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1st, The abscess may burst externally ; in some cases this has oceurred so high up between the ribs as to resemble closely an “empyema of necessity ;* in others, on the contrary, so near the umbilicus, and consequently so remote from the hypochondrium, as to remove almost all suspicion of its hepatic origin.
2d, It may pass through the diaphragm, and open into the pleura, or into the lung, so as to be evacuated through the bronchial tubes.
3d, The pus may escape into the cavity of the peritoneumma rare oceurrence; or,
4th, Into some portion of the intestinal canal—the stomach, duodenum, or colon, most frequently.
6th, The abscess may open into the gall-bladder, and the matter escape through the biliary ducts into the duodenum.
6th, The abscess may open into the vena cava ; or, 7th, Into the pericardium.
8th, In a last group may be included those cases in which the abscess makes its way in two different directions ; thus, it may open externally through the parietes, and at the same time into one of the hollow viscera.
In a remarkable case described by Dr Graves, an hepatic abscess communi. cated with the stomach by three openings, and with the pericardium by a fourth.
The following case belongs to the last group, and furnishes an example of an hepatic abscess opening-1, into the peritoneum ; 2, into the duodenum ; 3, into the gastro-duodenalis artery.
CASE.-The patient (Richard Stanley, 53 years of age) was a man of intemperate and dissolute habits, who, for many years, had suffered from a tight stricture of the urethra.
I first saw him on account of a violent and sudden attack of hematemesis. He had lost, literally, an immense quantity of blood, part of which was red and florid, the rest being black and coagulated. He was thoroughly blanched, cold, and almost lifeless. There was, at this time, a circumscribed hard tumour in the epigastrium, of a rounded form, and tender to the touch, which pulsated strongly, and over which a loud systolic bruit de soufflet existed.
The man was apparently in a dying state ; however, under the use of stimulants, etc., he rallied, the hemorrhage from the stomach ceased, but much dark melænic matter was passed from the bowels. The next evening a quantity of pus (about a pint) was discharged per anum, and for several days pus in smaller quantities continued to be passed.
After this the patient regained somewhat his strength, and for a month enjoyed telerably good health, when he was again suddenly seized with hematemesis, and lost a very large quantity of blood in a few minutes. But, although the hemorrhage did not recur, the consequent prostration and debility were so extreme, that for a day or two his friends almost hourly expected his death. Nevertheless, he gradually rallied, and two days after the attack of hemorrhage, passed, as before, a large quantity of pus by stool. He now became a patient of mine in the Whitworth Hospital, and was under observation for twenty-two days.
During this period he occasionally passed purulent matter of a healthy character, but did not again lose any blood from the mucous surface. The waxy, pale hue of his countenance, however, plainly denoted how serious had been the loss of vital fluid in the two attacks of hemorrhage already described.
The tumour in the epigastrium, which the patient now stated bad existed for several months, presented the same characters as before, but could now be traced under the ribs on the right side to become merged in a general enlargeinent of the liver.
It soon became evident that in this case the system was incapable of rallying; the prostration continued to be extreme ; the feet and legs became anasarcous, troublesome diarrhea set in, the scrotum became gangrenous, and death finally ensued from exhaustion, two months after the first attack of hematemesis.
Post-Mortem Examination of the Body. The abdomen contained a good deal of serum, and pus likewise flowed from the peritoneal cavity at its upper part. The liver was much enlarged. The first portion of the duodenum adhered to the lobulus quadratus, and, in this situation, a circular opening, an inch in diameter, communicated between the intestine and an abscess which had extensively excavated the corresponding portion of the liver. By a second and smaller perforation, the abscess had opened into the cavity of the peritoneum.
The head of the pancreas was thickened and enlarged. The gastroduodenalis artery, in its course behind the first portion of the duodenum, had been opened into, but was now filled by a firm and lengthy coagulum.
The stomach and spleen were healthy. The kidneys had undergone degeneration; the left lung was tuberculous.
Remarks.—The occurrence of hematemesis in connection with hepatic abscess is most unusual. I am not, indeed, aware of any case, except the one now detailed, in which it has been observed.
This symptom was calculated to render the diagnosis more difficult, by directing attention to the stomach rather than to the organ primarily affected.
We observe also, that we have here an instance of blood of a florid colour, constituting the fluid ejected from the stomach by vomiting. This is to be explained not only by the direct arterial source of the hemorrhage, but also, probably, by the fact of a larger quantity of blood being poured into the stomach from the duodenum, than its acids were capable of altering in colour. It is also deserving of notice how much the external tumour possessed of the characters of an abdominal aneurism-as, for example, in its strictly median position, and in its possessing both impulse and bruit de soufflet. It is not a little remarkable that, although an artery of such magnitude as the gastroduodenalis was opened, death was not directly owing to hemorrhage. Twice the reparative powers of the system closed up the opened artery, and the last time so effectually, that a firm lengthy clot, similar to that which results from the application of a ligature, was found to have sealed up the vessel to some distance on either side of the ulcerated opening.
The communication between the abscess and the duodenum would appear to have been somewhat valvular, as the discharges of pus were occasional and intermittent.
The opening into the peritoneum must have occurred very shortly before death, as there were no traces of recent inflammation in the peritoneum.—Dublin Medical Press. ECTUYMA ON THE FOREARM OCCURRING SUBSEQUENTLY TO ATTENDANCE ON
LABOUR CASES. Two instances of this description are reported. The first is that of M. Godefroy, Professor of Midwifery at Rennes, in whose case the eruption showed itself during the night following an accouchement, where, after a tedious labour, the patient was delivered by him of a still-born child, the operation of turning having been practised. Asanious and fætid fluid had been escaping from the vagina during labour, and at the time of delivery the child was found considerably decomposed ; but the operator was not suffering from any wound or abrasion at the time, and had taken the precaution of carefully washing both his hands and forearms upon the case being completed. The second case is reported by M. Guillemant, physician at L'Huis. This also was an instance of the same eruption occurring on the forearm after attendance upon a protracted accouchement, where the woman was finally delivered by embryotomy. The medical man in this case had also washed his hands and forearms immediately after the labour terminated, and asserts that he was conscious of no wound or scratch being present at the time. Nevertheless, during that day, symptoms began to manifest themselves, which speedily went on to the establishment of regular ecthyma, which for two months resisted all treatment. In both these instances, with the exception of difficult labours, the women were in perfect health.-Gazette Médicale, March 17. M. BAIZEAU ON THE TREATMENT OF CROUP BY LARGE DOSES OF TARTAR EMETIO
(PAR LA DOSE RASORIENNE.) The frequency and fatality of this disease, confer an additional value on any remarks suggestive of improvement in the measures adopted for its cure. With this view the subject appears to have been more fully investigated in France than in this country, and several important innovations in the method of treatment have originated there, as the result of this system of inquiry and observation.
Among these the employment of tartar emetic in large doses was suggested, as M. Baizeau allows, so far back as 1839, by M. Bazin; the same remedy was also proposed, but not employed by Laennec; and in the Dictionnaire de Dictionnaires, under the article Croup, we find it recommended by M. Fabre. Notwithstanding the opinion of such authorities regarding its value as a remedy in this disease, the matter seems to have been neglected ; and it is with a view to reviving this mode of treatment that M. Baizeau has published his interesting communication in the Gazette Médicale for March 10th. Several cases are there cited by him as examples of the successful treatment of the disease by this method, and others are referred to where similar results have been obtained.
The success attending the employment of tartar emetic in croup, M. Baizeau ascribes to the contro-stimulant action of this substance, and not to its effects as an emetic, believing that its influence here is somewhat analogous to the apparently specific power exerted by it in other diseased conditions of the respiratory organs.
However, the vomiting necessarily arising from such doses as are recommended by M. Baizeau, can scarcely but be considered as materially assisting if not in some cases superseding the other effects of this remedy ; the dose in different instances varying from six to twelve grains of tartar emetic in four ounces of water, and a teaspoonful of this to be given every two hours.
In combination with ipecacuanha, it is the emetic usually employed in the Hôpital des Enfans Malades at Paris, and only in those cases where it fails in producing its effects are others resorted to; the object being, that whatever emetic may be employed, the vomiting arising from it should be energetic and repeated, as would result from the doses given by M. Baizeau. And in support of this doctrine, M. Valleix has shown that out of fifty-three cases of croup, only one cure resulted in twenty-two of these cases where emetics were given sparingly ; while fifteen recovered out of thirty-one cases in which they were administered more freely.
M. Baizeau, however, asserts that the absorption of this remedy into the circulation subsequently to the cessation of vomiting, and the fact that its contro-stimulant properties are thus brought into operation, afford the true explanation of its success. For, says our author, it generally becomes more difficult to excite vomiting in children after a few successive doses of any emetic, and thus as the remedy is longer retained by the stomach, the chances of its absorption are increased, and in this case its contro-stimulant action consequently becomes more active.
We do not clearly see, however, the manner in which M. Baizeau reconciles this theory with such statements as that of Barrier, who mentions that from numerous facts it is proved that emetics, among which he mentions tartar emetic, are efficacious only in those cases where they are followed by vigorous and continued vomiting ; or with the twenty-two cases of M. Valliex, quoted above, in which the vomiting was mild, and in which only one recovery took place. This apparent discrepancy, however, is at once removed, if we recog
nise the efficiency of tartar emetic as an emetic properly so called, and as at the same time, a powerful contro-stimulant, the combined actions mutually contributing to account for its success. In this way, along with its rapidity of action, and apparently specific powers, its superiority in such cases would be immediately apparent, as possessing advantages which are not to be found in any other remedy.
Although M. Baizeau has thus attached, perhaps, rather little importance to the occurrence of the vomiting produced in the first instance by this substance, his paper in other respects is a good one. And while the number of cases treated in this manner has been too small to justify any decided general opinion as to its merits, at the same time many facts in connection with these cases, would at least induce us to place more confidence in this remedy, and encourage its further trial by medical men.-Gazette Médicale, March 10.
SURGERY. RESECTION OF THE HEAD OF THE HUMERUS ACCORDING TO A NEW METHOD OF
OPERATING. At the seance of Feb. 26, M. Baudens read hefore the Academy of Sciences, a memoir on this subject. No part of the skeleton, says M. Baudens, is better adapted for resection than the head of the humerus, and nowhere has the operation been attended with more encouraging results. In fourteen cases where he substituted resection for scapulo-humeral amputation, thirteen cures have been obtained. Referring principally to gun-shot injuries of this part, as our author appears to do, he states as the conclusion to which his experience has led him, that resection, when a ball has fractured the head of the humerus, ought to be the rule, and amputation the exception.
When the resection has been limited to the head of the humerus, he adds, that he has always obtained a re-establishment of the movements of the arm the only difference being, that the new articulation consists in a ginglymoid instead of an arthrodial joint. The points most necessary to be attended to in order satisfactorily to obtain this new articulation, are to maintain the humerus in the most immediate possible contact with the glenoid cavity, and to interfere as little as possible with the muscular fibres and nerves.
The methods of operation, based upon the formation of a flap, are rejected by M. Baudens, and the simple incision adopted ; not, however, according to the manner laid down by White, as this M. Baudens considers to present almost insurmountable difficulties to the surgeon. Instead of making as he did, the simple incision on the outer side of the shoulder, or in imitation of Percy, Larrey, etc., at the middle part, M. Baudens makes it on the inner side, and assigns three reasons for doing so, viz., 1st, the head of the humerus is at that point more superficially placed than anywhere else ; 2d, we can expose it in its full length, by prolonging the incision in the space between the acromion and coracoid processes ; 3d, the four muscles inserted into the tuberosities are more easily reached by the internal incision, which permits us at the first to reach the bicipital groove. These four muscles, the tendons of wbich are apt to be confounded with the capsule of the joint, must be cut at their insertions, for two additional reasons ; first, to overcome the force which they exert in causing the head of the humerus to rise under the acromial arch ; and, secondly, because these tendons being once divided, the capsule is itself, ipso facto, sufficiently opened for allowing a passage to the head of the humerus ; and it will thus be seen that, contrary to the general statement of authors on this subject-it is sufficient, instead of cutting at first the articular capsule, merely to divide the four above mentioned tendons on the two tuberosities of the humerus.
M. Baudens then goes on to state that other considerations, which have hitherto been overlooked, are suggested by the experience of fourteen resections
of the head of the humerus, performed by him, and of which considerations the following is given as a short summary :
1st, What limits must be assigned to resection of the head of the humerus?
If this extremity be simply splintered by a ball, removal of a segment of it is sufficient.
2d, When the fracture extends from the head of the humerus towards the diaphysis of the bone, within the medullary cavity, is it a case for amputation?
We answer no; in full reliance on numerous facts occurring in our experience.
3d, When a ball has entered the head of the humerus, is resection indispensable ?
When it is not resorted to, one of three results takes place; the patient either dies hectic, or has to undergo resection after all, or survives with an anchylosed limb, and suffers from fistulous openings and unceasingly renewed complications.
4th, Immediate resection ought to be preferred to that perforned after any lapse of time.
This statement is supported by the following statistica-eleven immediate resections have afforded ten cures and one death. Fifteen wounded, treated by expectant practice, gave the following results :-Died from hectic, etc., 8; subsequent resection with cure, 3 ; surviving with fistulous openings, 4.
5th, How do the articular movements become re-established ? • The articulation reproduced after the operation, differs from the old one, as in place of an arthrodial joint, we have always a true ginglymus formed and this ginglymus is so much the more powerful according as the deltoid, pectoralis major, latissimus dorsi, and teres major muscles, have been preserved in greater or less integrity.—Gazette Médicale, March 17. PARTICULAR METHOD OF APPLYING CAUTERIZATION FOR THE RE-UNION OP ANO MALOUS FISSURES, AND ESPECIALLY THOSE OF THE PALATE. BY J. CLOQUXT.
His remarks are confined to the treatment, by this method, of divisions of the velum palati, and he proposes in such cases to take advantage of the great amount of retractiop which occurs in the cicatrix consequent upon burns.
We need not in such cases, says M. Cloquet, cauterize the edges of the fissure throughout their whole length, converting them into a granulating sore, the cicatrization of which must be afterwards assisted by sutures, appropriate bandages and the maintenance of correct adaption. This method, long known to the profession, sometimes succeeds, but often entirely fails. The one which I propose, adds M. Cloquet, consists in applying the cautery to the angle of the tissure, and that only to a limited extent, leaving the contraction of the cicatricial tissue to operate, and then, practising a similar cauterization, and waiting for some time to renew the application in such a way as by repeated operations to bring the edges of the division towards each other, and to unite them by a succession of cicatrizations which may be regarded as so many successive points of suture. The double advantage is thereby gained of being thus enabled to watch, step by step, the results of the treatment, and to obtain unions of the most difficult nature by an operation, simple, scarcely painful, and exempt from all danger. It is especially in fissure of the palate that M. Cloquet con. siders the advantages of this mode of operating as incontestible, and he mentions four cases in all of which the operation had been attended with equally successful results. There had been no pain felt, no change in habits or regi. men necessary, and no complications had arisen. The operation was of the most simple nature, every surgeon could perform it. It required the aid of no assistant, an advantage of great importance in country practice; and, lastly, it could be practised on very young children. One objection urged against this method was the length of time required for completion of the cure, but the slowness of its action constituted its safety, and the inconvenience arising in