56

lungs; the expiration is prolonged, and the heart’s actionis to be felt faintly just under the left nipple, but it is mostconspicuous at the scrobiculus cordis. There is a systolicbellows-sound just above the ensiform cartilage; very distinctwhen the patient holds his breath. No bruit de souffle isnoticed along the aorta or below the nipple, but it is dis-tinctly heard by the scrobiculus cordis, a little to the left ofthe last bone of the sternum. The veins of the neck areconsiderably dilated, and pulsations are communicated to agreat many of them. The patient passes about two pints of

- ttrine daily, of the specific gravity of 1017; and he states thathe never strained himself. ,

Dr. Todd ordered him to be bled to six ounces, and pre-scribed pills of calomel, squill, and digitalis, one grain of each,to be taken thrice a day; as well as half a drachm of compoundjalap powder, every other morning.

For the first few days the cough became worse and thedropsy increased, the scrot,um being particularly large. Thelatter was punctured on the fitth day; very little fluid cameaway, and the patient complained of much debility. On theninth day he fell into a drowsy state, and died on the 8th ofJune, ten days after admission.The body was examined fifty-six hours after death. It pre-

sented a remarkable degree of lividity, though well formedand well nourished; the blue tinge was, however, mostmarked about the face and neck, the ears, and the scrotum.The small superficial veins of the chest were highly congested,the integument and areolar tissue of the lower extremitieswere in a peculiarly dense, somewhat cedematous state; and inseveral places, particularly on the inner aspect of the thigh,were bullæ of various sizes. Upon opening the chest, the’pericardium was seen to be unusually large; and on slittingup the sac, its cavity was found to contain a small quantity ofa dar k-yellow serous fluid, and a heart of enormous size; thishypertrophy appearing to depend almost solely on enlarge-ment of the right side, which had so increased in bulk as toform, in great part, the apex of the organ. The left side,however, had also outgrown its normal dimensions. Onopening the right ventricle, its walls, and especially thecarnese column2e, were found considerably hypertrophied; theenlargement was, however, more of consistence than bulk, theitnuscular substance having a peculiar tough, leathery feel.The walls of the right auricle, with its musculi pectinati, werealso much enlarged. The tricuspid orifice was so spaciousas readily to admit four fingers ; but the valves themselvespresented no evidence of diseased structure, save that alongtheir attached borders they were somewhat thickened andbpaque.The left ventricle appeared healthy, its walls were much

softer to the feel than those of the right ventricle; and themitral valve exhibited indications of softening and opacitysimilar to that which had been observed on the right side.The left auricle, the pulmonary and aortic valves, and thegreat bloodvessels, appeared to be healthy, though the aortaseemed to be very small in proportion to the great size of theheart. The latter measured fifteen inches around its base,and it weighed, when deprived of its blood, twenty-one and ahalf ounces. The muscular fibres of the left ventricle, whenexamined under the microscope, presented a peculiar granularappearance, and the transverse striae were not so sharply de-fined as in the healthy condition; but it is very difficult tosay whether this was the result of disease or a post-mortemchange. A good deal of free oil was scattered over the field,but no fibre in a state of marked fatty degeneration could be

’ distinguished.In the right ventricle, on the other hand, many of the

fibrillm exhibited oil globules, which seemed to take the placebf the sarcous elements, so as to give the appearance of astring of oil beads; while in other instances the fibres pre-sented a granular appearance, without any distinct oil globules.Upon the addition of acetic acid, minute globules of oil be-came very distinct in almost every fibre, and by pressing thespecimen between the glasses, the whole field became coveredwith oil globules, mostly minute, the light centre with thedark edge being exceeding well defined in almost everyinstance. ,

The liver was of the normal size, but appeared to be in anincipient stage of cirrhosis, being somewhat tough and granularon section. Most of its cells exhibited under the microscopemore oil than they usually contain in the healthy state.The lungs were enormously congested, and poured forth,

when cut into, much bloody serum. Under the microscopeno change of structure could be detected in these organs,there being no hypertrophy nor apparently other morbid stateof the minute arteries, which were carefully examined.

The kidneys were very large, each weighing rather morethan seven ounces, and greatly congested; the lobular mark-ings on the surface were quite distinct, and the normal rela-tions between the cortical and medullary substances appearedto exist, on a section being made, though each was considerablylarger than in the healthy state. When examined micro-scopically, the tubes, with their epithelial lining, exhibitedthe healrhy characters, but the Malpighian bodies were greatlyenlarged, many being twice the size they are in the healthykidney; and their contained loops of capillaries being filledwith blood, were very distinct and prominent, so as to give arugged, bulging appearance to the Malpighian capsule. Thearteries of the kidneys seemed to be healthy, neither theirlongitudinal nor circular coat presenting any evidence ofhypertrophy.

It has not escaped our readers that the fatty degenerationwas almost as much advanced in the liver as in the heart, theintimate connexion between the two organs being as manifestin health as in disease.

ST. MARY’S HOSPITAL.

Sporadic Cholera; Death; Autopsy.(Under the care of Dr. CHAMBERS.)

THE ravages made in this country by the epidemic choleraat two different periods, have stamped the very name of thedisease with a character which inspires fear and dread. Butthis indiscriminate apprehension should not be allowed to

reign among the public, and people should be made to under-stand that the common English or sporadic cholera is verydifferent from the epidemic, spasmodic, or algide, variety.Indeed, it is a great pity that both diseases bear the samename, and it has very justly been remarked, that thesporadic or English cholera alone deserves the appellation, asthe dejections are always mixed with bile, and are principallyowing to the presence in the intestinal canal of a largequantity of the same secretion. According to some authorsthe latter circumstance forms the actual and almost onlydistinction between the Asiatic and English cholera. Thelatter affection, if we may judge from the registrar’s reports,has been pretty prevalent of late, and it has, in fact, beenfound that the summer and autumn are the seasons duringwhich the disease is most likely to break out sporadically; itneed hardly be mentioned that it may reign epidemically withthe same mitigated form noticed in sporadic cases. We arehappy to say that such an epidemic does not exist at thepresent time, but it would appear, both from the registrar’saccount, and from what we have ourselves seen, that verysevere cases, quickly followed by coma and death, are, at thepresent time, occurring pretty frequently. Those who seemany of these sporadic cases must certainly be struck by thefact that the more severe the symptoms the more the diseaseresembles the Asiatic variety; cramps, vomiting, coldness,and blueness of skin, are then all present, but the alvineevacuations, though very abundant, do not become so com-pletely like rice water, as is almost always the case in theepidemic cholera. In illustration of this fact, we beg toadduce the following case, the notes of which were kindlyfurnished by Mr. Trotter, one of the resident medical officersof the hospital.

F. B-, a stableman, was admitted May 25, 1853, underthe care of Dr. Chambers. The patient’s countenance wasanxious, his complexion sallow, and he appeared muchdebilitated. It was stated that he had been in his usualhealth up to two days before he was brought to the hospital,when he was attacked with violent retching; some improve-ment subsequently took place, but the man felt unable toattend to his work. On the morning of admission theretching returned, and this symptom was this time accom-panied by cramps in the limbs and violent purging.The man was placed into a warm bed, and small and

frequent doses of calomel and opium were given. Early onthe next morning the cramps became more violent, beingpresent both in the limbs and abdomen; the surface of thebody was cold, the pulse small but regular, and the featurespinched. The purging continued, and the matters voidedwere becoming of a lighter colour, and more aqueous thanthey had been; the sickness increased, and the thirst wasvery intense. Towards the evening the surface becamecolder, and the hands and arms, though covered by the bed-clothes, were quite blue. The patient continued very rest-less, and, during the following night suffered much fromcramp, more particularly in the arms. The blue tinge of theextremities became deeper, and the purging continued, but

57

the sickness somewhat abated. At one o’clock in the morning’of the second day the poor man had some sleep, but he soonawoke complaining bitterly of thirst and cramps, and diedexhausted at five o’clock A.M., on the second day afteradmission.The treatment consisted principally of small and frequent

doses of calomel and opium, enemata of the latter drug, andvapour baths. The patient had also strong beef-tea, wine,and ice, to quench the intense thirst. The autopsy revealedno abnormal condition of parts, except old standing emphy-sema of the lungs. ____

GUY’S HOSPITAL.

Syphilitic Ulceration of the Fauces and Larynx; ImpendingSuffocation; Tracheotomy; Re-admission of the Patient afterhaving worn the Canula for Six Years.

(Under the care of Mr. HILTON.)OUR attention was lately directed to a most interesting

case, illustrating the advantages and ulterior effects of trache-otomy, and the ease with which a canula can be worn for agreat number of years. No doubt but the opening of thetrachea is a proceeding of some importance, which should notbe lightly undertaken; but this operation, when performedafter mature consideration, is a most admirable achievementof surgery; for it may save life by facilitating the admissionof air into the lungs, when the natural passage is closed upby disease; and may become still more valuable when thelarynx is permanently closed, by affording the patient, whowears the canula, an artificial larynx in front of his neck, bywhich instrument his existence may be prolonged to an in-definite period.

It is so very rare that hospital patients can be watched forseveral years, that we gladly give publicity to the presentcase, which will show what really becomes of some of thoseupon whom tracheotomy is performed. It is but justice toState, that Mr. Stevens, the original dresser of the patient,and who has now long joined the professional ranks, took thetrouble to attend to the case through a series -of years, andthat it is to his courtesy we owe the following details:-Sarah C-, twenty-eight years of age, and unmarried,

whose habits of life have been very irregular, was admittedJune 16, 1847. The patient had been in the hospital oneyear before admission, when she suffered from severe secondaryulceration of the uvula and soft palate. She remained in thehospital for a week at that period, the treatment adoptedbeing quinine, and the application of nitrate of silver to theulcers of the throat.When admitted, on July 16, 1847, as stated above, her

person and symptoms were described as follows:-The patientis a sallow, ill-conditioned looking woman, small, and uncleanly,with a countenance expressive of great anxiety. Since sheleft the hospital (a twelvemonth before this description waswritten) she has never been well, her mode of life has beenvery irregular, and she has frequently caught cold. The edgeof what remains of the soft palate is swollen and ulcerated, asis also the left tonsil; the throat generally is inflamed, and theepiglottis very irregular in its outline. The breathing isstridulous, 13 per minute; pulse 84, thready; skin cool andmoist; tongue pale and white. Mr. Hilton believes thedisease to be situated in the arytenoid cartilages. Donovan’ssolution, in decoction of bark, was prescribed, with morphiaat night, and a blister over the larynx.For the next five days the breathing became more and

more difficult, though the patient sedulously used the vapourof hot water to the throat. The peril soon became so immi-nent that Mr. Hilton performed tracheotomy five days afteradmission.An incision, an inch in length, was made as near the

middle line as possible, and a conical curved trocar andcanula thrust into the trachea about one inch and a -halfabove the sternum. The trocar was then withdrawn, and, toprevent the canula from slipping, it was tied round the neckby a tape. The operation was rendered somewhat difficult bythe head of the patient being forcibly thrown forwards onthe chest.Immediately after the opening of the trachea the dyspnoea

was extreme, but in about an hour the woman becametranquil, and slept comfortably at intervals during the night.She was ordered wine and beef-tea. For five days after theoperation the woman suffered considerable pain in the headand in the wound; several times she was almost choked bythe cough and accumulation of mucus in the-tube; but on thefifth day the pain abated considerably, and the respiration

became easier. She experienced great relief by inhaling thesteam from an infusion of conium.The patient continued taking about six ounces of wine per

diem, and on the eleventh day after the operation, the reportstates that she slept.well, the respirations were only twentyin a minute, and the pulse 104, soft. Mr. Hilton then orderedquinine, and good diet, with a continuance of the wine.On July llth, twenty-one days after tracheotomy, she began

walking about the ward without fatigue, and was pronouncedconvalescent. Her progress from this time was most satis-factory ; she gradually lost the sallow, unhealthy hue of skin,and gained flesh rapidly; the wound contracted firmly aroundthe canula, the latter requiring, however, occasional cleansing.No topical applications were used to the palate and larynx,but the ulcerations did not extend; they gradually assumed ahealthier appearance, and about three weeks after the opera-tion the throat was quite well.With Mr. Hilton it was a question as to the propriety of

removing the original canula, and substituting a broad one;but on considering the subject, as there was a probability ofmuch inconvenience resulting from the change, it was decidedthat the canula should remain untouched. By the patient’sown desire she was discharged on August 10th, 1847, sevenweeks after the operation, and was earnestly enjoined to becareful of exposure to cold, and to wear constantly two ormore folds of muslin over the mouth of the canula.This patient stayed away for about six years, when she

was re-admitted, May 12th, 1853, for a slight bronchial affec-’

tion, much emaciated, and suffering more from want than from’ actual disease. She was still wearing her canula, and Mr.

Stevens, who had been attending to her for a long time at herresidence, was kind enough to put the following memorandaat our disposal :-Since the period that this patient left the hospital in 1847

to the present time I have constantly seen her. She has beenliving in Spitalfields, and has had three children since theoperation was performed. Her husband has frequently duringthese years been out of work for days, sometimes for weeks,together, so that her living, at the best of times barely suffi-cient, has very often been totally inadequate, and she hasconsequently endured much privation. Her different placesof residence in Spitalfields have all been characterized bydarkness, dirt, and utter cheerlessness; she has been exposedcontinuously to all the vicissitudes of the weather, (to someextent perhaps unavoidably,) her clothing been inappropriateand insufficieut, and she has moreover entirely disregardedall our entreaties and injunctions relative to the tube beinglightly covered with a fold or two of muslin; frequent and

sometimes rather severe attacks of bronchitis have been theresult of this imprudence and carelessness. -

" The tube has required removal and cleansing four or fivetimes in the year, of course oftener when there has beenbronchial disturbance present; the secretion has at all timespassed freely and easily throvgh the canula, and never throughthe mouth. Carefully repeated trials have failed to detectthe smallest passage of air through the larynx and mouth tillabout four months ago, when a very slight stream was foundto pass, so small that even now (June, 1853) it is only sufficientto bend the flame of a candle. There has been no appreciablevoice, and it requires the greatest possible attention in ob-serving the movements of the lips to be enabled to recognisethe enunciation of a word. Further to demonstrate theimpervious condition of the larynx, I may mention that whenthe finger has been applied over the end of the canula, or, thecanula being absent, over the external orifice, complete in-

, capability of breathing has been the result. ’-

" Generally speaking, I have had no difficulty in removingthe canula, and substituting another, during the cleansing ofthe original one. On the last occasion, however, Feb. 23, 1853,there was great difficulty in the re-introduction of the tube,owing to a -very relaxed state of the tracheal mucous membrane,and towards the close of this nearly fatal operation, I was com-pelled to use considerable force to overcome the sphincter-likecontraction of the external orifice. On three or four occasionssmall abscesses have formed in front, but independent, of thetrachea, and these have occurred more often below than abovethe canula. -

"The form of tracheal tube through which this patient hasbreathed for six years is here introduced, for the purpose ofadducing the strongest evidence of its aptitude as regardsthe purpose for which it was intended. It should be alsonoticed that it is a curve through which a trocar can beintroduced with facility; indeed the tube here representedis the very one which was employed with the trocarat the time of operation, and has been used by the