99 through the tracheotomy tube, and his pulse (not accurately timed) seemed to be about 60. The contents of the rectum and bladder had not been discharged whilst he lay insensible. Quarter to eleven P.M.: Reaction complete ; pulse 74, and respiration natural; skin warm. Since the former report he had vomited a little on two occasions. There was pain at the fauces and in the tracheotomy wound. He had much thirst, which he attempted to relieve by moistening his mouth with cold water. Could not swallow. Ordered enemata containing (each) half a pint of beef-tea and two ounces of brandy, and thickened with starch, which are to be administered every six hours. Nov. 21st (second day).-Quarter to twelve A.M. : Had slept very little; had not vomited. Had passed urine once in the night; but the specimen was thrown away, Had slight pain at the pit of the stomach. Moistened his mouth with milk- and-water, but was unable to swallow. Pulse 92; respira- tion 20, regular; temperature 100’2°. Quarter past four p. M.: Pulse 85; respiration 27, easy; tem- perature 100°. He complained much of thirst. Quarter past eight P.M. : Pulse 88, soft and regular; respi- ration 22, perfectly easy; temperature 100.9°. His skin was perspiring freely. He was thirsty; could swallow a little fluid. Salivation was considerable. No vomiting since the previous night. Bowels not opened; he had had five of the above.described nutrient enemata, all of which had been re- tained. Had not passed urine during the day. With the stethoscope, the sounds of both lungs (anteriorly) and the sounds of the heart were found to be quite natural. He had no pain in his abdomen, and no uneasiness at the pit of the stomach on deep pressure. 22nd (third day).-Ten A.M. : Pulse 72; respiration 24; temperature 100’50. Had a troublesome cough, which dis- turbed him in the night. Urine high-coloured, clear, acid, without albumen or sugar; sp. gr. 1028’5. Half-past eight P.M.: Pulse 72; respiration 25; tempera- ture 101’2°. The tube had been taken out of his trachea at six P.M. He was now breathing very comfortably without it through the wound and by the mouth. 23rd (fourth day).-Half-past ten A.M.: Pulse 65; respi- ration 23; temperature 100°. He was breathing freely, and could swallow solid food without any difficulty. Half-past eight P.M.: Pulse 72; respiration 24; tempera- ture 101-2°. 24th (fifth day).-Half-past eight P.M. : Pulse 72, stronger; respiration 22; temperature 98 ’5°. Progressing favourably. 26th (seventh day).—Nine A.M. : Pulse 62; respiration 23; temperature 99°. 27th (eighth day).-Nine A.M.: Pulse 64; respiration 30; temperature 99 2°. 28th (ninth day).-Quarter past nine A.M.: Pulse 72; respi- ration 26; temperature 97 .4°. He was sitting up, dressed, having washed himself. Ate some meat yesterday. 30th (elventh day).-Pulse 72; respiration 19; temperature 97°. Ate a mutton chop without any pain, but had not much appetite. Dec. 6th (seventeenth day).-Appetite was improving; he still felt weak. Pulse was natural; bowels regular ; and tongue healthy. A small opening remained in the trachea, through which he partly breathed. 12th (twenty-third day).-Left the hospital, well. The wound in the trachea had apparently quite healed, for when he closed his mouth and nose, and attempted forcible expira- tion, no air at all escaped. The wound of the skin was almost healed. The colourless fluid in the bottle was examined by Dr. Stevenson, who found it to contain simply 33 per cent. of an- hydrous acetic acid (equivalent to 39 per cent. of monohydrated acid). It was a little stronger, therefore, than the acidum aceticum (P. B.), which contains 28 per cent. of anhydrous acid. Of this the patient took probably from two to three fluid ounces. The evidence which was collected upon this point from himself and his father and wife was so consistent as to place the matter beyond doubt. He himself knew the quantity contained in the bottle on the day previous, whilst his father and mother witnessed the suicidal act. The following is an abstract of the foregoing lengthy case. Within the first hour the symptoms were slight collapse and laryngeal obstruction, which was so severe as to lead to cessa- tion of respiration, but was at once relieved by tracheotomy. The lips and tongue were not at all charred or interned. Some six hours subsequently reaction was complete ; there was in- ability to swallow, with great thirst ;. On the following day the patient could swallow liquids, but had pain at the fauces, and considerable salivation. On the third day the tracheotomy tube was taken out without any subsequent impediment to . respiration. No symptoms of gastric, pulmonary, or cardiac L disturbance arose. Indeed, divesting the case of the laryngeal J complication (which, perhaps, would not have arisen had the man been sober when swallowing the acid), we find the symp- , toms were simply slight collapse, an inability to swallow L during one day, and thirst and salivation ; but it must be ; borne in mind that the result was in all likelihood modified by L the early administration of the magnesian antidote. ST. GEORGE’S HOSPITAL. DISEASE OF THE HEART; FIBROUS DEGENERATION OF THE LUNGS. (Under the care of Dr. OGLE.) FoR the following characteristic example of a not very com. mon condition we are indebted to Dr. Reginald Thompson, medical registrar to the hospital. , John L aged thirty-six, was admitted on the 27th of April, with the following history. He had been a photo- grapber, and had suffered from an attack of rheumatism seven years before admission, the attack lasting six weeks. In the last two years he had been unable to exert himself much on account of the palpitation and dyspnœa, which ensued after exercise. For four months he had suffered from cough, and had once spat blood. These symptoms were followed by cedema of the legs. On admission he was suffering from much dyspnoea and orthopncea, oadema of the legs and hands, and considerable cyanosis, the veins of the neck and forehead being very much distended. He had a good deal of cough, the expectorate. matter being viscid and discoloured. There was a mark of an old scrofulous abscess in the neck. Dull percussion was found at the apices of the lungs, most marked at the upper quarter of the left lung, with creaking breathing and increased vocal resonance. No evidence of tubercle was discovered. There were the usual symptoms of effusion at the base of the left lung behind. A well-marked but soft-blowing murmur was heard over the heart, and continued downwards and to the right of the apex; the area of percussion was larger than natural at this side of the heart. A murmur was also heard below the left nipple; both murmurs accompanying both sounds of the heart. The pulse was intermittent, small, and fluttering. The urine full of lithates, and albuminous. Temporary relief to these symptoms resulted from acupunc- ture on the 6th of May, but the symptoms of effusion even- tually increased, and he died on the 12th of the same month. The following notes of the condition of the body at the autopsy, twenty hours after death, are due to Mr. T. Pick :- A quantity of fluid was found in the left pleural cavity. The lungs were extremely lobulated on the surface, the lohulation being due to a prolongation of fibrous tissue ; and on section the lung was found to be intersected in every direction by dense bands of fibrous tissue, which made the lung hard and difficult to cut; between the bands there was considerable emphysema, and hence the lobulated appearance. There was a quantity of fluid in the pericardium. The right side of the heart was much dilated, and contained a deculorised clot. The mitral valve was thickened, and the tricuspid also. though to a less extent. The weight of the heart was thirteen ounces and a half. There was slight atheroma of the aorta. The liver was much congested, and was in an early stage of cirrhosis. The spleen firm and hard, the trabeculas well marked, and the capsule thick. The kidneys were large and much congested ; they were coarse in structure, and the Malpighian bodies were very prominent. The tubules were found distended. Other organs natural. Provincial Hospital Reports. NEWCASTLE-ON-TYNE INFIRMARY. WE publish a few facts of interest from the house-surgeon’s (Dr. Bolton’s) report of this important infirmary for the year ending March 31st, 1867. The number of patients admitted in the year was 4170; of which 357, or more than one-eleventh of the whole, were venereal; of these, 238 were female Lock cases.
Transcript
99
through the tracheotomy tube, and his pulse (not accuratelytimed) seemed to be about 60. The contents of the rectumand bladder had not been discharged whilst he lay insensible.
Quarter to eleven P.M.: Reaction complete ; pulse 74, andrespiration natural; skin warm. Since the former report hehad vomited a little on two occasions. There was pain at thefauces and in the tracheotomy wound. He had much thirst,which he attempted to relieve by moistening his mouth withcold water. Could not swallow. Ordered enemata containing(each) half a pint of beef-tea and two ounces of brandy, andthickened with starch, which are to be administered every sixhours.Nov. 21st (second day).-Quarter to twelve A.M. : Had slept
very little; had not vomited. Had passed urine once in thenight; but the specimen was thrown away, Had slight painat the pit of the stomach. Moistened his mouth with milk-and-water, but was unable to swallow. Pulse 92; respira-tion 20, regular; temperature 100’2°.
Quarter past four p. M.: Pulse 85; respiration 27, easy; tem-perature 100°. He complained much of thirst.
Quarter past eight P.M. : Pulse 88, soft and regular; respi-ration 22, perfectly easy; temperature 100.9°. His skin wasperspiring freely. He was thirsty; could swallow a littlefluid. Salivation was considerable. No vomiting since theprevious night. Bowels not opened; he had had five of theabove.described nutrient enemata, all of which had been re-tained. Had not passed urine during the day. With thestethoscope, the sounds of both lungs (anteriorly) and thesounds of the heart were found to be quite natural. He hadno pain in his abdomen, and no uneasiness at the pit of thestomach on deep pressure.22nd (third day).-Ten A.M. : Pulse 72; respiration 24;
temperature 100’50. Had a troublesome cough, which dis-turbed him in the night. Urine high-coloured, clear, acid,without albumen or sugar; sp. gr. 1028’5.
Half-past eight P.M.: Pulse 72; respiration 25; tempera-ture 101’2°. The tube had been taken out of his trachea atsix P.M. He was now breathing very comfortably without itthrough the wound and by the mouth.23rd (fourth day).-Half-past ten A.M.: Pulse 65; respi-
ration 23; temperature 100°. He was breathing freely, andcould swallow solid food without any difficulty.
temperature 99 2°.28th (ninth day).-Quarter past nine A.M.: Pulse 72; respi-
ration 26; temperature 97 .4°. He was sitting up, dressed,having washed himself. Ate some meat yesterday.
30th (elventh day).-Pulse 72; respiration 19; temperature97°. Ate a mutton chop without any pain, but had not muchappetite.
Dec. 6th (seventeenth day).-Appetite was improving; hestill felt weak. Pulse was natural; bowels regular ; andtongue healthy. A small opening remained in the trachea,through which he partly breathed.
12th (twenty-third day).-Left the hospital, well. Thewound in the trachea had apparently quite healed, for whenhe closed his mouth and nose, and attempted forcible expira-tion, no air at all escaped. The wound of the skin was almosthealed.The colourless fluid in the bottle was examined by Dr.
Stevenson, who found it to contain simply 33 per cent. of an-hydrous acetic acid (equivalent to 39 per cent. of monohydratedacid). It was a little stronger, therefore, than the acidumaceticum (P. B.), which contains 28 per cent. of anhydrousacid. Of this the patient took probably from two to threefluid ounces. The evidence which was collected upon thispoint from himself and his father and wife was so consistentas to place the matter beyond doubt. He himself knew thequantity contained in the bottle on the day previous, whilsthis father and mother witnessed the suicidal act.The following is an abstract of the foregoing lengthy case.
Within the first hour the symptoms were slight collapse andlaryngeal obstruction, which was so severe as to lead to cessa-tion of respiration, but was at once relieved by tracheotomy.The lips and tongue were not at all charred or interned. Somesix hours subsequently reaction was complete ; there was in-ability to swallow, with great thirst ;. On the following daythe patient could swallow liquids, but had pain at the fauces,
and considerable salivation. On the third day the tracheotomytube was taken out without any subsequent impediment to
. respiration. No symptoms of gastric, pulmonary, or cardiacL disturbance arose. Indeed, divesting the case of the laryngealJ complication (which, perhaps, would not have arisen had theman been sober when swallowing the acid), we find the symp-
, toms were simply slight collapse, an inability to swallowL during one day, and thirst and salivation ; but it must be
; borne in mind that the result was in all likelihood modified byL the early administration of the magnesian antidote.
ST. GEORGE’S HOSPITAL.DISEASE OF THE HEART; FIBROUS DEGENERATION OF
THE LUNGS.
(Under the care of Dr. OGLE.)FoR the following characteristic example of a not very com.
mon condition we are indebted to Dr. Reginald Thompson,medical registrar to the hospital. ,
John L aged thirty-six, was admitted on the 27th ofApril, with the following history. He had been a photo-grapber, and had suffered from an attack of rheumatism sevenyears before admission, the attack lasting six weeks. In thelast two years he had been unable to exert himself much onaccount of the palpitation and dyspnœa, which ensued afterexercise. For four months he had suffered from cough, andhad once spat blood. These symptoms were followed bycedema of the legs.On admission he was suffering from much dyspnoea and
orthopncea, oadema of the legs and hands, and considerablecyanosis, the veins of the neck and forehead being very muchdistended. He had a good deal of cough, the expectorate.matter being viscid and discoloured. There was a mark of anold scrofulous abscess in the neck. Dull percussion was foundat the apices of the lungs, most marked at the upper quarterof the left lung, with creaking breathing and increased vocalresonance. No evidence of tubercle was discovered. Therewere the usual symptoms of effusion at the base of the leftlung behind. A well-marked but soft-blowing murmur washeard over the heart, and continued downwards and to theright of the apex; the area of percussion was larger thannatural at this side of the heart. A murmur was also heardbelow the left nipple; both murmurs accompanying bothsounds of the heart. The pulse was intermittent, small, andfluttering. The urine full of lithates, and albuminous.Temporary relief to these symptoms resulted from acupunc-
ture on the 6th of May, but the symptoms of effusion even-tually increased, and he died on the 12th of the same month.The following notes of the condition of the body at the
autopsy, twenty hours after death, are due to Mr. T. Pick :-A quantity of fluid was found in the left pleural cavity. The
lungs were extremely lobulated on the surface, the lohulationbeing due to a prolongation of fibrous tissue ; and on section thelung was found to be intersected in every direction by densebands of fibrous tissue, which made the lung hard and difficultto cut; between the bands there was considerable emphysema,and hence the lobulated appearance. There was a quantity offluid in the pericardium. The right side of the heart wasmuch dilated, and contained a deculorised clot. The mitralvalve was thickened, and the tricuspid also. though to a lessextent. The weight of the heart was thirteen ounces and ahalf. There was slight atheroma of the aorta. The liver wasmuch congested, and was in an early stage of cirrhosis. The
spleen firm and hard, the trabeculas well marked, and thecapsule thick. The kidneys were large and much congested ;they were coarse in structure, and the Malpighian bodies werevery prominent. The tubules were found distended. Otherorgans natural.
Provincial Hospital Reports.NEWCASTLE-ON-TYNE INFIRMARY.WE publish a few facts of interest from the house-surgeon’s
(Dr. Bolton’s) report of this important infirmary for the yearending March 31st, 1867. The number of patients admittedin the year was 4170; of which 357, or more than one-eleventhof the whole, were venereal; of these, 238 were female Lockcases.
100
The subjoined particulars of the issue of grave surgical casesand operations go to show that the Newcastle Hospital is nohealthier than it should be, and that there is a large mortalityfrom pyæmia. Dr. Bolton associates the prevalence of pha-gedena and erysipelas with the long continuance of severe
weather; we presume from its tendency to overcrowd thewards.
Of the twenty-eight amputations, there were-of thigh forinjury 5 cases, of which 4 died ; thigh for disease, 5 cases, nodeaths ; leg for injury, 11 cases, 4 deaths ; leg for disease, 1
case, no death; arm for injury, 4 cases, 2 deaths ; arm fordisease, 1 case, no death; at wrist for injury, 1 case, 1 death.
sinking thifllt. Four deaths, as follows :—Male, aged twenty-five;sinking on admission from shock and loss of blood, and internallesions.
Male, aged sixteen; compound fracture of leg, collapsedfrom previous haemorrhage. It was deemed expedient to ’,operate without delay. Chloroform, when administered,seemed to act as a powerful stimulant at the time.
Male, aged thirty-eight; compound fracture of leg and thighthree hours previous to admission. Survived operation onemonth ; death from pytmia.
Male, aged forty-thr-ee ; crush of thigh; sank from pyæmiafive weeks after operation.The five amputations of thigh for disease were successful:
one girl, aged six, at hip-joint for osteo-sarcoma; four diseaseof knee-joint-males, aged seven, nine, and twenty-five ;female, aged twenty-six. Pyaemia supervened in two cases,but yielded to treatment.Of leg eleven cases. Four deaths, as follows :-Male, aged
compound fracture; pyæmia.Male, aged sixty-two; compound fracture of hand; ampu-
tation at wrist-joint ; gangrene of arm extending to shouldersupervened. Had been intemperate.
Male, aged forty-four ; compound fracture of arm; fractureof ribs and clavicle ; amputation at shoulder-joint. Death inforty-eight hours from shock, &c.
Amputation of the arm proved successful in a case of neu-roma of the left ulnar nerve; the patient, a machinist, agedtwenty-nine, had suffered excruciating pain for a period of tenmonths, which had resisted all remedial measures.The partial amputations of the foot include the operations
of Syme, Chopart, and Pirogoff, and were highly successful.The operation of ovariotomy issued very successfully. The
case was one of multilocular cyst ; and the patient recoveredrapidly without any bad symptom. Local anaesthesia duringthe first incision was perfectly obtained by the ether sprayfrom two instruments. In the after part of the operationchloroform was given, but not deeply. There was no vomitingor other inconvenient consequence from it. The patient wasoperated on and kept in a private ward, with a separate at-tendant. The temperature was carefully maintained at 60°.She took little of opium or other medicines.Owing to the long continuance of severe weather, erysipelas
and phagedena have prevailed more or less in the surgicalwards. Several cases of paralysis in old people, senile gan-grene, and frostbite were admitted. Of the latter two weresailors, who were deprived of the fingers of both hands fromexposure at sea.
Fractures of linalas treated as in-patients.—There were 142cases : of these, 94 were simple, attended with 4 deaths; 48were compound fractures, of which 21 were subjected to opera-tion, and the total deaths were 19.nf admissions as in-patients—491 were medical, with death-
Sixty-four deaths occurred in the medical cases, of which25 were from phthisis, 3 pleuro-pneumonia, 14 heart disease,2 aneurism of the aorta, 5 cancer of stomach, 7 disease of theliver, 3 of the kidney, 3 paralysis, 2 epilepsy.Twenty-four were amongst the surgical cases admitted by
letter. 11 scrofulous disease of spine, pelvis, thigh, and
ankle-joint, 5 cancer of the throat, mamma, rectum, &c.,6 disease of the bladder, 1 axillary aneurism, 1 harelip.
The last number of the ’’ Photographs of EminentMedical Men," by Dr. Tindal Itobertson and Mr. ErnestEdwards, contains admirable likenesses of Mr. Gay, Dr.iaa,nlcc;,tct’; F.R.S., and Mr. Griffin, J.P., ofWeymouth.
Medical Societies.OBSTETRICAL SOCIETY OF LONDON.
WEDNESDAY, JUNE 5TH, 1867.DR. HALL DAVIS, PRESIDENT.
CASES AND REMARKS ILLUSTRATING THE HISTORY OFPREGNANCY COMPLICATED WITH SMALL-POX.
BY ROBERT BARNES, M.D.,OBSTETRIC PHYSICIAN TO ST. THOMAS’S HOSPITAL, AND EXAMINER
IN 1rIDWIFERY AT THE ROYAL COLLEGE OF SURGEONS.
IN pursuance of a suggestion urged by the author to collectthe experience of the Society relative to the complication ofpregnancy with zymotic diseases, the present contribution wasmade. The histories of three cases were given. Amongst thequestions raised were these :-What is the influence of small.pox upon pregnancy? In the cases narrated, labour set inprematurely. In what way does small-pox excite labour?The children were born alive. The poison, therefore, does notalways act primarily upon the embryo. It is a law of verywide application that nature hardly tolerates the concurrentprogress of an active disease and pregnancy. In zymotic dis-ease, the poison, aggravated by the poison of impeded excretoryfunction, acts upon the whole system, increasing the irritabilityof the nervous system, impeding nutrition, including that ofthe uterus, and directly irritating this muscle. Blood chargedwith carbonic acid was proved by Marshall Hall and Brown-Séquard to be especially provocative of contraction in the in-voluntary muscles. The author had observed that pregnantwomen suffering from asphyxia, chronic or acute, were cer-tainly apt to abort. The blood in fever wants oxygenation, inthis respect resembling the blood in asphyxia. This is pro-bably the chief cause of premature labour. The author pointedto a difference between acute and chronic blood-poisoning. Inacute disease, where respiration is impeded and the blood israpidly poisoned, the first effect is upon the uterus. In chronic
poisoning, as in secondary syphilis, the embryo may be firstaffected : its nutrition is sapped, it perishes, and then uterinedevelopment being arrested, and involution commencing in aperiod varying from seven to twenty-one days, contraction setsin, and the dead fœtus is expelled. Premature labour mightalso be caused by the shock. To what extent is the life of themother endangered ? What is the influence of pure variola,as compared with that of modified variola ? The chief dangerprobably arises in the puerperal state. The mothers recoveredin the cases narrated. What is the influence upon the foetusas to infection ? The practical question was discussed whetherthe safety of mother and child be enhanced by inducing labour ? ‘:The author was disposed to answer this affirmatively, and con.sidered the best way was by the insertion of a flexible bougieinto the uterus.Mr. BENSON BAKER had had seven cases of pregnant women
under his care during the past winter who had taken small-pox and miscarried; they were all delivered of living children,but, with one exception, all the children died. None of thechildren had variola when born, but a modified or abortiveeruption came out within from three to eight days after birth.
! He could not but think that the effect of variola on the unim-
pregnated uterus might aid in elucidating some of the inter-esting and important suggestions of Dr. Barnes. He had
! observed cases in which amenorrhoea had existed for severalyears, and under the influence of variola an excessive men-
- strual flow had occurred; and others in which young girlsfrom ten years of age and upwards, who had never men-
- struated, had done so on the eruption of small-pox. And, lastly, he referred to other cases in which the catamenia had
been established by the variola, but in which the amenorrhœicI condition subsequently returned., Mr. STREETER, as a visitor, would avail himself of the pre-3 sident’s invitation to take part in the discussion, having long
taken an interest in this subject. He had himself read a paperupon it before the Westminster Medical Society nearly thirty
1 years ago, and in that paper, he believed, was contained the, earliest recorded case in this country of small-pox after vacci-
nation occurring with pregnancy. Referring for details of his* case to the printed record (THE LANCET, Nos. 751 and 757),the would only now state some of his conclusions, regrettingt that so little had been added to our knowledge of this compli-. cation since that time. One important point then shown was,that the child did not pass through the disease at the same
