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(130 per minute), and every other symptom of this disease, inits worst form. He was vomited freely for two days in succes-sion, during which he was somewhat purged by the ipecacuanhaalso. On the third day after his admission, his pulse, whichhad dropped steadily, had fallen to 72 per minute. On thefifth day, his tongue peeled. The half diet and diaphoreticshe has hitherto taken were now exchanged for full diet andquinine. To-morrow, the twelfth day from his admission, andthe fifteenth of his fever, he goes out, I think we may say, cured- - certainly recovered.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

ST. GEORGE’S HOSPITAL.

TWO CASES OF ŒDEMA OF THE GLOTTIS; TRACHEOTOMY;FATAL RESULT IN EACH CASE.

(Under the care of Dr. PITMAN and Dr. PAGE.)

WHEN dropsy of the glottis occurs as an idiopathic affection,the danger to life is often in the highest degree imminent; forif this form of inflammatory disease is not at once recognised,the patient may be destroyed in a few hours. In manylaryngeal affections that terminate fatally, the aperture of theglottis is found to be nearly closed by oedematous infiltrationof its lips, this condition being the final result, as it were, ofthe exploding violence of the disease.

Acute inflammation of the larynx is divisible into two forms:one, the acute catarrhal laryngitis, affecting chiefly the mucousmembrane of the larynx; the other, oedema, of the glottis,involving the submucous areolar tissue. This division is thatof Cruveilhier, and is simple, clear, and readily understood; ithas been adopted by Ryland, and more recently by Dr. Gibb,in his work on the Throat and Windpipe. The term " acutecatarrhal laryngitis" serves to distinguish the first form fromany other disease of the larynx, and in it all the active

symptoms of inflammation are present, accompanied by theirusual and well-known phenomena. On the other hand, inoedema of the glottis they are absent. And, as every phy-sician is aware, the line of treatment to be adopted mustnecessarily be exactly the reverse of that employed in the firstor severely acute form of inflammation; for instead of usingany depletory measures at the beginning, they must be of asupporting kind throughout.The symptoms, then, of oedema of the glottis are different

from those of acute inflammation. The great feature in theformer is the extreme dyspnoea, which continues to increase,with a hissing inspiration, and all the appearances indicatingimpending strangulation. There is no difficulty in swallowing,as in acute laryngitis, unless the epiglottis is also involved, noris there any external pain, but a feeling of constriction, withan increasing impediment to the act of inspiration. There isan absence of fever and other symptoms of laryngitis, andgenerally no inflammation of the fauces. The patient under-goes frequent spasmodic attacks of painfully suffocative breath-ing.

In the main, these were present in the two following cases,and we believe also in a third patient in the same hospital;but notwithstanding the treatment pursued, and the resort totracheotomy, the vital powers were so prostrated that a fataltermination was the result in each case. After death, nothingwas found beyond oedema of the glottis and the partsaround.We would here draw attention to a mode of treatment worthy

of more consideration than has been accorded to it-one that:promises speedy relief, and for which the profession are in-debted to Lisfranc. It consists in making small punctures inthe cedematous parts, to let out the fluid. When the fingercan be readily introduced into the mouth, the lips of the glottiscan be felt as two tense, smooth, and rounded tumours, justbehind the epiglottis; they cannot always, however, be reached.This plan of treatment was practised successfully by Mr. Busk,at the Dreadnought Hospital-ship, in instances of sailors thusaffected. Great relief was experienced by numerous punctureswith a sharp-pointed bistoury at the back of the tongue, theuvula, and the pharynx, repeated every two or three hours.The relief was found to be sudden and decisive, and muchserum was got rid of, its expulsion being promoted by gargleaof warm water. Here, then, was a cure effected without open-ing the windpipe.

It has been questioned by some pathologists whether the-form of oedema of the glottis which we to-day illustrate bythree examples is a real inflammation, from there being simplyan effusion of serous fluid. It is probably a low inflammatoryprocess, equally as active and rapid in its influence upon the-nervous system as the acute form, and therefore of great im-portance to recognise early. In certain cases, when death is-slow, pus or sero-purulent fluid is poured out in the submucousareolar tissue, and this latter can be sometimes drawn out inshreds. In other examples, where death has been speedy,serum alone has been found.

In the first of the following cases, death occurred in thirty-two hours, and in the second in seventeen hours, from thecommencement of the attack. For the notes of both cases weare indebted to Dr. Dickinson, Medical Registrar to thehospital.Austin G-, aged fifty-one, admitted Sept. 16th, 1859,

under the care of Dr. Pitman. Except an attack of syphilissome years ago, this man was said to have had good healthuntil four o’clock in the morning of the day of admission, whenhe awoke with extreme difficulty of breathing. He was broughtto the hospital at noon; he was then breathing with visibledistress and muscular effort, and with a loud hissing sound.His face and lips were pallid, and he was covered with coldperspiration. The pulse was very small and rapid. An emeticwas at once given, but no relief followed its action. Mr. Pres-cott Hewett, who was in the house, saw him immediately, andproceeded to cut down upon the cricoid cartilage, which waswith difficulty severed ; apparently it had become ossified.The incision was extended downwards through a few of theupper rings of the trachea, and a free opening made. A tubewas then introduced, through which he breathed freely. He

appeared to be much relieved by the operation, and expressedhimself to that effect. An hour afterwards, he was seen

to be breathing well through the tube, and partially throughthe nostrils. He pointed to the upper part of the larynx asthe seat of some uneasiness. The pulse was then 120, soft andfull, but not quite regular. When seen by the physician, hewas ordered to take, in the form of a pill, half a grain of opiumand three grains of calomel every two hours; twelve ounces ofwine were also allowed. This he swallowed with difficulty,some of it being ejected through the tube whilst coughing. Onthe following morning he was asleep, breathing deeply andregularly through the opening. As he had had a sleeplessnight, it was not thought right to disturb him. After this, hebecame more pallid, the finger-nails turned blue, and at noonhe expired, without any apparent dyspnoea.Examination twenty-one hours after death.-The body was in

good condition. There was an incision in the middle line ofthe neck, which had divided the crico-thyroid membrane andcricoid cartilage. The breadth of the neck at the upper partwas considerably increased. The muscles were brawny andinfiltrated with lymph, and the glands were somewhat en-larged. On examining the pharynx, the velum palati was foundto be thickened from effusion. All the parts were muchthickened in a similar manner down to the upper margins ofthe glottis. This thickening was more especially marked inthe right aryteno-epiglottidean fold. The glottis itself wasalso somewhat thickened, but no cedema existed below thetrue vocal cord, nor was there any distinct evidence of inflam-mation, or even congestion. The cartilages of the larynx wereossified. There were old pleural adhesions in both sides of thechest. The lungs and heart were healthy. The left kidneycontained a large mass of strumous deposit. The ureter andpelvis of the kidney on the right side were much dilated. Thecause of this was at first obscure, but afterwards, on minuteinspection of the mucous membrane of the bladder, a smallmucous polypus was found close to the orifice of the right

393

ureter, which in some positions exactly closed it, and had, no Idoubt, obstructed the flow of urine down it.Peter C-, aged twenty-five, admitted on Nov. 26th,

1859, under the care of Dr. Page. He worked at a baker’s.On the evening before admission he said he had gone to bedperfectly well; he awoke about one o’clock in the morningwith pain in his throat. At three he arose, as was his custom,and worked till six. At that time he was suffering greatlyfrom dyspncea. This continued until half-past nine, when hewas brought to the hospital. He was blue, struggling forbreath, and apparently at the point of death. Mr. Hammertonat once gave an emetic-dose of tartarized antimony, and bledhim to the extent of eighteen ounces. The emetic acted well,and the bleeding very greatly relieved him. He then had twograins of calomel every four hours. When he was seen atnoon, he way lying quietly, with a pale face, free from duski-ness, and with ruddy lips. The breathing was free from dis- tress-32 in the minute; the pulse 104, soft. He still com-

plained of pains about the larynx. The voice was low, butnot obviously unnatural in tone. The blood was neither cuppednor buffed. He was now seen by the physician, and laryn-gotomy was suggested; but, on consultation, it was consideredthat the case was not sufficiently urgent to warrant the ope-ration. He was visited in the evening by the physician, whofound him tranquil and easy, with no sign of venous blood inthe colour of the face or lips, a good pulse, and apparently ina promising state. He had a short time previously had a shortspasmodic attack of dyspnoea. About ten minutes after this,just after having expressed himself better, and got out of bedwithout help, he was suddenly seized with extreme shortnessof breath, turning blue, and struggling for air. The house-surgeon was in the hospital at the time, and the trachea wasopened as soon as possible, and before the pulse ceased; but henever breathed afterwards.Examination twenty hours after death.-The body was in

good condition. There was the mark of venesection on theright arm, and the blood being very fluid a large quantity hadrun out of the wound (which was quite recent) after death.The fauces and pharynx were quite healthy. There was verygreat oedema of the aryteno-epiglottidean folds, and of thewhole cellular tissue, as low down as the true vocal cords.The edges of the ventricle of the larynx were brought intoclose apposition by the swelling, and mucous fluid, of a milkyappearance, exuded from the sacculus on pressure. Below thetrue vocal cords there was no effusion whatever; but the mu.cous membrane was somewhat reddened. There was an in-cision into the upper part of the trachea, just above the rightlobe of the thyroid body, which would easily admit the passageof the index-finger. There were pleural adhesions of the rightside of the chest. All the viscera were healthy.

ST. BARTHOLOMEW’S HOSPITAL.

ŒDEMA OF THE GLOTTIS, SUDDENLY SUPERVENING IN

THE HOSPITAL, IN A CASE OF JAUNDICE FROMOBSTRUCTION IN THE HEPATIC DUCT.

(Under the care of Dr. FARRE.)IN addition to the two cases of dropsy of the glottis which we

noticed in St. George’s Hospital, the preparations of which wealso had the opportunity of examining in the museum, throughthe kindness of Mr. T. Holmes, the curator, another strikingexample came under our observation at St. Bartholomew’s, ofwhich the following is a very brief outline :-Thomas C-, aged forty, was admitted October 1st, 1859,

with icterus of five weeks’ standing. He had all the usual

symptoms consequent upon this: clay-coloured stools; sick-ness ; skin of a universal deep-yellow tinge, which extended tothe conjunetivse. He was submitted to mercurial and othertreatment with but partial benefit, after which ox-gall wasgiven with decided advantage for a time, and then discon-tinued. The mercurial treatment was abandoned on accountof the debility which it produced. On the 28th of Novemberhe was ordered gentle applications of electro-galvanism trans-mitted through the liver, with good results; and the skin didnot seem so dark in colour. His improvement, however, wasbut slight. An examination of the liver did not disclose anyenlargement, nor were there any symptoms of gall-stones, nor,in fact, any positive indication of the precise seat of biliaryobstruction.

Early in December, whilst sitting up in the ward, he was

suddenly seized with extreme dyspncea and hissing inspiration,and the symptoms were so urgent that tracheotomy was per-formed ; but death ensued within a few hours after the com-mencement of the attack, which a post-mortem examinationrevealed to have depended upon cedema of the glottis. Thejaundice was at the same time found to have originated in ob-struction of the hepatic duct from extension of inflammation tothe substance of the liver in its neighbourhood; and althoughthe hepatic ducts were dilated, no bile was found in them.

KING’S COLLEGE HOSPITAL.

WARTY GROWTHS IN THE LARYNX, THREATENING SUFFO-

CATION, IN A PREGNANT WOMAN ; TRACHEOTOMY ; DEATHIN FOURTEEN HOURS ; INEFFECTUAL LABOUR IN THEINTERVAL ; POST-MORTEM CÆSARIOTOMY.

.

(Under the care of Dr. BUDD.)OF the many remarkable and rare cases which have appeared

in the "Mirror" for many years past, but one only has pre-sented peculiarities in any way similar to the case recordedbelow. The instance to which we allude was that of a

female admitted into St. George’s Hospital, under Mr.Pollock’s care, for syphilitic laryngitis. Tracheotomy wasperformed, labour afterwards set in, and she was delivered of a.living child whilst wearing the tube, and made a good reco-very, (THE LANCET, vol. ii., 1856, p. 48.) The patient whosecase is here detailed (through the kindness of Dr. E. S. Thomp-son, house-physician to the hospital) was a woman at the full termof pregnancy, who had been subject to warty growths in thelarynx for some months, but which were not detected duringlife. After being in the hospital for a few days, the dyspnoea wasso urgent that tracheotomy was performed by Mr. Mason, thehouse-surgeon, with relief for the moment. The pains of labourset in, and every effort was made to effect a speedy delivery,but in vain, and she died fourteen hours after the windpipe hadbeen opened. Csesariotomy was now resorted to by Dr. San-som, the physician-accouchenr’s assistant, and the child re-moved from its matrix, but all efforts at resuscitation were un-availing. Thus both mother and child were lost. The preg-nancy was a painful coincidence, as in Mr. Pollock’s case ; butits end was not so fortunate. We record the case in our seriesof laryngeal affections, as it happens to be one of a rare kind,depending upon growths from the mucous membrane of the in-terior of the larynx. Our space on the present occasion pre-vents our going more into the subject than to observe that it ispossible that a diagnosis of their presence might have beenmade at a period when the symptoms were not so urgent, andwhen an operation would have held out better prospectsof success.A florid-looking woman, thirty years of age, married, and

nine months pregnant, was admitted into the above hospital,under the care of Dr. Budd, on the 10th of March, 1860. Shestated that she had always been healthy, had had four chil-dren and two miscarriages, and had been subject to occasionalsore-throat. She first observed an alteration in her voice inJuly, 1859; and on admission she could not speak above awhisper. Her breathing was attended with a loud stridulousnoise. There was an occasional feeling of suffocation, but nodifficulty in swallowing. She had a slight cough, with muco-purulent expectoration, which microscopical examination provedto contain lung tissue. Her face was dusky, lips blue, respira-tion hurried, and the breathing over both lungs feeble. Therewas some dulness at the apices, with harsh breathing andgurgling crepitus. There was no tenderness over the larynxexternally. On introducing the finger into the fauces, the

epiglottis felt somewhat thickened, and the vocal cords tumidand cushiony.A solution of nitrate of silver, half a drachm to an ounce of

water, was freely applied to the vocal cords, and iodide ofpotassium prescribed, with some temporary relief. On theevening of the 16th of March, however, the breathing becamemuch more difficult. Various antispasmodics and counter-irritants were tried, and local depletion, but without success;and towards morning the lividity of countenance and dyspnceabecame so great that a fatal termination was anticipated; shegrew rapidly unconscious, and it was evident that she couldnot live many minutes.Tracheotomy was performed without difficulty by 3,lr.