The following was the result of the experiment:-"The amount of mucus, after separation from the urine, and being perfectly washed and dried, weighed 62 grains. The amount of inorganic matter, after incineration, weighed 19.5 grains. This was found to consist principally of phosphate of lime, phosphate of magnesia, and a small quantity of carbonate of lime, which last was produced from the oxalate during the ignition." In pure mucus there is scarcely 2 per cent. of inorganic matter, while in this case there was very nearly 30 per cent. The circumstance of this large quantity of the constituents of a broken-down calculus being held in suspension by mucus is a most important feature in connection with the operation of lithotrity, as the surgeon will learn that, even where the detritus passes with difficulty in its coarser form, the im. palpable particles are readily removed by this effort of Nature. It is worthy of remark in this case that no fragments of stone were contained in the mucus, nor have I since been able to detect any remaining in the bladder, although the strictest examination has been instituted. A question, how ever, still remains undecided-whether the detritus of any other species of calculus besides that of bone-earth is capable of being thus suspended in mucus. I trust the recital of this case will lead the attention of the profession to the subject, so as to excite further investigation.

withdrawing the detritus between the blades of the instrument. The fragments thus removed weighed ten grains; and as the withdrawal of the lithotrite created some irritation, I relinquished all further examination for the time. Four days afterwards, in washing out the bladder, I again detected a portion of stone; passed a large lithotrite, and immediately seized a piece of stone about the size of a bean: this I easily crushed as before; and on that evening about fifteen grains of detritus passed. Since that time I have not been able to detect the presence of any portion of stone. All the symptoms have completely subsided, and the patient appears to be restored to perfect health.

Notwithstanding the freedom with which the detritus passed from this patient's bladder, I was surprised to find that a very large quantity of mucus was mixed with his urine, which, from the result of the examination of the mucus passed in the last case, I had not anticipated, believing that the secretion in the former instance had resulted from the detention of the detritus. I therefore sent this mucus to the College of Chemistry, as before, and, to my astonishment, found that the analys's shewed the existence of the same per centage of boneearth as in the former case.

I refrain from offering any opinion upon these cases, as I am at the present time actively engaged in the further investigation of the subject, which appears to me to bear a most important relation to calculous dis

ease.

and on my visit next day, I was astonished to find that upwards of thirty grains of detritus had been already passed. By the end of the week he had passed 130 grains, and was so free from every symptom of stone, that I was almost led to believe that the whole of the calculus had been removed; and, upon sounding, I could not detect the presence of the smallest portion. Being aware, however, that the lithotrite would often detect that which may ehude the sound, I injected four ounces of water into the bladder, and passed the smaller scoop lithotrite, when I immediately detected a portion of stone, which I seized and crushed,

Although there are, then, many difficulties that occasionally present themselves in the use of the lithotrite, in appropriate cases often productive of such admirable results as to give lithotrity a claim to be considered one of the greatest inventions of modern surgery. In three or four of the cases I have had, one operation has been sufficient to effect a permanent cure; but the best instance was one sent to me by Mr. Parrot, of Clapham, in which the patient was suffering from the most urgent symptoms, and was completely cured at one sitting." After the stone was crushed, a drachm of detritus passed away, and no symptom of stone has ever returned.

Although circumstances may arise that may render the operation of lithotrity un

safe, it does not necessarily follow that that of lithotomy should be performed; for, as I have already mentioned, it is the duty of the surgeon first fully to ascertain that the general health of the patient renders him fit to be submitted to such an ordeal. In the first place, I should say the state of the urine should be strictly investigated; and if it be found, by the application of heat or nitric acid, to contain a large quantity of albumen, free from the colouring principle of the blood, the patient must be considered totally unfit, at least at the time, to be exposed to the hazard of the operation. The state of the heart and lungs, of the ab dominal viscera, and more especially of the liver, should each be the object of close investigation;-I say especially of the liver, on account of the liability of that organ to disease, and not unfrequently to a fatty degeneration, concomitant with which the vital powers are invariably much diminished, and the subject of the complaint rendered incapable of sustaining the reparative efforts of the constitution. Such cases are not, however, to be despaired of medicinal means should be employed, change of air and scene recommended to the patient, and he will probably be restored to a condition in which he may be able to undergo the operation with reasonable prospect of a successful result. When none of these cogent reasons exist for delaying the operation of lithotomy, there is a previous preparation which the patient ought invariably to be submitted to, and for which no general plan can be laid down, as it must in every instance be regulated by the constitutional peculiarities of the individual. Thus, in plethoric habits, it may be necessary to have recourse to depletion, and both blood-letting and purging may be requisite; indeed, I have generally found them more efficacious when conjointly employed than when either has alone been resorted to; in cases of great obesity, it may also be necessary to reduce a patient before the operation can be safely performed: and my friend, Mr. Green, had, some years ago, a patient, from Manchester, who, when he first consulted him with stone in the bladder, weighed twenty-six stone: he was reduced, by strict dietetic discipline, to nineteen stone, and was then successfully subjected to the operation of lithotomy.

It is also highly desirable to prepare the mind of the patient, as well as his body, for what he has to undergo; and for this purpose it is proper to describe to him the position in which he will be placed during the operation, for I have not unfrequently seen patient, particularly in the better class of life, who had heroically made up his mind to submit to the operation, and walked firmly

a

to the table, completely give way on learning the constrained position in which he was to be placed. It is also of great use to prevail on the patient, for a few days before the operation, to remain occasionally for five or ten minutes in the attitude of grasping the soles of his feet, in order to accustom the muscle to so unusual a position; and this not only diminishes the terror, but also the inconvenience, which would otherwise produce a great increase of excitement during the operation.

The night previous to the operation, a purgative should be administered, and in the morning an enema given, for the purpose of securing complete evacuation of the rectum. In persons of very irritable habits, it is also advisable, after the action caused by the enema has ceased, to inject about thirty drops of landanum, in an ounce of gruel, into the bowel, with the view of lessening the muscular irrritability of the parts, and also to produce a beneficial sedative effect after the operation has been performed. Let me here suggest, that the surgeon himself should be certain that all these preparations have been effected before the appointed period for the operation, so that when that time arives the patient's mind may not be kept in agitation by unnecessary delay.

In lithotomy very various operations have been proposed, and, to a certain extent, adopted, at different periods, and a multitude of instruments of different kinds been employed; but I shall content myself with the description of what is termed the lateral operation, which is now almost invariably performed in this country, in consequence of its affording the most direct and safe passage into the bladder.

The high operation, nevertheless, demands some brief consideration, although in my opinion it ought never to be adopted, excepting where the prostate gland is so much enlarged, or the pelvis deformed, as to render the lateral operation inexpedient. Many surgeons contend, however, that a larger stone stone may be removed by opening the bladder above the pubes, than by the lateral section. I doubt the correctness of this view, and believe that such an opinion is generally founded upon the observation that the bladder can be opened with greater facility in the pubic region, in cases of distension from retained urine, but in cases of stone, as the bladder is thickened and contracted, deeply placed in the pelvis, and covered by peritoneum, it can only be opened with considerable difficulty, and it is almost impossible to remove a large stone from it without injury to its serous covering. I once saw the high operation performed by Sir Everard Home, and a most difficult and tedious operation it was: after he had cut down through the parietes of the abdomen above the pubes, he was obliged to make an opening in the perineum, and pass an instrument into the bladder from below, to enable him to open the bladder above the pubes. After much difficulty, a calculus was removed, but the patient died in consequence of this complicated operation a few hours after its completion.

A friend of mine a few years since was present at the performance of the high operation of lithotomy, by M. Civiale of Paris. In making the first incision through the parietes of the abdomen, he wounded the peritoneum, which led to the protrusion of the small intestines. He returned these into the abdomen, and continued his operation, and ultimately succeeded in extracting a stone : the patient was put to bed, and M. Civiale, on subsequent consideration, dreading the liability to extravasation of urine into the peritoneum, determined upon operating upon the bladder through the perineum. He effected this, and so completely succeeded in preventing the result he feared, that the patient

ultimately recovered.

In this case, although I should remain as much as ever disposed to repudiate the propriety of the high operation, I cannot too much extol the acumen shewn by the above eminent surgeon, in the means which he adopted to obviate the danger caused by his mishap in the commencement of the operation.

As to the instruments to be employed in lithotomy, there are but few that are not applicable if directed by the hand of an anatomist and surgeon; although, after considerable experience, I must, in justice to Mr. Key, express my preference to the straight staff, but it must be in the hands of those who can appreciate its value, and who know how to avail themselves of the advantages it affords. The operation of lithotomy should never be

undertaken without maturely considering every separate step necessary to its comple

tion, and at once looking forward merely to the ultimate object, the extraction of the

stone. Nor in contemplating each step should the facilities alone be considered; but every difficulty which can possibly occur, dwelt on, and the means of obviating it anticipated: indeed, as much, or perhaps more, depends upon the discipline of the operator's mind than upon the mere dexterity of his hand; for it can hardly happen that the manipulation should be dexterous when the instruments are not directed by judgment and coolness in the operator.

Original Communications.

CHILD-CROWING, OR SPASM OF

THE GLOTTIS.

ON CHANGE OF AIR AS A REMEDY.

BY JOHN ROBERTON, Formerly Senior-Surgeon in Ordinary to the Manchester Lying-in Hospital.

IN Dr. West's Lecture on the above disease, published in one of the numbers of the LONDON MEDICAL GAZETTE for February-a discourse which contains a very full and accurate account of the symptoms-I noticed that while admitting in general terms the benefit of pure air in the treatment, he warns his readers against the danger of a free exposure to the atmosphere : SO strongly, indeed, does he express himself, that the chances are, many will be deterred, under any circumstances, from giving change of air even so much as a cautious trial. His words are, "although the benefit that accrues from fresh air is often very great, yet it is very important that the child should not be exposed to the cold or wind, for I have seen such exposure followed by a severe attack of dyspnea, or by the occurrence of general convulsions. The hazard of such an occurrence is greater in proportion to the severity and long continuance of the affection."*

To the same effect is the following from Dr. Marshall Hall: - "The next object is to guard the little patient from the external atmosphere, when the north-east winds prevail, or the air is cold or damp; the patient's bed should be surrounded, at intervals of foot, by

about one

three distinct cur

tains, or tents of gauze, or of net; the air of the room should be protected from partial currents, be well supplied with hygrometric moisture, and be maintained at the temperature of 65° Fahr."+

Having had opportunity in the course of practice to treat a number of cases of this always alarming, and somewhat fatal malady, I was led, by

the little benefit derived from medicines, to venture on the employment of free exposure to a cool, dry atmosphere,

* Feb. 11, 1848. † Lancet, June, 1847.

as one of my principal means, more especially in aggravated forms; and, although I cannot affirm its invariable success, in no instance has it proved injurious. It will be seen from the cases I have given, that the success of this method has been very considerable, -in a large proportion of instances, decisive. Of course the exposure has been had recourse to with due caution -a condition necessary, however, in the employment of every kind of remedy possessed of power.

In the year 1834, a fatal case of spasm of the glottis occurred in my own family: this happened when the late learned Dr. Ley was putting forth a series of papers on the same disease, named by him Laryngismus Stridulus. The circumstance induced me to publish that, and two other cases, in the 13th volume of the LONDON MEDICAL GAZETTE, with the view of expressing my dissent from his pathological theory-viz. that the spasm is from pressure on the par vagum, or its recurrent branch, produced by the glands in the tract of those nerves becoming enlarged. At that period I had not made trial of change of air, but I soon found occasion to do so, and the results now to be given are, I hope, sufficiently important to warrant me laying them before the profession.

The symptoms of spasm of the glot tis, as they have occurred in my own experience, are chiefly the following :I enumerate them in the outset, because, as it is not my object to give a full description of the disease, this may hold me excused from very minute de tails in the narration of my cases. The particulars that are essential I will take care to supply, and avoid only what for my purpose is superfinous.

The complaint may occur at any stage of dentition. Earlier or later than the time of teething, no instance has come under my notice. At the commencement, the nurse will sometimes remark that the infant stiffens for a moment or two in her arms, as if suddenly alarmed, there being at the same time a catch in the breathing. This slight kind of spasm will recur occasionally for weeks, and be attributed to wind on the stomach. By and by, on the babe's awaking, or being crossed, there is heard a shrill, prolonged inspiration, and rapid expiration, repeated three or four times, with

increase of the stiffness of the body and limbs. The head is thrown back; the eyes are turned upwards; the countenance is flushed, and the look indicates alarm or terror; relief arriving only when the infant is able freely to cry. This latter is noticed in the early stage of the disease. Afterwards, when the child is more accustomed to the attacks, the crying, as one of the symptoms, will often altogether cease. After a while, the spasm may occur once, twice, or oftener, in an hour; but, in regard to this, there is no rule, for I have known it to come on once only in a day or two, and in other instances, every few minutes, day and night. According to my observation, the spasm occurs as frequently in the night as in the day, and strong infants will raise themselves in the bed in a sitting posture, through the urgency of the attack, grasping at the nurse as if for protection and help.

I have been referring to the complaint in its mildest form. Soon, especially supposing it to have commenced early in the period of dentition, the symptoms become aggravated, the struggle before the crowing or stridulous sound is more violent, accompanied with blueness about the mouth and eyes, in some cases, -in others with universal lividity of the face and neck, and swelling of the veins of the forehead; the look, and attitude of the head, trunk, and limbs, being what we may suppose they would be were strangulation takin taking place as the effect

of slow moderate violence. The attacks vary in different children. In some the spasm is brief, but so frequent, that the countenance is habitually blue; while in other infants, commonly the robust, the spasm is so prolonged, and so severe, as to fill the bystanders with consternation. I remember a hale grandmother, herself the mother of many children, who, on being told that her son's infant was suffering from spasm of the glottis, declared that this disease (of which she had never heard before) must be a fancy of her daughter-in-law's. But, when, on coming, she witnessed an attack, she was more terrified than any one of the bystanders. And a feeling of alarm, there can be no doubt, is the usual effect on those who for the first time witness a paroxysm of the disIn addition to the mere spasm and its effects, as now described, there are symptoms not present in all, but in, perhaps, a majority of cases, that justly excite a still more lively alarm. During a fit of crowing, the nurse will remark the drawing of the thumbs into the palms of the hands, and of the toes towards the soles. These are symptoms observed in many who ultimately recover. When, however, the thumbs are habitually retained in the palms, the toes being at the same time spas modically curved, experience has shown the danger to be imminent. In some infants, the hands also are bent strongly on the fore-arm.

In degrees yet more aggravated, the blueness and lividity of the face is constant, which is owing to the spasm of the glottis recurring, perhaps every five minutes. In a case which terminated favourably, I was assured by the intelligent mother, that the spasms were not absent more than ten minutes, day and night, for eight months.

In other instances, not rare, there are convulsions, mixed up, accidentally, it would seem, with the spasms of the glottis. On the other hand, I have in several noticed the crowing (not in every attack, but now and then) terminate in a distinct convulsion.

The look of an infant subject to spasm of the glottis, will commonly indicate to an experienced eye the presence of this disease. A majority of those affected are rather large and vigorous: they have a lively, excited, irritable manner, are never still in their nurse's arms, and are alternately laughing and fretting. The cheeks are tipped with red, and the eyes are bright and restless, but not clear and placid, as in health. Occasionally the scalp and forehead are sprinkled with small scabs, and the sanguiferous circulation, in a large proportion, is brisker and stronger than natural.

The following case, which I had occasion to watch in the course of last spring, exemplifies the course and treatment of the disease, in a decided though mild form :

I. March 3rd, 1848.- Master S., aged 11 months, a bright-eyed, powerful boy, just weaned. Has cut only the two lower central incisor teeth: the upper are near, and the gums inflamed. For about three months the nurse has

noticed chokings coming on suddenly, when he throws his head back, raises his hands, and makes a strangling noise, attended with flushing of the face and staring of the eyes. This passes off directly. The alvine evacuations are dark. Last night nurse noticed, while in bed, that he sprung up, struggling, as a spasm came on.

5th. Increase of the choking fits, which have occurred repeatedly in the night. Has a running at the nose, and cough.

6th.-Asleep when I entered the nursery. While I was talking with the nurse, awoke in a spasm. There was a long shrill inspiration, a quick expiration, and then a prolonged inspiration, as if the air found entrance with difficulty through a narrow chink. Meantime, the hands are outstretched, the limbs rigid, the head is thrown back, the face deeply flushed, and the eyes are staring, as though the babe were in terror. In a few seconds the spasms relaxed, so as to admit of free crying. Nurse says, that when in bed, on the accession of an attack, he usually raises himself, and lays hold of her. The spasm gone, he smiled, and was merry, as though nothing had happened. The motions, hitherto dark, are to-day more yellow. Catarrh nearly gone.

8th.--Yesterday and to-day, spasms more frequent and severe. Nurse says that there remains after each, blueness round the mouth and eyes: counted seven attacks in the course of last night. One to-day, on awaking, as he lay in his cradle, was uncommonly severe; the face remaining very dark until he was able to cry; motions offensive and whitish. A grain of Hyd. c. Creta, with the same quantity of rhubarb, nightly. One incisor out (the right upper central), the other not. to be carried to the shore at Lytham in a few days.

Is

10th.-Spasms severe and rather frequent, with blueness about the mouth and eyes. Motions still too pale; continue powders. Off to Lytham to-morrow.

25th.-Saw his mother to-day, on her return from Lytham, where she has left him with the nurse. Says that on the journey thither, he had five or six attacks of crowing, but that, after their arrival, had no return during the first five days. Is carried out on the shore