacle. Fracture of the Clavicle.-On the 10th of June, 1816, Mr. F. Bulley stated that he had under his charge in the Hospital, a man, whose clavicle had been fractured in the effort of mowing. The fracture was situated near the acromial process. There was but slight displacement. The fractured bone was kept in situ, by a strong buffalo-leather splint, covered with adhesive plaster, and bound down by straps of emplastrum roborans, which, with a pad in the axilla, and the arms bound to the side, he generally finds successful. Mr. Balley, also uses this leather in cases of fracture of the radius near the wrist with great advantage. Dr. Bradshaw remarked that the leather splints possessed an advantage over those made with pasteboard, in not occasioning that irritation of the skin which was frequently produced by the latter, owing to the pitch or tar contained in them. Hernia of the Stomach.-At the same meeting Mr. Harrinson presented to the Society a rough cast of the upper portion of the abdomen of a man, whose case he thus related :-While walking along the street the man was seized with a violent rigor and such excessive pain that he fell to the ground He had, however, recovered before Mr. Harrinson got to him. The cause of his sufferings remained unexplained for three or four days, when Mr. Harrinson discovered a small tumour in the upper part of the abdomen, to the left of the left rectus muscle, which disappeared on pressure, and dilated on coughing. It appeared to be hernia of the stomach, for if it were the colon, it would hardly have produced so great an amount of suffering. It did not require any treatment beyond the mechanical support of a truss to prevent it from protruding, and it was chiefly with a view to inquire what apparatus was best adapted for the purpose, that Mr. Harrinson brought the case forward, Mr. F. Bulley stated that there was an apparatus, invented by Weiss, consisting of a circle of ivory adjusted by a spring and a belt, for umbilical hernia, which he thought might suit this case. IX.-DISEASES OF THE SKIN. Allinoism.-On the 30th of September, 1846, your reporter exhibited to the Society three female children from Padworth who are albinos, of the respective ages of seven and five years, and of nine months. The complexion of the father was brown, and the mother dark. The eldest boy, nine years of age, was of the same brown complexion as his father, and so was the second boy, three years of age. The two elder girls were unable to bear the light of the sun, and could only see objects when very close to the eye. The mother had borne six children; her first-born, a female, was likewise an albino, and died at the age of four days. The three surviving girls were very liable to bowel complaints. 452 a statistical table of the cases of death which had occurred in his practice between August, 1845, and' August, 1846, in which the modes of death are arranged in the order in which they occurred,—as This table has already apnoea, asthenia, coma, &c. appeared in the Medical Gazette, and is therefore probably familiar to you all. I have now, gentlemen, gone through all the eases which have come under our notice during the past year. You will, I trust, agree with me in thinking that many of them possess great interest; and should their recapitulation have proved wearisome to you on the present occasion, the blame, I fear, attaches to your reporter. If to some I may have appeared too. prolix, the best apology I can offer you is the anxiety I bave felt to do full justice to every member of the Society. The great length to which this address has extended will prove that we have not had to complain of any lack of materials for discussion since our last anniversary; still we cannot but remark that we have mainly depended upon the presentation of morbid specimens, and that independently of those specimens, very few papers have been read during the past year. Now, though I by no means wish to detract from the interest and instruction which is to be found in the recital of cases which have terminated fatally, and in the examination of the organic changes which have resulted from disease, still there is an equally important class of disorders, which do not ordinarily go on to a fatal termination, and of which we never have the opportunity of examining the morbid alterations upon this table. Such disorders at present seldom come under our notice; and yet no one can doubt that in a practical point of view, it is of much more value to the practitioner to treat successfully the curable diseases, than to be learned in the pathology of those which are unfortunately incurable. I would therefore venture to suggest that some means be adopted for securing at each of our meetings the reading of a paper, and I feel assured that no member will decline to take his turn, which cannot come more than once a year. In conclusion, Gentlemen, it only remains for me to thank you for the patience with which you have listened to this, I fear too lengthy, address, and to express a hope that each succeeding year may produce a reporter more worthy of your Society. ON FUNCTIONAL DISORDER OF THE LIVER. By ROBERT HUTCHINSON POWELL, M.D., Tunbridge Wells. (Read at the Annual Meeting of the South-Eastern Branch of the Provincial Med cal and Surgical Association, held at Reigate, June 30th, 1847.) It is proposed in this paper to notice briefly some of the more frequent causes and modes of actions, with the principles of treatment pertaining to, certain functional' derangements of the hepatic system; but the limits. On the second of September, 1846, Mr. May read within which I am necessarily confined, will prevent X.-STATISTICS. any attempt at division into distinct heads. In my hence probably the difference of opinion as to the real remarks I would merely indicate those dynamical constitution of the bile. It consists, according to affections commonly known as "bilious complaints," | Berzelius, of about 74 per cent. of solid matter, in the arising, so far as the the liver is in fault, most probably proportion of,-bilin 5.0; chloride of sodium, lactate from increased and deranged excretion, and a slightly of soda and alcoholic extractive matter 1.5; alkaline vitiated condition of the bile, being seemingly produced sulphates, phosphates, with extractive, insoluble in by those morbific influences subsequently to be men- alcohol 0.43; mucus and cholesterine 0.20; water tioned. Such inquiries will not be deemed obtrusive, making up the remainder. when we recollect the frequency of biliary disorder in this-so to speak-age of bile, and the daily reference made to medical men for explanation of, and relief from, its due concomitants, which, from this continued discomfort, make every-day existence far from tranquil. We shall take a rapid glance at the anatomical and physiological relations of the liver. The intimate anatomical structure of the liver is by no means satisfactorily determined, notwithstanding the minute attention bestowed on it. I shall not pause to describe the most recent statements, but merely remark that it may be considered the largest glandular organ in the frame, supplied with a numerous and complicated vascular apparatus, and nervous fibrils; and the secreting structure being arranged in lobules, the aggregate acini, &c., endowed with functions highly important to the animal economy. It will be of consequence to bear in mind the anatomical relations of the liver, especially of its ducts, to adjoining viscera, as from these will be found to arise many sources of biliary derangement. According to Schultz, the quantity of bile secreted is considerable, but its exact amount has not been determined. Disease appears to alter its composition remarkably, the solid constituents being doubled, the fat and colouring matter undergoing the most remarkable increase, the saline ingredients being diminished. The bile appears, according to the researches of Bouchardat, to aid digestion only by furnishing soda for the saponification of the fatty ingesta; but Platner conceives this to be quite secondary and subsidiary to the liberation of bilifellinic acid, which combines with the elements of food, thereby preventing that decomposition and loss of its nutritive properties, which, he asserts, would otherwise ensue. The e conclusions need confirmation. The effect of bile in augmenting the peristaltic action of the intestines is well known,-an effect probably induced by its saline constituents, as, except the colouring matter, the other biliary ingredentsare found in health to have disappeared from the fæces when chemically examined; this disappearance, although contrary to the commonly received notions, clearly proves the important and necessary office subserved by certain constituents of the biliary fluid in respiration. The excrements of serpents being but slightly now revert to the more immediate object of this paper. The profession are doubtless aware of the modern notions held by physiologists as to the functions performed by the liver, and the uses of the biliary secretion to the economy. Of these the most important are said to be the production of a secretion indispens-coloured would seem to confirm this view. We shall able to life. Recent and numerous experiments by Schwann have incontestibly proved this, although contrary opinions have been advanced by others. The immediate end subserved appears to be, the abstraction from the blood of a fluid taking an important part in digestion and respiration, and the expulsion from the system of the debris of its tissues; its chief constituent being an organic compound, consisting, according to Dumas, of carbon, 63.5, + hydrogen 9.5, + nitrogen 3.3, oxygen and sulphur, 23.9; the last constituent being a non-oxidized body, goes far to prove its important office in respiration. Chemists of the highest repute differ with respect to this compound; Berzelius maintains it to be bilin, a neutral body united with soda, probably like albumen; Gmelin, biliary sugar; Thenard, picromel a resinous substance; Liebig and Demarçay conceive it to be an oily acid-the choleic, united with soda. The discrepancies seem to arise from the latter authorities neglecting to examine recent bile, as pointed out by Berzelius, decomposition occurring with facility. Choleic acid is readily decomposed by various re-agents, acids and alkalies giving rise to new compounds, The popular opinion with respect to the frequency of biliary disorder, as arising from indigestion, is certainly well founded; the operations ensuing on the introduction of ingesta into the alimentary canal, are so intimately related, both anatomically and physiologically, with the liver, as to render the communication of deranged action from the former to the latter highly probable. In fact, disorder in one organ cannot long continue without implicating others, such is the beautiful barmony existing in the human mechanism. Indigestion, as resulting from biliary disorder, is likewise observed in the present instance; it shall be our care to search out the functional derangement first causing deviation from healthy action; and, at the same time, that regard is had to the several functions, to direct our special attention to that aberration first in order, if such can be traced. The difficulty of drawing a line of demarcation between gastric and hepatic derangement is, very likely, the reason why both states have been considered together by many systematic writers; for practical reasons, however, both will require separate consideration in the majority ON FUNCTIONAL DISORDER OF THE LIVER. 453 of dyspeptic or bilious complaints. The functional rendered more active. But atmospheric humidity, derangement forming the subject of this paper, is particularly when uncombined with the air, must have probably attended by an increased and somewhat a noxious influence, either by checking excretion and altered biliary secretion, the excretion of which is both exhalation from the skin and lungs, or by resolving its retarded, and in part inflected, from it usual course. agency into that of the attendant negatively electric The experiments of Dr. Beaumont, who found re- condition of the atmosphere, which operates more gurgitation of bile into the stomach under certain readily on the system when the air is surcharged circumstances to which we will revert,-the sweet with moisture. Moreover, heat and cold are invariably taste experienced in the fauces, very likely arising attended with, if not caused by, a change in the from the presence of glycynin in the blood, which electrical state of that medium "in which we live, and is excreted from the buccal mucous membrane on move, and have our being," and probably best express such occasions, the constipation usually attending, this, its agency on the system: when + (plus) the nervous as well as the insalivation, acidity, nausea, and ejection and vascular system acting well,-cæteris paribus ; of bile by vomiting, go far towards establishing this when - (minus) all the functions of the frame become conclusion. Premising thus far, we proceed to in- torpid, the liver being peculiarly liable to inaction from vestigate the causes and nature of this departure from its size, situation, and vascularity. There can be no healthy action in the liver. I doubt that much remains to be determined under this head, and principles of treatment constructed with reference to its important bearing on vital action. The electrical state of the atmosphere influences the hepatic circulation, primarily or directly, by diminishing nervous action generally; and indirectly, by inducing barometrical states of the air effecting inadequate pressure on the surface. Now, in the disorder under consideration, the quantity of bile secreted seems to be augmented, obstruction of the systemic circulation seemingly favouring this by retarding the mass of blood passing through the portal vessels, thus determining a relative increase of electrical influence. Closely related to the electric condition of the atmosphere, is its magnetic state; this must exert an important influence on the frame, as there are the best reasons for attributing all its changes to chemical action, the result of its polarity, or generally of its magnetic properties. The electro-magnetic force, which appears to produce increased biliary secretion from the liver, seems likewise to determine a similar result in the stomach of its normal acid secretion, the liver representing the negative, the stomach the positive, pole. We find this view explana That the food ingested exerts a marked influence over the bile, is a matter of common observation; lean animal fibre seems least likely to tax unduly the biliary function; all carbo-hydrogen substances, alcoholic liquids, and fat in particular, evidently cause an increased secretion of bile. The total amount of food, if used in excess, may likewise have a similar effect, either from the presence of those articles of food just mentioned, or from the morbid erythism set up in the stomach and duodenum, which, being propagated to the biliary apparatus, causes misdirection of its proper secretion, at the same time that its elements exist in the blood in unusual quantity. The anti-peristaltic action of the bowels is probably but a sequel and symptom of this state of things; confined bowels, at first an effect, subsequently becomes a seeondary cause of, derangement. But adverting to the less-recognized or more obscure causes of biliary derangement, repeated observation has led me to attribute, in many cases, its production to atmospheric influence-a cause familiar to most persons, but the manner of its operation not being sufficiently understood. A predisposition to be affected from this source, whether congenital or acquired, is increased by the nervo-bilious, known as the choleric tempera-tory of the increased secretion of acid constantly ment, which renders the individual of this conformation very susceptible to all atmospheric changes. Life being beyond certain limits, antagonistic to external forces, its relative activity will determine the amount of resistance of the vital powers to those agencies. Changes of temperature, its excess or diminution, by depressing the nervous influences, are well-known causes of biliary disorder. Heat also acts on the liver by checking respiration, and consequently, the carbonic acid exhaled, thereby compelling other organs to take on supplementary action, the liver being the principal emunctory. Cold, if not intense, and if unaccompanied with humidity, does not seem to have much tendency to overload the hepatic vessels; rather otherwise, especially from respiration being attending biliary disorders, to which we shall presently advert. The magnetic currents accompanying certain winds may also strongly affect the system; the liver, from its size and office, giving most evident tokens of its disturbance. Again, lunar influence probably alters the magnetic state of the atmosphere which rests on the animal fabric. Cloudy weather, notoriously a cause of biliary derangement, is compounded' of many agencies in relation to the system; but its concomitant electro-magnetic conditions, produced in part by the interruption of light, are the most important. Another very frequent cause of biliary disorder arises from deranged nutrition, whereby the motive powers are diminished and digestion interfered with; |