18 SIMULTANEOUS INTRUSION OF SOLIDS INTO THE AIR-PASSAGES OF BOTH LUNGS. every two or three hours during the first night, use of anæsthetic agents? The profession is, I with half-ounce doses of tincture of bark to be am well aware, alive to the casualties incident to administered occasionally. I deemed her to be anaesthetic operations; but do we sufficiently guard now safe from relapse, though greatly reduced by against these exigencies in dental operations? her past sufferings, which have been unusually Should lethal vapours be applied, for example, severe; but I was mistaken. A few days' inter- when the teeth are known to be brittle, what mission were followed by suffering more acute operative skill can protect the patient from the than ever, and it was obvious that matter in passage into the glottis of teeth or the fragments quantity was yet retained within the cavity of of teeth when he is physically insensible? the pelvis. The wound in the ischiatic region, On the 7th of February, I accompanied Mrs. which had entirely healed, again burst open, and a young married lady, to one of our most many ounces of more or less foetid matter escaped eminent and skilful dentists for the purpose of every third or fourth day, but still without relief. having three teeth extracted. The patient had It now became necessary to consider the expedi- been suffering for some time, and it was deemed ency of making a more dependent opening, and desirable, in consultation, to administer chlorowith the concurrent opinion of Sir Benjamin Bro- form. die, I made a free incision on the left side of the' The anæsthetic soon exercised its influence, and orifice of the anus, and cut down into the cavity the operation was dexterously performed; but, of the abscess, from which some ounces of matter unfortunately, on removing the third tooth, a moescaped. Three attempts had now been made to af ford relief to this suffering lady, but without success. The pain remitted in a degree for a day or two, and returned with equal violence in spite of our most vigorous efforts to mitigate it, and she sank exhausted within a fortnight of the last operation. Original Papers. ON A CASE OF THE SIMULTANEOUS IN. SAGES OF BOTH LUNGS. lar on the lower jaw, it splintered beneath the grasp of the forceps, and it was necessary to have recourse to the "elevator." Fom commencing the inhalation of the vapour to the conclusion of the operation, only three or four minutes elapsed. The patient, on becoming conscious, had a violent fit of coughing and screaming. It soon subsided, and she expressed much satisfaction at having been so agreeably divested of her "old enemies." She suffered none of the after effects of chloroform, complained only of a little soreness about the chest, which I attributed at the time to the paroxysm of coughing, &c. I thought that the coughing was occasioned by a little blood having trickled into the glottis. It may be here noticed, that previous to the visit of Mrs. to the dentist, she had suffered from no affection of the chest. It was conse BY C. C. CLAREMONT, ESQ., M.R.C.S. ALTHOUGH cases are both numerous and inter- quently with no small surprise, on reaching her esting of foreign bodies occupying the air-pas- home, that I observed a remarkable peculiarity in sages, yet I believe but three are recorded where her breathing, and on auscultation, it appeared the substances have been a tooth or fragments of that the lungs were in a state resembling effervesa tooth. cence. Of these, the first is reported in the Dublin During the day and in the night she had freMedical and Chemical Journal for 1834, vol. v., quent fits of coughing, was restless, and experiby a Mr. Houston, and ensued upon extraction of enced uneasiness about the chest. Her breathing a tooth from a man aged thirty here the root during sleep was described by her attendant as and fangs of a lower molar passed into the right like that of a child suffering from catarrh. On bronchus, and death was the result in eleven the following morning (Sunday) I found all the days. symptoms of bronchitis increased, the whole of The other two cases are related in the Edin- the lungs engaged in the inflammation, the fits of burgh Journal for the same year. One, where an coughing were more frequent and violent, but artificial tooth (a pivoted incisor) disappeared unattended with pain. The patient expressed from its place during the process of mastication, her belief that she had swallowed a tooth; and and slipped into the lungs. It was ejected in this remark being confirmatory of a suspicion eighteen months; but phthisis had been set up, which I had begun to entertain, I lost no time in and the patient (a lady) sank at the termination seeking the co-operation of Dr. Jenner, who, on of the third year. being made acquainted with the facts, after a The other is a most remarkable case, that of a careful examination, expressed a doubt as to the young girl, aged seventeen, into whose lungs an existence of a foreign body in the lungs, both entire lower molar found a passage. On the lungs seeming to be generally and equally affecteleventh day it was dislodged, and recovery fol- ed; and, in the absence of stethoscopical evilowed. In neither of these cases was any opera- dence of such a fact, he was rather disposed to tive procedure adopted. attribute the symptoms to the irritating and pungent effects of the anaesthetic vapour. The patient was free from fever, and during her whole Now, if such accidents occur under ordinary circumstances, is not the danger enhanced by the respiration continued, and its influence upon the system was becoming very manifest. illness was not prevented from going about the house and superintending her domestic matters. The treatment adopted was that for simple bron- On the thirty-fourth day after the operation, chitis. she retired to rest, complaining of more than The symptoms continued to increase, the cough-usual pain in the old spot and of weariness. In ing became more violent, and the nights more the night, she stated that while making a painful restless, up to the evening of Wednesday, when effort to shift the position of her child she seemed during a paroxysm of coughing several small frag-" to twist" herself, and happening to cough slightments of dental enamel were coughed up. I say ly at the same moment, a substance flew into her several fragments, though I am disposed to think it mouth. She placed it in her husband's hand, originally consisted of one thin lamina; it might saying "Here's the tooth at last." I was sent have been crushed in the mouth. Great relief for, and on examining her breathing, found the on the left side immediately followed the dislodg- rhonchus and cooing had disappeared, only a ment of this portion or these portions of tooth, little harshness remaining. In twenty-four hours and on this side the characteristic râle was soon the lung had recovered its healthy and normal lost. Presuming the cause of the evil no longer tone. to exist, I looked for a cessation of the symptoms On examining the fragment ejected, I found it generally. I was deceived; for on the right side, covered with blood, and it was certainly a most instead of an abatement, we had an augmentation formidable-looking body to be an occupant of the of the symptoms; there was now considerable lung. It consisted of an irregular, rough, fourrhonchus over the whole of the right lung; the sided portion of the crown of a molar, with probreathing became more noisy, and my attention jecting, sharp corners. Weight, seven grains. was directed to a fixed spot (corresponding with It should be stated that a little hæmoptysis about the termination of the right bronchus), immediately had followed its dislodgment. where a remarkably loud cooing was heard at each inspiration; occasionally this was intermittent, and after one or two inspirations was heard again. She complained also of a fixed prickling Thornley-place, Oakley-square, 1858. pain passing from the margin of the sternum ON A CASE OF STRICTURE OF THE URE through to the scapula. Her breathing could be heard across a room of tolerable dimensions; it disturbed her husband at night, and was sufficiently loud to attract attention and elicit observations from her children. There was an inability to lie on the affected side, and she was frequently obliged to sit up in bed to relieve her breathing, and occasionally her sputa were tinged with blood. Her symptoms were augmented with accelerated circulation. THRA, TREATED BY RECTO-VAGINAL By Edward MENZIES, Esq., M.R.C.S. STAFF SURGEON, SECOND CLASS. Army Medical Department, April, 1858. Editor of THE LANCET, and at the request of [DR. SMITH presents his compliments to the Staff-Surgeon Menzies, who is stationed at Hong Kong, forwards for publication the accompanyOn Friday I again had the assistance and ad-ing case of Sergeant Williams, 59th Regt., should vice of Dr. Jenner. He thoroughly examined her it be thought worthy of a place in that periodical.] chest, but nothing could be elicited to throw further light upon the case. On percussion, the lung was resonant throughout; rhonchus prevailed generally over the right side of the chest, and, with the exception of the cooing, there was nothing to indicate the presence of a foreign body. On the next morning I was suddenly summoned, and found her coughing and retching violently; she pointed to the larynx, and requested me to examine her throat, as she felt something cutting like a fish-bone. I did so, and also examined the matter ejected. There was nothing to explain the attack; but I have not the least doubt that at this moment the sharp and rugged portion which was ultimately discharged was forced into the larynx, and not hitting the opening of the glottis, had fallen back to its old quarters. Sergeant R. Williams, an Englishman, aged twenty-seven, of sanguineous temperament. He has served in the army upwards of eight years. He was invalided from Hong Kong for dysentery in July, 1854, and having recovered his health in England, re-embarked for Hong Kong in April, 1857, on board the steamer Transit. On the passage out in June, in bad weather, he was thrown backwards off the mainhatch by a roll of the ship, and fell against the ship's side, striking the perinæum on a projecting piece of iron or wood; he could not ascertain what it was, being dark at the time. Profuse hæmorrhage from the urethra followed, and continued for four days at intervals. Pain and difficulty were then experienced on micturition; the former ceased in a few Matters thus remained for a month without days, the latter steadily increased. Shortly aftermuch abatement or increase of symptoms. Dr. wards, he noticed a hard swelling, about the size Jenner saw the case frequently, and shared in my of a hazel-nut, in the perinæum, at the seat of anxiety for the result. The patient occasionally injury. On his arrival at Calcutta, in August, he complained of a disagreeable taste in the mouth, was attacked with ophthalmia, and while in hosbut no fœtor was apparent to others. The rhon- pital eighteen days with that complaint, frequent chus on the right side, cooing, cough and noisy unsuccessful attempts were made to introduce a catheter. The passage became daily more con- no degree affected by the urine ceasing to enter stricted, and the symptoms more urgent. the urethra. The point of the smallest or the On the 4th of November, he embarked for largest catheter appeared to impinge in the bulChina, suffering much during the voyage, and bous portion against a solid wall or obstruction, finally, the day before his arrival at his destina- which could neither be penetrated by justifiable tion, he was attacked with complete retention of force nor entered by careful insinuation, although urine. He was brought to hospital on landing, up to the period of each attack of retention the and after various attempts to relieve the greatly patient could micturate in a fine stream or guttadistended bladder by the catheter, the recto- tim. It is, of course, impossible decidedly to vesical operation was performed on the 18th of affirm what was the exact condition of the canal, December, by Surgeon M'Wharrie, 59th Regt., through which no one could pass an instrument, under the influence of chloroform. The canula and which yet permitted the partial performance was left in until the end of the month without of the function of micturition; my own conviccausing any irritation, when it was withdrawn, tion is that a false passage existed, forming a and the urine flowed through the urethra in a semicircle round the effused lymph, the result of small stream, although the catheter could not be the injury, and that the point of the catheter was passed. always brought up sharp at the anterior entrance On the 17th of January, retention of urine again of this detour. I base this conclusion on my attacked him, and as the impermeability of the having arrived, in the early steps of the operation, stricture had been so long declared, Syme's ope- at a tube or canal, about the size of a crow-quill, ration was decided on, and performed at eleven which I at first took to be the urethra, but could P.M., under chloroform. A staff was passed as far not trace, and under which, at some depth, I as the stricture, a free incision made in the mesian found the canal itself. The closure of this temline, its point exposed, the strictured portion of porary channel for the urine, by congestion of the the urethra, about half an inch, divided, and No. surrounding parts, in the constant efforts to 6 catheter passed into the bladder; the hæmor-empty the bladder, causing retention of urine, rhage was trifling, and the operation perfectly may be easily understood. satisfactory. The catheter was left in for forty- This case appears to prove clearly that dilataeight hours, when great irritation was experi- tion of a stricture, after the recto-vesical puncture, enced, and it was withdrawn. The progress of may occasionally fail; but whether the plan of the case has since been highly satisfactory. Ca- treating retention by puncturing the bladder theters of gradually increasing size have been through the rectum, and subsequently dilating the passed, and there is now no obstruction in their stricture, if such can be accomplished, is always transit, the opening in the perinæum has perfectly to be considered as merely temporizing with a healed, and the function of micturition is restored disease which can only be permanently cured by in its integrity. the operation so ably advocated in the Edinburgh Remarks. The performance of two operations school, I leave to the decision of my professional -viz., recto-vesical puncture and perineal section, brethren; but on the principle of attaining the for the relief of so dangerous a condition as re-double object by one operation with greater certention of urine, and the cure of so important a tainty, I enlist myself under the banner of Profesdisease as stricture of the urethra in the same in- sor Syme. dividual, in the short space of one month, is probably unique in surgical practice, and invites a few observations which I beg to offer, simply with a view of exciting discussion on their comparative merits in similar cases. I witnessed the first (recto-vesical), in a case of retention of urine, at Guy's Hospital, last year, by Mr. J. Birkett, one of the present surgeons, an old friend and fellow-apprentice. I was certainly fascinated by its rapid and satisfactory result, and left the hospital with a strong bias in its favour, as a simple and expeditious mode of relieving a state of intense agony and danger, and one filling the patient with emotions of gratitude, and covering the surgeon with éclat and credit. General Hospital, Victoria, Hong Kong, Feb., 1858. ON A REMARKABLE CASE OF ENCEPHA- BY RICHARD BROWN, M.D., HOVE. Naomi J, aged nine months, residing in George street, Cliftonville, was brought to me for advice on the morning of the 15th of February. The mother stated that on the day before she first observed her baby's stomach was very much The case of Sergeant Williams, however, in-swollen; that up to this time it appeared in good duces reflection on the propriety of its indiscriminate application, and starts the question, whether, although the immediate object-viz., the relief of the bladder-is accomplished with such facility, is the ultimate and equally important end-viz., the cure of the stricture-so much advanced by this procedure as to give it a decided superiority over any other? In this case the stricture was in health, except that it got rather thinner, which she attributed to teething, as her children usually fell away at that time. The child was fretful, and occasionally cried out as if she were in pain in her abdomen, and sometimes vomitted her food; the abdomen was very much distended, and tympanitic generally, except the hypogastric region, which elicited a dull sound on percussion; but the mother assured me the child had passed its urine freely; she was anæmic-looking; pulse frequent and feeble; tongue white; evacuations of a greenish hue. Feb. 16th.-No improvement in the symptoms; the child very restless, and frequently screaming out as though in acute pain. 17th. The abdomen remains distended to the utmost, and tympanitic; the vital powers evidently sinking. In the evening of the same day I found the child in a semi-comatose state; pulse very rapid and feeble, and extremely cold. At midnight she expired. INFLAMMATION OF THE SKIN ON THE DOR- By W. H. MOOR, Esq., M.R.C.S., HERTS. J. H-, aged fifty-five, a strong, healthy-looking agricultural labourer, who had always enjoyed good health until within about twelve months ago, when I attended him for necrosis of the left superior maxilla, and removed the greater portion of the alveolar process, since which he states that he has always been ailing, though able to continue work. For some days previous to my first seeing him he had been frequently dipping his hands in is very generally steeped before sown. a strong solution of Cn. O, S O3, in which wheat 39 The following day I made a post-mortem examination of the body with my friend Dr. Davis. Upon opening the cavity of the abdomen, a quantity of fluid (serum) escaped; the small intestines were very much distended with flatus, and pushed up by a large tumour occupying the pelvic cavity, Nov. 12 (the day he was first seen).—The skin the hypogastric, and part of the umbilical region; on the dorsum of the hauds and fingers much inthe stomach was empty; the cæcum contained a flamed, red, rough, as though raised in parts from small quantity of greenish feculent matter; the the subjacent tissue, and hot, but presenting no whole of the viscera were healthy in appearance, breach of continuation; he complains of his but exceedingly pale; no signs of peritoneal in-hands feeling hot, tingling, and smarting; geneflammation. The tumour I found seated in the ral health good. right ovary, which I carefully removed with the uterus and its appendages, and afterwards gave it to Dr. Ormerod to add to the museum of the Sussex County Hospital. It was of an oval form, and a mottled white-and-red colour, the different coloured patches being separated by sulei, in which ran large vessels, giving the tumour very much the appearance of a small brain. Besides these patches were small cysts, here and there containing a clear yellow fluid. On dissection, more of these cysts were visible, and the difference between the white and red parts appeared very distinct, referable apparently to the different degree of vascularity of the different parts. The sub stance of the tumour consisted of a matter of about the consistence of cerebral substance in a child of that age. Under the microscope it displayed numerous cells, more or less affecting an oval form, some much more elongated, all nucleated. The uterus, particularly the cervix, was very much enlarged. Malignant disease of the ovary, though of rare occurrence, and seldom a primary affection, has, I believe, never been met with, except in adults, or before the commencement of sexual activity. Encephaloid tumours are less common than other malignant diseases of the ovarium; but the disease occurring as a primary affection in an infant at the breast, is unparalleled, and renders this case unique. The rapidity with which it ran its course, the age of the child, and the absence of any symptom that could excite the suspicion that the disease was malignant in character, are circumstances of great interest. Adelaide Lodge, May, 1858. On the 14th there were large bullæ on the dorsum of both hands and fingers, which I opened, liberating a dirty, greenish-looking liquid, which I am sorry I could not collect for analysis. This relieved him, but on the following day violent pain recurred. On the 16th there was much oedema on the dorsum of both hands and fingers. I made free longitudinal incisions, liberating a quantity of liquor sanguinis. The wounds bled freely; the blood contained a large amount of fibrin. dorsum of each hand, liberating a little pus from On the 18th I again made an incision on the the right, after which they progressed favourably. 14th of December. The skin on the dorsum of The patient was able to resume work on the the hands and fingers pecled off. Furneux Pelham, 1858. INDUCTION OF PREMATURE LABOUR IN A MEDICAL OFFICER TO THE LAMBETH WORKHOUSE. MARIA D was admitted into the lying-in ward of this workhouse on the 9th of last September, having, according to her own calculation, just completed the seventh month of pregnancy. Being afflicted with considerable contraction of the upper pelvic brim in the antero-posterior diameter, she had in four successive labours, occurring at the full period of gestation, been obliged to consent to the destruction of the foetus, in order that her deliverance should be effected. Under these circumstances, it was judged advisable in any future contingency to induce labour at the termination of the seventh month of pregnancy, with the view, of course, of attempting the preservation of her infant. Having satisfied myself that she was carrying a living child, I had recourse to the usual operation for inducing premature labour, and which was carried into effect two days subsequent to her admission. After the further lapse of fortyeight hours, labour came on, attended with vigorous pains, and very shortly the child, which presented with the vertex, was expelled entirely by the natural efforts. The infant, a male, was, notwithstanding its diminutive size, and its premature "forcing into this breathing world," healthy and well formed. I am happy to add that both it and the mother did well, and were discharged in due time from the ward in a most satisfactory condition. Lambeth Workhouse, 1858. SKETCHES OF SOME OF THE TROPICAL DISEASES. BY FRANCIS DAY, Esq, M.R.C.S. & F.L.S., ASSISTANT-SURGEON MADRAS ARMY, AND 3D INFANTRY HY DERABAD CONTINGENT. (Continued from June No., p. 489.) TREATMENT. In this, two great principles may be said to be clearly predominant above all others. The first is, that we should arrest as quickly as practicable the paroxysms of the disease, for a continuance of them brings about a cachectic condition of the patient, leading to numerous secondary lesions, favouring the continuance and promoting the return of the disease. The second is, that although complications such as have been described exist, the especial object of our general treatment must be, first, to attack the fever, for by it the intensity of the local complication, whatever it may be, is augmented, more especially during the paroxysm; but with a decrease of the ague comes a decrease in its severity, or even its total subsidence, therefore the employment of remedies for the local lesion may take place along with, although holding a subordinate place to the antiperiodic. The treatment of agues, although all the types run one into another, still naturally divides itself into that which is required for the simple dynamic and adynamic types, and this, again, may be subdivided into that necessary during the paroxysm, the intermission, and the termination or stage of convalescence. In the simple types, few words are necessary before commencing this subject. Sometimes merely rest, with clearing out the bowels, conjoined to slight abstinence, are quite sufficient for effecting a cure; or, if antiperiodics should be requisite, their exhibition is rapidly successful, whether the patients are Europeans or natives of India. The alvine, biliary, and all excretions, must always be carefully attended to in all cases of fever, or congestions will be favoured. At hill stations, a stiff dose of brandy-and-water will often cure a native in whom cold alone has been the exciting cause. During the paroxysm our principles of treatment are, to protect the important viscera, which object will be effected by guarding against congestions in the cold; too great vascular reaction in the hot; and relieving the whole system by the promotion of perspiration in the sweating stage; but at the same time we must be cautious and not proceed too far in the last, and so induce fatal exhaustion. In the cold stage, if the tongue is foul, emetics may be exhibited, by which it, and also the paroxysm, appear at times to be shortened; the feet may be put into warm water, to which mustard may be added, or hot bottles or bricks be applied to them; the body should also be well covered up and kept as warm as practicable. Opiates as a remedy are of great use in agues: given in conjunction with an antiperiodic, before the accession of a paroxysm, they sometimes augment their efficacy, probably by soothing nervous irritability; if there is want of rest during a paroxysm, and the pulse remains good or not much depressed, they are useful, but should not be administered at any time when there is a tendency to death by coma, or to one by asthenia, near the termination of a paroxysm. When symptoms appear to tend towards delirium tremens, in old drinkers, opiates are advisable. Digitalis has been also recommended as a remedy for restlessness, when the action of the heart is excessive. The same rules as those necessary for the exhibition of opium must be observed in its employment. In the hot stage, the patient should only be lightly covered; diaphoretics and cooling drinks are useful, to bring on perspiration, which may even be promoted by an emetic, if not previously administered. The remedies most appropriate are James's powder, tartar emetic, neutral salts, nitrates of potash and soda, according to the symptoms present, and the patient on whom the medicine is to be employed. Mixtures of sulphate of magnesia and tartar emetic, though decidedly serviceable in some cases, not unfrequently produce irritation of the bowels, and, as a rule, should be avoided. Should headache be severe, cloths damped in cold water or vinegar-and-water may be applied to the head, with cupping or leeches to the temples. In the sweating stage, diaphoresis, unless too profuse, should not be checked. Purgatives may be administered if the bowels have not been freely moved without them, or they have not been given before, for vitiated secretions in the bowels cause irritation there, and tend, by such irritation, to keep up the tendency to fever. Care must be taken that there is not retention of urine; if necessary, it must be drawn off with a catheter. In the intermission, the diet must be regulated and exposure avoided, whilst antiperiodic remedies must be administered, by far the most important of which is quinine; but to avoid needless repetition, it will be easier to examine it, and some other antiperiodics, together, at the end of these remarks on the treatment of agues. |