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538 A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. UNIVERSITY COLLEGE HOSPITAL. A CASE OF IMPERFORATE HYMEN, WITH RETAINED MENSES. (Under the care of Mr. H. THOMPSON.) Nulla autem eat alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, turn proprias collectas habere, et inter ae comparare.-MORGAGNI De Sed. et Caus. Morb., lib. iv. Procemium. THE retention of menses by mechanical obstruction is so grave a condition, and operative interference for its relief is so often attended with serious results, that the record of success- ful treatment cannot fail to be useful and interesting. We are indebted to Mr. Hopgood, dresser, for notes of the accompanying case :- C. A. L-, aged sixteen, was admitted on March 4th, 1867, with the following history :-She has never seen any menstrual discharge, but says she has felt pain over the genital organs, down the thighs, and also a little in the back at different times, lasting for about a week, and that during that time the labia were swollen. She first felt these symptoms about two years ago, and subsequently about every five or six months, the last time being at Christmas, remaining ten days. She says the stomach was then very hard. Upon examination through the rectum a large tumour was felt pressing from above, and resembling somewhat the preg- nant uterus. Upon opening the labia the orifice of the vagina was found occluded by a thick membrane, resembling the lining of the vagina. Upon percussing the abdomen there was considerable dulness over the pubic region, extending upwards for nearly four inches towards the umbilicus. The external parts were naturally formed, but the pelvis and genital organs were somewhat smaller than usual. She was unable to pass urine until the catheter had been used twice, after which she passed it herself. March 6th.-Being placed under chloroform, a careful exa- mination was made, and the urine having been drawn off, Mr. Thompson pierced the membrane with a trocar in the direc- tion of the vaginal canal, a finger being previously introduced into the rectum. About eight ounces of semi-fluid material, of a dark colour and very thick consistence, were drawn off. The canula was left in, and a bandage placed round the abdomen. 8th.-The canula slipped out during last night, and the opening being closed, another could not be passed. There was a little pain in the abdomen during the night, relieved by a hot poultice. In the afternoon Mr. Thompson introduced a larger trocar, and twenty-six ounces of fluid were drawn off through the canula, after which a small gum catheter was passed through the canula, the tube removed, and the catheter tied in; a compress and bandage were placed over the abdomen. 9th.-Complains of great pain in the abdomen, which is in- creased by pressure; the genitals are swollen and tender; there has been no more discharge. Hot poultices were applied, and twenty minims of tincture of opium, together with half an ounce of brandy, were given, and repeated. 10th.—The pain is much better this morning, but still there is considerable tenderness about the parts. Was sick last night. Bowels have not been open since the 5th. To have a warm enema. llth.-Bowels acted freely this morning after the enema. Pain and tenderness less. To continue the poultices. 13th.-Pain nearly gone. To discontinue the poultices. Slept very well last night, and the appetite is moderately good. There has been a little discharge by the side of the catheter. 15th.-The catheter was taken out of the opening and a director introduced, when a quantity of very offensive puriform matter passed along it. Two hooks were now passed through the edges of the opening, and a star-shaped incision made, after which the finger could be passed. Upon examination there was no os uteri to be found, but the finger went into a cul de sac somewhat wider at the sides than at the entrance. A sponge-tent was introduced, and left in eighteen hours. 16th.-The sponge-tent was removed this morning. There was very little discharge after removing the tent. Considerable pain for two or three hours after the introduction of the sponge- tent. The parts were well washed out with Condy’s fluid, and a piece of- lint dipped in lead lotion applied to them. 17th.—Another sponge-tent introduced for six hours. 18th.- Another sponge-tent introduced this morning, the parts being first well washed out with Condy’s fluid. The plug was taken out last night. There is a swelling in the left flank, about the size of an orange, extending over towards the middle line, tender upon pressure, and dull on percussion; with some symptoms of fever. 19th.-The swelling is much increased in size, being about four inches above the pubes, and crossing the abdomen nearly to the opposite side. The pulse rapid, weak; much general fever. No sponge-tent to be applied, but hot poultices to the abdomen. 20th.-The pain has not been so severe; the tenderness and swelling of the abdomen are less. Much fluid was passed by the bowels during the night, the matter being of a yellowish- brown colour. The appetite is not so good ; the surface of the body is dry and hot; the face flushed; the tongue slightly furred, with red papilla3 upon it. The pulse small and weak, 100 per minute. 21st.-The discharge by bowel diminishes, and the swelling is entirely gone. The dulness has disappeared ; the pain and tenderness over the uterus and in flank also. 22nd.-Very little tenderness to-day ; no pain ; the appetite is much better. There was a little discharge from the vagina. 26th.-There has been a little discharge every day since the 22nd ; but it has decreased in quantity up till yesterday, when it entirely ceased. There was a little again this morning. 28th.-The abdomen is now soft, and not at all painful. There has been a little more discharge from the vagina. The genitals are less painful, and the vagina admits the little finger. The bowels act properly. April 3rd.-There has been a considerable quantity of dis- charge during the night. Upon making pressure over the seat of the uterus and in the left flank, there is a discharge of thin white matter from the vagina; about half an ounce escaped this morning by such pressure being made. 9th.-The discharge from the vagina has gradually lessened since the 3rd, and this morning none is perceptible. There is now no pain, tenderness, heat, or swelling about the abdomen; the orifice of the vagina is tender, and admits the tip of the little finger without causing pain, but if it be passed beyond the orifice it causes slight pain. She is now able to walk about, and feels stronger than she did upon admission. The appetite is good, the bowels regular, the tongue clean, and she sleeps well at night. There is no discharge from the vagina. 10th.—Left the hospital to-day. Mr. Thompson remarked that he had adopted the mode of evacuating the retained menstrual fluid by slow percolation, rather than by permitting its rapid exit, on account of the large quantity-at least two or three pints-which existed. There was no question that the large and rapidly formed tumour which appeared a few days after the complete evacua- tion of the menstrual fluid, accompanied as it was by symptoms of almost an alarming nature, was an abscess, which subse. quently opened into the bowel, and discharged its contents by that channel. GUY’S HOSPITAL. A CASE OF CROUP IN WHICH TRACHEOTOMY WAS PER- FORMED WITH A SUCCESSFUL RESULT. (Under the care of Dr. WILKS.) MOST operators will agree that it is a great point to remove the tube as early as possible after tracheotomy performed for croup. Our own conviction is, that in the majority of cases the tube is retained long after there is any real necessity for its use. The trouble-sometimes even impossibility-of re- introducing a tube which has once been withdrawn no doubt renders operators shy of testing how far the patient is inde- pendent of its assistance, and thus the canula is retained and life endangered. Stopping the aperture with the finger is evi- dently not a fair test, for the tube offers no slight impediment to the passage of air to and from the larynx. For this reason we doubt the advantage of a little contrivance which M. Broca introduced in Paris a short time since. In this the month of
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Page 1: GUY'S HOSPITAL

538

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

UNIVERSITY COLLEGE HOSPITAL.A CASE OF IMPERFORATE HYMEN, WITH RETAINED

MENSES.

(Under the care of Mr. H. THOMPSON.)

Nulla autem eat alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, turn proprias collectas habere, et interae comparare.-MORGAGNI De Sed. et Caus. Morb., lib. iv. Procemium.

THE retention of menses by mechanical obstruction is sograve a condition, and operative interference for its relief is sooften attended with serious results, that the record of success-ful treatment cannot fail to be useful and interesting.We are indebted to Mr. Hopgood, dresser, for notes of the

accompanying case :-C. A. L-, aged sixteen, was admitted on March 4th,

1867, with the following history :-She has never seen anymenstrual discharge, but says she has felt pain over the genitalorgans, down the thighs, and also a little in the back at differenttimes, lasting for about a week, and that during that time thelabia were swollen. She first felt these symptoms about twoyears ago, and subsequently about every five or six months,the last time being at Christmas, remaining ten days. Shesays the stomach was then very hard.Upon examination through the rectum a large tumour was

felt pressing from above, and resembling somewhat the preg-nant uterus. Upon opening the labia the orifice of the vagina wasfound occluded by a thick membrane, resembling the lining of thevagina. Upon percussing the abdomen there was considerabledulness over the pubic region, extending upwards for nearlyfour inches towards the umbilicus. The external parts werenaturally formed, but the pelvis and genital organs weresomewhat smaller than usual. She was unable to pass urineuntil the catheter had been used twice, after which she passedit herself.March 6th.-Being placed under chloroform, a careful exa-

mination was made, and the urine having been drawn off, Mr.Thompson pierced the membrane with a trocar in the direc-tion of the vaginal canal, a finger being previously introducedinto the rectum. About eight ounces of semi-fluid material,of a dark colour and very thick consistence, were drawn off.The canula was left in, and a bandage placed round theabdomen.8th.-The canula slipped out during last night, and the

opening being closed, another could not be passed. Therewas a little pain in the abdomen during the night, relieved bya hot poultice. In the afternoon Mr. Thompson introduced alarger trocar, and twenty-six ounces of fluid were drawn offthrough the canula, after which a small gum catheter waspassed through the canula, the tube removed, and the cathetertied in; a compress and bandage were placed over the abdomen.9th.-Complains of great pain in the abdomen, which is in-

creased by pressure; the genitals are swollen and tender; therehas been no more discharge. Hot poultices were applied, andtwenty minims of tincture of opium, together with half anounce of brandy, were given, and repeated.

10th.—The pain is much better this morning, but still thereis considerable tenderness about the parts. Was sick last

night. Bowels have not been open since the 5th. To have awarm enema.

llth.-Bowels acted freely this morning after the enema.Pain and tenderness less. To continue the poultices.

13th.-Pain nearly gone. To discontinue the poultices.Slept very well last night, and the appetite is moderately good.There has been a little discharge by the side of the catheter.

15th.-The catheter was taken out of the opening and adirector introduced, when a quantity of very offensive puriformmatter passed along it. Two hooks were now passed throughthe edges of the opening, and a star-shaped incision made, afterwhich the finger could be passed. Upon examination therewas no os uteri to be found, but the finger went into a cul de

sac somewhat wider at the sides than at the entrance. A

sponge-tent was introduced, and left in eighteen hours.16th.-The sponge-tent was removed this morning. There

was very little discharge after removing the tent. Considerable

pain for two or three hours after the introduction of the sponge-tent. The parts were well washed out with Condy’s fluid, anda piece of- lint dipped in lead lotion applied to them.

17th.—Another sponge-tent introduced for six hours.18th.- Another sponge-tent introduced this morning, the

parts being first well washed out with Condy’s fluid. The

plug was taken out last night. There is a swelling in the leftflank, about the size of an orange, extending over towards themiddle line, tender upon pressure, and dull on percussion; withsome symptoms of fever.19th.-The swelling is much increased in size, being about

four inches above the pubes, and crossing the abdomen nearlyto the opposite side. The pulse rapid, weak; much generalfever. No sponge-tent to be applied, but hot poultices to theabdomen.20th.-The pain has not been so severe; the tenderness and

swelling of the abdomen are less. Much fluid was passed bythe bowels during the night, the matter being of a yellowish-brown colour. The appetite is not so good ; the surface of thebody is dry and hot; the face flushed; the tongue slightlyfurred, with red papilla3 upon it. The pulse small and weak,100 per minute.21st.-The discharge by bowel diminishes, and the swelling

is entirely gone. The dulness has disappeared ; the pain andtenderness over the uterus and in flank also.22nd.-Very little tenderness to-day ; no pain ; the appetite

is much better. There was a little discharge from the vagina.26th.-There has been a little discharge every day since the

22nd ; but it has decreased in quantity up till yesterday, whenit entirely ceased. There was a little again this morning.28th.-The abdomen is now soft, and not at all painful.

There has been a little more discharge from the vagina. Thegenitals are less painful, and the vagina admits the little finger.The bowels act properly.

April 3rd.-There has been a considerable quantity of dis-charge during the night. Upon making pressure over the seatof the uterus and in the left flank, there is a discharge of thinwhite matter from the vagina; about half an ounce escapedthis morning by such pressure being made.9th.-The discharge from the vagina has gradually lessened

since the 3rd, and this morning none is perceptible. There isnow no pain, tenderness, heat, or swelling about the abdomen;the orifice of the vagina is tender, and admits the tip of thelittle finger without causing pain, but if it be passed beyondthe orifice it causes slight pain. She is now able to walkabout, and feels stronger than she did upon admission. The

appetite is good, the bowels regular, the tongue clean, and shesleeps well at night. There is no discharge from the vagina.

10th.—Left the hospital to-day.Mr. Thompson remarked that he had adopted the mode of

evacuating the retained menstrual fluid by slow percolation,rather than by permitting its rapid exit, on account of thelarge quantity-at least two or three pints-which existed.There was no question that the large and rapidly formedtumour which appeared a few days after the complete evacua-tion of the menstrual fluid, accompanied as it was by symptomsof almost an alarming nature, was an abscess, which subse.quently opened into the bowel, and discharged its contents bythat channel.

GUY’S HOSPITAL.A CASE OF CROUP IN WHICH TRACHEOTOMY WAS PER-

FORMED WITH A SUCCESSFUL RESULT.

(Under the care of Dr. WILKS.)MOST operators will agree that it is a great point to remove

the tube as early as possible after tracheotomy performed forcroup. Our own conviction is, that in the majority of casesthe tube is retained long after there is any real necessity forits use. The trouble-sometimes even impossibility-of re-introducing a tube which has once been withdrawn no doubtrenders operators shy of testing how far the patient is inde-pendent of its assistance, and thus the canula is retained andlife endangered. Stopping the aperture with the finger is evi-dently not a fair test, for the tube offers no slight impedimentto the passage of air to and from the larynx. For this reasonwe doubt the advantage of a little contrivance which M. Brocaintroduced in Paris a short time since. In this the month of

Page 2: GUY'S HOSPITAL

539

the tube is stopped by a valve to an extent capable of beingvaried by turning a screw.We had the opportunity lately of observing the following

case, which has an interesting bearing upon the question. Theaccount is taken from Mr. A. B. Elliott’s notes.A boy of four years and a half old, stout, healthy-looking,

with fair complexion, was admitted on March 9th, having hada cold for several days, with cough, and a difficulty of breath-ing, which had become very severe. Half an hour after ad- mission he was apparently insensible, with blue face and hands.There was a slight cough, and violent inspiratory efforts were ’,being made; but no air could be heard entering the chest.The larynx appeared blocked, so that a loud, harsh sound wasproduced by the air which succeeded in passing through. The

pulse was exceedingly rapid. As it was evident that the childcould not live unless relieved, Dr. Wilks consented to theperformance of tracheotomy, which was accordingly done atone P.M. by Mr. Bushell, the house-surgeon. No chloroformwas administered. As soon as the tube was introduced, andthe air entered the chest freely, relief was obtained, the con-gestion of skin in great part disappeared, and the breathingbecame easy, though still rapid. There was still, however,enough blueness to show that the aeration of the blood wasimperfectly performed ; and as this was probably due in somemeasure to clogging of the bronchial tubes, a dose of ten grainsof ipecacuanha powder was given, and five minims each ofwine of ipecacuanha and of antimony ordered every four hours,with a diet of milk and beef-tea. In the evening the childappeared very comfortable, playing with an orange. Breathingwent on satisfactorily through the tube.March 10th.-Eight A.M.: The tube becoming clogged by

mucus, a probe was introduced by the clinical clerk, and theobstructing mass dislodged. The breathing, which had ceased,was again resumed through the tube; but as soon as the probewas withdrawn the passage of air was again arrested, and itwas found impossible to free the passage. At this time, asthe child was breathing easily by the mouth, the house-surgeondecided on discontinuing the use of the tube, which was ac-cordingly withdrawn. Two hours afterwards it is noted thatalthough breathing was carried on through the wound, andmucus was discharged through it, the child liked to have theopening covered up. He wished to get up and be dressed. Thepulse was 150, and there were slight mucous râJes in the chest.At two P.M. he ate some potatoes. In the evening scabs wereremoved from the wound. At night the child slept comfortably.llth.-He sits up, and talks a little in a whispering voice.

Pulse 148. Ate an egg for dinner. Mucus is dischargedthrough the wound.On the 13th and 14th he continued to improve. When we

saw him on the 15th he was looking perfectly comfortable,full of fun, and evidently not suffering any inconvenience fromthe hole in his trachea, through which air now only passedduring forcible expiration. A few days afterwards he wasquite well.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

APRIL 23RD, 1867.

MR. SAMUEL SOLLY, F.R.S., PRESIDENT.

ON THE PATHOLOGY AND TREATMENT OF CHOLERA.

BY GEO. JOHNSON, M.D.,PHYSICIAN TO KING’S COLLEGE HOSPITAL.

THE subject was brought before the Society in the hope thata full discussion might establish an agreement as to the natureof cholera and the principle of treatment. The chief conclu-sions of the author were given, and comment and criticismwere invited.

1. The phenomena of cholera result from the operation of amorbid poison. This proposition is very generally admitted.

2. The poison is often swallowed, and enters the systemthrough the alimentary canal ; water is frequently the vehicleof the poison.

3. The poison is sometimes tahen in with the air throughthe lungs.

4. In whatever way the poison is received into the system,whether through the lungs or through the alimentary canal, itenters the circulation before it gives rice to its characteristiceffects- This is merely the statement of a general law appli-

cable to all poisons. To deny this proposition is to assert thatin the case of the cholera poison a general law of physiology issuspended.

5. The symptoms of invasion which have often been ob-served are 1)2,o tauto evidence of blood-contamination.

6. What is the pathology of cholera collapse ? In whatrespects does it differ from other forms of collapse ? The chief forms of collapse, not choleraic, are these : 1st.

Collapse from hæmorrhage or from excessive purging. 2nd.From nervous shock-e. g., mechanical injury, the pain of per-forating ulcer of the stomach, &c. 3rd. From such poisons astobacco, digitalis, or antimony. One condition is common toall forms of collapse—there is a defect of moring blood. In casesof haemorrhage and profuse purging there is an absolute de-ficiency of blood in the vessels ; in cases of nervous shock andof poisoning by tobacco, &c., the circulation fails because theheart is weakened. In cholera collapse the blood is arrestedin the minute arteries of the lungs. The proofs of this arrestare partly anatomical, partly the harmony of the symptomsduring life with the post-mortem appearances, and partly theresults of various modes of treatment (venesection, injectionsinto the veins, alcoholic stimulants, &c.), of certain accidentsoccurring in the human subject (embolism of the pulmonaryartery and the admission of atmospheric air into the veins), andcertain experiments on animals. It is probable that blood con-taminated by the cholera poison is arrested by the contractionof the minute branches of the pulmonary artery, just as bloodmixed with a large quantity of atmospheric air is arrested, andas the blood is arrested in the lungs of a dog when a salt ofsoda has been injected into the veins.

The discharges from the alimentary canal are the means bywhich the poison and its products are thrown out of the system.The discharges always continue during recovery from collapse,a proof that they cannot be the cause of collapse. In the worstcases of fatal collapse there is rather an inverse than a directrelation between the degree of collapse and the amount of thedischarges.The suppression of bile and urine, and the diminished exha-

lation of carbonic acid during collapse, are explained by thedefective oxidation consequent on the impeded pulmonary cir-culation. When reaction occurs there is an abundant forma-tion of carbonic acid, bile, and urine, and these products ofoxidation, if not freely excreted, may then accumulate in theblood, oppress the nervous system, and thus induce a state ofconsecutive fever scarcely less perilous than collapse.

The principles of treatment.-Patients have recovered fromcholera in all its stages under the most varied and oppositemodes of treatment, and without any treatment. It is there-fore obvious that there is a natural process of cure. An im-partial inquiry seems to show that those methods of treatmenthave been most successful which have interfered least with thenatural progress of the disease. A routine opiate and repressiveplan of treatment is believed to be injurious in all stages. Ofcholera it may be said, as of many other acute diseases, thatfor the cure of most cases that are curable by any means, thevis medicatrix naturce will suffice. Yet there are few cases inwhich we cannot render some assistance, and not a few inwhich, by a discreet co-operation with Nature, we may turnthe scale, and save a life, which without aid would be lost.

If we can agree upon a principle of treatment we may greatlyhelp each other in working out the details.ON THE TREATMENT OF CHOLERA AND EPIDEMIC DIARRHŒA

WITH A RECORD OF CASES.

BY J. WILSON M’CLOY, M.D.,LATE RESIDENT MEDICAL OFFICER, LIVERPOOL PARISH INFIRMARY;

AND

ROBERT ROBERTSON, M.D.,SENIOR RESIDENT MEDICAL OFFICER, LIVERPOOL PARISH INFIRMARY.

i In this paper the authors commence by expressing their beliefi that the theory that the essential phenomena of cholera arereferable to a drain of fluid from the blood has of late receiveda rude shock. It has been shown to be inconsistent with manyof the acknowledged facts of the disease. Another hypothesisattributes the collapse of cholera to a totally different cause.To determine which is right, we must bring both hypothesesface to face with the disease, and ascertain which of them em-

! bracers the greater number of its facts and explains the moreextensive range of its phenomena. During the recent epidemicthe authors had unusual opportunities of observing the diseasein all its phases. Their experience they give to the professionin the hope that it will lead to the establishment of a morerational mode of treatment. Believing that mere statistics areuseless, they have given the particulars of a considerable num.


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