Imatges de pàgina
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account in further experiments upon this subject), and that the animals so treated remain for a time alive, with a voracious appetite, and capable of digesting food to a certain degree; but that they ultimately die emaciated, that they form no milky chyle, and discharge the fatty matters of the food unaltered, per anum. We feel that, in the present state of the inquiry, we are not justified in accepting these statements to the full extent, especially as a quantitative analysis of the ingesta and egesta in these cases might have been easily performed, and would have exactly determined the extent to which the removal of the pancreas incapacitates an animal for the digestion of fat. It is well known that fatty substances, when given in sufficiently large quantity, are passed unaltered or imperfectly digested even in healthy persons; and hence the emancipation of the fatty evacuations of M. Bernard's dogs may have indicated only an impairment and not a suspension of the digestion. This is still further rendered probable by the curious experiments of Brunner, published in 1709; in which a large part, if not the whole, of the pancreas was excised or destroyed in the dog, the health and activity being maintained, and the functions regularly performed for a considerable time afterwards, to an extent which is scarcely consistent with the idea that the digestion of the fat was wholly or nearly suspended. We feel, therefore, that the solution of the question, as regards the pancreas, must depend on new experiments, after the manner of those above mentioned, and performed with strict regard to quantitative results: the animals should be weighed before and for some time after the operation, and its immediate effects; they should be kept alive as long as possible, and careful researches should be instituted into all the secretions and excretions. In the mean time, it is probable that the removal or destruction of the entire pancreas will be found-not, indeed, altogether to suspend the digestion of fat, but to impair it so much as to be inconsistent with prolonged life; although it appears that a very small remaining portion of the organ is sufficient to enable an animal to live for at least several months.

[M. Moyse refers to a case in the Boston Museum which is of considerable interest.1.

"The patient was a labouring man, forty years of age. Thirteen years before death he was greatly reduced by hemorrhages from the bowels, and to this he always referred as the origin of his disease. Three years before death, he had a second attack, which was quite severe, and lasted several weeks. There was great tenderness in the epigastrium, with frequent returns of diarrhoea and discharges of blood, the functions of the stomach being, meanwhile, sufficiently well performed. In December, 1836, he was attacked with febrile symptoms, pain and obstinate constipation, followed by severe diarrhoea: the discharges contained no bile, but consisted in a great measure of blood, and the epigastric tenderness was extreme. In about a fortnight a fally substance was first noticed, and from this time it was observed, more or less, in every discharge from the bowels, until the month of May, when it entirely ceased. The following report was made during the first attack: Patient declares that for six weeks he must have discharged, on an average, half a pound of this substance daily; is also positive that he had no discharges of fat, except after eating meat or food cooked in fatty matters; that they would cease in twenty-four hours after abstaining from meal, and return again after resuming it; his wife, however, is confident there is no such connexion."

"After this there was a partial recovery: the appetite at first good, often craving afterwards indifferent; the alvine evacuations uniformly deficient in bile after December; complete jaundice for five weeks before death, which took place on the 16th of September, a tumour having been detected in the epigastrium in August, and signs of advanced phthisis being known to exist.

"On opening the cavity of the abdomen, a large fluctuating tumour of a regular oval form, was seen below the right lobe of the liver; the duodenum ran over, and almost around it. On incision, it was found to contain about 14 ounces of a bloodylooking serous fluid, without coagula, not viscid or greenish, and without any appearance of fally matter. The tumour or cyst measured four inches by three in extent; it was evidently formed by a dilatation of the pancreas; two calculi adhered to its inner surface, near the orifice of the duct, which was entirely obliterated; they had the usual characters of pancreatic concretions, and were found to consist of carbonate of lime. The remainder of the pancreas, forming the left extremity of the organ, was about two inches in length, much contracted, and feeling very hard; the duct

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itself was considerably enlarged, and opened freely into the cavity of the sac. slitting open the common duct, a portion of it, which formed part of the parietes of the cyst, was found in a very sloughy condition, it being evident that an opening was about to be formed, if it did not already exist, between the sac and the hepatic duct."

[Mr. Alfred Clarke, of Twickenham, in the Lancet for August 16th, 1851, relates a very remarkable case, and again in the Museum of St. Bartholomew's Hospital, there is a preparation illustrating a disease of the pancreas, likewise similar. We may conclude, therefore, that in cases of fatty alvine evacuation, the pancreas is probably the most important seat of the disorder. Several of the cases, however, would appear to show that the duodenum is not always necessarily involved, and that simple or malignant disease of the pancreas alone may be sufficient to account for the symptoms.]-Brit. and For. Medico-Chir. Review, July, 1853, p. 154.

50.-ON AN ALVINE CONCRETION, CONSISTING OF
CHOLESTERINE.

By DR. WILLIAM D. MOORE.

[This concretion seemed to have been formed in the intestinal tube. The patient was a young lady. There had been obstinate constipation and colicky pains for some time; and it was at length voided per anum.]

She had never suffered from jaundice, pain, or other symptoms, whereby the pas sage of a gall-stone could be inferred. The calculus in size and shape resembled a pullet's egg: it weighed 210 grains, but was superficially lighter than water, as was proved by its floating when placed in a vessel of that fluid. Its outer surface was tubercular, and exactly resembled that of a mulberry urinary calculus. Some shining scales were visible externally, and aleo throughout the mass when out. application of heat it first fused, and then burned with a bright flame. It dissolved completely in boiling alcohol, and on cooling separated from its solution, as was seen under the microscope, in broad tubular crystals of cholesterine, which, with a small admixture of fæcal matter, composed the bulk of the concretion.

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Many writers have supposed that because calculi found in the intestines, or voided per anum, have been proved to consist chiefly of cholesterine, they must necessarily have formed in the gall-bladder, and from that have passed either through the ducts, or by ulceration, into the intestine; and, in support of this view, it has been argued that, where the parts are neither inflamed, nor in a state of spasm, the ductus choledochus may be considered to be in a passive state, admitting of an easy and gradual extension of its fibres, so as at length to allow of the free egress of the stone. It has also, indeed, been clearly proved by the example of a case in which a biliary calculus, in passing to the bowel, about a fortnight before being voided per anum, induced jaundice, yet gave no pain; that "the progress of gall-stones (even when inordinate in their dimension), through the ducts, is not disproved by the absence of pain from the epigastrium."

However admissible the foregoing facts may be, and conclusive as the case detailed by Dr. Wilson is, in establishing the proposition he advances, a little consideration will, I think, show, that the fact of a calculus consisting in whole or part of cholesterine, is not sufficient to prove it to be of biliary origin. For cholesterine is, according to Berzelius, "universally diffused through all parts of the body, and dissolved in its fluids." Simon states that it is a normal constituent of the bile, of the brain, and of the spinal cord. "It has been found," he adds, “in the blood; in the vernix caseosa; in the fluid of hydrocele; in an encysted tumour of the abdomen of a woman; in the ovary and testicle in a diseased state; in an abscess of the tooth; in a scirrhous structure in the mesocolon; in fungus medullaris; in medullary sarcoma; and in a vesical calculus extracted from a dog." Such being true, it is of course easily conceivable that a concretion composed of cholesterine might form under predisposing circumstances, in some portion of the intestinal tube.

Dr. Douglas Maclagan was aware of the fallacy of inferring the origia of such calculi from their composition, for in his paper on the Constitution of Intestinal Concretions, published in the London and Edinburgh Monthly Journal of Medical Sci

ence for September, 1841, he observes, after describing a case in which vast numbers of small concretions had been passed, in reference to the question, as to whether these were a variety of gall-stone, that "the presence of cholesterine is no criterion. This substance is not only," he observes, "contained in the bile, and is thus poured into the intestinal canal, where it may easily be deposited; but it is frequently found in situations totally unconnected with the biliary organs." This statement is so very explicit, that I should not have thought it necessary here to enter upon the question, did I not find that many are still of the opinion that concretions of cholesterine must necessarily be derived from the hepatic system.

In conclusion, with respect to the patient, in reference to whose symptoms Sir Henry Marsh was consulted, it is clearly possible that the concretion voided by her may have been, not of hepatic, but of intestinal origin; and it appears to me that, if this be admitted, it will also be allowed to be more probable that a large calculus such as I have described should have formed in the intestine, than have passed in a young subject from the hepatic system to the bowel, either through the ducts or by ulceration, without giving rise to pain or jaundice.-Dublin Quarterly Journal, August, 1853, p. 247.

51.-OBSERVATIONS ON A CASE OF FECAL OBSTRUCTION.

By DR. ROBERT CHRISTISON.

[Dr. Christison remarks upon the frequency of habitual constipation amongst the better classes of society. Instances in which the bowels are only relieved once a week are comparatively common, and he records two cases of patients, aged 60 and 70, who stated that they had never had their bowels moved more than once a fortnight during their whole lives. In the case about to be related the patient had not had a stool for three weeks.]

On admission he had no appearance of any suffering. He seemed a fresh, vigorous, active, cheerful man. He took his food tolerably well; the pulse was natural; and the tongue was only a little furred. "The abdomen," to quote the Hospital journal, " is much distended, especially in the iliac regions, where there are two large prominent swellings projecting laterally, so that the crest of the ilium on each side is quite sunk, the tumours projecting much beyond the bones. There are different irregular swellings at different parts of the abdomen, especially in the track of the colon. Over some of these points percussion is quite dull; over others it is tympanitic. The circumference of the abdomen, where largest, is 394 inches."

As it was judged unsafe to give him active purgatives by the mouth at once, in case of the great gut being firmly obstructed with hardened fæces, a turpentine injection was properly administered by the clinical clerk in charge of him. The result was "a prodigious discharge of fæcal matter of all degrees of consistence," much of it composed of very hard scybala. A dose of jalap and calomel given immediately after this forerunner, brought away also a great mass of fæculent matter. Next day, being quite well, but with the abdomen as large as ever, another similar dose occasioned only an ordinary discharge. On the third day, the swelling being equally great, though now quite uniform, and everywhere clear on percussion, I gave him what has always appeared to me the most effectual of all safe energetic purgatives in cases of simple fæcal accumulation-two drachms of oil of turpentine with six drachms of castor oil in the form of emulsion. But he had only two scanty loose discharges, and the belly continued in the same state, presenting especially the singular enlargement and overlapping of the iliac regions.

It was now apparent that, owing to long continuous distension of the bowels with fæces and gases, their muscular coat had lost its tone, in some regions at least, and especially in the cœcum and descending colon. It was then proposed by the clinical clerk to resort to galvanism for relief from this paralytic condition; which suggestion was at once adopted. It is more than twenty-five years since galvanism was recommended as a useful remedy in cases of obstinate constipation; and we can easily see that it may be useful, and upon what principle it acts. The first way of using it was by directing the galvanic current from the mouth to the arms; and in that way it seems to have been most effectual and prompt in some cases. But its

action is thus rather painful; and ulterior observation has shown that passing the current in various directions through the abdomen itself may be sufficient. This remedy seemed even more applicable to the state of our patient after the bowels had been cleared out. And accordingly it acted with wonderful energy and success. After the current had been passed for some time from before backwards, as well as from side to side, he had, in an hour, a copious evacuation, in three hours another, and next morning a third. Flatus was also discharged in abundance; and the abdomen fell greatly, but still not completely, above all in the iliac regions. The pain of the galvanic action, however, had been so great that the patient begged to have a day's respite. In fact, he declared his willingness, and confirmed it with an oath, that he would rather be shot again than submit to be galvanised a second time. On the second morning, however, the remedy was applied more gently, and on two mornings subsequently. He had a daily discharge from his bowels, and sometimes two. The abdomen had now become natural in size and form. Since then he has had a natural evacuation every morning, without aid from either laxative or galvanism. He was dismissed after being fourteen days in hospital.

This is a case a little out of the common run, but not without instruction; and I have therefore thought it well to bring the chief circumstances under your notice. It is an excellent illustration of the influence exerted by galvanism over the animal functions. It appears to me to hold out a probability that the same remedy may prove serviceable in restoring the tone of the intestinal muscles, in other forms of inconvenient chronic flatulent distension of the abdomen.—Monthly Journal of Medical Science, Sep. 1853, p. 252.

52.-CASES OF COLIC.

By DR. ROBERT B. TODD, F. R. S., &c.

[The following excellent remarks upon the treatment of various kinds of colic, are from a clinical lecture upon the subject, delivered in King's College Hospital:] Whether the case be one of simple colic, or gouty colic, or colic resulting from lead poisoning, you must endeavour to get the bowels to act freely. What you want is, to create a free channel through the intestine; and this you may effect by purging and by the adininistration of enemata. The general plan of treatment which I commonly pursue with most cases of this kind in the hospital, is very much that which was suggested, some years ago, by Dr. Wilson, of the Middlesex Hospital. We commence by putting the patient in a warm bath, and, while he is there, a warm water enema is administered; when the first enema is returned, a second quantity of warm water is forced up, so as to distend the colon; this is done several times in succession. Frequently a cure is effected by these means without any further treatment: but it is often necessary, in order to empty the bowels fully, to give a purgative. And that which answers best in these cases, is a combination of compound extract of colocynth and croton oil. A drachm of the former, and from one to three drops of the latter, are divided into twelve pills, and one pill is given every three hours until the bowels act. The stomach bears these small and frequently repeated doses of the oil better than a full dose administered at once, and the operation of the medicine is more effectual. With respect to antiphlogistics,the abstraction of a little blood sometimes does good in colic; but, as a general rule, you will find that bleeding only prolongs the convalescence of your patient. Leeches, also, are occasionally beneficial, in cases where there is abdominal tenderness; but the majority will not require them. You will find great benefit from the careful use of opium, in the more obstinate and complicated cases. You may give it simply to relieve the pain, when that is excessive; or where there is great exhaustion, and the patient needs repose, you may give it freely to produce sleep; and, in administering it with this view, you will not find that your ultimate object will be retarded. On the contrary, the exhibition of opium often gives tone and power to the muscular coat of the bowel, and promotes the favourable action of purgatives. Moreover, opium is a valuable preservative against abdominal inflammation. When you keep up a certain opiate influence, your patient will be less liable to peritonitis, or to enteritis. Opium also regulates and moderates the action of purgatives; and this is

worth your always keeping in mind, for, in the use of purgatives, in cases of intestinal obstruction, it is often true, "the more haste the worse speed."-Med. Times and Gazette, July 23, 1853, p. 82.

53. ON THE TREATMENT OF TAPE-WORM BY THE MALE-SHIELD.

FERN.

By DR. ROBERT CHRISTISON.

[Dr. Christison has received many communications as to the result of the oleoresinous extract of the above plant in the treatment of tape-worm. He says:]

In every case without exception the worm was discharged after a single dose, and usually in one mass. In some it was brought away without any laxative, and occasiorally in that case with very little feculent discharge accompanying it. For the most part there was no pain or other uneasiness, either before or during its action. This was the case even in an instance in which the tendency to the disease had existed for no less than seventeen years, and in which the worm evacuated was the largest and strongest I had ever seen. Several patients, who had often previously used other anthelmintics, have noticed this absence of uneasiness during the action of the male-shield-fern, as something different from what they had experienced invariably before. It must be allowed, however, that several other individuals have complained of griping, sickness, or indescribable discomfort in the abdomen, and sometimes even of vomiting. But it admits of question, whether these occurrences depend on any direct action of the remedy on the human body, or upon the disturbed condition of the worm under the poisonous operation of the remedy on it. In fact, we have yet to learn that the male-shield-fern exerts any action on the human stomach or intestines, in the course of its deadly action on the parasitical inhabitants of them.

In only two cases have I heard of the disease having reappeared; and in both, the interval was about six months. Of course there may have been others which I have not heard of. When the worm does not show itself in the discharges for some months after the effective operation of the remedy, I think it is more consistent with reason to say that the disease had returned, than to hold with some that the cure was imperfect, that an ovum was left to reproduce the worm, or that the head had remained to sprout again and renew the multitudinous joints behind it. Nevertheless, I have latterly advised the subjects of tænia to repeat the dose of the extract once a month for a little, until joints shall have ceased for some time to appear. In none of these cases have any joints been subsequently seen in this way. But it is a very simple precaution to take occasionally a remedy so little disagreeable. A patient, as to whom I was consulted by Dr. Graham, of Cupar, had been liable to a return of the disease every few months for nearly twenty years, during most of which time he was in the army, and got oil of turpentine, with partial success, from the successive medical officers of the regiments in which he served. In this instance, I have recommended an occasional dose of male-shield-fern as a security. The first dose brought away a very large worm without occasioning any inconvenience; and no joints had appeared in the discharges eight months afterwards.

At first I gave eighteen grains for a dose. But afterwards, and, I admit, without any reason except a desire for greater certainty, I have advised an increased dose of twenty-four grains. On the whole there has been less complaint made of uneasiness during the operation of the remedy since the larger dose has been used,possibly because the worm is killed more speedily, and that the drug has no inconvenient action of its own upon the human alimentary canal, although given even in the larger quantity.

It was stated above that the ethereal extract of male-shield-fern had not failed in a single instance to bring away the worm with the first dose. In one case, which occurred in this city, it did seem to fail. But on repetition of the trial, with an extract prepared under my own instructions and superintendence, the effect was complete and speedy, as in all the other cases. On proceeding to inquire into the circumstances of the previous trial, I found that the extract had been obtained from a druggist, of unquestionable skill, who had made it for the first time; and it appeared that his preparation was of firmer consistence and more resinous-like than

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