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1847] Nunneley's Experiments with Hydrocyanic Acid. when he examined the body immediately after death, he found the explanation of the different statements made in reference to the state of the heart and vessels. When death is long delayed, or the dose of the acid very small, the blood is usually dark, and all the cavities of the heart may contain more or less of it, especially the right, which is often much distended. If the death had been sudden, the left side of the heart, and especially its ventricle, was almost always found perfectly empty and rigidly contracted, the right side being at the same time, though not always, much distended. In nearly every instance the aorta and its large branches were, like the left ventricle, found empty. As shewing that this different condition of the two sides of the heart is not dependent upon obstruction of the lungs the detailed post-mortem examinations are referred to.

ά

"This condition of the heart and great vessels sufficiently explains, what has given rise to much surprise, why it is that with the venous system so much congested so little blood should flow on a vein being opened. It is obvious that it cannot. The circulation is positively suspended; though there be motion of the heart, the blood is not propelled; there is no vis á tergo. For, as the left ventricle will not open to receive the blood from behind, so it cannot give the onward impetus; hence, should the blood in some degree flow, or afterwards continue to drain away, this will merely depend upon the circumstance of the aperture being in the most depending position, when, if the blood continues fluid, some of it will find an exit, as any other fluid does from an opening below its level, a mode of escape altogether different from that of ordinary venæsection." P. 77.

The author's subsequent observations, made while injecting the acid into the veins, also confirmed this view. In a minute, or a minute and a half, blood almost ceased to flow from even such large vessels as the external and internal jugulars.

Very erroneous ideas at one time prevailed as to the rapidity with which the effects of this poison are produced, and the possibility of certain voluntary acts being performed subsequent to taking it. Many authentic cases now prove that its action is by no means so instantaneous as once supposed. Mr. Nunneley believes some of his experiments tend to show that consciousness may, when the dose is not very large, be retained, after all voluntary power is extinct, and but little sensibility remains. This would indicate the spinal marrow as being more obnoxious to its influence than other portions of the nervous system, an inference likewise derivable from the violent spasmodic action alternating with paralysis which is produced. However this may be, the experiments confirm the statements now usually received of the length of time during which both consciousness and volition may be retained; for, although in a few instances the action of the poison was too rapid to admit of a manifestation of these, in most of the dogs and other warm-blooded animals about twenty seconds elapsed ere any symptoms were manifested, and in several a much longer period. There does not seem to be any fixed quantity of the acid which will invariably destroy life, much depending upon individual and varying circumstances. The more vigorous the animal, cæteris paribus, the larger is the quantity required. A full stomach lessens the effect, and age exerts a material influence. Mr. N.'s experiments seem to show that an animal is easily brought under the influence of the poison, just in proportion as it is young; within however

certain limits, for if it be very young, a larger dose is required than is necessary to poison one of the same species a little older. This is so curious a fact, that were there not sufficient evidence to support it, we should feel much inclined to doubt it. Is it to be regarded as another proof of the approximation of the young of the higher species to the adult of the lower?" The degree of concentration of the acid employed exerted no very material influence-a moderate degree of dilution, in some cases, seeming to have augmented its effect. Neither did death follow with rapidity in proportion to the quantity taken, supposing the minimum dose to suffice for speedy death. Thus, supposing 40 m. of Scheele's acid kills a dog in four minutes, it does not follow that SO m. or more would do so in half the time. Hence, when called to a person poisoned, we cannot, merely from the length of time he has survived, or the violence of the symptoms, determine anything with certainty as to the degree of concentration or dilution of the acid, nor, except within wide limits, much as to the absolute quantity taken."

Too much reliance was at first placed in our criminal courts upon the occurrence of the death-shriek, as symptomatic of this description of poisoning in man. Mr. Nunneley's experiments show that it is as often absent as present even in dogs, and in not more than one-third of the number is it very loud. When it does occur, however, it is entirely and distressingly peculiar. "It is different from any thing I have heard in any other condition of dogs or other creatures, and is, I think, when present, characteristic of the poison."

Treatment of Poisoning. Mr. Nunneley availed himself of the opportunities which his numerous experiments presented him with, of examining this important part of the subject; but with very defective results, respects the discovery of an antidote, or even the treatment of the effects of the poison. Chlorine, alkalis, and the preparations of iron, were found unavailing for the first of these objects. For counteracting the effects electricity was of no avail, if it did not aggravate these. Cold affusion, which has been so much lauded as a means of arousing the energies of the system, is thought of little avail by Mr. N. in any but the slighter cases of poisoning, and in these only when used with discrimination, and not too prolonged. He observed that shaking the animal briskly seemed to exert a marked beneficial effect in several cases. In bleeding, we have already seen, he has but little faith. Emetics, although immediately given, were of no avail whatever, when the dose of the acid had been large; but when this has been but small, or taken into a stomach already containing other ingesta, they may be useful. Owing to the favourable reports which have been published concerning the effects of ammonia, Mr. N. put these very freely to the test of experience. This convinced him that its efficacy has been exaggerated. Applied externally it was not of the least avail. I think all that can be fairly adduced in favour of ammonia is, that as it may be beneficial we ought to have recourse to it, not with the expectation of deriving benefit from it in severe cases, but that in those cases where the dose has been so small as to render it uncertain which way the balance will turn, it may assist it to incline on the side of life."

1847]

Southam on Ovariotomy.

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II. OBSERVATIONS ON THE OPERATION OF OVARIOTOMY. By George Southam, Esq.

Mr. Southam here presents us with the details of a case in which this operation was unsuccessful, adding to these some interesting remarks. He truly observes that, it is a duty of one who has recordad successful cases to give an account of those in which he fails, a duty, however, we fear, especially as regards the operation in question, very imperfectly fulfilled. The suppression of the particulars" by such practitioners, he observes, "can only be regarded as a proof that the operators thought they would reflect no credit on their judgment, either in a medical or surgical point of view. These ought not, therefore, to be adduced as objections, the fault being with the operator rather than the operation." This conclusion is scarcely correct. In ordinary operations we do not find the same refusal to publish unsuccessful cases; and we cannot but think that fear lest the medical public would regard the undertaking this one, in the cases in question, as utterly unjustifiable, has prevented disclosures so morally obligatory and vitally important for estimating the true position of ovariotomy as a legitimate operation, unsettled as this is at present amidst the crude statistical statements which have been adduced. Death from other operations does not, at least only in a very insignificant proportion of cases, occur in consequence of the case having been wrongly diagnosed, or the operation abandoned without being completed-circumstances avowedly of frequent occurrence in respect to ovariotomy. We see no reason to alter the opinions expressed in a former Number of this Review,* and we entirely doubt the accuracy of Mr. Southam's statement that, "by a majority of those who have made the diseases of females their more especial study, ovariotomy is now considered as perfectly justifiable." We believe exactly the contrary is the fact, and that few of our eminent obstetricians have so expressed themselves; and even if they had, we must appeal to a more competent tribunal, and one more accustomed to estimate the difficulties and calculate the chances of surgical operations in general; and we are aware of the names of scarcely any of our operating surgeons who have as yet admitted ovariotomy as a justifiable undertaking, except in very rare and exceptional cases.

We need state only a few of the particulars of the case. The patient was 26 years of age and had had five children. The tumour was first perceived ten months prior to the operation, had rapidly increased in spite of bandaging, frictions, and was complicated with ascites. Its diagnosis from uterine disease was a matter of some difficulty-Dr. Simpson's sound obscuring rather than aiding this. As a difference of opinion prevailed concerning the origin of the tumour, Mr. Southam made an incision but three inches long, mid-way between the umbilicus and pubes, until he had ascertained that it was unconnected with the uterus, when this was prolonged above the umbilicus, and the tumour, which was found connected to the broad ligament and posteriorly to the omentum, removed without much difficulty. The operation was completed within twenty-five minutes, the

Med. Chir. Review, N. S., Vol. I., pp. 26 and 42.

patient being repeatedly faint, although little blood was lost. The woman lived until the sixth day after the operation, sinking apparently from want of constitutional power. The post-mortem examination exhibited slight traces of recent peritonitis; and the pedicle of the tumour, which had been encircled with the vessels in the ligature, was in a state of complete sphacelus. "The risk from the operation would, no doubt," Mr. Southam observes, "be much diminished if the vessels could be alone secured, which I believe is practicable in a majority of cases, as there are seldom more than three that require tying."

The question of the malignancy of ovarian tumours forms an important element in considering the propriety of their removal. It can be best decided by watching and recording the condition of patients who have undergone the operation of extirpation; for we quite agree with Mr. Southam, that the microscope is at present a very unsafe guide in this matter. Of this opinion are several of our most eminent microscopic observers, among whom is Mr. Goodsir, who, reporting to the author upon a specimen of the tumour submitted to him, says:

"I put very little value on the microscope in detecting the nature of tumours of any kind. It is by what we call in natural history the habit, or general appearance, or bearing, of plant, animal, or morbid growth, that the species or nature in doubtful cases, is to be determined. In disease this tact in discrimination is to be acquired not by poring through a microscope, but by experience in the diagnosis and handling of tumours in the living, and the examination, by the naked eye, of their general appearance in the dead. The microscope can only verify the previous determination." P. 103.

We cannot admit that this grave operation was justifiably performed upon a woman of enfeebled frame, the subject of ascites; but Mr. Southam's narration of its unsuccessful issue is entitled to much praise.

III. OBSERVATIONS ON THE PATHOLOGY OF ABSCESS OF THE HEART. By T. H. Stallard, Esq.

Mr. Stallard details an interesting case of this. A shoemaker, æt. 60, and previously very well, was seized, 22nd March, while at work, with coma, cyanosis, and great prostration-his pulse (60) being full, soft, and feeble, and the respiration slow and gentle. Stimuli were given him, and next day he rallied somewhat, the pulse becoming stronger, and the respiration a little quicker. On the 25th he was thought to be asleep, but was found to be dead.

"On opening the left ventricle, which was accomplished by a V-shaped incision, an abscess was observed. It was situated at the apex of the ventricle, and of a very irregular shape, being most pointed towards the apex of the heart, from the surface of which it was separated by two or three lines of healthy structure; above, it projected considerably into the cavity of the ventricle, with which it communicated by a small fissure; the interposed septum was about one line thick, and appeared to consist of thickened endocardium. The cavity of the abscess contained a bloody, purulent-looking fluid; its lining membrane was of a light red tint, and presented a granular appearance. Around the abscess the muscular tissue was darker than natural, and in the outer wall of the same ventricle were observed several fissures, containing a dark-coloured fibrinous mate

18471

Stallard on Abscess of the Heart.

123

rial, and some of these, though not all, communicated with the cavity of the ventricle. The coronary arteries were much ossified." P. 107.

Mr. Stallard argues the improbability of this abscess having arisen from acute or chronic carditis, since all symptoms of this were absent, and no signs of the always accompanying endocarditis or pericarditis were found after death. The dark fibrinous matter found in the substance of the ventricle had all the appearance of coagulated blood. The presence of blood in this situation may be explained, 1, by the fluid being forced between the columnæ carneæ, so as slightly to rupture the endocardium. 2. Congestion of the coronary vessels may terminate in rupture. 3. A partial rupture of the heart's muscular fibres may occur and this the author regards as a frequent cause of angina pectoris. Blood effused from any of these causes may be slowly re-absorbed, remain for a period unchanged; or, if in sufficient quantity to interfere with the action of the organ, the constitutional powers being at the same time feeble, it may undergo the changes so ably pointed out by Mr. Gulliver,* and become softened into a puroid fluid, which, however, resembling pus in apppearance, is easily to be distinguished from it by the aid of chemistry and the microscope.

"I have thus endeavoured to show that the case I have related is one dependent upon the effusion of blood into the substance of the heart, that the abscess resulted from softening of the coagulum so effused, and that this having possibly existed for some considerable time, at length escaped into the ventricular cavity, and caused slow death by poisoning the circulating fluid. I shall now proceed to confirm this opinion by one or two recorded cases, and whilst my observations will tend to show that carditis, or myo-carditis, is more rare than is generally supposed, I by no means assert that it never takes place. Andral cites several cases to show that redness of the muscular substance, observed after death, had been caused by an attack of carditis, and this is also the opinion of Dr. Elliotson: but it is remarkable that, in all these cases, severe symptoms of cardiac disease preceded death, whereas none, or few, were present in cases specially related as instances of pure carditis." P. 111.

An abridged account is given of two cases of abscess supposed to arise from carditis, related by Mr. Salter in the Medico-Chirurgical Transactions,† (Vol. 22), and by Mr. Chance in a recent number of the Lancet. Mr. Stallard believes the symptoms and post-mortem appearances in these are best explained by the above hypothesis; and observes that the point is an important one, as a correct plan of treatment can only be founded upon a proper comprehension of the true pathology of the disease. In the one case antiphlogistic means would be called for, even though the symptoms indicated prostration, while in adopting Mr. Stallard's views, stimuli are indicated upon the following grounds :

"1. To stimulate the vital energies, in order to prevent the effused blood becoming softened and decomposed, and thus to favour its absorption or organization. 2. If the clot shall have already softened and entered the blood, to obviate or at least stave off the effects of poisoned blood, which alcohol has a great power of effecting. 3. Should the fluid have escaped into the pericardium, to stimulate the system to the production of pericarditis; which, however undesirable under ordinary circumstances, is in this instance curative, since it closes the opening

See Med.-Chir. Transac. Vol. 22, p. 151, or Med.-Chir. Rev., No. 63, p. 47. + See Med.-Chir. Rev., No. 63, p. 51. ‡ No. 1185.