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cular granulations, a large number of fresh, roe-like, prominent miliary tubercles. In some parts these were densely aggregated, but there were large interspaces between the groups; these also extended into the middle and inferior lobe. In the left lobe the deposit was confined to the upper lobe. Heart, spleen, liver, peritoneum, and kidneys, were normal; in the lowest part of the small intestine the solitary glands and Peyer's patches were somewhat enlarged; in the stomach were some hæmorrhagic erosions.
XI. On the Occurrence of a Blowing Sound in the Pulmonary Artery, associated with Affections of the Lung; on the Sounds of the Artery in Health; and on the Effect on them and on the Heart of the Act of Inspiration. By J. DA COSTA, M.D. (The American Journal of the Medical Sciences, Jan. 1859.) The author brings forward eight cases in which he detected a distinct blowing murmur in the place of the normal first pulmonary sound, at the second left costal cartilage, or in the second left intercostal space close to the sternum. The murmur was limited to this spot, and did not pass upwards or downwards. In the first case, a man, aged thirty-five, there was confirmed phthisis; besides cough and yellow expectoration, the upper right lung was dull on percussion, with crackling and prolonged expiratory murmur; on the left side a slight dulness existed anteriorly at the upper portion, and the respiration was harsher than normal. While under treatment, the author repeatedly noticed a blowing sound, at times low, at times of a higher and more whistling pitch, in the interspace between the second and third ribs on the left side; it was synchronous with the heart's impulse, and was followed by a distinct second sound. The other cardiac sounds were healthy, and no arterial or venous murmurs were noticed. The murmur was not always present in this case, especially when the heart's action was slow and the breathing calm. Case 2, a lad, aged eighteen, also phthisical, had slight dulness at upper right lung, with cracking and prolonged expiration; a frictionsound at upper left lung anteriorly near the second rib; dry râles were heard over the entire left lung, and part of the right. Later on in the case, the phthisical symptoms continuing, a rather short blowing sound, at times of a high whistling pitch, then again of a lower note, was heard in the second intercostal space, and synchronous with the heart's impulse. The heart was otherwise normal. The sound was best heard when the patient held his breath after expiration. The next four cases are precisely similar to those given; one of them, however, proved fatal; the blowing sound was distinctly heard a few weeks before death. The autopsy showed extensive disease of the left lung. It was throughout the seat of tubercular deposit, and contained cavities. The heart was not enlarged, the valves were healthy. No abnormal state of the pericardium, nor of the vessels proceeding from it, was noted. The exact position of the pulmonary artery to the deposit was unfortunately not specially studied. In the two remaining cases the author states that there were no phthisical symptoms; but in one, the upper left lung was duller than the upper right; the inspiratory murmur throughout the left lung, but especially at the upper portion, harsh, and expiration there prolonged. In the other there was relative dulness, with a higher pitch at the upper portion of the left lung, especially between the second and third ribs, where there was also more resistance and a slight sinking; respiration was harsher and stronger than normal at the left apex. In both these cases the cardiac sounds were normal, with the exception of the pulmonary systolic bruit.
Dr. Da Costa in the commentary dwells upon the anatomy of the parts, and shows that the sound could not have originated in any other part of the circulating system than the pulmonary artery. He discards the view of the murmur
The rarity of
being anæmic from the absence of other signs of anæmia. lesions of the pulmonary valves he regards as a proof against the murmur being explicable upon this view. He considers that local changes or obstruction in the pulmonary artery gave rise to the murmur, and concludes that it was produced by pressure upon the artery.
1. Because deposits in the coats of the pulmonary artery are uncommonly
2. Because, the cases having occurred mostly in young persons, the age the patients excludes deposits.
3. Because the murmur was usually soft, but became sometimes of a more whistling character.
The author holds that anything which tends to fix the pulmonary artery or compress it, as infiltration of the surrounding textures, pleuritic adhesions of the upper lobe, and the like, may induce the murmur.
He would have satisfied himself still more completely that the cause of the bruit does not in these cases reside in the artery, but is altogether external to it, had he tried the effect of pressure with the stethoscope, or the changes in the sound on change of position; thus, with regard to the former, external pressure, in our experience, much intensifies the sound, while the erect position diminishes it. It has also appeared to us that enlarged bronchial glands might at times encroach upon the calibre of the pulmonary artery, and thus induce a murmur such as that described by Dr. Da Costa's interesting memoir.
XII. A Case of Hemoptysis, Entrance of Air into the Veins and Discharge of Air by a Venesection. By M. PIEDAGNEL, Physician to the Hôtel-Dieu. (L'Union Médicale, 1859, No. 45.)
A gentleman, aged forty-two, of vigorous constitution and strong muscular development, had been affected for four years with a spinal disease, which, however, disappeared under treatment. For two months before coming under treatment he had influenza, with much cough, and occasional violent efforts at expectoration. On the 18th of February, 1858, while coughing, he suddenly fell down insensible, and discharged a considerable quantity of blood. The hæmorrhage ceased, but consciousness did not return. When seen by M. Piédagnel he was lying on his back, perfectly insensible, face pale, eyes immovable, pupils the same, but distended; hearing gone; no movement or sensibility. The whole skin pale, and insensible to stimulants. Respiration noisy, but does not resemble that of cerebral congestion, being active in inspiration, and at the end of expiration as in very feeble children. There was a slight râle on the right, but a strong and very moist one to the left; the percussion was less clear on the left, but no dulness either before or behind. Percussion of the cardiac region only causes a doubtful dulness; on auscultation a dull but tumultuous sound of the heart-beats was heard. The radial arteries were imperceptible; all the subcutaneous veins were empty. The diagnosis was doubtful; it could not be apoplexy; it might be laceration of the lungs or rupture of the heart.
A variety of stimulants were applied; after about half-an-hour there were symptoms of returning animation; the cutaneous circulation reappeared. A venesection being proposed by M. Vivier, was performed on the median-basilic vein. A little blood dribbled out; to the great surprise of the bystanders bubbles of air were then seen to issue from the opening in the vein, at first one, then several, passing out so as to form a sort of wreath on the skin, between the opening in the vein and the lower part of the fore-arm. On the blood and the air ceasing to flow, some light frictions along the course of the vein caused a new issue of air-bubbles; two, four, eight issued successively, then the flow stopped; the frictions were repeated several times; all precau
tions were taken to avoid error, and each time the same result ensued. At last blood and air ceased to appear; the patient did not improve, and death took place soon after. No autopsy was allowed. But the physicians were of opinion that a rupture of the lung had taken place, causing an entrance of air into the bloodvessels.
XIII. On Puncture of Hydatid Cysts of the Liver with the Capillary Trocar. By Dr. J. MOISSENET, Physician to the Lariboisière Hospital. (Archives Générales, Fevrier, Mars, Avril, 1859.)
Having had the misfortune to lose a patient affected with a considerable hydatid cyst of the liver by peritonitis, resulting from a palliative puncture with the capillary trocar, the author enters upon a minute inquiry relative to the different methods which have been employed for the purpose of evacuating the liquid contents of the tumour and the subsequent destruction of the hydatids. He finds that experience justifies the simple puncture, provided there is no escape of the fluid contents into the peritoneal cavity. Récamier, Legroux, and Laugier, Owen Rees, Aran, Boinet, Robert, Cloquet, and others have obtained successful results by puncture with a fine trocar. Cruveilhier, in speaking of Récamier's practice, warns against its general employment unless adhesions can be proved to exist, and the tumour presents a decided tendency to push outwards. Dr. Moissenet brings forward several other cases besides his own which proved fatal. The first series of general conclusions that his analysis bring him to are:
1. That the hydatid liquid, whether limpid or puriform, when poured into the peritoneum, whether as the result of accident or of an operation, induces acute or chronic inflammation, which is almost always, if not invariably, fatal.
2. That capillary puncture, though commonly not injurious, may induce effusion into the peritoneum of hydatid fluid, when there are no adhesions between the cystic and abdominal parietes; and that this effusion has taken place when the puncture has been made for exploration or palliation only; that is, when the cyst has been imperfectly emptied.
3. That the puncture of hydatid cysts, whether made with a capillary or an ordinary-sized trocar, may prove fatal by inducing inflammation of the cyst
The second series of conclusions drawn by Dr. Moissenet are:
1. That capillary puncture of an hydatid tumour, made even without the existence of adhesions, may be curative, when followed by as complete an evacuation of the liquid as possible.
2. That this result may be obtained by a single puncture, or by two or three successive punctures.
3. That the treatment commenced by capillary puncture must sometimes be completed by another method, as in the case of Dr. Owen Rees,* in which a larger trocar was used at the third puncture, and a gum-elastic sound left in the orifice.
QUARTERLY REPORT ON SURGERY.
I. On Foreign Bodies in the Urethra and Bladder. By PROFESSOR PITHA.
THE immediate cause of this communication was an interesting case, in which, on account of the introduction of foreign bodies into the bladder, the operations * Guy's Hospital Reports, vol. vi. Oct. 1848.
of lithotomy and lithotrity were successively performed on the same individual. He was a soldier, aged thirty-four, who came into the hospital in consequence of a piece of lead-pencil about three inches long, and pointed at either end, having slipped into the bladder while he was trying to pass it, as a substitute for a bougie. He had suffered excessive torment for a week, and the pencil (which was found divided into two parts) was removed by the lateral incision. He did very well. In two years he returned to the Clinic suffering from intense cystitis, brought on from the presence of a piece of sealing-wax which had entered the bladder during his manipulation with it. The patient protested against the repetition of lithotomy, which, indeed, would have hardly been advisable in the inflamed condition of the bladder, and it was resolved to have recourse to lithotripsy. He was brought under the influence of chloroform with great difficulty, and never to an extent sufficient to subdue the irritability of the bladder, which instantly rejected the smallest quantities of water which were thrown into it. The preliminary injection of the bladder had therefore to be dispensed with. The foreign body was seized with the greatest ease, and not to pursue the details, was crushed and entirely removed in the course of three séances, at intervals of two or three days. The patient completely and rapidly recovered. This case is very interesting, from the fact of there being no means of anticipating the amount of resistance which wax that had lain in the bladder for four weeks would offer; and further, by showing that lithotripsy may be safely performed, notwithstanding violent general reaction and the greatest irritation of the bladder, producing complete intolerance of the presence of any water whatever. Hitherto one of the most received axioms has been not to undertake the operation in an empty bladder. It may surprise some that the narcosis was not pushed to the extent of appeasing this irritability of the bladder, but repeated experience has shown that the highest doses of anæsthetic agents will not effect this.
The case is also interesting as exhibiting an example of the unexpected slipping of foreign bodies into the bladder having occurred twice in the same individual. This accident has not excited the attention its frequency and importance demands. If experience upon this point were collected, surprise would be excited at the extraordinary character of various objects found in the urethra and bladder,* of some of which it would be difficult to explain how they could be forced through the urethra, to say nothing of their slipping into the bladder. But even with respect to the commoner objects, most of which have some resemblance in shape or size to the catheter, such as pen-holders, pencils, glass tubes, metallic rods, pieces of wood, &c., one can scarcely conceive how, once introduced into the urethra, they should escape from the fingers and slip into the bladder. This may be intelligible enough as regards the straight, short, female urethra, but not so as to the male urethra, whose long curved canal is traversed with difficulty by a well-oiled catheter in inexpert hands. Some have sought for an explanation in a suction-action or a peristaltic movement of the urethra, but ample experience in introducing instruments does not favour this view. On the contrary, a powerful expelling influence is often exerted by the urethra, the instrument being forcibly ejected when it has reached the neck of the bladder, this resistance being in fact met with more or less in the widest urethra. The walls of the canal are naturally closely applied to each other, and its entire mechanism is directed so as to favour the passage from within outwards, and not the reverse of this. Demarquay has furnished this natural explanation, that the entrance of the body takes place at the period of erection, and especially of ejaculation. The urethra is then elongated, its walls are expanded and smooth, and its canal is gaping and well lubricated, while its curvatures are diminished. The penis in relaxing forces the body deeper inwards, and the efforts of the person to pre* See a paper by M. Denucé: Brit. and For. Med.-Chir. Rev., vol. xx. p. 264.
vent the occurrence by forcing back the penis, in order to shorten it, only add to the mischief. This seems the most rational explanation, for in fact these cases usually occur in onanists, who in order to induce ejaculation, penetrate deeper and deeper into the urethra, having already blunted the sensibility of the anterior portion. In the performance of catheterism, too, we sometimes find, in spite of the greatest skill, the passage of the instrument is obstructed. Presently, the repeated attempts induce erection, and the instrument at once passes on. Sometimes the catheter glides at once to the membranous portion, where it meets with insurmountable resistance. Believing that there must be a fold or a stricture, or that a faulty direction has been observed, we seek to withdraw the instrument. This, however, is impossible without violence, so fast and immovably is it held; and now a phenomenon which astonishes the inexperienced is observed-viz., the spontaneous deeper penetration of the instrument, as if propelled by some unseen power, a circumstance which has probably given rise to the suction theory. It is, however, a mere mechanical effect of the elastic return of the penis (after having been forcibly drawn forwards), during which the muscular walls, closely embracing the instrument, are also carried backwards. So strong may this spasmodic action of the muscles be, that nothing but rude force will overcome it, unless we wait for minutes or hours, until the spasm subsides. It may play the chief part where foreign bodies slip into the bladder during erection, at all events detaining them in the membranous portion of the urethra; and it will be the more certainly brought into action the more pointed and irritating the body be, especially as the state of erection increases the irritability of the urethra. It is well known that catheterism after coitus or pollution is much more difficult, and that in such case a seizure of the instrument most readily takes place, even in patients accustomed to the operation—a fact of some importance in the treatment of stricture.
For the removal of foreign bodies of a roundish shape from the urethra, such as beads, beans, calculi, &c., Professor Pitha has long been in the habit of using delicate long-bladed forceps (Kornzange), which can be easily manœuvred with one hand, while the fingers of the other fix the foreign body from behind. Several such forceps of different lengths and widths should be at hand, in order to choose from in particular cases. When the body is seated very deeply, as at the neck of the bladder, the instrument should have a gentle catheter-like curvature given to it; and such an instrument the author finds admirably adapted for the removal of fragments from the urethra after lithotrity. When the foreign bodies are too voluminous, they should be first broken up by means of Segalas' urethral brise-pierre, and when not capable of being broken, they must be removed by the button-hole operation, the wound in these cases always readily healing, even when situated in the perineum. In the case of sharp, pointed bodies, such as needles, awls, and the like, special manipulation is required. When a needle, e.g., is still in the region of the penis, we must ascertain by the touch its exact position, and then by pressure on the blunt end, force the point through the walls of the urethra, until it can be seized by a forceps. Pins should be thrust through in the same manner, and so manoeuvred that the head is directed towards the mouth of the urethra, and then removed by an urethral forceps. When the needle is implanted lower down in the urethra, we must act in the same manner with the fingers placed in the rectum. In bodies having yielding stems and blunt points, such as hairpins, these procedures are impossible, and for the removal of such, an instrument contrived by Matthieu, of Paris, answers admirably. Leroy has modified the instrument, so that it now resembles the brise-pierre à pignon. Smooth, cylindrical bodies, such as needle-cases, pen-holders, bougies, &c., soon pass into the bladder. Before this they may usually be removed with ease, providing their progress backwards be at once prevented by compression. Even