« AnteriorContinuar »
sists in sporules and filaments; the former are circular or angular, and without granular contents; the latter are elongated, branched, and jointed. The characters are the same as those found in herpes as contradistinguished from tinea and chloasmi; but the cryptogamæ are found not so much, as in man, in the hairs themselves, as between the hair and the sheath. Dr. Von Bärensprung rubbed some scales containing much of the confervoid growth on his left forearm. For some days no effect was produced, but after a time considerable itching reminded him of the experiment, and to his surprise be found a wellformed spot of herpes circinnatus of the size of a sixpence. This gradually increased, and in three weeks attained to the size of a crown-piece. In the fourth week the first spot began to heal, but others formed in the vicinity, and the author now arrested them by the application of white precipitate ointment,
QUARTERLY REPORT ON SURGERY.
By John CHATTO, Esq., M.R.C.S.E., London.
I. On Foreign Bodies introduced into the Bladder. By M. DENUCÉ.
(Moniteur des Hôpitaux, 1856. Nos. 126, 7, and 8.) In this paper, M. Denucé, of Bordeaux, relates a case that occurred to him. self, in the person of a woman who had introduced the handle of a stiletto into the bladder. After several days of severe suffering, she came to the hospital, and as the urethra was found to be in a very dilated state, the extraction of the foreign body was easily accomplished, by means of a polypus forceps passed along the index finger.
M. Denucé has collected the particulars of 391 published cases, and the cnumeration he gives of the bodies in question is both curious and useful. In 78 they were portions of catheters or lithotrity instruments-viz., 15 metallic catheters, 9 gum elastic catheters, 7 gutta percha catheters (a large proportion, considering the short time these dangerous instruments have been in use), 28 catheters (their nature not being specified), 16 bougies, and 3 branches of brise-pierres. Then we have 82 needles, pins, or tags, 1 stiletto, 1 crotchet needle, 6 bone or ivory needles, 6 ear picks, 3 ivory whistles, 1 ivory spindle, 1 ivory stiletto handle, 15 leaden balls, 3 small keys, and 8 instances of metallic fragments of various kinds. In 12 bones or splinters of bone, in 10 pebbles or china, 6 penholders, 15 needle-cases, 10 pieces of tobacco-pipe, 4 portions of glass tubes. In 21 instances fragments of wood, as 3 pencils, 1 piece of a match, 1 ramrod, 1 mustard-spoon handle, &c. In 34 there were fragments of plants, as ears of corn, stalks, &c. ; in 26, fruits or kernels; in 4, tents of charpie, 1 strip of linen, I skein of cotton, 3 débris of cotton or wool, 2 pieces of cord, 4 portions of wax candle, 3 pens, 1 piece of whalebone, 2 leather boot-laces, 1 piece of tendon, 2 débris of fæcal matter, 1 pessary, 1 shell, 14 instances of various fætal débris, 6 locks of hair, 2 of larve of insects, and in 1 pills.
If we abstract from this curious list the bodies which have obtained accidental entrance into the bladder, whether from clumsy surgical manauvres, or communications established through the walls of the bladder, either externally (as in the case of balls and wounds), or with the rectum, vagina, or ovary, there will still remain 258 cases in which no legitimate explanations can be giveu of the presence of these bodies. Those assigned by the patient are usually as singular as are the bodies themselves; some being said to find their way there while attempting self-catheterism, others from the patient having fallou on them, while others again are stated to have been swallowed. The true and principal cause of their introduction, when not accidental, is to be sought in the vagaries
of an abandoned depravity. Of these 256 cases, 119 are stated as having been males, and 96 females, while in 41 instances the sex is not indicated. In 14 instances they occurred in children from the age of a few weeks to fifteen years.
After a foreign body introduced into the urethra has become propelled into the bladder, in a few days it begins to be covered with incrustations. At the end of some weeks, these have attained a considerable thickness; while at the end of some months, true calculi may be constituted. The form of the body, however, exerts considerable influence upon the mode of deposit. In rounded or short bodies the incrustation becomes general, while in those which are elongated, it takes place especially towards the middle. Thus, in most cases in which calculi bave been formed on needles, the ends of these are found projecting beyond the deposit; and it is such calculi that especially give rise to cystitis and other dangerous accidents.
Among the 391 cases collected by M. Denucé, in 21 death took place indepen. dently of any operation. In 13 of these the affection was recognised at the antopsy; but it is not stated with precision whether the vesical affection was the cause of death ; in 2 death resulted from the débris of a fætus passing into the bladder; and in 6 it was the direct result of the introduction of the foreign body. These last were examples in which the points of pins or needles became imbedded in the walls of the bladder, giving rise to intense and fatal cystitis. Cases in which art does not intervene do not, how. ever, always terminate thus, the efforts of nature in some sufficing to liberate the economy from their presence. Thus they may be carried out by the urine, especially when the bodies are small and women are the subjects. In 31 instances in which the age is specified, this occurred in 14 men and 17 women. Occasionally, certain bodies, such as broken needles, escape by penetration of tissue, and this is stated to have occurred in four cases.
As in the great majority of instances nature will not be able to secure the discharge of these bodies, the surgeon, in order to prevent the occurrence of dangerous accidents, must interfere, endeavouring first to secure their removal by extraction, and if unsuccessful, resorting to lithotomy. In the cases here collected, lithotomy has been liad recourse to 125 times-viz., in males, perineal lithotomy, 87 times; recto-vesical, 2 ; hypogastric, 2 : and in females, urethrovaginal lithotomy in 22, and hypogastric in 12. Unfortunately, in only 61 of these cases has the ultimate result been stated. In 39 occurring in males, perineal lithotomy was performed in 36 (31 recoveries and 5 deaths), hypo.. gastric in 2 (both recoveries), and recto-vesical in 1 (fatal). In the 22 cases occurring in females, there were 15 urethral or vaginal operations (13 recoveries and 2 deaths) and 7 hypogastric (5 deaths and 2 recoveries). On the whole number, therefore, 48 recoveries and 13 deaths. The liypogastric operation has thus proved very fatal, 5 deaths taking place to 4 recoveries ; and in the latter, in two instances the operation consisted simply in enlarging an aperture already existing.
The performance of the operation may be rendered difficult by the nature of the bodies to be reinoved. Thus, their softness may be such as to render their recognition and removal difficult; the length of others may lead to their being seized in the middle, and brought across the aperture; while, if they have remained loug in the bladder, the size and irregularity of the incrustations present additional obstacles. The precision of measurement attainable by lithotrity instruments, however, now comes to our aid. As to the particular operation indicated, it may be stated in a general way that the perineal ope. ration in men, and the urethral in women, suffice for small bodies, or for such as are thin and elongated; those which are of larger size require the bilateral or vaginal operation; while the hypogastric, seeing its unfavourable results, should be reserved for quite exceptional cases. It must be remembered, how. ever, that in women the urethral operation is almost always followed by incontinence of urine, and the vaginal by vesico-vaginal fistula.
Extraction of the foreign bodies has been performed in 112 of these cases, death following in 3. In reference to the influence which the introduction of - lithotrity has exerted upon the improvement of extracting instruments, M. Denuce makes the following calculation :-Of the whole 239 cases in which interference has taken place, 127 occurred prior to, 122 subsequent to, 1830, when lithotrity may be considered to have generally established itself as an operation. In the early series, lithotomy was practised 100 times, and extraction 27 times only; while in the latter series, it was resorted to but 21 times, and extraction 101 times. Thus, formerly lithotomy, with its mortality of 15 per 100 was the rule; while now, extraction, with 3 deaths in 112 cases, is the rule, and lithotomy the exception. The progress that has been made is still more apparent when we consider the case of the male urethra, with its long, narrow, sinuous canal. Of 20 cases of extraction noted prior to 1830, 16 occurred in women, and but 4 in men ; while of 73 since that epoch, in which the sex is indicated, 46 occurred in males, and 27 in females.
II. On the Treatment of Hydrocele in Children. By M. RICHARD.
(Gazette des Hôpitaux, 1857, No. 41.) M. Richard, while attending for M. Guersant at the Hôpital des Enfans, met with no less than twelve cases of this affection in the course of one month; and although accident may have led to this accumulation, he yet believes that it is of more common occurrence than is usually supposed.
The hydrocele of children is commonly termed congenital, and as in the great majority of cases the vaginalis communicates with the peritoneum, congenital persistence seems to be one of the conditions of the disease. Not that all these serous collections can be reduced by the hand, for it is more common to find them irreducible; but nearly all of them, if watched sufficiently long, are found appearing and disappearing, increasing and diminishing, from time to time. Of these 12 cases, 2 only were purely funicular, the 10 others invading the scrotum and cord. The cysts of the cord, which often simulate a third testis, are in children and adolescents developed in the funicular portion of the persistent vaginalis; while in the adults we observe cysts of the epididymis, containing a turbid fluid and spermatozoa.
Experience has shown that in the treatment of these hydroceles, the persistence of the communication with the peritoneum is not of the importance that might have been expected. M. Richard's cases are treated in the follow. ing manner :-1. The liquid is evacuated to the last drop by means of a short exploratory trocar, of very small calibre. 2. An assistant exerts compression upon the lower part of the belly and the track of the inguinal canal. 3. From six to seven grammes of alcohol (10° of Beaumé's areometor) is then thrown in. 4. The canula is suddenly withdrawn so as to leave the fluid in the sae; and after continuing compression over the inguinal canal for a minute, the operation is concluded. The consequences are very simple. The tumour increases a little towards evening, becomes a little painful next day, after when all pain entirely ceases. From the tenth to the fifteenth day the tumour entirely disappears, and the child is cured. If he is of an age to admit of it, he is allowed to walk or play about after the operation. Sometimes at the instant of withdrawing the canula, owing to the strong contraction of the cremaster and dartos, a little of the injected fluid is expelled, the little patient being at the same time seized with erection, or even expelling his fæces. But this is of no consequence. Sometimes, however, a few drops of the fluid enter between the skin and the vaginalis. This is followed by redness of the skin,
and the formation of a small abscess, which bursts of its own accord without interfering with the progress of the cure. The smallest possible trocar must be employed in this delicate operation, although without practice such an instrument is more difficult to use. We must render the hydrocele very tense with the left band, isolating it as much as possible, and holding the trocar in the right hand, apply the pulp of the thumb and the index finger very near the pointed extremity of the instrument. In place of thrusting this in, as in the adult, we must insinuate its point as if using a bistoury. When the cure has been obtained, a good precaution consists in wearing an inguinal bandage for three or four months; for a principal advantage of the operation for congenital hydrocele is derived from the protection it affords against the production of hernia.
III. On Diphtheritic Ophthalmia. By MM. WARLOMONT and TESTELIN.
(Annales d'Oculistique, vol. xxxvi. pp. 228–243.) This article constitutes one of the additional chapters its authors have contributed to their translation of the last edition of Mackenzie's treatise On Diseases of the Eye.' A form of pseudo-membranous ophthalmia was, they say, indicated by Bovisson, of Montpellier, in 1847; and M. Chassaignac has alluded to the pseudo-membranes which occur in the ophthalmia of new-born infants; but the present affection has been particularly described by Gräfe, of Berlin, the disease indeed, thus far, seeming peculiar to Germany.
Symptoms.-In an eye in its normal state, but more frequently in one that has already suffered from inflammation, great irritation is suddenly set up, accompanied by much tumefaction of the conjunctiva, an inconsiderable amount of chemosis taking place. A network of large vessels rainifies over the conjunctiva, and the membrane itself, of a yellowish colour, is marbled over by a great number of minute red points. If an incision be made into the chemosis, Huid does not flow out, the submucous tissue being infiltrated with gelatiuiform fibrin. The upper eyelid is remarkably tense, and so much pain does its eversion produce, that Gräfe resorts first to chloroform. When the conjunctiva is thus exposed, it presents a polished yellowish colour, which is due to a fibrinous exudation that penetrates into its substance, and leads to arrest in the circulation. The exudation can only be detached from the membrane with difficulty. It may be well seen by causing the patient to look downwards, and by everting the superior eyelid sufficiently to see the oculopalpebral fold. The lower eyelid is also rigid, but little moveable, and very red. Besides the symptoms mentioned, there are two others—a great and continuous increase of temperature, and an abundant discharge of a dirty grey fluid, carrying with it yellowish flocculi. This condition, which constitutes the first stage of the affection, continues for a longer or shorter period; and the dipltheritic process may still be going on after the original swelling of the eyelid has diminished.
After awhile the rigidity of the eyelids disappears, and the conjunctiva assumes a spongy appearance, abundant fibrinous masses becoming detached from its surface. In parts it may retain its habitual colour, while in other places the exposure of the vessels gives rise to copious bleedings. The portions deprived of the mucous membrane swell more and more, and assume an appearance very like that seen in chronic blennorrhea. There are also numerous nodosities formed upon portions of the conjunctiva, which, resistent at first, soften with the progress of the affection. The chemosis of the ocular conjunctiva now loses its hardness and yellow colour, and a dense vascular network is developed, so that the diagnosis of the affection at this period is very difficult.
The third stage is characterized by retraction of the eyelid, proportionate to
the amount and depth of the original fibrous infiltration. In some patients, day after day false membranes are removed three-quarters of a line in thickness, and having a hole in the centre corresponding to the circumference of the cornea. These are the pathognomonic signs of the affection; but to them may be added various degrees of opacity or ulceration of the cornea.
Nature and Causes.-As to the nature of the affection, it is derived from an inherent disposition of the mucous membrane to take on the diphtheritic action. It is a general disease, occurring more frequently in unhealthy than in healthy individuals, and internal affections frequently prevail during its progress. Thus, among 40 children, the subjects of it, M. Gräfe found death result in 3 from croup, and in other instances from pneumonia or hydrocephalus. It also frequently coincides with diphtheritic inflammation of the skin or apertures of the mucous membranes. Eight of these 40 children were the subjects of congenital syphilis. When one eye is affected the other often suffers, whatever precautions may be taken to prevent inoculation. Epidemic influences are its principal cause, for after months have elapsed without a case occurring, great numbers may be suddenly met with. New-born infants are not especially predisposed to it, although in the ophthalmia they suffer from ; a fibrinous exudation, giving a certain amount of rigidity to the eyelid, may be observed. The affection is indubitably contagious. As already-existing inflammation, especially when traumatic, predisposes to it, operations must be abstained from when the affection prevails epidemically.
Diagnosis and Treatment. The only affection it can well be confounded with is gonorrhaal ophthalmia, and the author exhibits the distinctive signs at some length. With respect to treatment, copious depletion, by means of lecches applied near the angle of the eye, but especially to the root of the nose, is recommended by M. Gräfe. Ice-cold affusions are also to be frequently applied, and the eye is to be kept scrupulously clean, for which purpose milk is one of the best appliances. In certain forms of the disease caustics may be required. M. Gräfe strongly recommends the energetic employment of mercury, this being the only internal medicine of any value. The regimen must be strict, and but little fluid should be taken. In several cases the second eye has been preserved from an attack by keeping it closed.
IV, On Tracheotomy in Croup, By M. ANDRÉ. (Bullétin de
Thérapeutique, tome lii. p. 471.) The medical officers of the Hôpital des Eufans have long advocated an early, performance of the operation of tracheotomy in croup; and M. André, one of the internes of that institution, has just published an account of the operations performed during 1856. The following table exhibits the results according to age: