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WESTMINSTER MEDICAL SOCIETY.

SATURDAY, DECEMBER 1, 1849.—MR. HIRD, PRESIDENT.

FIVE new fellows were elected, three proposed, and two ad-mitted.Mr. CANTON related the particulars of a case of

FISH-BONES IMPACTED IN THE RECTUM CAUSING DEATH.

The patient, who was an old and intemperate man, had beenaccustomed, since February last, to lose, per anum, occasion-ally, a rather large quantity of blood, without his health beingapparently impaired. The source of the haemorrhage had al-ways been attributed to internal piles. A few days before hisdeath the haemorrhage became more frequent, the blood beingof a florid colour; at the same time a piece of fish-bone wasobserved projecting from the anus, and which, together with afew similar portions from above the sphincter, were removed.The temporary cessation of bleeding was followed, the nextday, by renewal of haemorrhage, when the finger, and subse-quently the forceps, were introduced into the rectum, and a

large number of thin and pointed bones dislodged. The patient,however, soon became blanched by another loss of blood, anddied.-Post mortem : The stomach and small intestineshealthy; the large gut, in its whole length, much distendedby fmces and flatus, and here and there fish-bones were found.The lower half of the rectum was of more than thrice itsnatural thickness, and the mucous membrane, in part, sloughy,.and extensively and deeply ulcerated at the back part,whilst two or three jagged perforations were discovered in it.Several dozen of fish-bones were entangled in the disease,some of which, bv opening into the haemorrlroidal vessels, hadgiven rise to the bleeding and consequent death. The boneswere of a dark brown hue, having, most probably, derived thatcolour from the bile; they, together with the rectum, wereplaced before the Society.Mr. MARSHALL related the following

CASE OF TVPHLO-ENTERITIS.

Anne Reeves, twelve years of age, a child of rather delicateconstitution, but had enjoyed tolerable health until within aweek of the present attack, when she complained that the ex-4:essive cold produced aching in the thighs, and then stomach-ache. On the 18th ult. she was taken with vomiting and purg-ing, for which some medicine was exhibited, and two daysafter she appeared in her usual health, indeed, unusually ac-tive and lively. On the Thursday following, four days afterthe first attack, she got up at her accustomed hour, but soonbegan to complain of pains in the abdomen, of an inter-mitting character, accompanied by bilious vomiting, butunattended by the slightest tenderness on pressure. Thecountenance was natural; the pulse slightly accelerated. Asthe bowels had not been moved for twenty-four hours, anaperient was given, and half a grain of opium and a grainof calomel. In the evening she began to complain of apain in the right iliac region, which was aggravated onher turning from side to side. The pain was attended witha slight degree of tenderness on pressure.- Friday, 23rd:Had passed a tranquil night; but, the local pain continuing,four leeches were applied, with marked relief, and a catharticenema was administered. The pulse became accelerated to 100,the countenancenushed.andthetongue rather loaded, but moist;she, however, passed the night quietly, and nearly free frompain; but on the Saturday morning,at half past six, suddenly thepain became extremely severe and general over the abdomen;the knees were drawn up; pulse 120; but there was no rigor,nor did the countenance appear at all anxious; the bowels hadbeen moved several times in the night. A dozen leeches wereimmediately applied to the belly. She lost a considerablequantity of blood, and expressed herself greatly relieved; andshe was then observed to lie with her legs extended; the

- Hushing of the face subsided. A warm linseed-meal poulticewas applied over the abdomen; and shortly after, warm flan-nels, with turpentine, were applied. Three grains of Dover’spowder, with three of calomel, were given every three hours.On the following morning the symptoms became generallyaggravated,-the breathing rather short, the pulse extremelyquick and feeble, the abdomen tympanitic, with frequentvomiting. She gradually sank, and died at two o’clock, threedays and a half after the second attack. The body was exa-mined about twenty-six hours after death. The abdomen wasconsiderably distended. The intestines generally were highlyinflamed, their convolutions being, in many, adherent to eachother, from the effusion of lymph, a large patch of which wasobserved upon the mesentery and on the colon. About twoor three ounces of a yellowish-coloured serum, of a faecal

character, was found. On separating the lower part of theeaecum from its attachment, the vermiform appendix wasfound of a deeper colour than the rest of the intestines; andan ulcerated opening was found about an inch and a half fromthe point from which it takes its origin from the cæcum. Thisopening is jagged and irregular, and admits a moderate-sizedbougie. About an inch from this ulcerated opening of theappendix, we found a hard substance, about the size of a smallhazel-nut, which we cut down upon and removed. It appearsto be fæcal, chiefly, and arranged in concentric layers round asmall nucleus of some vegetable matter.

RUPTURE OF THE RIGIIT AURICLE.

Dr. LANKESTER exhibited a heart, in which existed a rup-ture along the direction of the fibres at the upper part of theright auricle. It was taken from a man, by business a car-penter, thirty-four years of age, who had suddenly died theprevious Saturday, after his day’s work, whilst pulling a loadedtruck into his yard. For several months previous to his deathhe had been in a delicate state of health, suffering underattacks of fainting, palpitation of the heart, nausea, and achoking sensation in the throat. He had had no medical at-tendance several weeks previous to his death. When seized,he was attended by Mr. Staning, house-surgeon to the RoyalPimlico Dispensary, who found him quite dead, with largequantities of blood oozing from his mouth. The bodywas emaciated, and on examination the lungs, liver, stomach,and bowels, were found in a healthy state. On examining theheart, it presented about the usual size, but on handling itfelt unusually flabby. On cutting into, the whole muscularsubstance was less than usual, and the walls of right ventricleand auricle were remarkably thin. At the upper part of theauricle there was found an irregular opening, of the size of ashilling, the edges of which were remarkably thin, and pre-sented no other morbid appearances than a great deficiencyin muscular fibre. The walls of the whole auricle were ex-cessively attenuated, in many points appearing to be heldtogether only by the serous covering of the heart. Thefibulm of the muscles, under the microscope, presented nopeculiarity, except, perhaps, a less decided appearance ofthestrice which characterizes the muscular fibres of the heart.Dr. Lankester regarded this case as remarkable—1, as an in-stance of the rupture of the cavity of the heart, in which thatlesion least frequently takes place; 2, rupture as the result ofatrophy, with little or no dilatation; 3, the youth of the personaffected; 4, of absence of the usual forms of disease which in-duce rupture of the heart.

CASE OF -CHRONIC LARYNGITIS.

Dr. OGIER WARD mentioned a case and exhibited a specimenof chronic laryngitis attended with ulceration of the root of thetongue, and the base of the epiglottis, which rendered degluti-tion so difficult and painful,that the patient was absolutely dyingof inanition; for the attendant tuberculosis of the lungs was notsufficiently advanced to destroy life, nor even to give satis-factory physical signs of its presence. In this case, Dr. OgierWard applied a strong solution of nitrate of silver to theback of the fauces and the epiglottis, with the immediate re-sult of enabling the patient to take food, though previous tothe operation he had not been able to swallow even a littlewater. The same result followed each application of thecaustic, even to within half an hour of the patient’s death.The case was brought forward as illustrating the power ofthe nitrate of silver to allay irritation of the glottis, andthe slight dependence to be placed upon an improvement ofthe symptoms thus obtained even in cases where the physicalsigns of disease in the lungs are obscure or even absent;bronchial respiration at the upper part of the chest-lining theonly physical sign present of extensive tuberculosis combinedwith emphysema.

FOREIGN BODY IN THE LARYNX.

Dr. ROUTH exhibited a specimen of diseased larynx. It hadbeen taken faom a patient he had that day examined, withMr. Norton, of Baker-street. The patient, Oct. 25th, wasaffected with phthisis in the third stage. The case bore someresemblance to the case just mentioned by Dr. 0. Ward, al-though the cause of the ulceration was different. It appearedthat about two years back the patient had first begun to sufferfrom sore throat, which had continued more or less eversince. More lately, however, about three or four months, hisvoice became hoarse, like that of a patient labouring underchronic laryngitis. Towards the last week of his illness, when

! Dr. Routh first saw him, there was great pain and difficulty in deglutition. He took only liquids, but even these induced

such violent fits of coughing, that he at last refused to take

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any kind of food or medicines whatsoever. In connexionwith the disease in the chest, the case was supposed to be oneof tubercular ulceration of the larynx. As very great weak-ness was present, nutritious injections, wine, and counter-irritation were ordered, under the influence of which herallied for a day or two, but subsequently sunk again, andfinally died, apparently from pure exhaustion. The post-mortem examination discovered a large cavity in the rightlung, and much tubercular consolidation in the left. Thelarynx was generally cedematous; the whole of the cartila-ginous structure unusually ossified, the glottis having evidentlybeen unable to close during the descent of ingesta. Severalpoints of ulceration were observed about the parts, but notubercular deposits, as had been expected. Between the twovocal cords on the right side was a deep gangrenous-lookingulcer, with much thickening of the parts around; and aboutone inch lower down in the anterior part of the trachea wasanother ulcer, in which a piece of bone had been firmlywedged, behind which the ossified cartilage had been almostentirely absorbed, so as to break on the forcible extraction ofthe spicula of bone. The piece of bone had been inadvertentlylost, so that he could not exhibit it to the Society. It wasabout the size of a small pea, ragged, but more elongated,and had apparently been taken in with his food, thoughneither he nor his mother had any recollection of the occur-rence some two years ago. The spicula had probably firstlodged between the chordae vocales, snperiorily; and sub-sequently being liberated by the ulceration, had fallen forward,and got entangled in the cartilage below. It seemed to havebeen the source of all the mischief in the larynx, and hethought should be looked upon rather as the immediate causeof death, rather than the disease of the lung, which, thoughextensive, was much less in degree than what he had frequentlyobserved in other cases of phthisis.

Dr. SIBSON made a communication on

THE FALLING IN OF THE WALLS OF THE CHEST DURING INSPIRA-TION IN SOME DISEASES OF THE CHEST.

He had first observed the interesting phenomenon in questionin the case of a young man, aged thirty-four, who was ad-mitted, in 1843, into the Nottingham Hospital, under the careof Dr. Hutchinson and Mr. White. lie suffered from extremeobstruction to respiration, owing to excessive contraction ofthe fauces and larynx, the result of a long-standing syphiliticaffection. The countenance was pale, shrunk, and anxious;he spoke in a whisper. The inlet through the larynx was sonarrow that he could scarcely breathe. The case urgently de-manded laryngotomy; which was performed by Mr. White.Before the operation, the inspiratory efforts were very labo-

’

rious; the abdomen protruded considerably, and with force;but the sternum &nd ribs, instead of advancing, actually fellbackwards over their whole extent, during each inspiration.The chest was narrowed and flat; the abdomen prominent;the lungs were lengthened, their lower margin being nearlytwo inches lower than usual. The cause of that remarkableappearance, the falling backward of the whole walls of thechest, during inspiration, was apparent. The diaphragm de-scended with force, dragging after it the base of the lung, andso lengthened the whole lung from apex to base. As the aircould enter the lung only with the greatest difficulty, throughthe narrow larynx, the lungs being lengthened necessarily coi-lapsed, and the ribs over them Were forced inwards byatmo-spheric pressure. If a closed bladder, two thirds filled withair, be lengthened, its walls collapse; if it be shortened, thewalls bulge out; so with the lungs; if they be lengthened, whenthe air cannot enter them, they collapse at the sides; and ifthey be shortened, (as in expiration, owing to the pushing up-wards of the diaphragm;) they bulge outwards. This was pre-cisely the condition in the case in question; when he inspired,the lungs were lengthened, and the walls of the chest fell in-wards ; when he expired, the lungs were shortened, and thewalls of the chest moved forwards. Immediately after llr.White had performed laryngotomy, the air entered the lungsfreely, and all the conditions of respiration were reversed, thenatural action being restored; and the walls of the chest, in-stead of falling backwards, advanced during inspiration; atthe same time the lungs were no longer elongated; the chestbecame full, the face ruddy, and the countenance free fromanxiety. This being an extreme case was a type of its class.Since observing this case, he (Dr. Sibson) had observed thewalls of the chest to fall in during inspiration in many othercases; but in none to the same extent. Whenever thereis great obstruction to respiration in the outer air-pas-sages, as in croup, diseases of the larynx or fauces, the walls ofthe chest fall in, to a greater or less extent, in proportion

to the degree of the obstruction and the flexibility of theribs. The same phenomenon will be observed, also, if therebe spasmodic closing or narrowing of the glottis, as in hic-cough, laryngismus stridulus, or the fits of hysteria. If theobstruction to respiration diminish, the extent to which thewalls of the chest fall in during inspiration will diminish fromday to day. Thus, at first, the obstruction being very great,the whole of the sternum, and the cartilages and ribs to eachside of it may fall in; but when the obstruction becomes com-paratively small, then only the lower end of the sternum mayhave a reversed motion. On the other baud, if the obstructionincreases, the extent to which the sternum and ribs fall back-wards during inspiration will increase progressively. If therebe obstruction to the entrance of air into one of the large,bronchial tubes, as from the lodgment of a foreign body, thenthe walls of the chest may fall in during inspiration over thatportion of lung supplied with air through the obstructed.bronchial tube. If there be obstruction to the entrance ofair in the smaller bronchial tubes, as in bronchitis, vesicularemphysema, or hooping cough, the walls of the chest may beforced backwards,duriug inspiration,over a portion of the lungs..In such cases, the reversed inspiratory movement is confined tathe lower end of the sternum, and to the cartilages and ribs toeach side of it. If the obstruction to respiration in the smallerbronchi be confined to one lung, then the reversed movementof the thoracic parietes will be confined to that side. Dr.Sibson had observed the walls of the chest to be forced back-wards in come cases of effusion into the pleura; the descent ofthe diaphragm in such cases causes the lengthening, and con-sequent collapse, of the sac containing the fluid. When thewhole or a great part of one lung is incapable of expansion,owing to condensation, then the walls of the chest over theaffected lung are usually forced inwards during inspiration;in such cases the respiratory movements of the ribs of theopposite side are exaggerated, and the lower end of the ster-num is drawn over, at each inspiration, towards the unaffectedside, and the ribs over the affected lung are in turn drawn overby the sternum, and they consequently fall in during inspira-tion. In two cases of fracture of rib with general emphysema,the side on which the rib was fractured was indicated by thesinking in of the walls of the chest during each inspiration.When there is extensive effusion into the pericardium, andwhen the heart is enlarged and adherent, the lower end of thesternum and the adjoining left costal cartilages may in somecases be forced backwards during inspiration. The yieldinginwards of the sternum and ribs during inspiration is mostmarked in those whose cartilages are flexible; it thereforeoccurs most frequently in children and in young persons. In-deed, the inspiratory yielding of the walls of the chest isusually present in healthy infants, especially when they sob;in these the chest flattens during inspiration, the lower end of £the sternum receding ; but in rickety infants the chestnarrows and the sternum protrudes, the parietes being forcedinwards at the junction of the ribs to the cartilages. Thephenomenon is least marked, or is altogether absent, in thosewhose costal cartilages have become firm or bony; it is, conse-quently, seldom observed in the aged. It is very seldom thatthe four superior or thoracic ribs, or the four inferior ordiaphragmatic ribs, fall inwards during inspiration, under theinfluence of obstructed respiration; the reversed respiratorymovement being usually confined to the lower end of the ster-num ; and to the fifth, sixth, seventh, and eighth, or inter-mediate costal cartilages and ribs. When the form of thechest is normal, the lower end of the sternum and the adjoiningcartilages present the phenomenon in question, but when thesternum is unusually prominent, then the ribs alone are forcedinwards and the sternum protrudes. Dr. Sibson described acase in which, owing to disease of the cervical vertebras in-volving the phrenic nerves, the diaphragm was paralyzed, andin which, while the thoracic parietes advanced, the abdominalparietes shrunkinwards during inspiration; and concluded byreferring to observations of the phenomenon in different in-stances, made by Haller and Lower; by Dr. Stokes and Dr.Williams, in emphysema; and by Dr. G. A. Rees, Dr. Snow,and Mr. Hird, in children; and by pointing out the practicalvalue of the sign in question as an auxiliary in the diagnosis of

diseases of the chest. ’

Some discussion followed, chiefly in the shape of questionand answer. We regret that the unusual length to which our

report extends, prevents our publishing the account forwardedto us.! Mr. Nmm related the particulars of aí CASE OF RUPTURE OF THE CALCANEO-SCAPHOID LIGAMENT.

A lad, aged nineteen, " slipped up" whilst carrying a con-siderable weight. Swelling, great pain, and inability to rest

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the body upon the foot, followed. Five weeks after the aeci.dent, the time when the case first came under the care of Mr.Nunn, the swelling had in some measure abated, but the footcould scarcely touch the ground without producing intensepain. The arch of the foot was very much flattened, and thestyloid process of scaphoid bone could be detected more easilythan in the sound foot, in spite of the swelling and thicken-ing of the tissues. During six weeks, complete rest, iodinepaint, pressure by strapping, with camphorated mercurial oint-ment, hot fomentations, placing the foot on a higher level thanthe rest of the body, had each a trial given them, without pro-ducing at all an encouraging amount of improvement; theexquisite tenderness of the sole of the foot remained un-relieved. After the failure of these remedial measures, Mr.Nunn subjected the foot to a course of rubbing, or ratherkneading, with the balls of the thumbs. This treatment,although at first accompanied with severe suffering, produced,after a few weeks, most satisfactory results. The effusion dis-appeared, the morbid sensibility almost ceased, and the partwas ultimately restored to its proper office. Mr. Nunn said,that he considered the great tenderness to have arisen fromthe effused lymph having impeded the nerves in a solidmedium, and that thereby any pressure, however slight, wasimmediately transmitted to them, instead of being warded off,as in a healthy condition of parts, by the highly elastic padof fat- and muscle by which the nerves were protected. Mr.Nunn’s explanation of the success of the treatment was, "thatby means of the strong friction and kneading the more deeply-seated vessels were stimulated to increased, and, at the sametime, healthy action."

Correspondence.

INQUIRY ON CHOLERA.

" Audi alteram partem."

[DR. HASTINGS, President of the Provincial Medical andSurgical Association, presents his compliments to the Editorof THE LANCET, and begs to send a copy of the queries respect-ing cholera which have been issued by the Association toevery member of that body, and Dr. Hastings would feelobliged by their insertion in an early number of THE LANCET.]Worcester, Nov. 26, 1849.An inquiry into the history of the cholera in its recent visi-

tation to the different counties of England and Wales, which,if duly responded to, cannot fail to excite interest, has beenset on foot by the Provincial Medical and Surgical Associa-tion, and the following questions have been addressed to eachmember of that body. We have been requested by the Presi-dent of the Association, Dr. Hastings, of Worcester, to publishthem in THE LANCET, in the hope that those of our readerswho have been engaged in cholera cases will kindly assist inthe inquiry, by forwarding their replies to Mr. Hunt, of Bed-ford-square.The following notice appeared in the Provincial 3,1-edical and

Surgical Journal of September 19, 1849-viz."In compliance with the resolution passed at the annual

meeting held at Worcester, the annexed questions have beencarefully framed, and it is earnestly requested by the council,that the members of the Provincial Medical and Surgical As-sociation will assist in this laudable purpose, by forwarding asfull and complete a series of answers as possible, to Mr. Hunt,26, Bedford-square, London, who has kindly undertaken the

" CHAS. HASTINGS," President of the Council.

" QUESTIONS." 1. During the prevalence of the epidemic, has your own

neighbourhood, town, or district, been exempted from thevisitation ? If Eo, can you mention any local circumstanceswhich may account for the exemption ? Was the district

healthy during the visitation of the cholera about the year1832, and did circumstances then exist which may be supposedto have protected it ?

"2. If the cholera* has appeared in your district, how manycases have you seen ;-how many of these have been fatal ?

" 3. When did the disease break out, and how long did itprevail ? Please to state generally, whether many personswere simultaneously attacked or otherwise; and whether it" * It is proposed, to avoid confusion of terms, to restrict the term ’ cho-

lera’ to cases of vomiting, purging, cramps, and ’rice-water’ evacuations;the term bilious-cholera’ to vomiting and purging of bile, with cramps;and the term ’ diarrhœa’ to profuse alvine discharges, without either vo-nntmg or cramps.

commenced contemporaneously in more than one site in thesame town or district, or whether it appeared to spread fromone point only. Were there any peculiar circumstances ob-servable in its local character, or in the course or direction ofits advance, which may throw any light upon the importantquestion, whether the disease be of a contagious* nature orotherwise ?

"4. Have you invariably been able to trace the disease tolocal impurity of the atmosphere, or have you seen it attackpersons living in a pure air, apart from grave-vards and othersources of putrefaction, in well-drained and well-ventilateddwellings ? In cases of the latter description, if any havebeen observed, has there been any intercourse with the sickwhich may tend to-establish the doctrine of contagion, or thereverse ?

" 5. Did the cholera appear in your neighbourhood with orwithout the general and contemporaneous appearance of themilder forms of disease—diarrhœa, bilious cholera, &e. ? Hasdysentery or typhus been prevalent or otherwise ?

" 6. Were its ravages indiscriminate as to personal vigour,age, sex, station, occupation, &c.; or might the attacks betraced to some predisposing personal cause-as weak bowels,intemperance, debility, fear, errors in diet, uncleanly or seden-tary habits, or impaired health from any cause ?

"7. Were ’ premonitory’ symptoms of general occurrence,or did the disease frequently appear suddenly in the malignantform, with violent cramps, vomiting and purging, rice-water’dejections, and rapid collapse ?

" 8. Did the symptoms differ from those generally observedand frequently described ? Had the disease any peculiar typeeither of mildness or malignity ?

" 9. Are you aware of any exempting circumstances of anydescription, which have uniformly protected certain indi-viduals from the disease, snch as trades, habits, diet, &c., notinclusive of local habitation ?

" 10. Can you throw any light on the physical origin or re-mote cause of the recent or former visitation ? Are you ableto say, from your own observation, that the general symptomsand history of both are similar ? Have you instituted any re-searches into the density, humidity, temperature, or electro-magnetic phenomena of the atmosphere ? Have you observedthe progress of the cholera to be arrested by storms, wind, orrain ?

" 11. Have you made any post-mortem examinations of fatalcases of cholera, and with what result ? Do you know of anycircumstances which justify the immediate interment of thedead ? Did you ever observe cholera patients show signs oforganic life for hours or days after apparent death ?"12. Can you describe any method or principle of treat-

ment which has proved successful in so large a number ofcases of cholera, as to commend it to universal adoption ? Ifso, has not the method frequently failed in other hands, andcan you explain the cause of failure ?

"13. What mode of treating the epidemic diarrheea andpremonitory symptoms generally have you found most suc-cessful ? ’

"14. Can you suggest any means of preventing or arrestingthe spread of the disease, in the event of any future outbreak ?

" 15. What is your opinion as to the propriety of removingthe inhabitants, who have not taken the disease, from the in-fected dwellings to houses of refuge, in situations where thepresumed causes of the disease are not in operation ?"

THE ROYAL COLLEGE OF SURGEONS AND THEPROPOSED NEW CHARTER.

To the Editor of THE LANCET.SIR,—I am glad to find that the Council of the Royal

College of Surgeons are about to amend their Charter of 1843.Many of that council must have been struck from time totime with the groaning injustice which it dealt out to themembers of that college; and when we recollect that thatCharter was based upon retrospective legislation, it certainlymust strike every thinking man as an act of oppression at onceunique and unrivalled.Those who promised to protect and defend every member

of that college who might be disturbed in the exercise andenjoyment of the rights, privileges, exemptions, and immuni-ties acquired by him as a member, (and be it recollected,every member had the same privileges &c. prior to thatcharter,) were the first to break the bond of faith, to give thelie to their own by-laws, to exalt the few, to degrade the

"* * A house or district may be infected, so as to spread a disease notstrictly contagious. Respondents are therefore requested to confine thelatter term to evidence of communication by personal approach or contact.