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Birmingham Pathological SocietyAuthor(s): Bernard RiceSource: Provincial Medical Journal and Retrospect of the Medical Sciences, Vol. 7, No. 164(Nov. 18, 1843), pp. 136-139Published by: BMJStable URL: http://www.jstor.org/stable/25492489 .

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136 BIRMINGHAM PATHOLOGICAL SOCIETY. nius and Will advocate, is an improved method of

estimating the exact quantity of carbonic acid. A certain weight of the alkali to be examined is dis

solved in water, and put into an apparatus, which

contains some sulphuric acid in a separate vessel. The whole apparatus with its contents being then

carefully weighed, the sulphuric acid is caused, by very simple means, to mix with the alkali. Of course

it expels the carbonic acid, and the apparatus is so

contrived that the whole of it is expelled without

carrying any water with it. The apparatus is lastly weighed afresh, and then the loss of weight indicates the exact quantity of carbonic acid expelled, from

which the quantity of alkali can easily be computed. The authors give easy methods of correcting any inci dental errors. The principle of their method of

acidimetry is the same. Their manner of deter

mining the commercial value of oxide of manganese is founded on the circumstance that oxalic acid (C2 03) is, by combination with an additional equivalent of

oxygen, converted into two equivalents of carbonic acid (Cs 04); and it consists in ascertaining how

much oxalic acid can be converted into carbonic acid by the oxygen contained in a given weight of the manganese. The apparatus and principle of using it are the same that are employed for the preceding cases. We do not doubt that the labors of Drs Fresenius and Will will be fully appreciated by the

manufacturing community.

BIRMINGHAM PATHOLOGICAL SOCIETY. March 4, 1843.

BERNARD RICE, Esq., in the Chair. Dr. Fletcher exhibited to the society the left lung,

in which there was an ulcerated portion which had laid open numerous branches of one division of its bronchus, so that they communicated with the cavity of its pleura; a hepatised portion of the right lung, and a kidney, from a patient who had died from the

effects of emphysema and Bright's disease of the

kidney. John Smith, aged thirty-four, a bricklayer and

boiler-setter by trade, now in a very emaciated state,

says he always enjoyed good health, and was a strong man until eight weeks since, when he was attacked

by violent cold, sore throat, and a severe pain in the

left side, which was much increased by inspiration and coughing, accompanied by great fever and heat. For this he was actively treated, was bled and blis

tered, and took antimonial medicines. The pain in

the side had gradually left him; he has now expec toration of pus to a very considerable extent, to the

amount of more than a pint in the course of the day and night, which has existed about six days, and still

continues without diminution. Present State.-He has great difficulty of breathing

on the sightest exertion; cannot lie on the right side; his countenance expresses great anxiety; he is thirsty and feverish, and has a white tongue, and a pulse of

120; makes water freely, and his bowels are open.

Examination of the Chest.-The chest measures

thirty-seven inches round over the nipples, the right measures eighteen, and the left nineteen. The respi ratory motions are nearly absent on the left side, and are greater than normal on the right; the heart beats just on the right side of the sternum.

Percussion.-The left side of the chest sounds dull all below the level of the second rib, when the

patient sits with the body erect, above which the sound given out by percussion is sonorous, and the line of demarcation between the dull and sonorous sounds varies according to the position the patient is placed in. If the chest is bent forward, the level

of the dull sound rises above the level of the second

rib; if the chest is reclined, it sinks below; and a

corresponding reverse of the rise and fall of the level

of the dull sound takes place at the back of the

chest in the different positions in which the patient is

placed. The right side of the chest sounds more

sonorous than normal all over, except at the situation

of the heart. Succussion gives no sign. Auscultation.-No respiration is heard in those

parts of the left side of the chest which are dull on

percussion, but it is heard superiorly where the sound

is sonorous, more especially in the posterior parts of

the humeral and upper part of the interscapular

region, and bronchial in its character. Puerile respi

ration is heard all over the right side of the chest,

except where the heart is situated. Pills of the com

pound rhubarb pill, with small doses of ipecacuanha, were prescribed at bed-time; the following draught

three times a-day:

Disulphate of quinine, three grains; Tincture of opium, five minims;

Syrup of red poppies, one drachm; Water, eleven drachms.

And a linctus, containing hydrocyanic acid, to be

taken when the cough is troublesome.

25. The patient seems on the whole better, the

level of the fluid is somewhat lower, and, as the medi

cines appear to be borne well, they are to be continued,

and a blister, 12A 8 inches, placed upon the left side

below the arm. Expectoration goes on freely. Oct 27. The patient appears better; the medicines

agree and the blister has risen well; the level of the

fluid is now as low as the third rib anteriorly when

the patient is sitting with the chest erect; the chest

measures now thirty-six inches over the nipples, of

which the right measures eighteen, and the left

eighteen, so that it has diminished an inch; expectora tion has increased.

30. The level of the fluid is now down to the level

of the fourth rib. The chest measures thirty-five

inches and a half; the left side, having diminished half

an inch, measures seventeen inches and a half; whilst

the right side still measures eighteen inches. The

patient is now able to lean on the right side; tinte

ment metallique is now heard at the posterior part of

the left side of the chest, and respiration is heard

much lower down, cavernous in its character poste

riorly; the patient is generally improving. Nov. 4. Improving in all respects. To continue

the pills and mixture.

Simple ointment, one ounce; Tartar emetic, half a drachm. One drachm to be

well rubbed into the right side night and morning.

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BIRMINGHAM PATHOLOGICAL SOCIETY. 137

6. Same reports, except that the cough is at times

very troublesome, without expectoration. Ipecacuanha wine, oxymel scillu, and tincture of

camphor, of each one ounce. Mix. A teaspoonful when the cough is troublesome.

10. CEdema of the legs and feet; otherwise im proving; the respiration on the left side of the chest is heard lower down, and the whole side sounds better on percussion; tintement metallique is still heard.

29. (Edema increased; the urine is scanty; gene rally weaker, but the left side of the chest is im proving in physical signs; expectoration has continued to the amount of a pint in twenty-four hours; the left side of the chest is very much diminished in size, and the heart has gained the left side of the sternum. A small abscess is now discovered pointing just under the seventh rib on the outer side of the region of the heart, which evidently communicates with the cavity of the pleura, as the contents can be pressed into the chest.

Dec. 7. The abscess has increased. It was now

punctured by Mr. Amphlett, and more than a pint of

pus escaped. 14. Expectoration has ceased; the abscess has con

tinued to discharge; the patient continues generally in the same state.

20. The same state since last report; the expecto ration and discharge from the abscess have alternated, at times the expectoration has returned when the abscess has ceased to discharge, and, upon the abscess

again discharging, expectoration has ceased; from this it was evident that the abscess did not discharge suffi

ciently to empty the cavity of the chest. An attempt was consequently made to pass a probe or director

into the sinus, and dilate it; but this was found im

practicable. This state continued, the patient gra dnally getting weaker, and the cedema increasing, and the kidneys remaining inefficient in their action, until

six, a.m., January 18, when the patient died sud

denly in a fainting fit.

Sectio Cadaveris, Twenty-four Hours after Death.

Body much emaciated, and swollen from general anasarca; an ulcerated opening on the left side of the chest, just on the outer side of the region of the

heart, and below the seventh rib. Head not examined.

Chest.-Right side: adhesions of the pleura; lung large, and very edematous, and the scat of hepatisa tion in its middle lobe, and not crepitant in any of its

extent; the hepatised portion sank in water, and the

lung generally very imperfectly floated. Left side: pleura imperfectly divided into two cavities by adhe

sions, which were besides very general, and lengthened to from an inch and a half to two inches, and appeared thickened and very old, and the pleura itself much thickened. The upper cavity contained about a

pint of purulent fluid. The walls of the lower cavity were covered with purulent fluid, and underneath the

seventh rib, which was carious in this situation, a

pustulous canal formed a communication between the

cavity of the pleura and the external wound. The

lung generally crepitant, and in its structure healthy,

except that it was reduced to about a third of its normal size; and at its most depending portion there

was an ulcerated cavity, large enough to contain a

small walnut, by which the bronchi communicated

with the cavity of the pleura. This cavity was situ ated opposite to the external orifice of the sinus which communicated externally. The lung was in structure much more healthy than its fellow, and generally pervious to air.

Heart quite normal in structure, and all its cavities

quite empty. Abdomen.-Liver about double its normal size, and

fatty. Spleen, pancreas, stomach, and intestines

healthy.

Kidneys.-Left half as large again as normal, yel lowish white in color, and granular in the second

stage of Bright's disease. Right, about a fourth

larger than normal; much congested in the first

stage of, Bright's disease. Ureters and bladder

healthy. Dr. Fletcher said that this was a case which had

been of great interest to him, and its result served to confirm his views relating to the operation of para centesis thoracis, in cases of empyema. He felt sorry that he had not seen the case before any communica

tion had taken place between the bronchi and the

cavity of the pleura. Then the operation would have

been agreed to without the slighest opposition; as it

was, he did propose the operation, but was overruled

by objections from his medical friends, which he could not controvert-namely, that the patient was empty ing the cavity of the pleura by expectoration, as evidenced by the lowering of the line of demarcation

by percussion, and was also improving in his general health. But he thought that the result of the case

and the state of the lungs, as found at the post-mortem

examination, proved that the operation was as neces

sary at the time he first saw the case as it was before

the communication between the bronchi and cavity of

the pleura took place; and, as a proof that the very

imperfect communication with the bronchi was not

equal to empty efficiently the cavity of the pleura, the formation of the fistulous opening externally was sufficient evidence. Thus, although there was a com

munication with the bronchi in this case, by which

was yielded, by expectoration, more than a pint of

pus in twenty-four hours from the cavity of the pleura, still this was not sufficient to prevent the formation of

an external aperture, showing that if this had been

previously effected by art, the patient would have

been in a better state, and may have had a better

chance. Dr. Fletcher would not say that the life of

the patient would have been saved, for another cause

of death presented itself at the post-mortem examina

tion-namely, the diseased kidneys; and the state of

other organs proved that the patient had not enjoyed that immunity from disease which he had stated.

Dr. Fletcher said he could not let pass the oppor

tunity this case afforded him to speak of the operation of paracentesis thoracis, which he considered one of

great importance and utility, and especially as, from the valuable and correct signs of diagnosis of the dis

ease, and the easy practicability of the operation, it was likely to get into the hands of all practitioners of

surgery and medicine; so that it behoved us to have

well-founded notions to guide us in its performance, to be well acquainted with the cases in which it is

required, to be aware of its defects, its merits, and

the objects really to be sought for by its means.

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138 BIRMINGHAM PATHOLOGICAL SOCIETY.

All writers on the subject seemed to join (which Dr. F. most cordially did) with Dr. Forbes in con

sidering "that it is a measure which has frequently

proved successful, and that, too, in a disease which is

generally, if not always, beyond the influence of medicine, and too often beyond the power of nature to remove." Nor is it Dr. Fletcher's opinion that

the very unfinished paper which has been published of the late Dr. Hope's at all lessens the statement of Dr. Forbes, although it is there stated that by blisters, mercurials, diuretics, and, where hectic had set in, combined with mineral acids, he had cured thirty-five cases consecutively during the space of four years; for what is this when the number and the class of

patients is considered? Dr. Hope mentions having seen 15,000 out-cases at St. George's, from which these cases are taken; the only wonder was that he had not found a greater proportion to so large a number. Dr. Fletcher said he found a greater pro portion amongst his patients at the General Dispen sary, and said that it must also be borne in mind that

at St. George's Hospital, even the cases of effusion into the pleura, which Dr. Hope had, must have been necessarily slight, or they would have been admitted

in-patients of the institution. Dr. Fletcher said that

many cases, he knew, gave way under the treatment

Dr. Hope had mentioned, and in many Nature, un

assisted, effected a cure. He had seen one very severe

case effectually cured, under the care of M. Bouillaud, in La Charite, by his method of bleeding, " coup sur

coup ;" but he had had three cases which had resisted

severe, continued, and well-directed treatment, and had afterwards yielded to the operation of paracentesis thoracis, two of which were so perfect in their cure as to require a close investigation before a stranger would be aware that any disease had ever existed, and in one (which he had published in the " Lancet,"

Vol. II., 1840-41, page 716) there is only the cicatrix in the side left to indicate it.

Dr. Hope's statement, that empyema does not cause death without some complication, Dr. Fletcher said, he could distinctly contradict. He had seen, at a

post-mortem examination, no other cause for death than an effusion, to a great extent, into one of the cavities of the pleura, and knew of other cases which had been reported to him by medical gentlemen, and he did not hesitate to appeal to the profession gene rally on the subject. He believed that this cause of death has been sufficiently common as to have been known to most who have been diligent in seeking post-mortem examinations.

Dr. Fletcher said that the success of the operation of paracentesis thoracis, and its utility and necessity, having been established, it only remained to consider what danger attended it; and considering it to be

performed with common and ordinary discretion by a medical man, intelligent and fairly informed, he did not think there was any great risk attending the

operation; and, as evidence of this statement, he alluded to the very little mischief attending punctures of serous membranes generally, and wounds of the

thorax particularly, providing they were not com

plicated by the injury of any important viscus. With respect to the use of the grooved needle of

the late Dr. Thomas Davis, which had been said by

that gentleman to indicate the nature of the contents

by allowing the fluid to run along the groove which passed into the cavity containing the fluid, Dr. F. could only say that he had had two cases with Mr.

Crompton, in which the use of the grooved needles did not at all enlighten them on the subject for them to act, as Dr. Davis said he believed that the parietes

of the chest must be very thin, and also that the fluid

must be thin in consistence; and he believed that

the use of a small trocar would do no more mischief

than the needle, and had the advantage of substituting

one operation for the two recommended by Dr. Davis.

There were reasons depending upon the physiolo gical action of the lungs in inspiration which induced Dr. Fletcher to believe that when all hope of subduing the effusion by the ordinary means appeared lost, the earlier the operation was performed the better, and

the more likely was the patient to be cured, and left

with the lung of the diseased side in its full integrity, and unimpaired in its functions. In severe cases of

pleurisy there was a layer of lymph thrown out upon

the contracted lung, which bound it down, and pre

vented its ever again expanding. Now, it was a great

object to get away the fluid that pressed upon the

lung before this layer of lymph was sufficiently firm

to have this effect, which permanently prevented the

use of the organ, and prevented the expansive power

of the lung in inspiration. The existence of this

expansive power of the lung has been long the subject

of controversy, but Dr. Fletcher had no doubt that it

existed. Cases of hernia of the lung are noticed as

tumors which rise on the motion of inspiration, and

contract during expiration. Dr. Fletcher had seen a

case of this kind of a tumor situated on the right side

of the chest, which was under the care of Mr. De Kane,

of Wolverhampton, which rose up during inspiration, and the air was heard at the same time rushing into it,

and was effaced during expiration. A contracted lung,

which had been taken from a patient who had for.

merly suffered from a pleurisy, was during last year brought before the society by Mr. Russell, in which

the lung had pushed itself out into hernia-like

projections through portions of the organised layer

of lymph by which it had been bound down; and

to prove that the lung may retain its healthy struc

ture after considerable pressure, this lung may be

referred to as nearly approximating to a healthy

condition after years of compression. And in the

case now before the society, the lung of the diseased

side was much more healthy than its fellow, and was

the one by which alone respiration could have been

carried on; so that in case the lung is relieved from

compression before the lymph is sufficiently firm to

bind down the lung permanently, it may be expected

to resume its functions. Such facts bring us to this point

relating to the operation of paracentesis thoracis-that

as soon as it is clear that medical remedies fail, the

sooner the operation is performed the better.

Mr. Rice then brought before the notice of the

society an instrument he had found exceedingly useful

in the treatment of a case in which it was necessary

to puncture the bladder above the pubes, and keep an

instrument continually fixed in the bladder to draw

off the urine. It was his own invention. The following

is the case in which it was used :

JohnRoss, aged seventy-two, suffered from reten

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RETROSPECT OF THE MEDICAL SCIENCES. 139

tion of urine from stricture and enlarged prostate. The bladder was tapped about the pubes, in conse

quence of the advanced age of the patient, as it was

considered improper and unsafe to attempt to cure the stricture. The sharp edges of the canula of the trocar, when reintroduced after having been with drawn, caused much irritation and pain. A catheter, with apertures at the side and stop-cock, was then made for him, which he was able to wear with great

comfort, but this still produced irritation on being taken out to be cleaned. A catheter was then made

with an aperture drilled into the centre of the end. This instrument answered very well; it could be withdrawn and returned without pain or inconve nience. He lived several years, and returned to his work, and improved so much in flesh as to require the catheter to be lengthened several times, the only difficulty in the case being that of having the catheter of sufficient length to keep it in the bladder, but not so long that by any change of position of the patient it might be pressed against the mucous lining of the

bladder on the opposite side. The patient died after

living in comfort by the use of this instrument for about three years, from English cholera, brought on by eating fruit in excessive quantities.

Mr. Elkington then brought forward a liver affected with cirrhosis, which had been taken from a male child,

only eight years of age. He said he had seen the child only a few days before death. He was drop sical, and had frequent sickness. He had been sub

ject to hemorrhage from the nose about once a-week

from the time of birth. On examination of the body, there was found general anasarca, and all the organs of the body healthy except the liver, which was generally affected with cirrhosis, and about two thirds only of its normal size. The gall bladder of a

green color, and full of dark colored mucus.

Mr. Elkington presented a monstrosity in a case of twins united by the anterior part of the abdomen about the epigastric region, somewhat similar to the Siamese twins. One placenta and one short cord, about a foot in length, had served both the children. One of the children breathed when it was born, but

very soon died. In the labor the whole of the first child was born, then the hand of the second pre sented, the feet of which were brought down, the turning effected, and the child born without diffi culty.

The case was referred for dissection, which Mr. Elkington was requested to do, and bring forward the report at a future meeting.

RAE TR O S PB CT

OF THE

MEDICAL SCIENCES.

OBSERVATIONS ON RANULA. BY M. JOBERT (DE LAMX

BALLE), SURGEON TO THE HOPITAL SAINT LOUIS.

M. Jobert remarks that tumors of various kinds have been confounded under the common term ranula, which he proposes to limit solely to the tumor formed by an obstruction of one of the Whartonian ducts.

Having spoken of the variety of measures resorted to for the cure of thisaffection-namely, puncture, caustic, excision of a portion of the cyst, extirpation of the

whole cyst, setons and injections-none of which he observes can be entirely depended on-he gives the results of two cases which he has treated, on what it is now fashionable to call an autoplastic method, which

may be briefly described thus: The tongue being raised and pushed backwards, an

assistant seizes one side of the tumor with a forceps, and the surgeon the opposite side, so as to steady it

thoroughly; he then removes from the anterior sur face of the cyst a portion of the mucous membrane

elliptical in form, about three lines broad, and from six to eight lines long. This is removed without open ing the proper cyst of the tumor. The cyst is next

opened in its whole extent, and the viscid albuminous

looking fluid which it contains is discharged. Then the edges of the cyst are turned outwards to either

side, and one stitch is passed on each side through the

edge of the cyst and that of the mucous membrane, so as to confine them together.

In the two cases which M. Jobert relates, this

operation was followed with no ill consequence what ever. The saliva flowed profusely for the first few

days, but this was soon restrained within its normal

limits; the cyst contracted, and there merely remained an aperture, through which the saliva discharged itself

naturally. M. Jobert observes that, whether the tumor consist

of an accidental mucous cyst, or of an obstructed Whartonian duct, this method of cure is equally effica cious. The object in both maladies being to provide a permanent means of escape for the contained secre tion.-Annales de la Chir., Sept., 1843.

A CASE OF SPINA BIFIDA SUCCESSFULLY TREATED

BY REPEATED PUNCTURES. BY ALEXANDER H.

STEVENS, M.D., NEW YORK.

October 17 1837. An infant, daughter of Mr.

Leach, of Skeneateles, eight months old, was operated on by Dr. Stevens this morning for'spina bifida. The

tumor was seated over the upper part of the sacrum,

about three and a-half inches broad from side to side,

nearly the same in a vertical direction, and rising about two inches above the surrounding surface, indented along the middle vertically by a thick

irregular band of integument. The covering of the tumor was not healthy skin, but a peculiar thin

membrane of a reddish color, traversed by numerous vessels like varicose capillary veins. The healthy integument formed a hard edge at its line of union

with the covering of the tumor. The whole swelling was somewhat pendulous, narrower at its base than

about the middle, and in size held about the same

relation to the size of the infant as it did at the time

of birth. It had been once punctured with a needle, when the child was only a few weeks old. The

wound, which had never cicatrised fairly, is now covered with a sort of scab.

In the operation to-day it was punctured with an

iris knife, and about four ounces of clear serum, tinged with a few drops of blood, issued from the puncture in the integuments. The child did not appear to suffer any inconvenience from the evacuation of serum, but it produced a slight sinking at the anterior fonta nelle. The child's general health is good. There did not appear to be any deficiency of bone about the outer portion of the base of the tumor. The healthy integument mounted a few lines above the base,

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