Imagens das páginas
PDF
ePub

suffocating dyspnca. The kernel then became firmly fixed in the right bronchus and after three days I was called upon to determine if it could be removed. Trachæotomy was resorted to for the purpose of reaching it. The instrument used to dislodge the foreign body was made from a very small flexible catheter and small steel wire similar to the bristle probang without the sponge attachment and by careful manipulation the point was passed beyond the kernel, the bristle portion expanded, and instrument withdrawn sweeping the kernel before it.

LITHOLAPAXY WITH ANÆSTHETIZATION OF THE BLADDER AND URETHRA

BY MEANS OF COCAINE.

Prof. Bruns, of Tubingen, describes a case of crushing a stone in the bladder, in which, instead of a narcotic, anæsthetization of the bladder by cocaine was successfully carried out. After previously disinfecting the bladder with a solution of boric and salicylic acids, one ounce and a quarter of a two per cent. watery solution of cocaine was injected into the bladder, and two and one half drachms of the same into the urethra; there the liquid remained for six or eight minutes, after being as much as possible brought into contact with all parts of the bladder by moving the patient in different directions. The crushing of the stone (which consisted of the oxalate, was very hard, and weighed 60 grains), was done in 33 graspings, lasting about 22 minutes, without the patient feeling the least pain. After evacuation, half an hour later, anæsthetization had become incomplete and the patient complained of pain when the bladder was full. After three days he was allowed to leave the bed, and after a week he was discharged.

Bruns concludes from the above that fifteen grains of cocaine suffices for the complete anæsthetization of the bladder and urethra during half an hour, and believes this fact to speak in favor of litholapaxy against cystotomy. At the same time he tries to refute all objections that have been raised to litholapaxy. First, he denies the superiority of cystotomy on account of antiseptic treatment, for its success has hitherto not been infallible, whatever the method of operation. Not until we succeed in obtaining by suture a regular healing per primam intentionem, will cystotomy be fully protected by antisepsis. The further objection, that after crushing, fragments remain in the bladder is no longer justified, for with the aspirator even

the smallest fragments will be recognized,being felt and heard by means of the catheter. Besides, a second attack is not obviated by cystotomy, for it does not always come from fragments remaining behind. Finally, one of the highest authorities on this question, Sir Henry Thompson, founding his opinion upon a great number of cases, says that in most cases crushing. entails less danger to the life of a patient than any kind of cystotomy.

With reference to this communication of Bruns, the Lancet of June 20, 1885, publishes an account by Dr. Fenwick (Hospital for Stone and Urinary Diseases), describing a case in which he failed successfully to anæsthetize the bladder; but we are not told how long the cocaine remained in the bladder, and besides half an ounce (16 grms.) of Auid is not sufficient to produce the effect intended.

SWALLOWED A SCARF PIN.

It is well to be prepared to allay the anxiety that is always caused by the swallowing of a foreign body. Dr. Arthur Trevor reports (Lancet) the case of a baby who swallowed a sharp-pointed scarf-pin about three inches long. He let matters alone, and the pin was safely passed per rectum, in a few hours.

FOREIGN BODIES INTRODUCED INTO THE EAR.

In the Med. Press Doctor Ormsby says that by far the safest and best mode of removal is by means of constant syringing with a strong stream of warm water. Forceps and snares and probes have been recommended, but if the patient happens to plunge, or become violent, in all probability the foreign body may be only driven farther into the canal; and farther out of reach; and particularly with children it is worse than useless to try any method but syringing with a gentle and constant stream of water; perseveringly applied this seldom fails to dislodge the foreign matter no matter what it may be. Insects sometimes crawl into the ear; they may be dislodged by making the patient lie on the opposite side, and pouring water into the affected ear; the insect not being able to go farther back, owing to the membrana tympani, and feeling the inconvenience of the fluid will beat a hurried retreat through the external opening. If any instrument is used except the syringe, a horse-hair snare may be employed with the least danger of doing injury, and if any exploration must be made with children, they should be placed under the influence of an anæsthetic.

THE DIAGNOSIS OF FRACTURES NEAR A JOINT. This is oftentimes a very difficult matter, and has frequently caused the sweat of anxiety to bedew the forehead of the most experienced surgeon. Crepitus, deformity, and mobility, these classical signs of fracture, Dr. Oscar J. Coskery tells us in the Med. Chronicle for July, are not infrequently wanting. But there are three other signs that stand us in good stead; fixed pain, the site and quantity of the hæmorrhage, and the perfect helplessness of the limb. It often happens, as for instance in fractures of the fibula alone, that we can observe no deformity, crepitus, or mobility, but, if we tollow the line of the fibula up, at one certain point the tip of the finger elicits pain. If this is always complained of whenever pressure is made upon this point, he thinks the diagnosis is plain. The pain is evidently due to the soft parts being irritated by the sharp edges of the fractured surfaces.

The second of these signs, the site and quantity of the hæmorrhage,should be considered thus: The patients whose cases he details fell, striking upon the outer side of the limbs, and ecchymoses slowly made their appearance on the inner side, and then in considerable quantity. Had the bleeding been the result of contusion alone, it not only would have appeared sooner, but at the point injured. As it was from the small and non-contractile vessels of the bone, the bleeding was longer in progress than it would have been in the soft parts, where very probably, a larger vessel would have been ruptured. Again, during this slow bleeding the blood had time to gravitate to a dependent position, or direction of easiest escape.

The absolute helplessness of that portion of the limb that contains the broken bone is, probably, the most important of these signs. The fact that a patient has not made a step after the accident, or raised his hand above his head, is a strong point to start from in attempting the diagnosis.

There is one mistake that he has several times seen made in diagnosticating fractures of the femur. When the patient is told to raise his thigh from the bed he can do so by contracting the hamstring muscles, sliding the heel upon the bed, and thus the lower end of the femur is pushed up by the head of the tibia; but the psoasmagnus and the iliacus do not contract.

ENUCLEATION, WITH REPLACEMENT OF THE HUMAN GLOBE BY THAT

OF A RABBIT.

A novel and suggestive operation is that recorded in the Boston M. and S. Journal, (Sept. 17,) by Dr. H. W. Bradford. When enucleating the eyeball, the nerves and muscles were carefully divided, and the eyeball just removed from a rabbit was inserted (some fresh egg albumen being previously poured into the orbit), the muscles and nerves being then accurately sutured together. The rabbit's eyeball retained its vitality and the patient possessed the power of moving the eye, a great improvement over the artificial substitute. The value of the operation cannot from one trial be fully estimated, and it is extremely dubious whether vision could be obtained by the union of the optic nerve. That it would prove, however of some practical value in the case of children upon whom enucleation has been performed, is credible, for it is well known that in those cases the orbital cavity is imperfectly developed. It is true that we would not expect the globe to increase in size if a fully matured rabbit's eye was taken; but Dr. Bradford suggests that the substitution of a young dog's eye might obviate the difficulty, as it would, in all probability if well nourished, increase in size as it would have done in its normal position. Cosmetically it could be used in those cases that are often met with where an artificial eye cannot be used on account of some deformity in the conjunctiva or lids.

PARACENTESIS IN PERICARDIAL EFFUSIONS.

I

2.

Dr. D. S. Leech considers (Med. Chronicle, September,) that paracentesis is called for:

Whenever life is imperilled by the copiousness of the effusion.

It should be tried, even if pericarditis be not in itself dangerous, in any cases of considerable pericardial effusions in which the pulse threatens to fail, whether it be due to inflammatory or degenerative changes in the cardiac muscle, or to general debility from severe or prolonged disease.

EXCISION OF THE LARYNX. This comparatively rare operation was performed by Mr. Henry Morris, on the 11th of July, for what turned out to be epithelioma. The patient had been suffering from severe laryngeal symptoms for four years; trachæotomy became urgent four months ago, and, more

recently, constant spasm and dyspnæa, due to the pressure of the growth on the upper part of the trachæotomy-tube had rendered his existence unbearable. The growth was confined within the airpassages; it filled the upper part of the larynx completely, and the cricoid cartilage partially. The larynx was removed by cutting through the thyro-hyoid membrane, and the tissue between the cricoid cartilage and the first ring of the trachea. The gullet and pharynx were not opened. The patient nearly a week after that operation had not had a bad symptom.

CASE OF RECOVERY FROM MALIGNANT PUSTULE.
Dr. W. E. Buck thus writes in the British Med. Jour., July 4.

Mr. F., aged 31, a veterinary surgeon, experienced on October 6th, a stinging sensation at the back of the right wrist. A small bleb was formed, which he scratched off, and there was some tenderness of the arm pit and elbow. He had a slight rigor. On October 8, he was seen by Dr. Meadows, who prescribed some salicylate of soda and tincture of aconite, in frequent doses, as his temperature was 104°, and the rigors continued almost the whole of the day. A black eschar began to form on the afternoon of the 8th, and on the night of the gth, it became about the size of a sixpence; its base was red and cedematous, and surrounded by some vesicles in a circular shape.

The temperature was about 104°; the patient felt cold and his tongue was foul. I visited the case with Dr. Meadows, and we injected pure carbolic acid under the eschar, using an ordinary hypodermic syringe. Unfortunately we could only introduce a small quantity, as it oozed out on the withdrawal of the syringe, and with it a serous looking fluid. I dried some of this fluid on a coverglass, stained it with methyl-violet, and found the well known bacilli of anthrax. We prescribed large and frequent doses of sodahyposulphite, and ordered also a large quantity of meat. Under this treatment he rapidly improved. On October 12, we again injected carbolic acid. The temperature came down, and, as the patient said he felt all right, the hyposulphite of soda was reduced to three times a day. The eschar did not finally separate for nearly six weeks, and the ulcer then soon healed. I believe that the main remedy in this case was the injection of pure carbolic acid, a mode of treatment which does not seem very painful.

There was a clear history of the disease, which was contracted

« AnteriorContinuar »