783

A BOLD OPERATION AND A PHYSIOLOGICALTRIUMPH.

EARLY in the present year, most of the leading journalsof Vienna-e.g., the Neue Freie Presse-were full of a mar-vellous operation which had just been performed by Prof.Nussbaum, of Munich: how that he had lain bare thenerves of the arm of a soldier, one of the luckless victimsof the late war, even to their very roots; and not only this,but had given a good tug to each. At first one did not feelinclined to pay much heed to such a statement, on the pre-sumption that the story proceeded from the fertile brain ofsome Bavarian or Austrian penny-a-liner, but when furtherinquiries had been made, and when the first instalment ofthe history of the case appeared in the Oesterreichische

Zeitschrift, the seeming canard was found to be no exagge-ration of a true story. We will now proceed to give a briefabstract of this case from a full record of it which Prof *Nussbaum has contributed to a recent number of theDeutsche Zeitschrift fiir Chirurgie, under the title of H Bloss-legung und Dehnung der Riiekenmarksnerven. Eine

erfolgreiche Operation."Rudolf Hailer, a soldier, twenty-three years of age, re-

ceived at Bazeilles, on Sept. 1st, 1870, a blow with the butt-end of a rifle on the nape of the neck, and another on theleft elbow. At the former spot a deep-seated abscess madeits appearance, which in due course was opened and healedup again. Upon this there followed contraction of the leftpectoral region, of the whole left upper and fore arm, and ofthe hand on the same side. This contraction was certainlynot organic, but was a veritable spasm, which became themore violent the more that attempts were made to opposeit. Besides this, there extended all over the dorsal aspect ofthe forearm an ansthesia, which increased to such a degreethat, in December, 1871, deep incisions, tenotomies, &c.,could be practised without any pain being experienced bythe patient. The spasms varied in intensity, being some-times so violent that the finger-tips were for hours drivenhard into the palm of the hand. The great pectoral musclewas always as hard as stone.

All possible remedies were tried, one after another, butall to no purpose, such as the preparations of iodine, mer-cury, opium and belladonna, blistering, exercise of the limbaffected, subcutaneous tenotomies, and the application ofboth the interrupted and constant galvanic currents. Withregard to the inhalation of chloroform, it was found thatwhen narcosis was complete all spasmodic action ceased,and the limb became so supple that it could be extendedupon a splint; but when the influence of the drug began topass away, even before the patient returned to conscious-ness, the spasm returned with renewed vigour. This latterphenomenon was of importance, as tending to negative thehypothesis that the patient was malingering, on whichassumption he had previously suffered, as may readily beimagined, treatment the reverse of mild.

’

The poor fellow, whose case had been given up as in-curable in the various lazareths where he had been undertreatment, came at last into Professor Nussbaum’s hands,who arrived at the conclusion that he was suffering fromsome powerful irritation of the motor nerves of the arm, inwhich the spinal cord was probably also implicated. Prof.Voit, the celebrated physiologist, was taken into counsel,and made an elaborate report upon the case, of which thefollowing is a summary :-The contractions do not depend upon the first blow re-

ceived upon the elbow, but upon the second one, by whichthe nape of the neck was injured. The cause cannot be

peripherally seated because the sensory nerves are paralysed,while the motor nerves, on the contrary, are irritated-itbeing known that both kinds of nerves are peripherallyunited into one trunk. Since, then, the cause must be cen-trally seated, all remedies directed to the periphery, evenextending to an amputation at the shoulder-joint, would beof no avail. The seat of injury will be found at the lowercervical vertebrae, at the spot whence the brachial plexusderives its factors. It is possible that there is no lesion ofthe spinal cord itself, but that only the roots of the leftlower cervical nerves are injured; the posterior roots being

either torn across or having received such shock as to in-terfere with their conductivity, while the anterior roots, onthe other hand, have not been so directly involved, being pro-bably irritated by some vertebral displacement, the presenceof bone splinters in the intervertebral foramina, adhesions,&c. All this is suggested by the history of the deep-seatedabscess which formed in the nape of the neck. The factthat the contraction has lasted for so long a time, and thatthe motor nerves are not as yet paralysed, lends some degreeof hope to the prognosis.Encouraged by the success of an operation which he had

performed ten years previously upon a scrofulous girl, sixyears of age, in which in the course of a resection of theelbow for an anchylosis at an inconvenient angle, sometraction was exercised upon the ulnar nerve, and a

spasmodic contraction of the fourth and fifth fingers whichhad hitherto existed was in consequence completely cured,Professor Nussbaum determined to hazard the following boldexperiment.On February 15th, the patient having been brought com-

pletely under the influence of chloroform, an incision aboutthree inches long was made over the site of the ulnar nerve,which was next lifted out of its groove, gently extended,and then replaced; after which the wound was cleansedand closed by suture. A second incision of about the samelength was then made in the axilla, just over the artery,after which the nerves which closely surround the vessel-cutaneous as well as muscular-were drawn one by one outof the wound; the median, radial, and ulnar nerves beingrecognised to a certainty by the twitching of the musclesof the fingers which they respectively supplied, and, afterbeing subjected to the same treatment as the ulnar nerve,were replaced and the wound sewn up. Lastly, a transverseincision, also alout three inches in length, was made overthe left clavicle, as though preparatory to the ligation ofthe subclavian. After the platysma had been divided theknife was laid aside, and, by means of the finger and forcepsonly, the four lower cervical nerves, which lay partly infront of, partly behind, the artery, were isolated. Tractionwas then exercised upon each, and each was followed withthe tip of the right forefinger to its point of exit fromthe vertebral column. Here each was pushed upwards anddownwards, and right and left, a pretty good tug at thenerve, in a direction as though it were to be pulled awayfrom the spinal cord, bringing the operation to a close,After this the nerve, which seemed to have been somewhatelongated by this treatment, was replaced. It is noteworthythat, in the course of the operation, no abnormalities, no con-siderable adhesions, and no thickening of neurilemma weremet with. The four upper cervical nerves were not touched,as there had been no dyspnoea or spasm of the diaphragmto indicate that there was any lesion of the phrenic nerveat its origin. After the patient had recovered from narcosis,the result of the operation, which, as may readily be im-agined, had been awaited with the utmost suspense, wasfound to be successful beyond the hope of the most sanguine;.for not only did the spasms not return, but the forearm andfingers could be flexed and extended at will, and the skin ofthe arm, which before the operation was so devoid of sensa--tion that puncture and the application of hot sealing-waxwere painless, had regained sensation to such an extentthat the patient, even when blindfold, could localise theslightest touch.

Hailer made a good, but necessarily slow, recovery, thoughhe had to run the gauntlet of pysemia, which was at thattime rife in the hospital; but, thanks to careful treatment,.and to a judicious removal from the tainted atmosphere ofthe public building to a private institution, he managed to-elude the toils which death was spreading for him. The-wound in the neck healed first, being skinned over at the-end of five weeks; while that in the axilla gave the mosttrouble, the suppuration being profuse, and there being aconstant tendency towards erysipelas ; but at the end of tenweeks it had quite healed up. The wound at the elbow didnot suppurate much, but was faabby and oedematous, whichcircumstance was probably due to some pernicious influenceupon the circulation exercised by the axillary wound above,for when this had healed the cubital wound rapidly closedup. Thus at the end of eleven weeks there had beeneffaced (save scars) all traces of an operation which put torest troubles which for one year and a half had day andnight rendered life unbearable.

784

Since then Dr. Ga.rtner, of Stuttgart, has performed ananalogous operation, the history of which is recorded in thearticle which we have here analysed.

MEDICINE IN CHINA.*

THESE medical reports, published by order of the In.spector-General of Customs, Peking, contain matter of muc),novelty-indeed some of them are not only interesting inthe facts they narrate, but excellent specimens of medicalreports. There are twelve contributors to the volume.The first paper is by Dr. Dudgeon, on the health of Peking,

He says that fever is the most fatal of all the ailments tcwhich foreigners are subject, and, next to small-pox, is themost prevalent disease among the Chinese themselves,

Carbuncles, which are at all times prevalent among the

Chinese, were especially so during the summer of 1871. Dr.

Dudgeon says he was much struck by their frequency andsize. They were situated almost exclusively on the pos.terior part of the trunk and neck-the largest was almostone foot long by eight inches broad, the smaller ones

averaged about four inches in diameter. The individualsattacked were commonly beyond the middle period of life,and in a debilitated condition of health. The mortalitywas of course great. Ague was also very common duringthe same period, and Dr. Dudgeon remarks that the sym-ptoms of this disease are minutely and correctly describedin all Chinese medical books from 2600 B.C. down to thepresent dynasty.

Dr. Watson’s Report on Newchwang contains some in-teresting information quite apart from that of a medicalkind.

Dr. F. Wong, in his Report on the health of Canton,adverting to the relative rarity of typhoid fever there, statesthat he has, during a residence of more than ten years, seenonly two cases of that fever among foreigners. This im-munity from enteric fever is the more curious seeing thatthe conditions usually supposed to be productive of thatfever are in full operation. In Canton large numbers of thenative population are in the daily habit of using water andinhaling air charged with the impurities of human excreta.The creek San-t-’sung, is not far from the foreign settle-ment ; it is comparatively narrow and crowded with boats ;the alvine dejections and other impurities of thousands ofinhabitants along it are daily discharged into the stream,and yet the water-too dirty one would say for washing-isdaily used for culinary purposes.Boucnemia tropica, or elephantiasis Arabum, is a dis-

ease often met with in Amoy. Drs. Muller and Manson, intheir report on this district, state that their ideas of thepathology of this disease are in accord with those generallyaccepted-namely, that it is an affection of the lymphaticsexcited by malarious influences. They have never, or veryseldom, observed enlargement of the spleen coexisting withthis disease, although ague and malarial fever are the normalaccompaniments of its development, and its ostensible ex-citing cause. They recommend in elephantiasis of the legs,accompanied by acute exacerbations that the treatment byblistering, iodine, and bandaging, with quinine and ironand a liberal diet, should be persevered in for some months.The operative measures proposed for adoption in those casesin which the disease involves the genital organs are dis-cussed, and the method employed by the authors is veryelaborately set forth and illustrated by woodcuts.

Dr. W. W. Myers, in his report on the sanitary conditionof Chefoo, alludes to the remarkable efficacy in his hands ofnecacuanha in the treatment of dysentery, two the utility ofnrropine as an antidote in cases of opium poisoning, and tothe advantageous employment of quinine as an applicationto granular lids, with pannus, as recommended by Mr. Baderin the columns of THE LANCET.

Dr. Edward Henderson’s memoranda on Steppe-Murrainin Shanghai is a paper embracing the results of a gooddeal of hard work and careful thought, and the facts re-corded ought to be of interest to those engaged in the studyof the diseases of China.

* Medical Reports for the Half-year ending March 31st, 1872. (No.3.)

Foreign Cleanings. HYDROTHERAPY IN ORGANIC DISEASES OF THE HEART.

IN an excellent paper on the above, published by Dr.Hirtz in the September number of La Gazette Medicale deStrasbourg, the use of hydrotherapy in certain cases of heartdisease is advocated by the author. Dr. Hirtz, having statedthat therapeutical indications in cardiac affections are

afforded rather by the symptoms than the local lesions,proceeds to lay down three distinct series of rules in regardto the treatment of such maladies.

-

1. Cases of exaggerated venous tension (cyanosis of face,cervical veins dilated, oedema of legs, extreme oppression,orthopnoea, drowsiness, weak beatings of the heart, smalldeep pulse, fall of temperature, frequently albuminuria);abstraction of blood in small quantities repeated two or threetimes the same day. No digitalis.

2. Cases of arterial tension (rapid and hard shock of theheart, shaking of the walls of the chest through palpita-tion, haemoptysis, oppression on the slightest exertion,rates in the chest frequently, cedema of extremities, face notcyanosed, but lips and cheeks red, cephalalgia, giddiness).Infusion of digitalis.

3. A third group of cardiac affections more prevalent inyouthful subjects, and where a real organic disease is com-plicated by disorders in hsematosis. They do not consist inchlorosis, but in anaemia of various degrees, linked with anactual lesion of the heart, and often with stricture. Thesymptoms are prostration, pallor, muscular weakness, and,locally, palpitation, and frequent oppression, accompaniedby oedema in many cases. It is in this group of cases thathydrotherapy, in the form of cold douches and lotions, shouldbe employed, and proves highly successful. At the sametime the patient should be sent to the country.

THE ORIGIN OF GIANT CELLS IN TUBERCLE.

Schiippel, of Tubingen, has recently published in theArchiv der Heilkunde the results of a series of microscopicalresearches touching the origin of giant cells, which he hadformerly found to exist in tubercle. His recent researchesshow that the origin of these cells is due to the trans-formation of vascular contents, or the organisation of ele-mentary granules into giant cells. They are, therefore,formed at the expense of the blood plasrna, whether theytake rise in the vessels themselves or out of them. Theprocess is, therefore, a free formation of cells.

FEBRIFUGE AND ANTIPERIODIC PROPERTIES OF LAURUS

NOBILIS.

M. A. Doran has communicated to the Paris Academy ofSciences the results of various researches showing the febri-fuge properties of Laurus nobilis. The leaves are first driedover the fire in a closed vessel, then pounded and reducedto a fine powder. The dose is about fifteen grains. The

powder is made to macerate in a glassful of cold water forten hours, and the patient takes both the liquid and thepowder two hours before the expected fits. No abnormaleffect follows, and one dose is often sufficient to break thefever. The dose must be repeated three times. The authorrecords thirty-four cases with only six failures, in all ofwhich latter the type was quartan.

ACTION OF PHOSPHORUS ON THE ORGANISM.

Dr. Wegner has been carrying on numerous experimentswith animals (mostly rabbits) on the above. The resultsmay be summed up briefly thus: Phosphorus administeredin small doses produces a chronic intoxication, characterisedby an alteration of the blood through the presence ofphosphorus in this liquid, and which acts in a specialmanner on the osteogenous tissues, producing an exaggeratedformation of compact tissue in the situations where thiskind of tissue forms normally. The doses required to pro-duce these results were only 1/66 grain a day for rabbits, andgrain a day with dogs.-Archiv fiir Pathol.

USE OF COLLODION IN ERYSIPELAS.

Dr. Broca recommends painting with collodion over thehealthy skin, all along the edges of the inflamed surface,and over a space of at least six to eight centimetres inbreadth.-Tribune Médicale.