THE
MEDICAL EXAMINER,
AND
RECORD OF MEDICAL SCIENCE.
NEW SERIES.—NO. LXXII.-DECEMBER, 1 8 50.
ORIGINAL COMMUNICATIONS.
Fragments from the note-book of an office pupil of the late Dr.
George M’Clellan, containing cases and clinical remarks*
*The manuscript book from which these fragments are extracted was
anly preserved for its writer’s own use, but the Editor has thought that
records, however slight, of the views and practice of so eminent a man,
would not be unacceptable to the readers of the Examiner.
May 12th, 1843. Calomel—effects of large doses.—Dr.
M’Clellan in referring to-day to the effects of large doses of calo-
mel upon the system, mentioned some experiments which were made
upon dogs in India by Annesley. He gave ~j. or more of calo-
mel to one dog, and a few grains of the same to another, and
killed them both after a certain number of hours. After repeat-
ing these experiments, he invariably found that the large doses
had the effect of blanching the gastric mucous membrane, contracting
the intestinal exhalents, stimulating greatly the liver, and apparent-
ly of forming with the intestinal mucus, a thick saponaceous com-
pound; while the examination of the animals treated with the small
doses, developed only the engorgement of the mucous membranes
which is usual after death.
In remarking upon these experiments, Dr. M’Clellan said that
he thought the happiest effects had resulted from doses of calomel
ranging from 20 to 60 grains, in many cases where smaller quan-
tities were usually given, as in certain forms of gastric irritation,
inflammation and congestion, congestive hepatic disorder, dysen-
tery, and the symptomatic affections of the abdominal viscera, ac-
companied by foul watery evacuations which frequently occur
after bad wounds. Such doses generally cause only one or two
evacuations, which are often more consistent than those which
preceded them, stimulate largely the liver, correct the disposition
to diseased exhalation, and, in general gastro-intestinal affections,
often put a stop at once to vomiting and purging. He has sel-
dom seen large doses of calomel productive of any but a
pleasant effect when given in a state of system accompanied by
dry skin, and generally defective secretions, and is always care-
ful to diminish or discontinue the doses upon the re-establishment
of these.
He has sometimes found that the long-continued action of ca-
lomel even in small doses, when it did not produce salivation,
caused very disagreeable consequences, among the most trouble-
some of which was amaurosis, which he has occasionally seen to
be produced. Mercurials given with the effect of causing slight pty-
alism, he never found to give rise to such or any other unfortu-
nate results. (
Nitrate of Silver.—This powerful escharotic has a most de-
lightfully mild and tranquillising effect upon the mucous membranes,
and is an invaluable remedy for inflammation or irritation of those
tissues. Its effects in sore throat and ophthalmia have long been
known. In the latter disease it deadens the irritability, blanches
the mucous membrane, contracts the vessels, and sometimes in the
most painful, strumous ophthalmia, with intolerance of light, after
one or two applications, enables the child to bear the full glare of
the sun. He generally has it dropped into the eye in the propor-
tions of from gr. j. to gr. iij. to a f.gj of water, or else applies to
the surface, moistened bibulous paper, previously smeared over a
stick of caustic, or where granulations exist, applies the solid ni-
trate itself. He has found the sedative and counter-irritatant ef-
fects of the caustic freely applied to the outside of the lids, to as-
sist very much in the treatment of scrofulous ophthalmia with
great photophobia, as well as in the severe inflammations occurring
in adults.
Dr. M’Clellan has found this remedy serviceable in allaying ir-
ritation and inflammation of other organs. He administered it in
the only real case of idiopathic gastritis he ever saw, where the
patient could retain absolutely nothing upon her stomach, and
was afflicted with the most obstinate and constant singultus-like
vomiting. After all ordinary means had failed, he gave the ni-
trate of silver in doses of | grain, repeated as often as they^were
rejected. After a few hours the vomiting ceased, and she was
soon, with that and other treatment, enabled to retain any kind of
nourishment.
Dr. M’Clellan also finds this remedy invaluable in erysipelas;
not only to set up a circumscribing barrier, but to deaden the irri-
tability of the part, and reduce the inflammation, smearing it light-
ly over the skin, so as not more than to blacken it. It lessens ir-
ritability of the skin generally, can often be applied with great
benefit over parts affected with dermalgia and neuralgia, and has
also a delightful effect in removing the irritability of corns when
painful. Blistering the surface with caustic over the course of a
nerve affected with neuralgia, has frequently acted like a charm
in his hands.
June 19th, 1843. Cataract commencing.—A young man pre-
sented himself, wha has had within the last few months, an increas-
ing dimness of sight; but which, as yet, by no means amounts to a
total loss of vision. There are slight milky opacities in both his
lenses, and he has rather an undue determination of blood to the
eyes; iris and conjunctiva too highly colored.
The Dr. thought, that as it was only the commencing stage,
it would be possible to make it disappear by the use of cathar-
tics and slight alteratives. He therefore gave:
JL Ext. colocynth. compos. 5j.
Hydrarg. chlorid. mit. 5SS-
Ant. et Potass. Tart. Sr. ij.
M. et divid. in pill xxx.
3 pills to be taken every 3d night.
He believes that it is often possible to stop the progress of cata-
ract in young people, but seldom or never in old.
Diseases of the Prostate Gland.—Inflammatory enlargement of
the prostate rarely occurs but in young men, and is then generally
owing to irritation from gonorrhoea or similar causes. In this dis-
ease, a burning pain is felt in the part, with which the rectum
sympathises so much, that the pain is often attributed to that organ.
The tumor can often be perceived in perineo, but is always felt
distinctly by the finger introduced into the rectum. It can be best
combated by general depletion, leeches and cups to the perineum—
cold and soothing applications constantly injected into the rectum,
purgatives, &c.
The chronic enlargement that occurs in old men, is a very per-
verse disease, and often impossible to cure. Frequently the only
thing that can be done, is to prevent obliteration of the urethra by
the use of bougies.
The Dr. out of many cases, only knows two which have been fully
reduced, and in these suppuration took place, and the tumors were
entirely removed.
Spontaneous Absorption of the Prostate.—He mentioned a
very interesting case of a man under the care of Dr. Morton, who,
when young had been a victim to masturbation, and in after life
was always subject to emissions; in coition, semen would be dis-
charged before he had obtained an entrance. Almost lost the use
of lower limbs, &c.
In him, the prostate had been entirely absorbed. By introduc-
ing a catheter and putting the finger into the rectum, it could be
run along the whole course of the catheter without meeting with
the prostate. He since saw a case in the dissecting rooms where
there was no prostate, and where the patient appeared to be of the
above description.
Stricture from Enlarged Prostate.—When the prostate is en-
larged, the Lobulus Morgagnii, or third lobe, very often projects
up across the opening, forming what may then be well called, the
palate of the bladder or uvula vesicae. In such cases, it is next to
impossible to get a common catheter into the bladder. It must
be longer than common, and very much curved—when with tact,
it is easily passed in.
Jl few remarks upon Strictures of the Urethra.—These should
at first be always examined with a wax bougie—inasmuch as by
the careful use of it, the exact nature and appearance of the
stricture can be easily ascertained. The wax becomes warmed in
the passage, and takes an exact mould of the contracted part. If
it will not enter the stricture, the application of force will expand
and bend the end of the bougie, and will show the mouth of the stric-
ture upon its point. If it will enter, the part which it has entered
will be an exact reversed copy of the stricture, (dilated somewhat
by pressure, to be sure,) while the force applied will bend the part
behind—back in the healthy urethra.
These bougies are also very convenient for cauterising the
urethra ; a small piece of caustic must be firmly imbedded in the
end of the bougie, and part of it covered over—thus there is no
danger of its falling out, and any part of the stricture may be touched
by it.
Patients are sometimes under treatment for months, from the
idea that they have strictures, caused by the apparent impos-
sibility of passing up a catheter. These difficulties often arise
from the lacunae or follicles of the urethra, or the prostatic ducts
being enlarged, and may occur even from their existence in the na-
tural state.
A pointed bougie will frequently catch against these obstruc-
tions and give the idea of an impassable stricture. If a large bou-
gie with a blunt round extremity is used, it will pass the obstacle
in nine cases out of ten.
It is well to carry the point of the bougie pressed upon the lower
or posterior surfaceof the urethra,till it arrives at the pubis, for the
lacunae of the urethra are chiefly upon the anterior surface, and
when it passes that part, to press it upon the anterior portion ; for
the verumontanum, and the prostatic and antiprostatic ducts, are
upon the posterior part. To show the possibility of the catheter get-
ting into one of these ducts, Dr. M’Clellan mentioned a case in
which a surgeon had made numerous attempts to get into the
bladder, in a case of prostatic enlargement. At last he changed
the position of the instrument slightly. The man cried out that
something had given way, and the instrument passed its whole
length without difficulty, apparently into the bladder. No urine
came, however, and the attempt was not renewed. The man ul-
timately recovered, but died a short time after of a bilious fever.
On an examination it was found that the catheter had entered
the sinus pocularis, gone through the ejaculatory duct, torn through
the vesicula seminalis, and some recto-vesical attachments, and
produced a large abscess there.
He mentioned another very interesting case in which the catheter
penetrated the ureter by being carried too far.
It was that of a man who had swallowed a date stone, which
lodged in the appendix caeci vermiformis, producing inflammation,
which ended favorably in a large abscess circumscribed by the perito-
neum in the lower part of the abdomen, so that the bladder floated
in it. This produced a tumor above the pubis, which was mistaken
very naturally for retention. Dr. Physick introduced a catheter
two or three times, but only a tablespoonful or so of urine would
come off. Thinking that he had not penetrated the bladder, he, on
one occasion, made use of more force than usual, but with the same
results. Finally the man was tapped above the pubis at Phy sick’s
request, by M’Clellan, when the state of affairs above described
was found ; no urine in the bladder, but a large abcess in front of
it. The man died in a few days, when an examination developed
that the catheter had passed up the ureter about an inch, tearing the
mucous membranes, so that a large blister of urine had formed
between the mucous and muscular coats.
Irritable Urethra.—Where the urethra is very irritable, the in-
jection of a solution of nitrate of silver is an invaluable resort.
In many cases of stricture, and in particular predispositions, there
is great irritability of this canal, increased by the slightest touch
of a bougie.
He recollects the cases of two gentlemen, brothers, suffering
from stricture, in which the most gentle application of the bougie
gave rise to intense agony, nervous chills, and even convulsions.
In both these cases, the use of an injection of nitrate of silver,
gradually increased from the strength of three grs. to an f.oj. water
up to six or ten grs. entirely cured this morbid sensibility, and in
a few weeks the bougie could be introduced in both cases without
any unpleasant results.
Sept. 2^th^ 1843. Hydrocele of the Neck*—A young gentle-
man, set. 19, from Mount Sterling, Kentucky, has had a tumor in
his neck, which has been increasing for two years, until it de-
formed him very much, presenting a uniform, oedematous-looking
enlargement of all the front and sides, looking somewhat like
the leg of one affected with elephantiasis. It was of a soft
consistence, yielding a semiliquid feel, and had given him little
pain or- uneasiness, except that it produced difficulty in breath-
ing at night, and snoring.
* This case is reported at length, with remarks uopn this affection, in.
M’Clellan’s Surgery, page 318.
Dr. M’C. pronounced it to be a hydrocele of the neck, or
watery tumor contained in a sac, probably encircling the thyroid
gland. He determined, as the only safe course, to make an explo-
ratory puncture, and let out the matter.	„
Last Sunday he did so, by introducing a lancet at the most pro-
jecting part of the swelling, upon the left side, and let out about
a pint of dark bilious looking serum, tinged with blood. He
injected a little warm water to clean out a few flakes that were
in it, and closed up the wound, merely applying some lint upon it.
Monday morning. The tumor had filled up to its usual size,
appeared to be a little inflamed; it was very difficult for him to
swallow, and he was suffering from considerable constitutional
derangement. He had had a slight chill in the morning, and then
(10 o’clock) his pulse wTas quick (120) and irritated, and he was
querulous and excited. Dr. M’Clellan bled him 10 ounces (he
had been purged on Saturday and Sunday,) and ordered
JL Sulph. morph., grs. iss.
Ant. and potass, tart., gr. i.	z
Aq. fluvial, f.^ij.
S. 40 drops every few hours, and also gave aq. camphorse every
few hours, which remedies had the effect of calming him very
much.
Tuesday, Wednesday, Thursday and Friday, he continued get-
ting rather worse; at times violently delirious, and at others appa-
rently in a typhoid state; a little subsultus tendinum and mutter-
ing delirium.
He could swallow water with difficulty, and could take no
nourishment but a little liquid preparation of arrow root and
ice cream, &c. Cold lotions were kept applied to the part, and
on Wednesday fifty leeches were applied, which had the effect of
diminishing the pain.
On Saturday the Dr. felt an obscure fluctuation on the opposite side,
and opened it with a lancet, letting out f.gj or ij. of a bloody serum,
of a suspicious looking character, and he then ordered the appli-
cation of poultices. From all the symptoms, he feared very much
the development of fungus, a result which has often taken place in
similar tumours, although, sometimes, puncture and even the em-
ployment of setons in these cases, have given rise to suppuration
and obliteration of the sac, and have resulted in perfect cures.
Tuesday, Sept. 26.—His bad symptoms have all abated, and the
wound is now in a state of full suppuration. He is easy and per-
fectly compos mentis. Pulse weak but natural; and there is every
prospect that the process of suppuration now going on will result in
the closing of the sac and spontaneous cure of the disease, without
the formation of fungus.
Saturday, Sept. 30th.—The puncture on the other side, which
had closed entirely, again opened yesterday, and full suppuration
is now going on at the orifice, and the right and left sides now
appear continuous.
Nov. 1st.—He has gone home, perfectly cured, the tumor
reduced in size, there being only a little lump on the left side near
the orifice of the wound, which is still suppurating freely.