Imagens das páginas
PDF
ePub

the commencement of a seizure, and that this contraction has been absent when the cervical sympathetic has been divided.

IV. On the Practical Use of a Laryngeal Speculum in the Diagnosis and Treatment of Diseases of the Tongue. By Dr. Semeleder. (Zeitschrift der k. k. Gesellsschaft. der Aerzte zu Wien, July 12, 1858.)

Garcia,* Czermak,t and others, have employed a speculum for the examination of the fauces and the neighbouring parts; a strong light is necessary, which, whether it be sunlight or artificial illumination, must be thrown on to the speculum while the observer protects his own eye from the glare by a shade, similar to that of the ophthalmoscope. The speculum is to be warmed, to prevent its being dimmed by the patient's breath, and its temperature may be tested by being applied to the observer's cheek. In patients whose velum palati is not adherent, the soft palate should be pressed firmly upwards with the mirror, in order to prevent it from slipping down behind the speculum, and also because by this means the fauces will not be irritated and reflex action excited. The patient's tongue offers numerous impediments, and some management and experience is requisite to manipulate properly. When making an observation, the patient should quietly take a deep breath, and hold it as long as possible. The slanting direction of the speculum will enable the observer to see the root of the tongue, the epiglottis, and the introitus laryngis. Within the larynx the superior thyro-arytenoid ligaments, the chordae vocales, and through them, with a good light, the inner surface of the trachea may be seen. Dr. Semeleder agrees with Dr. Czermak, that occasionally the bifurcation of the trachea may be recognised. The amount of control which patients can exercise over different parts of the fauces varies, and accordingly the extent of surface reflected in the speculum varies also.

The case which Dr. Semeleder reports is as follows;—A girl, aged fourteen, came as an out-patient, with ulcers of the soft palate and fauces, and was cured with a solution of iodine in glycerine, applied locally. Ten weeks after, she returned, with a hard tuberculated nodule on the middle of the tongue, two lines long, covered with enlarged vessels, which in a fortnight was converted into a large ulcer, with hard, thick edges. Mercurial treatment only aggravated the disease; improvement took place on returning to iodine treatment locally and generally.

"On the 8th of April the author commenced the use of Garcia's laryngeal speculum. In the middle of the tongue was a large nodule, and in front a small one; on the right side of the nodules was a deep, ulcerated fissure, curving posteriorly towards the mesian line, and terminating three-quarters of a line behind the point of union between the anterior papillae vallate, like a button-hole or loop-hole, in a hole which was three lines in diameter; from this hole asteroid fissures were given off, which were partly lost at the sides, partly disappeared behind the epiglottis. The papillae vallate of the right side occupied this fissure, and could not therefore be seen. The epiglottis and epiglottic folds, as well as the chordae vocales, were somewhat reddened."

Dr. Semeleder found that he was able to make the local application of the solution of iodine in glycerine! with much more precision by the aid of the speculum, and that the curative process was thus much accelerated. Fresh granulations formed, and a gradual contraction and cicatrization of the cavity ensued.'

Dr. Semeleder remarks that negative results—i.e., the proof of the parts shown by the speculum being in a normal condition—are also useful, and concludes his paper by observing that by proper manipulation the use of the speculum faucium may be continued for a considerable period at a time without giving rise to any inconvenience to the patient, whereas the awkward introduction of the instrument would at once give rise to retching in the same individual.

Since the appearance of the paper from which the foregoing extract has been made, Dr. Semeleder has, in the same journal (19th July, 1858), described an improved illuminating mirror instrument for examination of the fauces, to be worn as an eyeglass or a pair of spectacles by the observer. It is described as follows: A metallic, highly-polished concave mirror, eight centimetres in diameter horizontally, and with a focus of twenty to twenty-five centimetres, is provided with a central opening, to the posterior surface of which a metallic nut is attached, with a perforation corresponding to that in the mirror. The nut is held by two cups, which are pressed against one another by two springs given off at the back of the mirror; the

* 8ee British and Foreign Medico-Chlrurglcal Review, Jin. 1854.

t Sltzungsberlcht der Math. Phypjk. Classe der k. Academic Wisaenschaftea. 1858.

t B lodloii gr. ilj. potassli lodidi gr. xvj. glycerins JJ.

nut is moveable on two axes, but is sufficiently fixed to retain any given position. A concave disc corresponding to the circumference of the eye is attached to the posterior surface of the cups, and fitted into the frame of an eyeglass or spectacles; this disc is also perforated, so that there is a continuous channel from the mirror to the eye of the observer.

T. Remarkable Case of Aneurism ofthe Thoracic Aorta. By John H. Paceard, M.D. (The American Journal of Medical Sciences, July, 1858.)

This case is related by the author because, as he thinks, the sternum had perforated, and become enclosed within, the aneurismal tumour. It occurred in a coloured porter, aged thirtyeight, who in February, 1858, came under Dr. Packard's care, with a lump as large as a foetal head at the upper part of the sternum, somewhat to the right of the median line, which had first begun to form in July, 1857. The treatment, of course, was palliative, as there was no doubt in regard to diagnosis. An eccentric or expansive pulsation was visible all over the tumour; but there was no bellows-murmur nor anything like a thrill. The clavicles seemed to disappear at about an inch and a half from their sternal extremities, but the sterno-cleidomastoid muscles could be traced on each side, passing over the upper part of the tumour as if to its point of insertion. The man continued at his work till March, towards the end of which month a rapid increase in the tumour ensued. On the 2nd of May it measured eleven inches transversely and ten inches and a quarter from above downwards in semi-circumference. The upper part was discoloured, and on the 6th of May rupture took place externally, followed by severe haemorrhage, and death in the ensuing night.

Autopsy ten hours and a half after death, the tumour only examined. The anterior wall of the sac was extremely thin, the skin was easily separated from it, except at the point where the sterno-cleido-mastoid were attached; their lower part was converted into fibrous tissue, and their bony connexions were destroyed. The sac contained an enormous clot, very firm behind and below, but the consistence gradually diminishing, and its red colour deepening towards the external orifice. On introducing the hand into the cavity, Dr. Packard found several pieces of roughened bone. "Two of these, evidently remnants of the sternum, lay free, surrounded and supported by half-coagulated blood; they were irregular in shape, bare, and eroded, as if by a solvent action of the blood; the line of separation between them was irregular, oblique, and much like a fracture. The end of the right clavicle, and the upper two ribs on the same side, in a similar condition, projected through the wall of the sac; both sterno-clavicular articulations were absorbed. Above the second rib the sternum was entirely gone, except a slender strip which had formed its border on the left side; the inner edge of this strip was bevelled off internally by absorption. The outer and front surface of the first rib on the right side was laid bare, and slightly hollowed out by the pressure of the aneurismal sac. It would seem that the dilatation had gone on so rapidly that the bones, so to speak, were not absorbed quickly enough, and the walls of the sac, even in the act of giving way to them, formed adhesions round them." The aorta was the vessel affected from about an inch above its origin; the trachea was flattened, and the lungs perfectly healthy.

The author has examined the records of the profession without meeting with a similar case. He explains the occurrence thus; "The periosteum covering the inner surface of the upper piece of the sternum was absorbed beneath the pressure of the tumour, adhesions meanwhile forming between the sac and the periosteum around the edges of the bone; then the anterior wall of the sac itself being broken down, the bone was loosened from its anterior periosteal layer by the insinuation of the contents of the sac between them, and dropped into the cavity, the anterior wall of which thenceforth consisted of two layers—skin and periosteum—the latter becoming lined by a sort of serous membrane, perhaps by the organization of coagula."

VI. Ulceration of the Aorta. By A. N. Talley, of Orangeburg, South Carolina. (Charleston Medical Journal and Review, Sept., 1858.)

In a female about fifty years of age, who was under Dr. Talleyss care on account of pulmonary phthisis, and in whom death ensued suddenly and unexpectedly, the autopsy revealed, in addition to the disease in the lungs, the following conditions. The pericardium was greatly distended and of a dark chocolate hue, it was occupied by a large coagulum surrounding the heart and moulded to it. The heart itself was healthy in appearance, but on opening the aorta a circumscribed ulcer was found as large as the end of the middle finger,- which had perforated the vessel. From this point to the origin of the vessel, a distance of an inch and a naif, the lining membrane was of a dark red colour, coated with lymphy deposits. The semilunar valves were free from disease. From the character of the ulcer, its indurated edges, and the general aspect of the lining membrane of the vessel, Dr. Talley concluded the disease to be of long standing. The coats of the aorta were somewhat thickened close to the seat of ulceration, but the calibre of the tube was not at all increased, so that the disease presented nothing resembling aneurism. The symptoms having been eminently those of the third stage of phthisis, the author's attention was not directed specially to the state of the heart during the patient's life, so that he is unable to inform us whether the condition of that organ revealed by the post-mortem was attended by any peculiar phenomena during life.

VII. Aneurism of the Hepatic Artery, By Dr. Heinetch Wallmann. (Archiv fur Pathologische Anatomie und Physiologie, Band xiv. Hefte 3 und 4.)

The extreme rarity of aneurism of the hepatic artery justifies our placing the following

case briefly before our readers. Mrs. P , widow, a native of Bohemia, aged thirty-six,

had always enjoyed good health until three months before she came under Dr. Wallmann's care. , Since then she had frequent severe attacks of pain in the epigastrium, with free intervals, without jaundice or disturbance of the secretions or catamenia; she lost flesh, and the severity of the pains increased. On admission to the clinical wards of the Joseph's Akademie, Feb. 3rd, 1858, she was much emaciated; heart and lungs normal, the spleen enlarged, the liver projecting three*finger breadths below the ribs, and with hard edges; no ascites or fever; she had never had a blow in this region. The paroxysms of pain occurred daily, and at the time the epigastrium and hepatic region were very tender, but not at other times. The faeces had previously been firm and of brown colour, and suddenly became whitey-grey, but there was no icteric hue. Soon after this change of colour, the distended gall-bladder could be readily felt as a smooth round tumour. Ten days prior to death the patient became intensely jaundiced, the paroxysms of pain continuing, and the liver increasing in hardness and size. Death occurred on the 27th February, consciousness being preserved to the last. We can only make room for the prominent points noted in the autopsy. The liver was partially adherent to the diaphragm, the peritoneal covering thickened, the organ large, soft, friable, and green; the biliary ducts of the liver distended, the branches of the vena portae filled with fluid blood. The gall-bladder was much enlarged and distended with thick black bile, with numerous plates of cholesterin; the cystic duct was impervious, and the upper half of the hepatic duct distended; its communication with the cystic duct was interrupted by a tough, fibroid plug; the common duct was distended throughout. The stomach was contracted, so as to resemble a portion of intestine; the intestines themselves were collapsed. There was a pound and a half of sanguinolent serum in the pelvis; darkened coagula lay in the region of the transverse colon, in the left hypochondrium, and elsewhere in the abdomen. Between the upper edge of the stomach and the lower margin of the liver there was a tumour nearly as large as a child's head, so as to occupy a large portion of the space belonging to the lesser omentum. At the concave side of the liver, near the left margin, it was intimately adherent to the hepatic coat over a space 14 in. by 2 in. The tumour had an irregularly oval form, and at its lower convex end, close to the transverse colon, was a ragged opening an inch and a quarter long, from which a dark coagulum projected. This sac was filled with concentric layers of blood and fibrine, weighing altogether 1{ pounds. The sac consisted of dense wall?, from two to three lines thick, consisting of areolar tissue, with rough transverse bands bridging across the interior. The sac rested with a broad basis upon the hepatic artery, with which it communicated by a fissure one centimetre (0-393 inch) long, by four millimetres (0-156 inch) broad, the edges of which were hard and smooth. The hepatic and common ducts were partly inclosed in the walls of the sac. The portal vein was partly adherent to the posterior wall.

The author in his summary observes that the aneurism was probably due to a dilatation of all the arterial coats, which were gradually destroyed by pressure and other processes, because the arterial coats could only be demonstrated at the neck of the arterial tumour; they were not to be found at any other portion of the sac. The paroxysms of pain he accounts for by the irritation of the branches of the hepatic plexus enclosed in the sac, and the pressure exerted upon the solar ganglia and adjoming nerves. For the cause of the aneurism, Dr. Wallmann can offer no explanation.

VIII. Some Facts in Relation to the Nocturnal Incontinence of Urine in Children. By Dr. Addinem, Hewson. (The American Journal of the Medical Sciences, Oct, 1858. From Transactions of the College of Physicians of Philadelphia.)

In the House of Refuge (of Philadelphia ?) there are on an average 292 boys, and the habit of wetting the bed had become so prevalent, that Dr. Hewson, in 1857, was requested to suggest a cure. He found that no less than 78 boys were guilty of the practice, or a proportion of about 1: 3?. Dr. Hewson consequently subjected the whole establishment to a close critical inquiry, and continued his observations for live months. The results which he gives are drawn from the consideration of 63 of the 78 cases which remained in the house during the whole period; of these, 29 were whites and 34 negroes, and as the total number of whites and blacks was respectively 201 and 91, the affection was more than twice as prevalent among the blacks than the whites. The worst cases also occurred among the blacks. The average age of all was thirteen years, the extremes being seven and eighteen years; the greatest number affected at any given age was 9, the age being fourteen. The appetite was excellent in 53, poor in 10, though only 34 had the appearance of good health; 24 suffered from ascarides, including 5 of the 6 most inveterate cases. Herpes circinatus occurred in 7 white boys, and 1 had itch; 27 had clean, healthy tongues, 13 being white, 14 coloured; 19 had pale, putty-looking tongues, 8 being white, 11 coloured; 17 had a furred tongue, 8 being white, !) black; 26 had 1 evacuation per diem, 16 from 2 to 4, blacks and whites being equal in both instances. One black boy had no control over his sphincter ani; 20 suffered from constipation, including 3 of the 6 worst cases, but the worst case of all was regular in his bowels. Twentyseven of the cases urinated two or three times a day, besides morning and evening discharge; 28 passed water more frequently; 3 could give no account; 4 had no control over the bladder at all. The urine was normal in colour in 46, very pale in 17, acid in all. Average specific gravity among whites, 1016, among the blacks, 1020. Uric acid was deposited in 31 specimens, urate of ammonia in 8, urate of soda in 1, triple phosphate in 1. It does not appear that the urine of each boy was examined more than once. The prepuce and penis were discoloured, and the former elongated, either from frequently pulling or scratching or from masturbation, in no less than 46 cases, 21 being whites, 25 blacks. Eighteen boys confessed to masturbation; in 12 there was no suspicion of it, but the remaining 63 were strongly suspected, in spite of their denial. The greatest number were always reported as having wetted their beds on Wednesday and Saturday nights, the smallest always on Sunday nights; 2 did it every night without intermission, only 12 did it once a week, 3 not as often, and the remainder varied from 6 or 7 to once or twice a week. The diet on Wednesday and Saturday was salt pork, or fish and hominy for dinner for the coloured boys; the white boys had the same on Saturday only, and fresh boiled beef, soup, potatoes, rice, cabbage, and bread on the other days; and for the evening meal they had mush and molasses regularly every evening except Saturday and Sunday evening. On the former evening they had soup, on the latter bread and molasses. A sudden fall of the barometer or thermometer, or of both, always appeared to increase the number. Other influences at work were the better treatment of the white than the black boys, in regard to ventilation, exercise, and work.

The various remedies employed were first bromide of potassium in 2j to 3 grain doses thrice daily, with which 9 were cured; 2nd, tincture of sesquichloride of iron, from three to five drops thrice daily for six weeks (this failed entirely); 3rd, cantharides externally and internally (equally ineffectoal); 4th, each boy suffering from constipation received a dose of magnesia, those who had worms one drachm of turpentine and five grains of bicarbonate of soda, three times a day, and all received five drops of Squire's juice of belladonna, prepared by Bentley's process; they also had all a dry supper of bread alone, as previously ordered, and the cold douche. Each boy was made to rise and micturate an hour after retiring at night. A sudden diminution followed, and two weeks after commencement of this plan, only four cases besides those who wetted their clothes in the day were reported, and on their supper being reduced (as a punishment), the former four also lost the bad habit, and those only remained uncured who had diurnal incontinence, though they were improved.

IX. On the Pretence of Inosit in the Urine in Renal Diseases. By Dr. H. Vohl in Bonn. (Archiv fur Physiologische Heilknnde. Jahrgang 1858, Drittes Heft.)

Inosit, a saccharine matter, stated by Lehmann to be incapable of vinous fermentation, has hitherto chiefly been found in the muscular tissue of the heart. In the present paper the author shows that grape-sngar may in diabetes mellitns be replaced by inosit, the formula for grape-sugar being C,3HiaO,a+ 2 HO, for inosit CtjHnOu+4 HO. Cloetta has recently shown that inosit ocurs in the urine of persons affected with albuminuria—a circumstance that suggested the inquiry to Dr. Vobl which has led to his discovery. In a case of diabetes mellitus in which the test for grape-sugar oeased to yield the usual result, Dr. Vohl subjected the urine to the following examination:—The residue obtained by evaporation of the urine in a waterbath was precipitated with canstio baryta, aud the filtrate mixed with equal parts of weak spirits of vine (50 per cent.) again filtered, and the clear fluid mixed with strong alcohol, (90 per cent.) Chloride of sodium crystals were deposited on the walls of the glass cylinder, and also shining crystals resembling sulphate of lime, which on being dissolved in water and decolorized by animal charcoal, yielded on evaporation fine large tabular and columnar crystals. The crystals effloresced readily, and at a temperature of 100° C, yielded a residue of 16 to 17 per cent. Evaporated to dryness with nitric acid on platinum foil, and then treated with chloride of lime and ammonia, the reaction for inosit was obtained.

Dr. Vohl found that the increase of inosit was in the exact ratio of the diminution of the grape-sugar. At last, when the grape-sugar had altogether disappeared, ho was able to obtain as much as 18 to 20 grammes of pure inosit from the urine passed in the course of a day. Dr. Vohl tried to convert grape-sugar directly into inosit, but this he failed in achieving.*

QUARTERLY REPO'RTON SURGERY.
By John Chatto, Esq., M.R.O.8.E., London.

I. On a Nev> Elatlie Bandage inFraeture of the Jaw. By Prof. Boutsson. (Bulletin General de The"rapeutique, tome lv., pp. 13 and 02.)

In this paper, Professor Bonisson, of Montpellier, describes a new form of bandage, which he has found very useful in the treatment of fracture of the lower jaw, and which being constructed of clastic material, allows of the combination of solidity with the amount of mobility requisite for carrying on mastication, insalivation, deglution, and speaking. The point of support is derived from the cranium, by means of an open skull-cap, constructed of broad strips of leather or jean. One of these bands passing in front of the forebead, encircles the cranium below, and another passes along its antero-posterior diameter above, being joined to the first at its two extremities, and by two transverse bands. Next, a sling, composed partly of leather and partly of caoutchouc, is nicely padded and adapted to the chin, and is then attached on each side by means of two leather straps and buokles, to the band of the skullcap, a horizontal strap being attached behind, opposite the mastoid process, and a vertical strap in front, opposite the coronoid process. The amount of support may be easily regulated by means of the buckles, and its lightness, suppleness, and ease of application render the apparatus not oidy an effectual, but a comfortable means of adjustment. It secures effectual adaptation of parts, and with modifications may serve also in compound and comminuted fracture, as also in a variety of other accidents and diseases of the jaw.

II. On Intra-Ocular Haimnrrhage after Extraction of Cataract By Dr. Rivaud Landrau. (Annales d'Oculistique, tome xI., pp. 129-137.)

In relation to a clinical lecture upon this accident, by Mr. White Cooper, Dr. Rivaud Landrau observes that in more than 2000 operations for extraction, performed during seventeen years' special practice at Lyons, he has only met with this complication in four instances, the particulars of which he furnishes in the present communication. He rejects Mr. Cooper's hypothetical explanation that the occurrence is produced by reason of the complication of the case by the existence of deep-seated disease of the eye. In his own cases he has found, notwithstanding their differences in other respects, there has always been an evacuation of vitreous humour, either taking place during the operation itself, or resulting afterwards as the consequence of a contusion. The portion of the humour which remains, being propelled forwards during the spasmodic contraction of the ocular muscles which ensues, becomes detached from the choroid, and the haemorrhage is the consequence of the rupture of the minute vessels meandering in the hyaloid and between it and the choroid. It is impossible that the central artery of the retina should furnish the blood, as supposed by some authors, so considerable is the quantity sometimes. Mr. Cooper believes that the detachment of the vitreous humour is a consequence, not the cause of the haemorrhage; but this gives no explanation of the rupture of the small bloodvessels, to which the haemorrhage is due. This haemorrhage is to be found whenever there is a considerable escape of the vitreous humour; and as the haemorrhage is in the author's view but a consequence of such escape, its prevention is only to be sought in the measures which prevent the loss of this substance.

* Want of space compels ns to postpone several interesting articles.—E».

« AnteriorContinuar »