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"In place of dividing layer after layer, I detach the portion of ocular conjunctiva which covers the muscles from the sclerotic, and raise it with broadnibbed forceps until the muscle is exposed. This being divided with curved scissors, I restore the detached portion of conjunctiva to its place; this, by closing the wound, prevents the access of air, and obtains all the advantages of a subcutaneous wound. Experience has confirmed my preconceived notions of the theory; in the four operations I have performed, there has been no sign of suppurative inflammation.

"The result of these operations has been very satisfactory; but not so immediately advantageous as M. Dieffenbach observed. In one instance there was a complete and instantaneous restoration of the natural position of the eye, in the others only an amelioration. This circumstance appears to be a natural consequence of the true origin of strabismus. At one time the deviation of sight is originally muscular, and the result of spasmodic contraction in a single muscle; at another time the contraction is consecutive or even primitive; but it has simultaneously affected many muscles.."

On the Cure of Strabismus. By Dr. F. A. von Ammon.'-[In the great number of the papers written on this subject, it is scarcely to be expected that more than two or three remarks on each should be worth abstracting. In the present article, by the editor of the Monatsschrift, the following passages are worthy the attention of our readers]:

A principal point is the determination of the indications for the operation; and I think it the more important, because the whole history of the affection, notwithstanding the works of many excellent physiologists, is extremely obscure and uncertain. Nor could this be otherwise, when the abnormal position of the eye is in different cases so varied, and so often the consequence of diseased conditions of the brain, the abdominal nervous system, and of the globe itself. Here is a wide range for the production of the disease, independently of the cases which are produced by diseases of the orbit. No rational physician will expect to cure such a strabismus by myotomy; and the operation can be applicable only when the malposition of the eye is primarily dependent on the muscle, i. e. when there is a shortening of one of the muscles of the eye, which holds the eye to one side and limits its motions towards the other; but even here more than one condition must be laid down.

But unfortunately the necessary basis of the operation, pathological investigation, is at present absolutely and entirely deficient; no one has yet clearly convinced himself on the dead body that a shortened state of the muscle exists in squinting. The operation, however, may itself be made the means of investigating the nature of the disease; and here again, as bas been the case with club-foot and wry-neck, surgery may be made the assistant of pathology.

With regard to the true orthopaedics of the eye, i. e. its acquiring the right position after the operation, this consists in the constant endeavour and active exertion of the patient to give his eye the proper direction. A club-foot or a wry-neck would just as soon return to its right position after division of the tendons without assistance as a squinting eye will. A good method of insuring success is to tie up the sound eye; the eye that has been operated on then always moves to the centre of the orbit, and the longer it is kept there the more likely it is to remain. In few cases will this or some similar measure be unnecessary.

The author also suggests the propriety of endeavouring to make a subcutaneous, or rather a subconjunctival division of the muscle, which he believes would avoid all the inconveniences to which the present method is subject. He has performed it on the dead subject and on animals, and has no doubt it may be applied to actual cases of strabismus.

Monatsschrift für Medicin, &c., June, 1840; and Br, and For. Med. Rev., Oct. 1840, p. 373.

THE

AMERICAN MEDICAL INTELLIGENCER.

Vol. IV.

November 15, 1840.

No. 16.

ART. I.-MEDICO-CHIRURGICAL TRANSACTIONS.' [We adopt the following abstract of the valuable papers contained in the last volume of the Medico-Chirurgical Transactions, from the Edinburgh Medical and Surgical Journal.-ED.]

We have much pleasure in giving early attention to the annual call, which we are happy to see that the respectable association, whose volume is now before us, continues to make upon our services; and we shall consider the papers in the order of the subjects of which they treat, beginning with those on Practical Medicine and Surgery.

The first communication on the former series is entitled Notices of the Effects of Lead upon the System; by James Alderson, M. A. and M. D., Physician to the Hull General Infirmary. In two cases, which came under the author's care, of young women employed in lead-works, of the respective ages of 25 and 18, who were affected with paralysis, the one both in the upper and lower extremities, the other in the hands only, there was the singular anomaly of complete loss of vision, which followed closely on the paralytic symptoms. After the ineffectual use of ordinary remedies, the author was successful in restoring vision, by the additional measure of bandaging up the eyes, day and night, for several weeks, so as entirely to exclude light. This plan he adopted from a supposed analogy with the successful employment of splints, in cases of loss of power of the extensors of the wrist and

arms.

"The action of light," he observes, "is the proper stimulus of the retina, and its continued action whilst the nervous expansion is paralysed, is precisely similar to the continued extension of the extensor muscles of the arm and hand; as in this latter case, relieving the muscles from their continued extension by means of splints has been found to restore their suspended power, so it was, by analogy, to be supposed, that by removing the stimulus of light altogether from the eye, the power of vision would probably be regained."-P. 83.

The author offers some general remarks on the treatment of the various affections arising from the poison of lead on the system; and gives the case of a family in which that poison was introduced through the internal use of rain water, lodged in a leaden cistern; which was found to have varying quantities of lead in it, according as it had been recently disturbed, or long quiescent. The water, we are informed, was always filtered before use; but in this state it was sweetish, and afforded distinct evidence of the

Published by the Royal Medical and Chirurgical Society of London. Volume xxii. being the 4th volume of the 2d series. 8vo. London, 1839.

presence of lead. By other experiments, however, it is to be inferred, that filtration will deprive water of nearly all the lead contained in it, and exhibit that substance separately in the filter.

The author seems to us to underrate very much the importance of opium in colica pictonum, and to carry his analogical reasoning rather too far, when he attributes that severe complaint to paralysis of portions of the intestine. If the paralysis which is found to be produced in some particular muscles of the body, by the poison of lead, were always, or even occasionally, attended with severe pain in the parts affected, there might thus be some degree of support afforded to the author's reasoning, which we would submit that it does not otherwise possess.

The next medical communication contains Notices of the Occurrences at the Small-pox Hospital, London, during the year 1838; by George Gregory, M. D., Physician to the Small-pox Hospital. The total number of persons admitted with small-pox in some of its forms was 695, of which 187 died, or 27 per cent., which is about 1 in 3 ds. Of the unvaccinated there died at the rate of 40 per cent., or 1 in 2, which is in the same ratio as the deaths from small-pox in 1781. Of the vaccinated 8 per cent. died, or 1 in 12; and the severity of the disease increased materially with age.

Much difficulty occurred in forming a correct conclusion, both in respect to such as had been or had not been previously vaccinated. In the former cases, the cicatrix was the chief guide; but it was not always a sure one; while the highly modified character of the disease in many of the latter afforded strong presumption of occasional prior vaccination. The principal results are given in a tabular form.

The next communication gives a Statistical Account of Cholera in the Seamen's Hospital in 1832; by George Budd, M. B., F. R. S., Physician to the Seamen's Hospital. In our account of the 21st volume of the MedicoChirurgical Transactions, we had occasion to notice some interesting histories and dissections of several cases of cholera, by the author of this communication and his colleague, Mr. Bush. In the present paper, Dr. Budd gives some general deductions in reference to the statistics of that disease, of which we shall give a general abstract.

With regard to the mortality which occurred at different periods of this epidemic, the number of admissions increased during the months of June, July, and August; and the average mortality was 93 cases in 160, which is 58 per cent., or 1 death to 1.72 cases. At first, the number of deaths was double the recoveries; but towards the end of the epidemic, about half the number only. In the Echo, cholera vessel, however, such disparity did not

occur.

Mortality was much influenced by age; being least in persons between the ages of 15 and 30, and greatest in those above 50. Of 13, whose ages exceeded 53, not one recovered. Liability to the complaint was least between the ages of 20 and 30, but it increased much with advancing life, just as has been found by M. Grisolle to be the case with susceptibility to the poison of lead. Deranged health he likewise found to be unfavourable to recovery; for the proportional mortality was greater in persons affected with cholera who belonged to the hospital ship, the Dreadnought, than in those who were previously healthy. Much diversity occurred in the proportional diffusion of the disease in different epidemics; and in the Donor, which was fitted up precisely as a cholera ship, not one of the medical gentlemen or nurses took the complaint; though one of the former and three of the latter lived on board, and many examinations were continually conducted there, and in very ill ventilated cabins. The author, indeed, states the very satisfactory fact, that not a single death occurred among the medical officers of the Dreadnought, or of the cholera hospitals connected with it, during the whole existence of that disease in London.

The last of the medical papers contains Cases of Measles, occurring oftener than once in the same individuals; by John Webster, M. D., Consulting Physician to the St. George's and St. James's Dispensary. In the first of these cases, the author attended the patient in a regular attack of measles when 2 years old, and again about two years afterwards. In the second the patient, a young lady of 15, had measles regularly under the author's care, but was reported, on evidence which he had not the smallest reason to doubt, to have had the disease twice before; the first time at Madras when four years of age, and the second at Blois six years afterwards. Another instance of a similar kind is mentioned by the author on the authority of Dr. Forbes, of Argyle street.

The first of the surgical papers is a Case of Malignant Disease, occupying one half of the Tongue, in which a Ligature was applied from beneath the Jaw; by James M. Arnott, Surgeon to the Middlesex Hospital. The subject of this very creditable operation (which was suggested by one performed by M. Jules Cloquet and M. Mirault respectively, in two cases of cancer of the tongue,) was a young woman of 15, who had a tumour about the size of a pullet's egg, of a purple hue, which occupied the right half of the tongue, extending from nearly half an inch of the apex to the isthmus faucium; and reducing, by compression, to a narrow slip the width of the left or sound half of the organ. It began at about nine years previously, in a blue swelling, about the size of the tip of the finger, which remained stationary till the last six weeks, when it rapidly increased during the use of pills, which she took for fits with which she had been attacked, but which produced no affection of the mouth. It measured two inches and a half in length, one inch and a quarter in breadth, and one inch and a half in thickness; was covered posteriorly by warty excrescences; and when drawn forcibly to the left side, allowed the boundaries to be traced by the finger under the arch of the palate, where sound structure could be felt beyond it. The operation was performed on the 6th of June, 1838, in the following way: "The patient being seated, the head slightly extended, and the os hyoides felt, an incision was made from over it upwards and forwards, an inch and a half in length in the mesial line, through the skin, cellular substance, and raphe, of the mylohyoid muscles. With the edge of the knife, but chiefly by its handle, way was made for the finger between the two genio-hyoid and the two genio-glossi muscles. A tenaculum was next passed through the apex of the tongue, by means of which it was drawn out of the mouth, and held so during the subsequent part of the operation by Mr. Mayo, (Mr. Tuson, Dr. Warren of Boston, U. S., and Mr. B. Phillips, being likewise present.) Into the wound in the neck a strong needle with an eye at the point in a fixed handle, was now conducted, and passed through the basis of the tongue into the pharynx, a little to the left of the mesial line: the loop of ligature which it carried was then, by means of a blunt hook, drawn forwards out of the mouth, and the needle withdrawn from the wound over one of the ends. The loop being cut, two ligatures were obtained; one of these was placed along the upper surface of the tongue, so as to bound the disease on its left side, and carried through the apex of the tongue from above downwards by means of a large curved needle, through which the oral end of the other ligature was now also passed. Fixed in a porte-aiguille, this needle was next carried through the floor of the mouth immediately behind the last molar tooth, on the right side, directed at first, and for the greater part of its course, perpendicularly downwards, then inclined mesial, and brought out at the incision in the neck. There were thus two ligatures, the four ends of which hung out of this wound; one of the loops was so disposed as to encircle the right half of the tongue at its basis beyond the tumour; the other was placed longitudinally on the upper surface of the tongue, longitudinally and obliquely below. Being tied, (and this was done as tightly as possible,) the diseased

mass was circumscribed posteriorly, laterally, and in some measure inferiorly. A third ligature was now passed through the fore-part of the tongue, so as to isolate at this point the diseased from the healthy structure."-Pp.

23-25.

The operation was well borne; and the patient, for a fortnight, had food and medicine conveyed into the stomach solely through an elastic gum catheter, introduced into the oesophagus along the left side of the mouth. The strangulation of the diseased part not being completely effected by the ligatures, it was found necessary, on the fifth day after the operation, to endeavour to tighten them, by carrying a canula over them. The plan, however, did not answer; but on the twelfth day, the author succeeded in his object, by means of a loop of silver wire, which effected the death of the part, and produced separation on the fifth day from its employment. The process of cicatrisation went on favourably; and on the 10th of July, the patient left the hospital. There was no appearance of a recurrence of the disease after a lapse of sixteen months; and a stranger would not discover, by her speech, that she had lost so large a portion of the tongue. He would merely remark that she lisped.

The following communications follow in the surgical division:

Case of Fracture of the Coracoid Process of the Scapula, with Partial Dislocation of the Humerus forwards, and Fracture of the Acromion Process of the Scapula; by John F. South, Esq., Assistant Surgeon to St. Thomas's Hospital. The title of this paper sufficiently describes the nature of the injury, which was satisfactorily made out by examination after death. A notice is appended of a fractured coracoid process, which came under the notice of Mr. Arnott, at the Middlesex Hospital.

Case of Aneurismal Tumour in the Orbit, cured by tying the Common Carotid Artery; by George Busk, Surgeon to the Seamen's Hospital, Dreadnought. This was the case of a seaman of 20 years of age, who, by a severe blow on the head, became for some time insensible; had hemorrhage from the right ear, and deafness in that organ; swelling in the eyelids and integuments of the left eye, with fixed dilatation of its pupil; incapacity to move its globe: and slight paralysis and feeling of numbness on the left side of the face. Purulent discharge took place on the right ear, which continued some time; and soon afterwards pain in the left eye, and deposit of purulent matter between the laminæ of the cornea, which was discharged by ulceration. In about four months from his accident, he had small-pox; and on his recovery, and return from the Small-pox Hospital, (to which he had been sent,) the eye was found to be prominent, and to have a large and irritable ulcer on the cornea. The deafness continued, with tinnitus aurium, and the paralytic affections of the globe of the left eye and muscle of the face remained unabated.

Some improvement took place, after some weeks, in the ulceration of the cornea and general health; but a distinct pulsation was then discovered in the globe of the eye, which was found to proceed from a firm pulsating tumour, in the upper and inner part of the orbit, within the superciliary ridge. The eye was hot and uneasy, and the patient was much troubled with loud noises in the head, but no pain. Pressure on the left common carotid put a stop to the pulsation and noises; and hence the author inferred the existence of a common cause, and this most likely an aneurism of some vessels within or close upon the orbit. An operation was determined upon, and the common carotid was accordingly tied in the usual place and manner. The patient went on favourably; and in about two months was discharged cured. The ulcer of the cornea was healed, and the noise in the head ceased; but the paralysis of the eye and face continued; and the deafness was very singularly transferred from the right to the left ear.

The author is disposed to consider the affection now mentioned as arising

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