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sound could not have originated in any other part of the circulating system than the pulmonary artery. He discards the view of the murmur being anæmic from the absence of other signs of anæmia. The rarity of 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 rare.
2. Because, the cases having occurred mostly in young persons, the age of the patients excludes deposits.
3. Because the murmur was usually soft, but became sometimes of a more whistling cha
The author holds that anything which tends to fix the pulmonary artery or impress 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 in Dr. Da Costa's interesting memoir.
XII. A Case of Hæmoptysis, 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 di-tended; 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 heartbeats 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 precautions 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 blood vessels.
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. Cruveilheir, 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 brings 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 itself.
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.
By JOHN CHATTO, Esq., M.R.C.S.E.
I. On Foreign Bodies in the Urethra and Bladder. By PROFESSOR PITHA. (Wein. Medicin. Wochenschr., 1858, Nos. 50, 51, 52.)
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 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 anaesthetic agents will not effect this.
* Guy's Hospital Reports, vol. vi. Oct. 1848.
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 urethræ. 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 sinooth, 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 prevent 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 manoeuvred 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 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
*See a paper by M. Denucé: Brit. and For. Med.-Chir. Rev., vol. xx.
nrethra, we must act in the same manner with the fingers placed in the rectum. In bodies having yielding stems and blunt points, such as hair-pins, 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 if the body has reached the membranous portion of the urethra, it can be removed by pressing it forwards through the rectum, while the curve of the urethra is diminished by traction of the penis. The cases wherein an instrument breaks in the urethra may be easily managed in this way with patience and presence of mind.
When the foreign bodies have reached the bladder, they are extracted with greater difficulty the longer and thinner they are. After they have remained in the bladder, too, they become incrusted, and are more difficult of removal, especially when the bladder has been rendered irritable. It is a matter of great difficulty to seize them in the longitudinal direction, but the extractor of Luer is admirably adapted for regulating the direction in which the body shall be removed, and with its aid, our difficulties are reduced in these cases to the discovery of the foreign body.
II. On the Treatment of Hernia by Electricity. By Dr. CLEMENS. (Deutsche Klinik, 1858, No. 34.)
In the first of a series of articles upon applied electricity, the fruits of ten years' investigation, Dr. Clemens gives an account of his employment of it in the treatment of hernia. He commenced its use in 1850, by endeavouring to produce a diminution in the size of the hernial apertures in a case of large double inguinal hernia. One of the poles of the battery, a massive metallic knob, was introduced deep into the canal, pressing a flap of skin inwards, and a moderately strong galvanic stream, increased daily, was passed along this during six minutes. At the end of a week the herniæ protruded less easily, and the apertures had become narrower. When the examination was made before and after each séance, a great difference was always found in the accessibility and size of the sac-an observation since repeated hundreds of times. The application of the galvanism also has the good effect of increasing the peristaltic movements, which in becoming more energetic effect a favourable change in the position of the intestines, by altering the situation of the portion which had so long remained opposite the aperture, and had consequently become relaxed. A more complete evacuation of the contents of the canal is also brought about. The impaired vitality of the intestine, of the hernial canal, and of the abdominal coverings is always renovated through this application of electricity. When the hernia is recent, no means of treatment is so certain and so exempt from all danger; and even when the hernia long has protruded it has often been returned under the influence of the galvanic stream or the electrical flask. Dr. Clemens has usually preferred frietion-electricity to galvanism, as its operation is more rapid and its effects are more energetic. Among twenty-seven patients so treated, none have complained of the least unpleasantness; but, on the contrary, they have found many inconveniences disappear under its influence, and especially obstinate constipation. In very sensitive persons diarrhoea may follow an energetic séance. When a hernia has been recently produced, as by a fall, lifting, &c., the success of the method is often surprisingly rapid, and in marked contrast with the slow progress of treatment by trusses, &c. A double hernia thus produced was cured without any bandage in twenty séances, and has remained so now for two years the treatment only commencing a week after the accident.
Dr. Clemens states that for large hernia, which can only be kept up imperfectly by any ordinary truss, he has contrived a galvanic truss, which operates with remarkable efficacy. It is constructed of copper and zinc plates, or pieces of copper and silver money, having felt or leather interposed, which is kept moistened by the saline solution necessary for the excitement of the pile. He again dwells upon the importance of exciting peristaltic action, not only in hernia, wherein it may often prevent strangulation being produced, but in various other affections due to a sluggish movement of the intestine. In numerous experiments upon animals, in which powerful shocks were employed, no ill effects resulted from the increased intestinal action produced.
III. Isolated Fracture of the Last False Rib. By M. LEGOUEST. (Gazette des Hôpitaux, 1859, No. 17.)
This rare form of fracture of the ribs occurred to a soldier, aged forty-five, who while
playing fell with his side against the corner of a table. Violent pain, an imperious desire to cough, and difficulty of breathing, revealed the nature of the accident. Examination detected the exact seat of the fracture to be at the junction of the middle with the posterior third of the last false rib. Crepitation was plainly felt at this point, but this was at some distance from that at which he had been struck. The corner of the table had forced the moveable end of the rib inwards and backwards, and the fracture had taken place in consequence of the excessive bending thus produced. No bandage was here applied as in ordinary fracture of the ribs. Such a bandage, having in view the limiting thoracic respiration and the rendering it abdominal, is useful in fracture of the true ribs (except the seventh), but is injurious in fracture of the false ribs. In point of fact, in the space comprised between the base of the transverse process of the first lumbar vertebra and the point of the last false rib, the circumference of the diaphragm is attached by an aponeurotic arch, one end of which is fixed to the base of the first lumbar vertebra, and the other to the lower edge of the last false rib; the remainder of the anterior circumference of the muscle rising up to be inserted into the cartilages of the false ribs and the seventh sternal rib. Wherever by inducing abdominal respiration the contractions of the diaphragm were rendered more energetic, the patient's sufferings were only increased; and he was left to his own instincts, which very soon taught him the manner he could breathe with least inconvenience.
IV. Case of Spontaneous Fracture of the Femur, with Consolidation. By M. ROBERT. (Gazette des Hộp., No. 18, 1859.)
A porter, aged fifty, of small stature but robust constitution, and in good health, with the exception of having suffered for about two years from pains of the lower limbs, supposed to be rheumatic, was quietly descending a staircase when he felt a cracking in the right thigh, and fell down; the fall being induced by the fracture and not the reverse. After two months and a half treatment the fracture, situated just below the trochanter, had completely consolidated, there being an abundance of callus, and shortening to at least the extent of four centimetres, giving rise to considerable lameness.
M. Robert, commenting upon the case, observed that, as far as he knew, it was unique. Every one is aware that the bones are sometimes spontaneously fractured when they are the seat of serious disease. In the case related by Dupuytren of a lad who had fractured the humerus while throwing a stone, a hydatid in the medullary canal was found to have reduced the bone to a mere shell. Tubercular deposit in the medullary cavity would be expected to produce the same effect; and cancer induces also the absorption of the osseous tissue. M. Robert has himself met with four examples of fracture of the humerus or femur in this disease. The cause in such cases giving rise to the fracture would likewise prevent its consolidation. In explaining the occurrence of this accident in the present case, M. Robert has recourse to the hypothesis of syphilitic disease, inasmuch as the man about twenty years ago suffered from chancre, but has never since had any symptoms of constitutional syphilis. He states that he has seen other examples of apparent cure, in which the individuals, remaining fifteen or twenty years without any consecutive manifestation, have still, after such a lapse of time, exhibited evident signs of syphilitic cachexia. Syphilis appearing at so late a period, gives rise to indeterminate accidents which cannot be classed among those which are manifested in the secondary and tertiary periods. These ultimate accidents may be almost designated as those of the plus-tertiary period, and they always are observed affecting either the osseous or fibrous tissues.
[The occurrence of tracture from muscular contraction independently of the cancerous diathesis, is not so rare an occurrence as M. Robert seems to suppose. We would refer him
to Dr. Van Oven's case, related by himself to the Medico-Chirurgical Society ;* to the collection of cases published by Dr. E. Gurlt, in the Deutsche Klinik,' Nos. 25-29, 1857; and to cases related by Mr. Henry Smith, in Medical Times,' vol. xxxvi. 1857.]
V. On Calculous Diseases in Hungary. By PROFESSOR BALASSA. (Wien. Medicin.
Wochenschr., 1858, Nos. 25 and 26.)
This article is the substance of a reply made by Professor Balassa, of Pesth, to a circular asking for statistical information, issued by Professor Gross, of Louisville, U.S. Owing to the absence of rural hospitals in Hungary, Professor Balassa observes, almost all the cases of
* Medical Times, vol. 26, p. 652, 1852.