ON THE MEANS OF PREVENTING THE FORMATION OF CYSTO-PHOSPHATIC DEPOSITS
159 phenomena revealed by metallic applications. Such is the transfer phenomenon, which was discovered solely by chance, and which patients can neither invent nor simulate. There is another phenomenon which you will soon witness on many patients I shall present to you, and which bears the same signification as the preceding one. It is a fact connected with hysterical amblyopia to which I called your attention in my last lecture. You know that in hysterical subjects there exists amblyopia on the
... same side where you find anaesthesia. One of the characters of this amblyopia is achromatopsy, or a narrowing of the field of vision in respect to colours. The narrowing may extend to such a point that the patient loses all notion of colours, and sees objects only with the appearance presented by a sepia painting. Moreover, this particular fact must be noted that the colours disappear according to a mathematical order. Thus violet first disappears, then green, then red, then yellow. Blue is the last, and the patients continue to see it until the completion of the phenomenon, and when they have lost all notion of the other colours. This is a phenomenon, I should say, which an hysterical patient can scarcely guess or be acquainted with. It happened to myself, though I have for a long time been well acquainted with this phenomenon, to make a mistake in remembering the order of colours, which is, as you observe, different from the one presented by the spectrum. Here is an hysterical patient affected with hemianæsthesia and amblyopia of the left side. You remark that with the left eye she has lost all notion of colours. We know that this patient is sensitive to gold ; we have proved it on a previous occasion. We apply a plate of metal to her left temple. A quarter of an hour is allowed to elapse. We now pass papers of different colours before the eye which is affected with achromatopsy. And now you see that the perception of colours is coming back according to the regular order. You see it is blue she first discerns, then yellow, then orange, next comes green, and violet is the last she perceives. You must watch narrowly in order to catch all the phases of the phenomenon, as sometimes the reappearance or return of sensibility to colour, produced by the metallic application, takes place with great rapidity. As you see, this is a very demonstrative experiment which generally succeeds very well, and which we have repeatedly verified.2 I must, however, remark that some patients present an exception to the rule in this sense, that the notion of red returns regularly to them before that of yellow and blue. But, as I say, this is really an exception; at any rate, it may be asserted that, according to the regular order, green and especially violet are the colours which return the last. If you now remove the plate of metal you will find in a few moments that perception of colours will disappear in the following order: first violet disappears, then green, then red, then yellow ; blue persists till the last ; finally this also disappears, and the eye returns to the condition in which it was when the patient was presented to you. Here is another hysterical woman, who has been under treatment the last few weeks, and in whom all the symptoms of the disease-whether by the influence of the treatment or not, I do not know-have been remarkably amended. She has no longer any hemianæsthesia, and has lost all her convulsive fits for a long time. Is she completely cured ? Has she ceased to be under the influence of the diathesis ? Is she not exposed to a recurrence of her nervous ailments under the action of the first passing emotion ? Some observations which we have recently made lead us to think that there exists perhaps a criterion for judging the question, and the fact, if we are not mistaken, is one of importance for the future of the patient. If you remember, this patient has proved sensitive to gold, and she has been treated, apparently successfully, with that metal. Well, we shall now apply some gold pieces to the left arm, this side of her body having been the one originally affected with anaesthesia. Fifteen or twenty minutes elapse after the application, and we then find that the patient complains of discomfort, that she gets drowsy, and presently seems ready to fall asleep. We prick her arm with a needle, and we see that sensibility, which was normal before the application, is now almost completely abolished. There is cause to believe that the patient is still under the influence of the diathesis, or in other words, that she is not yet entirely cured. (To be continued.) 2 The experiment was repeated at a late sitting of the Société de Biologie, M. Bert, Professor of Physiology at the Faculty of Sciences, being present on the occasion. AND EMERITUS PROFESSOR OF CLINICAL SURGERY. THE operation of lithotrity is occasionally followed by chronic cystitis with painful symptoms, and by frequently recurring production of the cysto-phosphatic deposits previously described. This condition may persist for a long period, and it may sometimes never wholly disappear. The numerical proportion of these unsatisfactory cases to those which are wholly successful is happily small; and even that may probably be diminished by the exercise of judgment on the part of the operator, and by his conformity to certain rules in operating. There are two points to which it is necessary to pay special attention in order to avoid the unfortunate results in question. The first is, not to apply the crushing operation to any stone of a size beyond that which may be termed strictly moderate, a term which it is difficult to define, but which is designed as a caution against regarding lithotrity as desirable for calculi of large size ; the second is, not to delay unnecessarily subsequent repetitions of the sitting when the stone has once been attacked by the lithotrite. These rules are established by practical experience of the operation ; but the correctness of the principles enforced is also exemplified by the pathological observations described in the preceding paper. That which has happened to patients who are troubled long after the operation with recurring concretions is, without doubt, a serious injury to the mucous membrane of the bladder, permitting a phosphatic deposit to adhere to some portion of its surface. This deposit increases by aggregation, and is detached in some form as a concretion, which produces symptoms relieved only by its removal. The process is repeated periodically, sometimes with lengthening intervals of time, and with a tendency to cease, if due care be taken, although the term of recovery is often a long one. In other cases, the tendency steadily increases, and the opposite condition follows. In speaking of injury to the mucous membrane, I by no means imply injury through the use of instruments. Little harm occurs from the modern lithotrite in delicate and careful hands, a remark which does not apply to instruments of early construction. With the latter, injury was often inflicted on the bladder, and strong objections were long entertained to the operation on that account, and very justly so. The causes of injury to the membrane already described as resulting in loss of polish and in roughness, which attracts phosphatic precipitate, are threefold. First: This morbid change may be caused by the long residence in the bladder of any calculus, particularly one with harsh, uneven surface, and so may have already taken place before the patient seeks relief from the surgeon. In this stage, whatever may be the composition of the stone, the enveloping crust is phosphatic, and the symptoms are severe. Such a condition is no doubt best met by lithotomy, under almost any circumstances. Secondly: The bladder being healthy, an operator may crush a stone, say of uric acid, but of a size which, although quite within the mechanical power of the lithotrite to crush safely, is still too large to be disposed of in four or even five sit tings. There is then some risk that from much contact between the sharp angles of broken stone and the mucous membrane of the bladder, which must take place, abrasions commence, all of which do not heal, and the inner coat is left, at the conclusion of the process, bruised, sore, and slow to recover the natural condition. This might probably have been regained after two or three sittings ; but four, five, or six have been more than the membrane could sustain with impunity. With a stone of this size also it is probable that lithotomy would offer equal, if not better, chances of a successful result. Thirdly : The bladder being healthy at the outset, and the stone not necessarily being large, but one well adapted for successful treatment by lithotrity, the operator may per.