On examination, the pupils were found to be rather contracted; and, when Dr. P. looked attentively into the posterior chamber of the right eye, Dr. P. could perceive numerous small bodies floating about in the posterior chamber of the eye, glittering with a kind of phosphoric brilliancy. The Doctor at first distrusted the evidence of his own senses, and proposed a dilatation of the pupils, by means of belladonna, which was effected, and then M. Gally and himself, together with M. Renaud, surgeon to the hospital, and Dr. Vidal, had a full opportunity of clear ly observing the corpuscles above-mentioned floating about in the posterior chamber of the eye, when the eye was in motion, and settling down, so as almost entirely to disappear, when the organ was quiescent. These phenomena could be distinguished by the naked eye; but, to remove ambiguity, a lens of some power was employed, and the same facts were verified.

We need hardly remark, that muscæ volitantes have been hitherto accounted for in a manner very different from the above. They have been attributed to a particular condition of the internal membranes of the eyeto varicose vessels expanded on these membranes, or in the humours of the eye-and to an affection of the retina. Demours, however, has observed that these musca volitantes arise and subside, according as the eye is in motion or at rest—a fact which accords with the phenomena that appeared in the present case.

There is one difficulty in supposing that these bodies are located in the vitreous humour of the eye-namely, the cellular structure of that humour. Our author endeavours to get over this difficulty, by supposing that the cellular texture of the humour is broken down before the muscæ volitantes take place. There is no doubt that the vitreous humour is occasionally found so fluid as to escape in operations on the eye. The case is very curious, and should attract the attention of oculists and others to the subject. The occurrence of muscæ volitantes is very common, and, therefore, opportunities for observation will not be rare.-REVUE

MED.

XXV.

NATURE OF TUBERCLES-PHTHISIS PULMO

NALIS.

"MEDICUS,"

The following letter, signed and dated from Exeter, is inserted, because it relates immediately to an important practical subject, involving the health and lives of a great proportion of the population of this country. We may be allowed, once more, to protest against the habit of identifying the Editor of this Journal with every opinion that may appear in the various reviews of books. The review of Dr. Alison's work was written by a talented physician, but not by the Editor. This, however, is of little consequence.

servations on that doubtful question, the oriSIR, Having perused Dr. Alison's obgin of tubercles, and your remarks upon them, is my apology for entering upon a subject so involved in mystery; lest the adoption of his opinions, sanctioned by you, give currency to the practice of indiscriminate depletion and starvation, which, in a majority of cases, will shorten the duration of human life. I do not mean to deny that cases may, and do occur, which may render early temperate depletion necessary, to control active inflammatory action; but, from my own experience, I am led to believe that the greater number of cases are to be met in habits of lax fibre, in which the digestive organs are primarily invaded, be the cause what it may, That a foreign body ("quicksilver") should excite active inflammatory action in the pulmonary organs is a natural consequence; the same effect is produced in all organized tissues, until the extraneous substance be removed by the vis medicatrix, or the interference of art; but to say that tubercles, thus generated, are vested with the distinctive attributes of tubercles found in the scrofulous subject, is a doctrine I can by no means subscribe to, unless Dr. A. is prepared to prove an identity in their constituent principles; in the latter, chemical analysis has detected phosphate and carbonate of lime, but, I apprehend, such result could not be discovered in tubercles created by artificial means. In the one, by removing the cause of inflammatory action, the effect will soon cease -not so in the other; for after inflammatory

action has been subdued by depletion and antiphlogistic treatment, the disease will progress to the softening stage, under the first exciting cause. Again; in the one case, the inflammation will be active, and disorganization will be early induced; while, in the other the inflammation is passive, and tardy in its advance, such as we would expect to meet with in those habits in which they are found. Dr. A. seems, also, to have overlooked the fact, that tubercles in the lungs differ from tubercles in the other viscera, being, in their incipient stage, more vesicular, and generally met with at the extremities of the bronchial tubes. In this hasty sketch, which I will hereafter pursue at greater length, I am induced to offer my views on the subject, with the two-fold object of guarding against the continuance of a treatment which I have found highly injurious, (repeated depletion) and with the hope to reconcile, in some degree, the existing discrepancy of opinion upon a question which involves human life. The matter of tubercle I consider to be a peculiar morbid secretion, preceded by active congestion in the invaded organs, and that congestion may, in one case, be the effect of languid circulation in the exhalent arteries, as a consequence of debility; while, in another case, it may be the result of passive inflammatory action, dedendent upon idiosyncrasy.

Such a disease is not to be found in our systems of nosology-but it is to be seen in practice and the name is, we believe, just as proper as cerebral apoplexy. We know that, in this last disease, there is not always a rupture of vessels, but a complete engorgement of the vascular system of the brain, by which the functions of the organ are more speedily annihilated than when an artery gives way, a quantity of blood extravasated, and a portion of the brain torn up. It is so with the lungs. In some way which

we cannot explain, the organ becomes suddenly gorged with blood, and the patient is actually and literally choaked, in consequence of effusion of blood into the air-cells of the lungs. The following case will illus trate these observations.

M. Del, aged 29 years, of apparently good constitution, had been, for some months, closely confined to sedentary avocations, and was subject, for some years previously, to stomach-complaints, for which he was in the habit of applying leeches to the anus. On the 31st August, 1828, this gentleman found himself affected with one of his stomach attacks, and confined himself to an abstemious regimen for its removal; but not getting better, he sent for M. Lefranc, a physician, who visited him on the 2d of September. Dr. L. found the patient sitting by the fire, with pallid face, turgid and lachrymose eyes, and complaining of a fixed pain directly under the sternum, accompanied by a sense of heat there, and some difficulty of breathing. Whilst the Doctor was asking him some questions, the patient suddenly exclaimed that the "pain was gone." His face became of a violet hue, he fell to the ground, some frothy saliva issued from his mouth, and he instantly expired.

Dissection. The vessels of the head were more than usually exsanguious. The lungs, excepting a small portion at their summit, were of a violet colour, and so gorged with blood as to resemble liver. There was no other disease in the chest. In the stomach and bowels there were marks of derangement, especially in the mucous membrane about the pylorus, and in the small intestines.-Revue Medicale.

The above is a striking example of pulmonary apoplexy-and when we reflect on the number of people who die suddenly, without any subsequent examination, we may fairly presume that the disease is not of extremely rare occurrence. We may lay it down as a rule, indeed, that in all, or almost all, very sudden deaths, the cause will be found in the heart or lungs, rather than in the brain or spinal marrow. The heart

is most frequently the seat of disease in such rapid terminations of life. The most fatal apoplexies (cerebral) require some hours to extinguish the functions of the heart and lungs. What is the

nature of these rapid accumulations of blood? The word "determination" is evidently absurd. The blood cannot be determined to any particular organ, except by causes acting in the organ itself "Attraction" of blood would be more proper than "determination."

XXVII.

HEPATIC ABSCESS.

It seldom happens that inflammation of the liver runs into suppuration in this country, where depletion is so speedily and actively employed in all inflammatory affections. Mr. Waldron, of Bath, has recently published an instance of this kind, in the second number of our Midland cotemporary.

The patient was a young lady, 21 years of age, who evinced symptoms of hepatie inflammation on the 21st of July, 1826, and was four times bled, besides leeches, purgation, blisters, mercury, and the other items of the medicamenta antiphlogistica. Nothing, however, would stop the inflammation, and by the 15th of August, a tumour with fluctuation was evident on the left lobe of the liver, attended with great inconvenience to the respiratory functions. A puncture was made, and large quantities of pus and bile flowed out. The relief was great-the discharge gradually subsided-and her health so far amended, that, by December, she ventured out in the carriage. The consequences (as was supposed) of this exercise were fatal. "All her urgent symptoms returned with increased violence, and defied all attempts even at mitigation, and, on the 3d of March, 1827, she died."

On dissection, marks of the original abscess and puncture were discernible; but the liver was greatly enlarged, and was, in fact, a mere shell, its whole interior being excavated into a mighty abscess, containing some pints of matter. Violent Summer heats and habitual constipation were considered to be the causes of this disease.

We are disposed to doubt that this was a second abscess formed in consequence of the carriage exercise during convalesence from the primary one. We believe that the great abscess, which ultimately excavated the whole organ, was going on at the time,

or, at all events, took its rise from the period at which the first abscess ripened. The immense discharge of bile which continued to flow for some days after the puncture, surprised Sir George Gibbes, as well as Mr. Waldron. Circumstances have come to our knowledge, on several occasions, which induce us to think that physiologists have formd a very erroneous estimate of the quantity of bile which is habitually or occasionally secreted by the liver. We are quite satisfied that, under states of excitement, or after torpor and congestion, the biliary apparatus will throw out some pints of bile in the course of the 24 hours, though the usual daily secretion may not be more than six or eight ounces. The abscess which was opened by Mr. Waldron, in the first instance, must have communicated with some of the large biliary or hepatic ducts, otherwise the flow of bile could not have been so great by the external wound.

XXVIII.

IMPERFORATE ANUS-OPERATION PERFORMED-FATAL TERMINATION.*

There are many varieties of imperforate anus, some of them much more favourable for a surgical operation than others. It is known that, in some cases, the anus externally seems pervious and well-formed, whilst the rectum is obstructed higher up by a membranous partition. This kind of "imperforation" is generally considered as almost certainly curable by the knife, but the case we are now to detail, proves that, under certain circumstances, it is one of considerable danger.

M. Piédagnel, D. M. P. was summoned, on the 15th November last, to visit the infant of Mad. de L. thirty-three hours old. The belly was tense and tumid, the scrotum and penis greatly injected, the breathing hurried, the pulse almost imperceptible, the skin hot and of a violet hue, the face deeper still, the legs and thighs bent upon the pelvis. M. Piédagnel immediately pronounced the little patient to labour under imperforate anus, when the nurses informed him that it had passed but little urine, had had no

* Journal Hebdomadaire, No. 10.

stool, and returned an enema as fast as it was given; that it had constantly refused to take any fluid, and had vomited several times. The anus itself was well formed, but on attempting to introduce a female sound, it was abruptly stopped about an inch up the canal, and could not, by any management, be made to pass beyond that point. The little finger being substituted for the sound, encountered the same obstacle, and the Doctor concluded, without any further hesitation, that the lower portion of the gut ended at this spot in a cul-de-sac, whilst the other was situated at a greater or less height, or separated from the former by a membranous partition.

The only plan was to perform an operation for the child's relief, and in the course of an hour M. P. proceeded to do so, assisted by Dr. Baudelocque, and M. M. Campaignac, Littré, and Reynaud. The general symptoms were but little altered, and that was for the worse; but a swelling was felt above the pubes, which appeared to be the bladder greatly distended. On again introducing the finger in anum, the membrane felt before was thought to be rendered tense by the pressure of fluid above, and presented a kind of fluctuation. A speculum was formed by means of a bit of card rolled up, assisted by dilating the anus by opening the blades of the dressing-forceps, when the extremity of the cul-de-sac was brought into view. A little depression existed in the centre, through which a probe was attempted to be passed in vain. Wishing to avoid all risk of injuring the bladder, which seemed, as was stated above, to be much distended, the catheter was introduced, but no urine flowed, save a few drops in the end of the instrument. Considering that if the bladder was really empty the sought-for object was already gained, and if full, it was located above the pubes, and consequently out of the way, no more attempts with the catheter were made, but the speculum re-introduced into the anus, and the part dilated to its utmost extent. A a narrow bistoury was then passed up, the cutting edge turned towards the sacrum, and the point thrust through the little depression, in a direction upwards and backwards. Out of the opening thus made issued a considerable quantity of thick viscous fluid, resembling lees of wine, and containing a greenish matter. It was thought to be a mixture of blood and meconium, and on pressing the abdomen,

the quantity that passed from the wound was augmented, and unequivocal meconium was observed. The opening not being large enough to allow free egress to the matters pent up, was enlarged towards the left side, by means of the probe-pointed bistoury carried along the groove of a director. The liquid matter issued after this in a large jet, injections of warm water were employed, and the wound on examination was found to be large enough to admit the extremity of the little finger.

The belly diminished in size and relief was experienced, but in six hours afterwards the symptoms were as bad as before. Part of a large elastic gum catheter was introduced into the rectum, and secured there by like that observed at first, came away. Soon tapes, when a considerable quantity of fluid, placed in a warm bath, and a poultice apafter the operation the infant had been plied to the abdomen, and at night it was ordered a mixture of oil of almonds and common syrup; at this time there was some, but no material amelioration in the symptoms. Next morning the patient was something better, and on being taken out of a warm bath, discharged per anum a large quantity of green matters, not tinged with blood. The portion of catheter was removed, and a fold of lint introduced in its stead, but removed also in the course of a couple of hours. In the evening the abdomen was increased in size, especially below, which seemed to be owing to the bladder. No urine had been passed during the day, and several unsuccessful attempts were therefore made to get an instrument into the viscus. Our author thought of puncturing the bladder, either by the rectum or above the pubes, but was deterred by the repugnance of the parents and the general state of the child, who was sinking fast. As will quickly be seen, it was fortunate that no such operation was attempted. Death took place at 7 o'clock that evening and at 1, P. M. next day the dissection followed, in the presence of the gentlemen formerly named.

On removing the sacrum, the rectum was found to consist of two portions, an upper and a lower. The latter was about an inch in length, of natural breadth, and terminating above in a cul-de-sac,

in which was discovered the opening made by the operation. This portion of the gut was composed of the sphincters and the mucous membrane, whilst, towards the culde-sac, strong and resisting fibres divided into several bundles and formed a kind of ring, closed, before the operation, by the mucous membrane which has been divided. The upper portion of the rectum was itself divided into two, in the following manner. Immediately above the partition which had been punctured, a pouch went off from the rectum, three or four inches in length, and two in breadth, extending along the vertebral column, and filled with blood, partly in a liquid, partly in a coagulated state. This pouch was bounded behind and at the sides by the serous and muscular coats of the gut; in front by the mucous coat, thus torn away from the others, and forming, by such dilaceration, the cavity in which the blood was contained. The other division of this upper portion of the rectum was situated anterior to the pouch above-described, was five inches in length by two or three in breadth, and extended from the umbilicus to within a few lines of the lower portion of the gut. It was greatly distended by air, and ended below in a cul-de-sac, the size of the finger, which presented at its extremity an opening, a line and a half in extent, evidently made by the operation. The mucous membrane, as was mentioned, was detached from the other coats behind and in front; although adherent, the cellular membrane, which formed this union, was more or less filled with clots of blood. All the intestines were greatly distended with gas and green matters, but the rectum contained gas only, and formed that considerable tumour, which, during life, had been mistaken for a distended bladder! This latter viscus was perfectly healthy, and situated behind the pubes and anterior walls of the abdomen.

M. Piédagnel, and the Editors of the Journal Hebdomadaire, have each appended some remarks to the case, which, however, we need not transcribe. It is clear that the operation failed in this instance, from the circumstance of the rectum, above the partition, having been divided, by the separation of its mucous membrane from the other coats, into two distinct cavities, only one of which had been opened into by the bistoury. Had the operator been aware of this, which, of course, he could scarcely be, the patient

VOL. X. No. 20.

might not improbably have been saved, by successively opening into both the divisions of the rectum, and giving a free exit to the matters collected above. There cannot be a doubt, we conceive, that the pouch described in the dissection existed before the performance of the operation, although the injection administered afterwards would clearly have tended to enlarge it. M. Piédagnel candidly confesses that, had it not been for the objections of the relatives, and depressed condition of the patient at the time, he would certainly have punctured that tumour above the pubes, which he thought was the bladder, which proved after death, to be the rectum. The circumstance we only mention to shew the uncertainty of surgery, as well as of physic, uncertainties which, in no country but this, are visited with barbarous denunciations of ignorance on the head of the unfortunate practitioner.

XXIX.

CASES OF FOREIGN BODIES IN THE LARYNX AND TRACHEA.

Dr. J. Reiche has published two interesting cases of this kind, in a German cotemporary, for the purpose of shewing the great duced and those of croup, as well as pointsimilarity between the symptoms thus proing out some diagnostic marks.

Case 1. On the 7th Dec. 1824, Dr. R. was summoned to see a little girl, ætatis 2, whom he found playing in her bed, and apparently well. The breathing, however, was a little hurried, and, every quarter of an hour, the child took an inspiration so slow as to occupy fifteen or twenty seconds, and accomplished with the most extraorThe child apdinary effort and distress. peared dying, and yet the succeeding expiration brought a perfect calm, only interrupted by a slight cough, without expectoration, or any thing otherwise particular.

* Rust's Magazin für die gesummte Heilkunde: 27 vol. per Cahier, 1828.

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