1847]

Civiale on Lithotrity and Lithotomy.

539

among these latter, M. Royer-Collard observes that error and difficulty surround the subject when we attempt to submit this to arithmetical precision. In the first place, how are we to determine the hereditary relations of insanity? Admitting that we may be able to determine the insanity of individuals submitted to our examination; it is far from being always the case when we try to appreciate the mental condition of those we have never known. Where are the limits which separate sanity from insanity? A man has manifested peculiar tastes or strange ideas, without ever becoming mad. His son is manifestly insane, and will you call this hereditary or not?

"Another source of error deserves consideration. It is not only mental alienation, properly so called, that may induce insanity. All kinds of cerebral lesions, various nervous affections of uncertain nature and seat, certain congenital diseases of the organs of the senses, may exert the same influence. I may cite especially Epilepsy. What disease has more affinity with insanity, or is more frequently hereditary? Then again there is hysteria, hypochondriasis, and even that exaggeration of the general state of the economy termed the nervous temperament.' Apoplexy itself, and the habitual disposition to cerebral congestion, may easily, in transmission from parents to children, become in these a hereditary cause of insanity. The latter is only the result, the consequence of the original disposition which the son has inherited—only the chance of circumstances has terminated in him what nature had commenced. An accidental disease, a violent moral commotion, a change of climate, may determine in him the invasion of insanity, which the same would have doubtless also have caused in his father. Lastly, there is the singular fact of some diseases which do not seem at first to tend towards any particular condition of the brain, and yet do produce, either directly or by hereditary transmission, an entire alteration in the intellect. Pellagra, a disease as strange as it is terrible, almost always gives rise in succeeding generations to a description of insanity hence named pellagrinous. So, too, physicians of lunatic asylums know how frequently ulcerations are met with near the ileo-cæcal valve in the melancholic insane having a propensity to suicide. And who can say that this is not one of the tortuous paths by which insanity is transmitted from parent to child.

"I had occasion to consult upon this subject one of the men whose opinion carries most weight in question of mental disease, Dr. Calmeil, and this is his reply. During 15 years I took the greatest care in interrogating those who brought their relatives to Charenton. I insisted much upon questions relating to hereditariness, and went into the minutest details. I noted apart all that might some day throw light upon this important fact. But, when I had during several months, a year or more, continued to observe, to question, and to verify the exactness of the accounts which had been furnished to me, I discovered eight times out of ten that I had been deceived by the ignorance of some, and the voluntary falsification of others. Every year I was thus obliged to undo my work and begin again, until I have finished by abandoning it.'"-Bulletin, T. xiv., 760-776.

M. CIVIALE ON THE STATISTICS OF LITHOTRITY AND LITHOTOMY.

M. Civiale recently read a paper upon the Value of Lithotrity before the Academy, in which he detailed the results of his large practice. These are thus briefly summed up. From 1824 to 1836 he had been consulted by 506 stone patients, of whom 307 were submitted to lithotrity, and 199 were considered as unfit cases. Among those lithotrized 9 were between 7 and 20 years of age; 55 between 20 and 40; 105 between 40 and 50; and 138 between 60 and 80. The number of cures amounted to 296; incomplete cures to 3: and deaths to 7.

From 1836 to 1845, of 332 stone patients, 241 were lithotrized, and 91 deemed

unfit. This gives a total of 838 patients, of whom 548 were treated by lithotrity. To these are to be added 25 operations on account of relapse; 8 combinations of lithotomy and lithotrity; and 10 treated since the tables were drawn up; giving a general total of 591 cases in 22 years, 566 of whom were cured, 14 died, and 11 were more or less incompletely relieved.

He comments at length upon the disingenuousness of the adversaries of the new operation, who, in their criticisms upon the publication of the first portion of the above table, chose to comprehend in their enumeration of his failures the cases which he had declined to operate upon as unfitting. Out of the 838 stone patients, there were 290 in this predicament; and he observes that surgeons have not hitherto paid attention to this element in their calculations. In a statistical table which he long since published, containing 5,900 cases, in 859 lithotomy was not practised, and in 595 others all indications are absent; so that from the 5900 we have to abstract 1434. Most lithotomists have indeed omitted to keep any account of the numbers in which the operation was either declined or considered unjustifiable.-Bulletin, T. xiv., p. 821.

At a subsequent sitting, after referring to the various statistical tables of the results of Lithotomy: he thus states his appreciation of the two operations :-" 1. That lithotrity well performed, and within the limits of its legitimate application, saves 96 or 98 patients per cent. 2. That about a fourth part of stone cases which are refractory to lithotrity may be treated by lithotomy. 3. That by lithotomy employed exclusively, and without distinction of age, from 20 to 30 patients per cent. are lost. 4. Applied to children alone, it saves nine-tenths. 5. Applied to adults and old persons, it saves from 50 to 75 per cent."-Gazette Medicale, No. 34.

ON THE INDUCTION OF CYSTITIS AND ALBUMINURIA BY BLISTERS. M. Morel-Lavallée communicated to the Academy of Medicine the results of his researches upon the induction of Inflammation of the bladder by the use of Cantharides. These are, first as regards the Etiology. 1. The mode of preparing the blister is indifferent. 2. In general the action is more certain and more marked in proportion to the size of the blister; although the author has seen a blister not larger than half-a-crown placed upon the forehead determine the production of a false membrane of the bladder. 3. The distance of the topical application from the bladder is a matter of indifference. 4. It may happen that, upon the same subject, one blister produces no ill-effects upon the bladder, and yet, after a short interval, another of precisely the same size and make, re-acts powerfully on that organ. Generally, it is the last one which produces the inconvenience, though it may have been placed in quite another place, in which the epidermis offers the same, defensive characters. Is this because the progress of the disease, which renders the topical application necessary, induces a debility favourable to absorption? 5. The preventive power of camphor is illusory.

Symptoms.-1. Albuminous Secretion.-The albumen may exist in three states: 1, in that of solution; 2, as a deposit at the bottom of the vessel; and 3, as false membrane forming in the bladder. The albumen existing in a state of solution is infinitely more abundant than in Bright's disease. In exceptive cases there are mere traces of albumen, but then the symptoms referable to the state of the bladder, as pain, &c. are few or none. In the third stage of the affection the false membranes vary in thickness from that of the merest pellicle to that of half a playing card. Sometimes they are rejected in such considerable rolls as to require traction to aid their expulsion from the urethra. Albumen is always found

1847] Production of Cystitis & Albuminuria by Blisters. 541

dissolved when it also exists as a deposit or false membrane; but the deposit is generally absent even when false membranes are present. 2. Functional Symptoms. Sometimes there is no pain, &c., and the albuminuria is the only symptom of the action of the cantharides on the bladder; but generally there is frequent micturition, strong smelling urine, periodical pains, &c. &c.-Revue Medicale, June, p, 288.

M. Bouillaud, likewise, recently called the attention of the Academy to the frequent production of albuminuria by blisters. He stated that, for a long time past, he had detected albumen in the urine of persons in whom no suspicion of serious disease of the kidney could be entertained. Recent observations have confirmed this remark, and have likewise shown him that the action of cantharides is capable of inducing its appearance. In the cases of patients admitted for other causes than Bright's disease, large blisters were laid upon regions of the skin wherein cupping-glasses had been applied. One of these was a man suffering from pleurisy with some effusion, whose urine tested had given no trace of albumen until after a blister had been applied, when it appeared in abundancesymptoms of strangury likewise existing. Blisters have since been applied upon eight or nine other patients, and in all of these next day albumen, which had not previously existed in it, was found in the urine (always most markedly so when the blisters had been applied to surfaces previously denuded of epidermis), tenesmus being likewise produced; and, in other patients who were blistered without any such effect on the bladder resulting, albumen was not found.

M. Martin-Solon observed that we should not confound a transitory albuminuria of this sort with albuminuria properly so called. In the first, the urine continues healthy, some albumen only being mixed with it; while, in the other, it undergoes a complete change, a description of combination resulting.

At a subsequent sitting, M. Vernois detailed the observations he had made confirmatory of those of Morel-Lavallée. Blisters were applied upon 26 men and 9 women, and albumen was found in the urine of 16 of the former and 3 of the latter. Strangury existed in 15 of the men and 3 of the women. In 7 of the men this existed without any coincident albumen. In two cases, in which the blisters were applied over scarifications, the pain and albuminous deposit were proportionally greater. In two ecchymoses, and in one phlyctenæ, were found on the bladder after death.-Bulletin de l'Academie, Tom. xiv. p. 745.

In reference to this subject M. Miquel has addressed a letter to the Gazette des Hopitaux (No. 82) upon the best mode of preventing the irritation of the bladder here referred to. He says that M. Bretonneau and himself, after long experience, have found this to consist in not leaving the blister on the part too long. Four hours often suffice to produce vesication, and the intervention of a piece of tissue paper in no-wise impedes this.

He takes the opportunity of reporting upon the excellent effects M. Bretonneau has derived from the employment of large flying blisters, after local or general bleeding in rheumatism; these being applied to all the joints affected, so that three or four different ones have sometimes been blistered within the 24 hours. They are always taken off when the patient has complained of their irritation for 15 or 20 minutes, which he does in from 4 to 8 hours. Vesication may only follow the second dressing, and, if the blister has not been kept on too long and the epidermis has not been destroyed, the pain is very tolerable, and the healing prompt. M. Bretonneau has observed that when the skin has been repeatedly blistered, it at last ceases to vesicate, although there is nothing anormal discoverable about it. Small pimples on a red ground are produced by the blister, and if this be retained on, the bladder will become irritated though the skin do not vesicate. M. Miquel has found that a piece of the omentum of the calf or pig, which, if washed, will serve several times, forms the best dressing for

blisters, especially if the epidermis has become torn. For the removal of the little pimples, furuncles, &c. which spring up around the margin of blistered surfaces, especially if these have been dressed with rancid substances, he finds the sulphuret of potass to form the best application, (1 part to 20 of water).

In relation to this subject we may here notice a new formula for a very active Blistering Plaister devised by M. Mialhe. After noticing the effects which cantharides sometimes produce on the urinary organs, he goes on to say

"Upon what does this phenomenon depend? Doubtless, it must be referred to the absorption of the active principle-cantharidine: and to prevent its production we should put a stop to such absorption as soon as the desired local effect has been produced. Among the means suggested for preventing the specific action of cantharides upon the bladder, none is so good as that indicated by M. Bretonneau-the interposition of a piece of tissue paper soaked in olive oil. Cantharidine being soluble in fatty bodies, the oil serves as a vehicle for its introduction into the economy, but this introduction ceases to be active as soon as the serous effusion has taken place, since oily are not miscible with aqueous fluids. Another means consists in the association of camphor with the epispastic, but it attains its object less frequently than the other plan, notwithstanding that some practitioners consider it as infallible. Nevertheless, we believe the association of camphor with vesicating plaisters useful for two reasons. First, the abuse which has been made of camphor of late has placed beyond all doubt the fact that this substance is endued with anaphrodisiac properties; and secondly, that, inasmuch as it possesses the power of softening the resinous substances contained in blistering plaisters, these become more fluid, adhere better to the skin, and consequently act more promptly. Now, we have assured ourselves by experiment that, all things being equal, the dynamic action of cantharides is so much the less to be feared as the local action is rapidly produced; or, in other words, that the absorption of cantharadine is so much the more marked as the serous effusion has taken long to produce. Hence we conclude: 1, That we should give the preference to the most active epispastic : 2, That vesicants should only be kept in contact with the skin for the time strictly necessary to effect a detachment of the epidermis; and 3, That camphor forms an advantageous addition to blistering-plaisters." The following is the formula for preparing an active one.

"Powder the cantharides without previously drying them. Pass them through a silk sieve, and suspend the pulverization as soon as 100 parts of a fine powder have been obtained, which are to be placed in a wide-mouthed flask with the ether. Place the rest of the cantharides in a tinned pan with the lard and suet, and a sufficient quantity of water to cover them completely. Boil this gently for an hour, continually stirring it the while, and then let it cool in the pan. Next separate the fatty matter at the surface from the settling at the bottom, which last is to be thrown away. The fatty matter collected is to be melted without

Camphor, under the auspices of that arch-quack M. Raspail, has obtained as much vogue among some classes of our neighbours as have Morrison's Pills, and other nostrums among ourselves.

1847]

Velpeau on Abscess of the Breast.

543

water, and strained through a cloth into a tin water-bath, the pitch, wax and camphor added, and the whole heated until complete fusion takes place. Lastly, add the cantharides prepared with the ether, heat until the ether is entirely evaporated, that is to say for about an hour, pour the plaister into a marble mortar, and stir it until entirely cold.

"The effect of this vesicant is very prompt, taking place in from two and a half to three hours, according to the susceptibility of the cutaneous tissue, the more or less elevation of temperature of the part, and the closeness of the adhesion of the plaister. It offers some analogy with the Emp. Cantharid. of the London Pharmacopoeia, which is well known to be very preferable to that of the Paris Codex; but it is more active, as we have assured ourselves by repeated trials : and this because it contains a larger proportion of the fly; and because all the blistering principle contained in it exists in a state of perfect solution, by reason of the manipulation it has been subjected to.”—L'Union Medicale, No. 22.

[Judging from the frequency with which the subject of strangury following the application of blisters is noticed in the French writings, we suppose it is a matter of common occurrence. In our own practice we seldom or never meet with it, which perhaps may arise, in some degree, from our always directing the early removal of the blister. Still, among the common people, it is no uncommon occurrence to leave a blister on for from 12 to 24 hours, long after the epidermis has been raised or even ruptured by the fluid effused beneath it, and yet stran gury is rarely met with.-Rev.]

ON ABSCESS OF THE BREAST. By M. VELpeau.

"Subcutaneous inflammation of the Breast proceeds much as an ordinary phlegmon. When the abscess is formed between the mamma and the chest, the swelling is considerable, the breast raised up, but after an incision the cure usually takes place rapidly. But when the phlegmasia invades the substance of the breast itself, it is rare to find only a single abscess produced. We sometimes see 10, 20, 40 or 50 manifesting themselves in succession. An instant's reflection will show that this result is a natural consequence of the anatomical disposition of the inflamed tissue. The glandular parenchyma consists of different lobules, each of which constitutes a little organ having its own function, and which may become heated and irritated under the influence of lactation. Each lobule does not attain at the same time the same degree of irritation. One first inflames, then suppurates, and constitutes a first abscess: a neighbouring lobule then becomes affected and, in its turn, forms an abscess; and so it may go on with all of them until we have as many successive abscesses as there are lobules.

"This distinction of abscesses of the breast into at least three orders is of the highest importance; and if we do not adopt it, our ideas upon the subject will be but very vague, and devoid of all precision as respects prognosis and treatment. Parenchymatous abscesses may last four or six months, or a year even, according to the rapidity of their succession and their number. The subcutaneous abscess lasts only as long as an ordinary phlegmon; and the submammary abscess has not the long duration of the parenchymatous one.

"Each of these has again its special treatment. We may endeavour to procure the resolution of subcutaneous abscess, and that by ordinary means and, if suppuration occurs, we open it promptly, in order to avoid the burrowing of the pus among the tissues. Sub-mammary phlegmon should be treated especially by general measures, and leeches around the nipple. Topical applications are of little use, as they are separated from the centre of inflammation by the whole

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