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DUBLIN JOURNAL
OF
MEDICAL AND CHEMICAL SCIENCE;
a 4 — \, aad ae ay a" See : EXHIBITING 4 t- | qAL COMPREHENSIVE VIEW smd «th ve * . 2 Se Pe vie an: ae Bayag ; 3 soul y rely OF THE £2 ‘¢ LATEST DISCOVERIES “ ~ * wa ie MEDICINE, SURGERY, CHEMISTRY, AND THE COLLATERAL SCIENCES.
DUBLIN: PUBLISHED BY HODGES AND SMITH,
21, COLLEGE-GREEN ; ~ LONGMAN, REES, annCO., ann SIMPKIN ann MARSHALL, LONDON; MACLACHLAN anv STEWART, EDINBURGH ; anp SMITH ann SON, GLASGOW.
1834.
Printed by R. Gratsperry.
HISTORICAL - } MEDICAL } ~ f
ep pe
- *
CONTENTS OF No. XIE.
ORIGINAL COMMUNICATIONS.
Arr.
1. On some Compounds formed by the action of Chloride of Platinum and Chloride of Tin. By Mr. Kang, - - : ° :
2. Report of a case of urinary Calculi, containing Human Teeth, removed from the Female Bladder. By Grorce WiLitam O’Brisgn, M.D.,
3. Medical Cases and Observations. By Mr. Rices, ~ - -
4. Report of a Case in which a Foreign Body was supposed to be present in the Trachea. By Ricuarp T. Evanson, M.D., - - -
6. Two Cases of Popliteal Aneurism. By Mr. Cottis, - z
7. Researches on Solidification of the Lungs in New-born Infants. By Epwarpb Jorerc, P.D.C.M.B., - -
8. A Case in which a large Molar Tooth entered and nae Seong the Larynx during the Operation of Extraction. By Joun Houston, M.D., - - - - - - ° - - -
9, On the occasional Occurrence of Mental Incoherence during Natural Labour. By W. F. Monrcomery, M.D., - - “ -
10. Practical Observations on the Treatment of some of the Diseases of the Lungs, &c. By a" Lirrie, M.D., - - = -
BIBLIOGRAPHIC NOTICES.
Observations on Obstetric Auscultation, with an Analysis of the Evidences of Pregnancy, and an Inquiry into the Proofs of the Life and Death of the Foetus in Utero, by Evory Kennepy, M.D., - - -
Transactions of the Medical and Physical Society of Calcutta. Vol. vi. -
A Lecture on the functions of the Sere es by Rosgert J. Graves, M.D., - - - -
Principles of Geology, by Gis os LYELL, iy “i M. G, S., - - -
SCIENTIFIC INTELLIGENCKE.
1. Chemical and Physical Science.
On the Development of Heat in the Flowers of the Caladium Pinnatifidum. —Onthe Reduction of Mr. Faraday’s Discoveries in Magneto-Elec- tric Induction to a general Law.—On the continued Rotation of a closed Voltaic Circuit, by another closed Circuit.—Composition of Mummy Powder.—Preparation of the Proto-tartrate of Meret and Potash, : - “ “ - - - . - -
a
19 29
36
42
69
132
il CONTENTS.
2. Natural History.
Peculiarity inthe Respiration of the Crocodile, —- - - - - 138
3 Anatomy and Physiology.
Causes of the Presentation of the Head in Accouchement.—On the Develop-
; ment of the Hair an¢ Wool.—Action and sounds of the Heart.—-Ex-
tracts from the Life of Caspar Hauser.—Glandular Nature of the Placenta, - - - - - = - ns - - 139
4. Pathology and Therapeutics.
Luxation of the Pubis in Labour.—Opium in Phthisis—Cholera among the Insane.—Extra-uterine Pregnancy.—Hemorrhage between the Placenta and the Chorion ; Abortion at seven months.—Vaccinaticn, Cowpox.—Congenital Exstrophy of the Bladder, - - - - t5l
5. Surgery.
‘vane nr =
Torsion of the Arteries.—Lisfranc on Superficial Cancer, ° - -
CONTENTS OF No. XIV.
ORIGINAL COMMUNICATIONS.
Art. Page
11, On the Use of Mercury in Ulceration of the Cartilages of Joints. By James O’ Beirne, M.D. - - - - - - - 159 12. A Case of Pneumo-thorax from Perforation. By Mr. Poor, - - 185
13. Surgical Report of Cases, treated in the Meath Hogpira! during the past Year. By Mr. Porter - 3 > : - 189
ia. A Case of Trial for Poisoning by Wc. By eae Epwarpb Bearry, M.D. - - - - . : - 203
15. Cases of certain Nervous Diseases, occurring principally in Females, with Observations. By Mr. Cusack - - : : - - 220
16. Pathological Researches.—Inflammatory Affections of the Brain, and its investing Membranes. By W. 1. Morcan, M.D. - ~ - 232
17. Cases of Uterine Hemorrhage. By Fieerwoop Cuurcnitt,M.D. - 244
BIBLIOGRAPHIC NOTICES.
Notices concerning Works on the Practice of Physic, Surgery, Pathology,
and Physiology, recently published in Germany, - - - 254 Cyclopedia of Practical Medicine, Part xix. : 2 - - - 269 Medical Periodicals in Germary, - - - - - “ - 275
SCIENTIFIC INTELLIGENCE.
1. Chemical and Physical Science.
Spark during the Freezing of Water by A‘ther.—Test for Hydrocyanic or Prussic Acid, and Method of appreciating the Quantity.— Extract of a Letter from Mr. William eiceery to M. a eh OF the Rota- tory Movements of Camphor, - - : - 28]
2. Natural History.
Extract from a Paper read by Dr. Houston, at a Meeting of the Zoological Society of Dublin, on the Diseases of the Animals which died in their Collection, - - - - - - - > ~ - 285
3. Anatomy and Physiology.
Analysis of a Memoir on the Mechanism by which the Sounds of the Heart are produced.— Discovery of Lymphatics in the Human Placenta and Funis.—Observations on the supposed Vision of the Blood-vessels of the Eye, - - - = - - - - - ~ 289
a
At | CONTENTS. #
4. Pathology and Therapeutics.
Page alic Bruit de Soufflet in Compression, or Engorgement of the Organs contained within the Cranium.—Snow Blindness.—Experiments on Cicuta and Henbane.—Treatment of Porrigo (Tinea).—lIodine An- tidote for Strychine, &c.—On the Poisonous Effects of the Cyanuret of Potassium, administered in the form of Enema.—Apparent Death which was continued for twenty Days, - - -s = - 300
Enceph
5. Surgery.
Lacerated Perineum, Treatment of by Operation.—Hearing, through the Apertures made by the Trephine.—Purification of Theatres of Dis- section, &c.—Traumatic Tetanus.— Neuralgic A ffections of Stumps.—
On the Branchial or Gill-like Openings in the Neck of the Human Foetus, as a Cause of certain Malformations.—Section of the Tendo Achillis, as a Means of Cure for Club-foot (pied bot).—Re-union of the Extremity of a Finger, which was completely cut off—On the Employment of Casts, (moules en platre,) in the Cure of Fractures of the Leg.— Worms in the Blood.—A Case of Scorching by Electric:
_ Fluid. —Wound of both Femoral Arteries without Hemorrhage, - 304
CONTENTS OF No. XV.
ORIGINAL COMMUNICATIONS.
Arr. Page 18. On Rupture of the Peritoneal Coat of the Uterus. By Mr. Wuire, - 325 19. On the Cause of the Pulse being affected by the Position of the Body. By Mr. Travers R. Buacktey, - - - - - - 332 20. Some Considerations on Scrofula, and the various means of Cure em- ployed at the Children’s Hospital, Paris, more particularly on the Effects of Iodine in the Treatment of this Disease. By James Eacer,
Mi - - - - - - - - - 344 21. Report of the Obstetric Practice of the Wellesley Tenale Tnstitution
during the Year 1833. By Henry Maunszxtr, M.D. - - 367 22. Letter from Dr. Witi1aMs on the Subject of Asphyxia, - - - 380 23. Extract of a Letter from Dr. Arrowsmiru to Dr. Graves, - - 383
24. A Case of Constriction of the Aorta with Disease of its Valves, and an Anomalous Tumour in the Right Hypochondrium. By Roszrr Law Nixon, A.B. - - - - - - - - 386
25. Researches on the Diagnosis and Pathology of Aneurisms of the Great Vessels. By Witriam Stoxes, M.D. - - - - - 400
26. Description of the Calculo-Fractor for Pulverizing the Calculus in the Bladder. By Mr. Feancis L’Esrrance, - - - - 440
BIBLIOGRAPHIC NOTICES.
An Introduction to Botany, by Mr. Joun Linptey, - - - - 444 An Investigation into the Remarkable Medicinal Effects resulting from the External Application of Veratria, by ALExANDER Turnsutt, M.D. 451
SCIENTIFIC INTELLIGENCE.
1. Chemical and Physical Science.
On a Method of so far Increasing the Divergency of the two Rays in Cal- careous Spar, that only one Image may be seen at a time.—Professor Faraday’s Recent Discoveries.—On the Action of Gases hurtful to Vegetation.—Experiments with Potassium and Sodium.—On the Influence of successive Impulses of Light upon the Retina, - - 462
2. Natural History.
Remarkable Skulls found in Peruu—Communication from Professor Scouler on the above subject.—Mode of Flattening the Head among the Tribes on the Columbia.—-Rapidity of Msge@hle Ona Introduction of Frogs into Ireland, - - - 478 a
ig
CONTENTS.
3. Anatomy and Physiology.
Remarks on an Anastomosis recently observed outside of the Liver, between
the Vena Porte and the Vena Cava inferior.—Professor Mont- gomery’s successful Injection of the Lymphatics in the Umbilical Cord.— Difference between Growth and Development ; Observations on Precocity ; Relations of the Genital System to the Growth of the Body - - - - - - - - : - -
4. Pathology and Therapeutics.
Reynaud’s Observations on the Tuberculous Diseases of Monkeys, as Com- pared with those of Man.—Irregular Formation of the Breasts 5
Supernumerary Nipples.—Explanation of the Phenomena of Metal - lic Tinkling.—Electricity for the Cure of Warts.—Relative Morta- lity of Different Countries ; Influence of Civilization on Longevi- ty; Mortality of Towns.—Ricord’s Treatment of the Ulceration of
the Os Tince, - : - - “ = : - 2
5. Surgery.
New Hernial Bandages ; Eolian Pads.—Ke-union of a Portion of the Thumb
entirely separated.—Caries of the Spine affecting the Cervical and Lumbar Portions.—Cancer of the Diploé, and of the Medullary Canal of each Femur, - - - - - - - =
NOTICE.
481
484
493
We have been prevented, by an unavoidable circumstance, inserting the Re- view of Dr. Blundell’s Work on Midwifery: it shall appear in our next Number.
THE
DUBLIN JOURNAL - MEDICAL AND CHEMICAL SCIENCE.
1 MARCH, 1834.
“ PART I. YF ORIGINAL COMMUNICATIONS.
tent son some Compounds formed by the Action of Chlo- pide of Platinum and Chloride of Tin. By Rosert J. Kane, M.R.1.A., Professor of Chemistry to the Apothe- caries’ Hall of Ireland, Corresponding Member of the So- cieties of Pharmacy and of Medical Chemistry, of Paris, &e. &e.
A\w accidental observation of the intensely red colour produced by mixing solutions of proto-chloride of tin and of per-chloride of platinum, induced me to examine into the nature of their mu- tual reaction at considerable length. I had very nearly reached the termination of my labours, when the records of them were, by some accident, mislaid; and except so far as my memory could serve, [lost every corrected statement of those results, to obtaming which I had devoted a space of many months. I re- solved to recommence the investigation at a future period. J have subsequently attempted to put that resolution into prac- tice, but have not been able to devote to it the necessary time. Still less do I now see any probability of having at my disposal VOL. Vv. NO. 13. B
S
vo
Mr. Kane, on some Compounds of
sufficient leisure ; and have therefore resolved, as I cannot again myself complete this train of research, to bring forward such a general account of the novel phenomena that I observed, as may have the effect of inciting others to the task. I fortunately possessed in the laboratory book such accounts of the experi- ments as may be sufficient for that purpose.
A solution of the chloro-stannite of ammonium (first de- scribed by my friend Dr. Apjohn) was placed to. evaporate in an unglazed biscuit ware capsule, in which there had been many weeks before chloride of platinum. The tin solution eradually became coloured red, and seeking for the cause of this, it ap- peared that the trace of platinum, which the dish had absorbed, was sufficient to colour intensely the solution of the chloro- stannite. To verify this rationale I mixed together solutions of proto-chloride of tin and per-chloride of platinum. A splendid red colour was immediately produced. To determine the nature ofthe body formed by the union of the two chlorides, and which possesses this brilliant tint, was the object of my future investi- gations.
Per-chloride of platinum and crystallized proto-chloride of tin were dissolved separately in small portions of water, and the solutions mixed: they became instantly of an intense wine red colour. This red liquor was divided into two equal portions ; one portion was evaporated very cautiously nearly to dryness, when on cooling it solidified into a mass of intensely deep rec crystals, very deliquescent, and staining the skin brown. ‘They were soluble in a small quantity of water, in alcohol and in ether ; these solutions were red. When they were evaporated the substance again separated in the crystalline form. It crystal- lized more readily from its etherial than from its alcoholic or watery solution.
These crystals are in plates, presenting an appearance like moirée metallique. When heated they give out much water acidulated with muriatic acid, (they had not been weil dried), some chloride of tin, and finally, after having been subjected
the Chlorides of Platinum and Tin. S
to a full red heat, metallic platinum and some peroxide of tin remains behind.
Although soluble in a small quantity of water, this sub- stance is totally decomposed by a larger quantity 5 ared pow- der separating, which, when dried, becomes brown. ‘These erystals are soluble in muriatic acid; the solution is reddish brown, and contains proto-chlorides of tin and platinum; the addition of potash not producing the separation of any chloro- platinate of potassium.
These crystals are, as was mentioned before, decomposed by much water: in order to examine the products of this de- composition, a quantity of the crystals was mixed with a large quantity ef water; a considerable quantity of red precipitate immediately fell: this was separated by the filter.
The liquor was acid. It contained free muriatic acid, a mixture of proto-chloride of tin, and much per-chloride. It did not contain any platinum.
The precipitate in drying became of a brown colour; it had not any trace of crystalline structure. It was totally indissolu- ble in water. When heated it gives out a white vapour which reddens litmus paper, and condenses into a white solid matter (chloride of tin). Metallic platinum, mixed with some per- oxide of tin, remains behind.
When acted on by nitric acid it forms a yellow liquor, from which per-oxide of tin is separated. When digested with muriatic acid it dissolves, forming a fine red solution, very similar to the original one. When acted on by an alcali, a black powder is formed. We shall recur to the detail of these reactions presently.
In order to analyze this powder, the following method was pursued :
‘Twenty grains of the red powder were boiled in water of am- monia until it was converted totally into the black powder. The water of ammonia was then neutralized, and nitrate of silver added. Chloride of silver was thrown down, which whea
2 Mr. Kane on some Compounds of
dried weighed 18.2 grains, equivalent to 4.48 grains of chlo- rine.
Twenty grains of the red powder were boiled in aqua regia until they dissolved entirely. The solution was then evaporated nearly to dryness. Nitric acid was added to it in excess and it was again evaporated: when nearly dry a quantity of water was poured on it, when a considerable quantity of per-oxide of tin was precipitated, which, separated by the filterer and ignited, weighed 12.2 grains, equivalent to 9.6 grains of metallic tin.
The liquor from which the tin was thus separated contained all the platinum as per-chloride. It was considerably concen- trated and then mixed with sal-ammoniac and alcohol. The scarcely soluble chloro-platinate of ammonium which was thrown down having been collected, weighed 10.7 grains, equi- valent to 8.13 grains of bi-chloride, or to 4.73 of metallic platinum.
By this analysis there were obtained from twenty grains of
the powder, Chlorine = 4.48
Tin = 9.60 Platinum — 4.73
18.81
The platinum existed evidently as proto-chloride, and it 1s very probable that the rest of the chlorine existed in the state of proto-chloride of tin. Now the platinum, united with 1.69 grains of chlorine to form proto-chloride, and the remaining 2.79 gains of chlorine converts into proto-chloride 4.64 grains, or very nearly exactly one half of the tin. In what state of combination was the other half? Let. us call to mind that when proto-chloride of tin is decomposed by much water, a white powder falls which contains pro-toxide and proto-chloride of tin, the tin being evenly divided between the two. It is evident that the proto-chloride of tin, existing in the crystalline substance, was decomposed by the large quantity of water, and
the Chlorides of Platinum and Tin. 5
we consequently obtained as much prot-oxide as proto-chloride of that metal in the precipitate.
Arranging, therefore, the results of the analysis on this principle, we shall have
4.73 Platina 4.75 Platina } = 6.42 Chloride of platina.
1.69 Chlorine 4.48 Chlorine 2.79 Chlorine _ 743 Chloride of tin. : 4.64 Tin 9.60 Tin d 4.96 Tin — 565 Oxide of t 69 Oxsiven } =. 5, xide of tin. 18.81 19.50 .50 loss. 20.00
Now calculating the atomic relations existing between these
proportions, we find them approximating very closely to
1 atom proto-chloride of platina = 134.20
12 atom proto-chloride of tin = 121.45 14 atom pro-toxide of tin = 100.35 356.00
and its formula, (Ch. + Pt.) + 14(Ch. + 8n.) + 13 (O. + Sn.)
On that supposition the precipitate would contain in twenty grains, Proto-chloride of platina = 7,56 Proto-chloride of tin = 0.02 Pro-toxide of tin =H ,02
There is a slight deficiency in the quantity of platina de- tained by experiment, and a trivial excess in the quantity of proto-chloride of tin. But the coincidence is sufficiently close to warrant us in considering such to be the real composition of this body.
6 Mr. Kane on some Compounds of
This substance is soluble in muriatic acid. ‘The solution is of a fine red colour, like the original liquor from which it had been precipitated. It is not decomposed by water if the murt- atic acid be considerably in excess. This solution, when eva- porated, gives a soft crystalline mass, very acid, and resoluble in water. These crystals were evidently composed of the chloro- platinite of tin, united to chloride of hydrogen (muriatic acid), and were evidently analogous to the oxygen salts which crystal- lize with oxide of hydrogen (water) in combustion.
When this acid solution is mixed with solution of corrosive sublimate, avery interesting effect is produced. The brown powder is again thrown down, the corrosive sublimate uniting with the muriatic acid. If the solutions be boiled together, a different effect is produced; the proto-chloride is converted into per-chloride of tin, while the corrosive sublimate loses either one-half or the whole of its chlorine.
We know that the proto-chloride of platinum and the proto- chloride of tin are both slightly negative, and their compound should therefore act feebly as a chlorine acid. Hence it unites with the positive chloride of hydrogen, forming a crystalline compound; from which, corrosive sublimate, being a much stronger acid, takes away the base; or we may suppose the muriatic acid to combine separately with chlorides, and a mere mixture of chloro-stannite and of chloro-platinite of hydrogen to exist in solution. Which ever view we adopt will have many analogous cases amongst the oxygen combinations. The former is that which I prefer in consequence of the red colour which a mere mixture should not possess.
By the action of much water the crystals are decomposed into this reddish brown powder and muriatic acid. From the analysis of the powder I therefore consider the crystals to be composed of one atom of proto-chloride of platinum, and three atoms of proto-chloride of tin. Its formula is (Ch. + Pt.) + 3 (Ch. + Sn.)
When ammonia acts on the crystals or on the red powder, it
the Chlorides of Platinum and Tin. 7
takes away the chlorine, and as much water is decomposed as converts the metals into prot-oxide and the chlorine into muria- ‘tic acid. Sal-ammoniac exists in the liquor, and there remains a jet black brilliant crystalline powder, which consists of plati- num and tin, both in the state of pro-toxide.
This substance is insoluble in water, soluble in muriatic acid. The solution is olive coloured, and containing platinum and tin, both in proto-combination. This solution is decomposed by water except it contains a considerable excess of acid. The precipitate is of a dirty white colour. Solution of sal-ammo- niac did not dissolve this powder. It was not acted on by so- lution of nitrate of silver or of ioduret of potassium.
When heated nearly to redness there appeared a sudden scattering, as if from an explosive disengagement of gas, and im- mediately afterwards it suddenly glowed intensely as if burning like tinder. During this combustion no gas was disengaged. When the process was carried on in close vessels there was a slight absorption of oxygen, but the combustion took place, though less completely, in hydrogen and carbonic acid. After this ignition the powder preserved all its external character. It was, however, then insoluble in muriatic acid, and soluble in aqua regia. The solution contained per-chlorides of platinum and tin.
It is easy to explain this phenomenon. The black powder is a combination of prot-oxide of platinum and prot-oxide of tin. The former substance is decomposed at a low red heat, giving out oxygen in which the prot-oxide of tin burns. The oxide of platinum does not yield enough of oxygen to convert the whole of the prot-oxide of tin into per-oxide, and therefore the combi- nation is less brilliant in carbonic acid than in atmospheric air.
The ammonia, by acting on the brown powder, takes away nothing but muriatic acid; the metals remain in the same pro- portions as in the brown powder, but both in the state of prot- oxide. If, therefore, the analysis given above of that powder
8 Dr. O’Brien’s Case of Urinary Caleult
be correct, this brilliant black crystalline substance is composed of one atom of prot-oxide of platinum, and three atoms of prot- oxide of tin. Its formula 1s
(O. + Pt.) +3(0. +58n.)
When this crystalline powder is digested in solution of pot- ash it loses its brilliant appearance and becomes dull. ‘The liquor contains prot-oxide. of tin. The dull black powder 1s prot-oxide of platinum. When the reddish brown powder, or the red crystals are digested in solution of potash the same ef- fect is produced; the chlorine and oxide of tin being dis- solved, and the oxide of platinum alone remaining behind. If the potash be considerably in excess, it takes up a quantity of the oxide of platinum, and becomes greenish coloured. ‘This oxide of platinum dissolves rapidly in muriatic acid.
T hope that the above description of these compounds may be found sufficiently interesting to lead to a more perfect inves- tigation. It must be imperfect to a certain extent, and I only bring the subject now forward that it may be more completely
investigated by others.
Art. Il.—Report of a Case of Urinary Calculi, containing Human Teeth, removed from the Hemale Bladder. By Gerorce Witiiam O’Brren, M. D., Licentiate of the Royal College of Surgeons in Ireland, and Surgeon to the Clare
Infirmary, Ennis
Mary Mac Manon, a labouring woman, aged fifty years, was admitted into the county of Clare infirmary, on the 9th of Octo- ber, 1833, suffermmg from symptoms of stone in the bladder. She complained of severe pain, and appeared much harassed and reduced by the complaint. |
The account she gave of her previous state of health was not very satisfactory ; from her statement, however, it appeared
removed from the Female Bladder. 9
that about four months ago she became affected with acute pain in the loins ; this, however, gradually diminished ; but was sue- ceeded about six or seven weeks since, by difficulty in making water. The desire to evacuate the bladder is now constant, and the pain felt on attempting to do so quite excruciating, es- pecially after the bladder has been completely emptied. The flow of urine is at times altogether interrupted; and the pain becomes then most severe until the evacuation is again re- stored. For the last three days she has had complete retention. hrregular shivering fits, followed by copious cold sweats and by loss of appetite and rest, have contributed to reduce her to a very helpless state.
Upon sounding the bladder, a seas can be distinctly felt, and seems to be of considerable size. She states herself, that once or twice, the stone came so close to the orifice, that she has been able to scratch some of it off, with her finger. The necessity for attempting to remove the stone having been determined on, the patient was placed in the sitting pos- ture on a chair, the legs being held asunder by an assistant. A small forceps was now introduced, with which, after much trou- ble, the calculus was seized ; but having broken on account of its brittleness, it again slipped away from the instrument. The forceps having been once more introduced, the calculus was with great difficulty secured between its blades. An effort was now made to bring it through the urethra, but after a long trial, it altogether failed. Finding that the stone could not be got thus to pass, a small incision (about a quarter of an inch long) was made, with a blunt pointed bistoury, in the ante- rior part of the urethra, as being the most convenient di- rection. On this being done, the calculus was readily extracted. It was of an oval shape, with its sides much flattened, and one of them smooth as if it had rubbed against another stone. From the opposite side appeared a projection about a quarter
of an inch in length, presenting a striking resemblance to a hu- ~ VOL. Vv. NO. 13. C
10 Dr. O’Brien’s Case of Urinary Calcul
man tooth, with the fang turned outwards. On clearing away the calculous matter from around this projecting body, it proved to be indeed a human tooth ; one of the molars possessed of a perfect covering of enamel.
During the operation the patient fainted, and continued so weak that it was necessary to remove her immediately to bed. A fuli opiate was administered and she remained tranquil for a few hours; at the end of this time, however, another paroxysm of pain came on, and after much suffering another calculus came away. From this time she got complete and permanent relief. This second calculus was of an egg shape, somewhat larger than the first, and quite smooth. On examination it hada glossy appearance at one end, which on being scraped presented the extremity of another tooth.
The patient slept well on the night after the operation, (which she had not done for some time before,) and she ex- pressed herself as having been greatly relieved. The urine at first flowed freely and constantly through the wound, which, however, had completely healed in a week. Her amendment was now in every respect rapid. She could retain her urine perfectly, and her general health and appearance were much improved.
In reply to our inquiries, she could give no account of the teeth which had been found in her bladder, nor had she any idea of their being there; but mentioned that all her teeth had been loose for the last thirty years ; since she had taken mercury for a venereal complaint, communicated by her husband. A num- ber of her teeth had from time to time fallen out; some having been found in her bed, which had dropped out at night, while she was asleep; but she could not say that every one had. been found that had dropped out. She had not had any serious illness from the time she had taken mercury until the present attack ; and at no time did ske appear to have had any complaint like inflammation in the abdomen. We are therefore left wholly to conjecture, in attempting to account for the novel
removed from the Female Bladder. 11
phenomenon, of human teeth being found to constitute the nu- clei of stone in the bladder.
In attempting to account for the presence of the teeth in this situation, it has been supposed that they may have been swal- lowed and so have passed by ulceration from the intestinal ca- nal to the bladder ; but this mode of accounting for the pheno- menon, is the more difficult, from the absence of all antecedent symptoms of abdominal disease, and the occurrence having taken place in the female ; unless indeed we may suppose the communication with the bladder to have occurred far up in the intestinal canal. The generation of the teeth in a diseased ova- rium, and their transit thence to the bladder, is a supposition equally difficult to reconcile with the history of the case ; and we are left but one mode of accounting for the occurrence, by sup- posing that the teeth may have been introduced by the patient herself ; an explanation for which there is no sanction in any thing that could be gleaned from the history of the case; but which certainly derives countenance from the records of some extraordinary cases of this description. I have not been my- self, however, led to adopt this opinion, but rather incline to the idea of the teeth having found their way from the intestinal canal into the bladder; though nothing in the history of the case enables me to account for their having done so. What was of most consequence to the patient, however, she was dis- charged from the hospital perfectly well, on the 12th of Octo- ber; after having been nine days under treatment.
12: Mr. Riggs’ Medical Cases and Observations.
Arr. Ul.—Medical Cases and Observations. By Caaruts Warsurton Rices, Surgeon to the Mullaglass and Cam- lough Dispensaries.
CONTRACTION OF THE CHEST, CONSEQUENT ON PLEURITIC INFLAM-~ ; MATION.
SamugL Wurtz, aged 27, became a patient at the Mullaglass dispensary on the 28th of March last, presenting the following symptoms :—much emaciation ; expression of countenance anx1- ous; breathing hurried, frequent slight cough, with trifling mucous expectoration; voice weak, and articulation abrupt.. Pulse 110, small, but firm; skin hotter than natural ; perspires freely on the breast and forehead towards morning; bowels pretty regular. Cannot lie on the right side; sleeps badly, and often awakes agitated by alarming dreams ; appetite much impaired. Left side of thorax dull throughout on percussion ; this- was rendered peculiarly evident from the opposite side. affording an unusually clear resonance; expansion of the: af, fected side hardly perceptible, that of the other proportionably. augmented. The stethoscopic signs were absence of the vesi- cular murmur, except over the subclavian, acromial and upper scapular regions, where it was heard feebly ; that on the sound side very loud, much more so than I had previously heard it under any circumstances of age or disease. Heart’s action visible at the apex, which occupies nearly the natural position, and its impulse audible over the greater extent of the diseased side. The account he gave of his illness was, that on the 12th of January last, when overheated and fatigued, he cooled suddenly, but experienced slight bad effects; after three days he again underwent much exertion, was overheated, and again allowed himself to cool incautiously. In the course of that night he was seized with acute lancinating pain under the left mamma ; the stitch he describes as having been most
Mr. Riggs’ Medical Cases and Observations. 13
intense. Heated salt, which is usually resorted to by the common people in this part of the country under similar emer- gencies, was applied to the side, and in two days from the be- ginning of the more violent attack, he was almost as instanta- neously relieved. The subsidence of the pain was immediately preceded by a sensation of something giving way within the chest. For two days prior to the urgent seizure, there was, he states, an indistinct pain, or rather uneasiness on either side of the lower part of the sternum, unattended by any consi- derable febrile disturbance. This feeling continued, in some degree, up to the period at which he came under my observa tion, and was that to which he referred me for the cause of his ill health. He was pertinacious in attributing the seat of this disease to that situation, and of ascribing all his other symp- toms as originating in the cause of the uneasiness there. He had been treated for a gastric affection, had applied a blister to the epigastrium, and used other remedies without experi- encing any benefit. ‘The history and symptoms, general and local, were characteristic of effusion into the left pleura ; and the following stethoscopic phenomenon, elicited by the effect of position and gravitation on the effused fluid appeared to fur- nish a positive confirmatory indication. On exploring the upper scapular region, immediately after his having reclined back- wards, respiration was inaudible ; but after the position forward had been maintained for some time a faint murmur was appreci- able. I repeated the examination of this fact several times; with the same result from each trial. He was put on the use of blue pill in small doses, conjoined with squills, and had a blister applied to the side. There was an unequivocal amendment i a week ; he could lie with ease on the unaffected side. Pulmonary irritation nearly gone, the cough and expecto- ration having almost ceased. Pulse 100; gums slightly tender. This treatment was continued with certain modifications, the fluid undergoing progressive absorption, which failed, however, to restore the sound on percussion, or that of respiration, and a
14 Mr. Riggs’ Medical Cases and Observations.
new feature, that of contraction of ‘the chest, was observed to be developed, becoming marked in an exact ratio to the ab- sorption. As there has been no variation in the condition of the chest for the last two months, I look upon the deformity as having reached the limits to which this rare and obscure form of disease extends, and presenting those distinctive charac- ters of this peculiar sequence of pleurisy as prominently at pre- sent as can be expected at any subsequent period of the person’s life. The diseased side is found, on admeasurement, to have shrunk three-fourths of an inch. On inspecting the motions of the chest, those of the left side have almost ceased. ‘There is very slight, if any, elevation during inspiration, and consequently no depression accompanying expiration, whilst, as would be an- ticipated, on the healthy side these motions are increased : there is heaving resembling the breathing of an asthmatic person ; the muscles of respiration seem, as it were, to aid the lung in the execution of its double function. In a state of quietude the inspirations amount to twenty-four in the minute; but the the slightest effort, even that of ‘speaking, produces marked acceleration. ‘The posterior costa of the scapula projects from the flattening of the side, which withdraws the natural support from that bone, and which, for obvious reasons, occurs most anteriorly, or towards the inferior costa. Respiration is faintly audible under the clavicle, gradually diminishing to the inter- costal space between the third and fourth ribs, where it ceases to be heard. In'the upper part of the back it exists to about the same extent, and in the same degree. ‘The sound on per- cussion presents similar gradations ; the dulness increasing from above downwards. .
I shall now offer a few observations on the pathology of this affection, and in these I will be ‘chiefly guided by the researches and opinions contained in Laennec’s work, referring the symptoms that were present at the invasion, and during the progress of the case under consideration, to the facts and prin- ciples deduced by that author, and attempting an analogical
Mr. Riggs’ Medical Cases and Observations. 15,
Inquiry to ascertain, by rational inferences, in what degree his conclusions will tend to illustrate the phenomena that were manifested in the foregoing case.. On reviewing the symptoms, I think it may be inferred from the undefined uneasiness expe- rienced at the lower part of the sternum, and the general indis- position, supervening on fatigue, and sudden cooling, that in- flammation in a latent form existed previous to the invasion of the acute pain, and that the violent pair indicated an intense augmentation of the inflammatory action ; and also that the instantaneous subsidence of the pain, and consequently the abatement of the high degree of inflammation may be attri- buted to sanguineous, or sero-sanguineous effusion ; or, according to the pathological nomenclature of Laennec, acute hemorrha- gic pleurisy arose during an attack of latent pleurisy. The sudden cessation of pain, and the subsequent condition of the patient, authorize, I think, the opinion that an internal hemor- rhage occurred, which controlled the inflammation, as ob- servation proves it may do. ‘There exists a diversity of opi- nion as to the cause of the more complete forms of contrac- tion of the chest. Laennec conceived that hemorrhagic pleu- risy could alone give origin to it, whilst other pathologists, doubting the propriety of limiting the production of the affec- tion to a single form of disease, have assigned other states of disease within the thorax, as contributing to, or occasioning its formation. Laennec ascribes the production of the deformity to the transformation of the pleural envelope into a fibrous or cartilagmous membrane, retaining permanently the compressed lung; and, therefore, as the absorption advances, the chest re- cedes ; and, finally, when the absorption is complete, and the costal and pulmonic surfaces are in apposition, or rather their adventitious membranes are approximated, they become, by an ulterior process, agglutinated. I think it will appear pretty evident, that in this case, from the time of the attack till he was put under treatment for the affection, very slight, if any,
16 Mr. Riggs’ Medical Cases and Observations.
absorption of the effusion had taken place ; and during this, a period of more than two months, the lung was compressed in a very considerable degree. Whether the non-expansion of the lung was owing to the duration of the compression, or its hav- ing an adventitious inelastic investment, binding it down, and preventing its expansion, must remain undecided. Perhaps both causes conspired to produce the effect, and that either singly would be insufficient to account for its production. This conclusion is perhaps justified by considering that it may not be invariably the result of hemorrhagic pleurisy, and the consequent formation of the fibrous, or fibro-carti- laginous covering, but may arise from other morbid conditions, the exact characters of which remain to be determined by pathological inquirers. A subject with this deformity was brought for dissection to the anatomical rooms in Trinity Col- lege some years ago; I was then a student at that school, and shall never cease to regret the opportunity I then lost of having this morbid condition inspected. The body was that of a lad about puberty ; on the left side of the chest, the lung was shrivel- led to the size of a very small clenched hand, invested by a thin, but compact membrane, of a bluish white colour, glistening, and bearing a close similitude to the tunica albuginea of the testis. It did not adhere at any point to the costal surface. There was no fluid in the chest, and the degeneration seemed to have obtained for a considerable period. Here there must have co-existed with obliteration of the lung, considerable con- traction of the thoracic parietes; and yet one anatomical cha- racter, which Laennec has given, the adherence of the pulmo- nic tothe costal surface, was absent. This I can state with the utmost certainty, as I was engaged in dissecting the body, and was struck with the peculiar smooth and shining appearance the surface of the contracted lung presented.
Mr. Riggs’ Medical Cases and Observations. 17
SINGULAR EFFECT FROM THE APPLICATION OF TARTARIZED ANTIMONY.
In a paper treating of thoracic disease, it will not, I con+ ceive, be inappropriate to subjoin the particulars of a singular growth, resulting from the application of tartarized antimony. I have not seen any similar instance noticed ; nor has it, so far as I could ascertain, been observed in Dublin or Edinburgh. I am, therefore, probably right in applying the epithet sin- gular to this production. It occurred on the breast of a man about twenty years of age; and in its dimensions and figure bore a pretty close resemblance to the expanded hand of a labourer: it was of uniform thickness, from eight to ten lines, very irregular on its circumference, occupying the centre of the sternum, and extending laterally over the sternal portions of the cartilages of the ribs, with which it seemed firmly incorpo- rated, being altogether immoveable. The surface of the tu- mour had a shining hue, and a constricted tense aspect, very like the skin on a cicatrix of some months’ duration. Minute, tortuous, but very distinct vessels were seen through the inte- guments covering it. It was dense, firm, and unyielding, and possessed all the physical characters of cartilage. It was devoid of sensation, and the compression, or rubbing of the fingers, gave no pain, nor any feeling but that im- parted to the skin. The man said it was intensely itchy when his surface was heated ; but that, and the annoyance from the bulk, were the only inconveniences it occasioned. At the time at which this description was taken it had existed nine months. Mr. Wilson, a distinguished surgeon, who has since retired from professional life, saw it at the same period. The tumour was produced by the hasty and indiscriminate in- unction of tartar emetic ointment, the circumstances of which were thus related by the man:—he had obtained a box of the ointment from a young man in the neighbourhood, a phthisical
VOL. V. No. 13. D
18 Mr. Riges’ Medical Cases and Observations.
patient, with directions to apply it night and morning, as he had himself done until the pustular inflammation was excited, to remove a catarrhal affection, with a high encomium, and promise of immediate efficacy. Instead of conforming to the directions, he rubbed the ointment in after very short periods, as that of one or two hours, until the eruption appeared, and then continued the application indiscriminately over the in- flamed ‘and suppurating pustules, until an intense general inflammation arose, the pain and tumefaction of which forced him to desist. No means were used to allay this violent action ; extensive suppuration and separation of the part ensued, fol- lowed by the gradual generation of the growth described. The nature and cause of this formation appear simple and ex- plicable, by attending to the physiological fact, that however identical the primary effect of inflammation may be in the dif- ferent tissues, and on the various surfaces in the body, there is a tendency to transformation or assimilation of the adventitious formation to a structure similar to that by which it was fur- nished. This is exemplified, for instance, in inflammation of the serous, mucous, and cellular membranes, each of which, under inflammation, secretes fibrine, which finally assumes the organization of the tissue that produced it. The result of in- flammation of the periosteum, as observable in cases of one species of node, and the state of the texture that exists in the progress of exostosis, so ably described by Professor Macartney, may be adduced as bearing on this principle, and as serving especially to explain the subject under consideration. It may, I think, be assumed, that the tumour was occasioned by the inflammation having been communicated to the perichondrium and periosteum, giving rise to a gelatinous exudation, which gradually increasing, and acquiring a concrete form, ultimately attained the cartilaginous consistence.
Dr. Evanson’s Case of Foreign Body in the Trachea. 19
Art. [V.—Report of a Case in which a Foreign Body was sup- posed to be present in the Trachea. By Ricuarp T. Evan- son, M. D., Lecturer on the Materia Medica at the School of Anatomy, Medicine, and Surgery, Park-street, and one of the Medical Attendants at the Institution for Diseases of Children. |
(Read before the Surgical Society of Ireland.)
In the month of August, 1832, Mary Brown, an infant, one year and one month old, was brought to the Institution for the Diseases of Children. The countenance expressed great uneasiness. ‘The face was pale and swollen ; and when I first saw the child, it had one of the hands applied to the throat, as if to indicate the seat of distress. Ona nearer ap- proach I was struck by the peculiarity of the breathing ; respira- tion was difficult, and a stridulous sound on inspiration, suggest- ed the idea of croup; but this idea was at once abandoned, being supported neither by the peculiarities of the symptoms, nor the history of the case.
On closer examination, the child was found to be hot, rest- less, and uneasy, and the pulse rapid. Expiration was short, but not impeded, nor accompanied by any peculiar sound. Inspiration, on the contrary, was long, forced, and difficult, and accompanied by a rough, rather stridulous sound. The child was hoarse ; and on looking into the mouth, the tonsils were found enlarged, and the back of the pharynx inflamed. No fit of coughing occurred during the examination ; but the mother stated that the child was subject to severe fits of coughing, which, however, from her description, did not seem to resemble the cough of croup. ‘The throat appeared swelled externally, more so than the face; and the hand continued often to be applied to the trachea as if uneasiness were felt there. The cry, though hoarse, became clear when the child screamed aloud. Bronchitis of the right lung was indicated on applying the stethescope.
20 Dr. Evanson’s Case of Foreign Body in the Trachea.
It was evident from the symptoms that the trachea was the seat of disease, but it was not a case of croup: what then was it? To the history of the case we were to look to deter- mine the diagnosis. I suspected the presence of a foreign body in the trachea, and inquired if the child could have swallowed any thing likely to stick in its throat ; when it ap- peared that up to Friday previous to the day (Tuesday) on which the child was presented at the institution, it had enjoyed perfect health. While its parents were at dinner on I'riday, the child, who was present, caught hold of some herring, which it forced into its mouth. Immediately, it was seized with a violent fit of coughing, and threw out what it had attempted to swallow, pointing to the ground where it fell. This was carefully examined, but no bone could be detect- ed. The child continued to cough violently, and the mother tried to force down with her finger whatever might be sticking in the throat. On withdrawing her finger, the child appeared to become hoarse. To this violence may be attributed the inflammation of the tonsils and pharynx.
The child passed a sleepless night, coughing and _ hoarse. On the next morning, the peculiar stridulous breathing (already. noticed) was perceived, from which we may infer it to have been the consequence of inflammatory action set up during the night. Castor oil was administered by the mother, we need hardly add, without any benefit to the symptoms, which becom- ing each day more severe and constant, the child was brought to the Institution on the Tuesday following ; the fourth day af- ter the accident, previous to which the child had been in per- fectly good health.
After hearing the history just detailed, little doubt was left on my mind, that the cause of the child’s sufferings was the presence of a foreign body in the trachea ; most probably a bone of the fish which the child had attempted to swallow. The particular character of such a foreign body, sharp and ad- herent, and calculated to cause inflammation in the mucous membrane of the trachea, would account for the peculiarity of
Dr. Evanson’s Case of Foreign Body in the Trachea. 21
some of the symptoms, differing from those more commonly ac- companying foreign bodies in the windpipe, especially such as are smooth and moveable. The usual stethoscopic signs of alternate freedom or ob- struction to respiration were absent; and a sound subsequently heard, as if indicating the movement of a smooth body up and down the trachea, was found to depend on the passage of bubbles of air, caused by respiration in the mucous secre- tion, with which the trachea became ultimately loaded. The constancy of the stridulous sound in respiration indicated the inflamed state of the mucous membrane, which could not fail to have been induced by the injury consequent on the pre- sence of a sharp and wounding body, and this view was con- firmed by the fact of this peculiar sound not having been heard until the morning after the accident, when there had been time for the occurrence of inflammation. This sound, though resem- bling that of respiration in croup, yet formed the only point of _resemblance ; the cry being quite clear when the child screamed aloud; and the character of the cough being materially diffe- rent ; neither indeed did the cough resemble that commonly attendant on the presence of a foreign body, it did not:take place in sudden and violent paroxysms, with comparatively com- plete tranquillity between, but was more of a harassing, teazing kind, though occasionally in a severe fit enough. The pecu- liarity moreover of the difficulty of breathing taking place du- ring inspiration, and not expiration, made a difference between the symptoms of the present case and those usually observed ; especially when the foreign body is round and smooth; but the foreign body in this case (if any) was sharp, angular, and likely to remain fixed ; while the history of the case lett. little doubt that a foreign body had been ‘swallowed, and what that foreign body was. After this statement, the case may appear clear enough, but when first presented, and before the history and symptoms could be thus collected and collated, it will be conceded that
22 Dr. Evanson’s Case of Foreign Body in the Trachea.
the case was one of some difficulty, if not doubt. Under these circumstances, and feeling that operation would most probably become necessary, I had the child brought to Mr. Crampton, consulting surgeon to the Institution, who examined the case with much care. He passed a bougie to remove the possibi- bility of any substance adhering in the cesophagus; when strangely enough, the child was found to experience immediate relief, the breathing having become freer and more easy. ‘This amendment, however, was but temporary, the former symptoms quickly recurring. As the child did not appear in any imme- diate danger, and some of the symptoms at least, were to be attributed to inflammation, it was determined to try the effect of active antiphlogistic treatment, before recourse was had to ope- ration, especially as the mother evinced a determined opposition to such a proceeding. Leeches were ordered to be applied to the throat ; and a purgative of calomel and jalap, with a strong solution of tartar emetic, prescribed. Next day the child was presented at the Institution, but no relief seemed to have been experienced from the remedies employed. The leeches had bled freely, the child had been well purged and often vomited, but the symptoms appeared to have increased rather than to have been mitigated, and even the bronchitis was found to have extended ; and now occupied both lungs. The child was again seen by Mr. Crampton, and operation immediately decided upon, but some hours elapsed before the parents’ consent could be obtained, or they got to bring the child to the Meath hospital, where Mr. Crampton was to have it under his care, as at the Institution for children accommodation for intern patients 1s not provided. The child was now seen by several medical men, all of whom agreed in the diagnosis already given, there being no second opinion as to the nature of the case.
When brought to the hospital the child was found to be in urgent danger, all the symptoms had become rapidly aggravated, and the general strength appeared failing fast. The surface
Dr. Evanson’s Case of Foreign Body in the Trachea. 23
was cold, face somewhat livid, and eyes glassy ; no cough was heard, but much uneasiness was apparent.
It is unnecessary to detail the steps of the operation which was performed by Mr. Crampton; suffice it to observe, that a little time was permitted to elapse after the external incision had been made, to allow of the subsidence of the hemorrhage ; a useful precaution worthy of notice. On plunging the knife into the trachea the child screamed aloud; but after the incision was completed, the voice was lost. The child started convul- sively (the mouth being covered with foam) and appeared in imminent danger of suffocation; but on the excision of the piece of trachea being completed, relief was obtained. The bone was carefully searched for, but could not be detected, though an elastic bougie was passed upwards two or three times, through the wound. The child was now restored to its mother, and placed in bed ; no immediate or very palpable improvement having attended on the operation, such as often occurs in cases where foreign bodies in the trachea have been operated for and removed; but which we are not always im- mediately to expect, even when the body is moveable in the passage.
On the morning after the operation*, however, some amend- ment was manifest ; though the child still continued to suffer much from some.of the prominent symptoms. The respiration was laborious, stridulous, and wheezing, being seventy in a mi- nute, while an occasional violent fit of coughing was necessary to remove the copious secretion of thick mucus that blocked up the opening in the trachea, which was with difficulty kept clear. The child, however, began progressively to improve, calomel and hippo being the only medicines administered. An occasional fit of violent coughing, at times threatened suffo-
Mr. John Hamilton kept an accurate daily report of the progress of the case,
while in hospital, with which he has kindly furnished me.
24 Dr. Evanson’s Case of foreign Body in the Trachea.
cation, but was to be attributed to the cause already assigned— the blocking up of the opening, with the profuse and tenacious mucous discharge. |
On the Monday following the operation, the quantity of this discharge was observed to be sensiby diminished: the cough was slighter and less frequent; respiration being, better performed through the natural passage.
The child continued to improve, and the wound, which had much contracted, now allowed of being closed without inconve- nience: but the cough was still occasionally very troublesome, and assumed so much of the character of pertussis, that a mix- ture containing carbonate of soda and opium was prescribed.
The mother now removed the child from the hospital, being provided with this medicine. Ina few days she returned, bring- ing with her the child, which had now nearly quite recovered. ‘The wound had completely healed, and the natural respiration been restored ; but some cough still remained, and the voice continued faint and hoarse, as was indicated when the child made a noise or cried. The change of voice continued for some time, nor was it restored to its natural sound for several months. But it has since become quite natural, clear, full, and Joud; while the cicatrix from the wound has contracted so much, as to leave little or no deformity, being, in fact, hardly perceptible.
The peculiar character which the cough had latterly as- sumed, with the continned hoarseness and feebleness of voice, may be, perhaps, accounted for by the irritation of the glottis, naturally connected with the inflammatory action going on in the upper part of the larynx ; some cases being on record, in which the adhesion of small foreign bodies (as saw dust) to the glottis, produced cough, very like pertussis ; while the thicken- ing, consequent on the inflammation, would account for the change of voice, and the resolution of that thickening, for its restoration.
This case cannot but be regarded as interesting and impor-
Dr. Evanson’s Case of Foreign Body in the Trachea. 25
tant. That the child had been rescued from impending death, by the operation of bronchotomy, no doubt could be enter- tained, and this may be deemed a sufficient corroboration of the correctness of the opinion which led to the performance of that operation ; for had a different course been adopted, it is but reasonable to suppose that a different result would have taken place. Still it was unsatisfactory that no foreign body had been found, and that neither during the operation, nor at any time subsequently, was the bone detected, though anxiously looked for by the medical attendants. Undoubtedly we may suppose that the bone, though present, might have easily es- caped amid the quantity of mucus that was expelled both by the mouth and through the artificial opening, and so have eluded detection. But still it was dissatisfactory that we should want this unequivocal proof of the correctness of our practice, though this by no means impeached the fact, that by that practice the child was saved.
But even this source of dissatisfaction is removed, if we may rely on the statement made by the child’s mother, and which re- lieves the history of the case from all imperfection ;—if, indeed, it is to be relied upon: for this, however, T cannot vouch ; but I feel called on to state what I have been told.
On going some days after the child’s removal from the hospital, to inquire after it, I stated my surprise that no bone had been found, when I observed a look pass between the parents, which made me suspect some concealment, and I im- mediately charged the mother with deception. She then con- fessed that she had herself extracted the bone, but had con- cealed it; at first, through fear that farther operation might have been resorted to, and subsequently through dread of censure, for having herself meddled, and then concealed what she had done. She produced a portion of fish bone, which she had carefully wrapped up in paper, and which she stated to be but part of what she had originally found; another portion broke off and was lost’ while I was examining it, so that the
VOL. Vv. NO. 13. E
26. Dr. Evanson’s Case of Foreign Body in the Trachea.
fragment which I was able to preserve, is but a small part of the bone originally found. This appears to be part of the bone of a herring, or other small fish, and was of its usual co- lour, though somewhat less firm than natural, when I obtained it. The woman’s story is this; on the fourth night, after operation, she thought she felt something hard stick in the sponge with which she was clearing away the mucus from the wound. A projecting point now began to appear whenever the child coughed, and the direction of this body seemed to be from the upper part and side of the wound. She assigns, as her reason for not informing some of the medical attendants of this fact, her dread that another operation would be resorted to for the ex- traction of this body. It projected so much before morning, that she was induced, herself, to attempt its removal, which she accordingly effected, but not without being obliged to use some force, and a small quantity of bloody matter followed, with which, also, the extremity of the bone was stained—this extre- mity, which she pointed out, being sharp and hooked. When removed, she states the bone to have been soft, and of a green- ish colour, like that of the mucus expectorated. On putting it into some whey to steep, this colour disappeared, and the bone lost its softness on drying. She says that she intended to have told me this when she saw me, which did not occur until my visit to her house, and then she made the statements I have mentioned. One circumstance she distinctly dwelt upon, that the child was found better next day, and breathed more freely through the mouth. This statement I find corroborated accord- ing to date in Mr. Hamilton’s report, who, at the time, knew nothing of the woman’s story, and does not, I believe, now cre- dit it, though he expresses no doubt that a foreign body had been present in the trachea. I do not enter into any discussion as to the probability of the woman’s statement ; I rather incline myself to believe it: but though its veracity would render more satisfactory the result of the case, as leaving nothing to conjec- ture, it is by no means essential to establish the correctness of the diagnosis or practice.
Dr. Evanson’s Case of Foreign Body in the Trachea. 27
AA striking and unexpected corroboration of the correctness of both, is derived from the details of the following case, most curiously similar in its history and symptoms, though far diffe- rent in its result; for the particulars of which I am indebted to my friend Dr. Maunsel.
A healthy child, about two years old, was suddenly seized with a paroxysm of coughing, followed by stridulous breathing, and so much dyspnoea, as appeared to threaten instant suffoca- cation. ‘The case was treated by a medical man as one of croup, which, in fact, it closely resembled. Relief appeared to follow the treatment, but similar paroxysms recurred from day to day, and became on each repetition more alarming. About ten days after the first attack, Dr. M. saw the child in the absence of the medical attendant. It was much debilitated; the breathing remained permanently stridulous, and paroxysms threatening suilocation, followed upon the least excitement. As the pro- traction of the disease threw doubt upon the supposition ori- _ ginally entertained of its nature, a more accurate inquiry was instituted respecting the circumstances attending its commence ment ; when it was discovered, that at the moment of the first seizure, the child had been sitting upon the knee of one of the servants, while the latter was dining upon fish. From a consi- deration of these circumstances, Dr. M. imagined that the symptoms might probably be accounted for by the presence of a portion of fish bone in the trachea, and suggested the perfor- mance of bronchotomy. As the case was enveloped in a good deal of obscurity, the operation was not, at first, acceded to. Eventually, however, it was performed, about three weeks after the accident, but the child was so much weakened, that it ex- pired immediately after the operation. A portion of herring bone was found lodged in the ventricle of the larynx.
From the history and result of this case, we derive a most instructive corroboration of the justness of the views entertained respecting the preceding one, and almost cease to feel any con- cern as to whether the statement of the bone having been dis- covered in that instance be true or not. Atall events, the history
28 Dr. Evanson’s Case of Foreign Body in the Trachea.
of these cases establishes, that the occurrence of a foreign body in the trachea of aninfant, leading to symptoms closely simulating those of croup, and capable of being confounded with it, is not an isolated fact. We have hence a salutary warning (if such in- deed be wanting) of the necessity for the most scrupulous ex- actness in investigating cases of disease oceurring in infants, who are themselves unable to afford us any clue as to the nature of their sufferings, while those around them are but too often interested in deceiving and misleading us, in order to con- ceal their own neglect or mismanagement.
When called upon, then, to treat a case of croup, (for every affection of the throat, accompanied by any wheezing sound, is so called by the attendants ofan infant,) we may bear in mind the possibility of a cause for the symptoms present, far different from what may have been suspected, and the consequent neces- sity for timely recourse to operation.
Far be it from me to wish to inculcate or induce a hasty recourse to such a proceeding, or to represent bronchotomy in the infant, as a trifling or even easy operation, such as it ap- pears to be when performed on the still, attenuated subject. No one who has witnessed its performance in the living infant, beset as it is with difficulties and dangers ;—the short neck, nu- merous blood-vessels, narrow, deep-seated windpipe, in frequent or convulsive motion,—can fora moment think lightly of this operation, or feel inclined, heedlessly, to undertake it. Yet we have just seen two cases, in which its performance became unex- pectedly necessary, and in one of which, its timely aid seemed to avoid impending dissolution ; while in the other, its undue pro- crastination hastened a death, which its earlier employment might, most probably, have prevented.
From these cases, also, we may glean a few points of general practical interest. We see that the irritation of a sharp foreign body in the trachea of a child, leads to an inflammation of its mucous membrane, ultimately extending over the whole bronchial tubes, accompanied by copious mucous or purulent secretion, and attended by stridulous breathing, much re-
Mr. Collis’ Cases of Popliteal Aneurism. 29
sembling croup; but not (it would appear) leading to the formation of the false membrane, so peculiarly characteristic of that disease. Had the foreign body been even coughed up, the resulting inflammation might still render the case subject for operation, like those instances in which croupy symptoms are induced by the inflammation of the larynx or upper part of the trachea, consequent on the irritation caused by the swallowing of vitriolic acid, or boiling water: and it is in such cases, before the inflammation has extended downwards, that bronchotomy is so serviceable, by affording the means of respi- ration, until the inflammation that obstructed the natural passage has subsided, or been subdued. Under such circumstances, re- lief is afforded by timely opening of the trachea, even though the foreign body, when such is the cause, be not removed, but this we may at least suppose capable of escaping or being re- moved from the opening several days after it has been made. Whether such a result is to be looked for, or may be at- tempted to be brought about by instruments, when the foreign body is situated lower down in one of the bronchi, is a question of great importance, but of ulterior research, which I do not now venture to enter upon. It has already received attention from Dr. Brown, in an elaborate essay published by him in the Edinburgh Medical and Surgical Journal; and I doubt not will derive farther illustration from the pen of Dr. Houston, in the very curious and interesting case, contained in this number.
i Se et
Art. VI.—Two Cases of Popliteal Aneurism. By Maurice
Conus, A.M., one of the Surgeons to the Meath Hos- pital.
Cast I.— Double Popliteal Aneurism, of fifteen years’ stand- ing. The right Aneurism becoming diffuse from injury. Ligature of both Femoral Arteries. Recovery.
November 1, 1833. James Brady, et. 38 years, a strong, healthy man; formerly an infantry soldier, and consequently
30 Mr. Collis’ Cases of Popliteal Aneurism.
exposed at times to violent and fatiguing exercise. In the year 1818 (without having received any injury of which he was aware) he felt a pain in both hams, and soon after perceived a tumour in each popliteal space. ‘These became somewhat larger when exposed to fatigue or cold; from the commence- ment a throbbing was felt in the tumours, but the patient was never prevented from attending to the duties of his occupation, These tumours continued stationary until August, 1833, when his right leg was much and severely bruised between two cows, (he was at this time employed as a cattle driver). ‘The tumour, in this limb, shortly after increased and became painful ; the throbbing augmented. The leg and thigh became swollen, and the foot numb and cold.
He came to the Meath Hospital in this state about six weeks ago, and as he refused to remain in the house at that time, I directed a cold evaporating lotion to be kept on for some time, and subsequently a moderately tight roller ; under this plan the swelling diminished and the pain abated. He shortly after resumed his labours, and exercised his limbs con- siderably, and in consequence, the tumour began again to increase. His leg and foot became swollen and cedematous, and he complained of numbness, and a want of sensibility im the limb. The tumour in the ham became more diffused ; and the pain, and an uneasy sense of constriction in the limb deprived him totally of rest. At this period there was no alteration in the aneurism of the left limb. In this state he was admitted into the hospital; the veins upon the surface of the limb were very distinct, and the saphena particularly promi- nent. There was a slight erysipelatous blush over the inside of the knee. Pulsation much diffused over the tumour. Pulse 90, rather hard; tongue clean; bowels regular. His general health was but little affected. There was not the slightest evi- dence of other disease in the remainder of the arterial system. He never suffered from palpitation of the heart, or difficulty of
Mr. Collis’ Cases of Popliteal Aneurism. 3h
breathing. He was placed in bed, kept quiet, allowed mode- rate diet ; some purgatives, and an opiate at bed-time, and a cooling evaporating lotion to the swelling. The pain dimi- nished, and the external inflammation subsided; but the tu- mour became daily more tense and extended: so that upon consultation it was determined to tie the right femoral artery, as the limb, as well as his life, became more and more en- dangered. I performed the operation on the morning of the 10th. The vessel was tied in the upper third of the thigh, with a single round ligature, consisting of three threads of three-corded silk. The patient did not lose a spoonful of. blood in the operation. This case proceeded favourably, and the ligature separated upon the seventeenth day. From the pe- riod ofits application the tumour gradually diminished, and the swelling of the leg entirely disappeared.
December 3. Able to walk about a little. The surface of the tumour is soft, and gives a slight sensation of fluctuation. It will, in all probability, suppurate before the patient gets quite well. |
On the 14th, I tied the left femoral. In endeavouring to separate the artery from the vein, I made a small opening, about the size of a pin’s point, into the artery, from which a rapid jet of blood took place. The artery was immediately compressed against the pubis, and a double ligature applied; one part of which was tied upon the highest exposed position of the vessel, and the other upon the lowest, leaving between both about a quarter of an inch of the artery. He did not lose more than about an ounce or two of blood. The tumour disap- peared almost entirely after the application of the ligatures. The limb retained a moderate degree of temperature ; every thing went on favourably, and on the 27th both ligatures came away. This man’s health is daily improving. His appetite is good, bowels regular. He walks about every day, and is gaining strength. The tumour in the left ham has almost entirely dis- appeared ; that in the right is daily becoming smaller.
32 Mr. Collis’ Cases of Popliteal Aneurism.
This case presents many points of deep interest ; among these, the following seem to me to be the most remarkable :
Ist. The great length of duration of the aneurismal tumours without their being productive of any unpleasant effects ; they existed almost stationary from the year 1818 to 1833. Iam not aware of any similar case being upon record.
2d. Both tumours occurring simultaneously, a very unusual circumstance, and the more particularly so, that there does not appear to have been any general disease of the arterial system.
3d. The disease occurring in both situations without any sensible injury.
4th. The little inconvenience suffered by the man; he was never prevented from attending to his duty, which at times must have been very laborious, until the period of his first ap- plication to the Meath Hospital.
In this case we had to consider many circumstances before undertaking the first operation. It was true, that the disease ex- isted in more places than one; but the conditions under which the patient had so long borne the disease were changed ; the right aneurism had become diffused from injury. The limb oedematous, and inflammation setting in. No alternative re- - mained, but to tie the vessel, or allow the man to die of gan- gene.
This operation having succeeded, I was encouraged to the performance of the other by the general healthy state of the arterial system, as shewn by the great length of time which elapsed from the first period of disease, by the patient’s bearing the first operation so well, and from the importance of placing him out of the danger of an accident, such as had happened to the right aneurismal tumour.
Case Il.—Popliteal Aneurism in a healthy subject. Opera- tion. Copious hemorrhage from the wound on the eighth and thirteenth days. Employment of pressure. Reco- very.
November 8, 1832. Michael Maddock, et. 30 years; a
Mr. Collis’ Cases of Popliteal Aneurism. 38
labourer, generally very healthy ; resides in the country, about five miles from Dublin; applied for relief this day. He has a large pulsating tumour in the left ham, which completely fills up the popliteal space, and which projects very much toward the outside. The swelling is hard, smooth, and elastic ; pulsa- tion strong ; the bruit de soufflet very distinct ; a slight blush of redness over the most prominent part of the swelling. By compressing the femoral artery (the action of which is very great) all pulsation in the tumour ceases. He cannot bring his leg into a straight position. The leg is swollen and cede- matous, and of a mottled colour. Complains of much pain in the ham, and numbness of the leg and foot. His pulse is about 100; no fever ; no indication of disease of the heart, or arterial system generally.
About five months ago he first felt pain in the ham, but did not perceive any swelling until three months subsequently. He continued at his work until three weeks since, when the tumour became suddenly larger, and very painful; the limb became much more cedematous, and he was obliged to remain in bed. A few leeches and a cold evaporating lotion were applied with relief.
Operation.—12th. I tied the femoral artery in the upper third of the thigh, at the usual place. Nothing particular occurred during the operation, excepting a little delay arising from some difficulty which was experienced in passing the needle around the artery, in consequence of its peculiarly close adhesion to the vein and sheath. Upon the application of the ligature the pulsation in the tumour immediately ceased, and he was placed in bed, the wound being dressed as usual. In the evening he complained of shooting pain along the back of his leg and thigh; did not sleep. No alteration in the size of the tumour, the apex of which is of a light purple or copper colour.
15th. Suffered much from pain in the foot and back of the leg. The muscles of the entire limb were occasionally thrown
VOL. V. No. 13. F
34 Mr. Collis’ Cases of Popliteal Aneurism.
into spasmodic action. A cold evaporating lotion was applied to the ham, which gave considerable relief. The leg and foot cedematous; the tumour feels more firm and contracted.
20th. Scarcely any alteration since the last report until this day. Upon dressing the wound, he complained that it felt much hotter than before, and a slight streak of blood was ob- servable upon the dressings. About four o’clock, p. mM. he experienced a sensation as if something gave way suddenly, and immediately afterwards he observed blood to gush from the sides of the wound. Before assistance could be obtained he lost, if was calculated, about twenty-four ounces of blood. ‘Temporary pressure with lint and the hand was applied, and I was sum- moned to his assistance. I found the man’s bed loaded with blood: I made an assistant compress the artery as it passes over the pubis; I then opened the wound through its entire length with my finger, removed all the coagula ; I then applied a small firm compress to the bottom of the wound, which I filled up with pieces of sponge, and over these I applied a presse artere, with a graduated screw, which was kept very tight until the 22d, when it was loosened, but not removed. During this interval he was bled from the arm, purged, took digitalis, &c.
25th. Some degree of erysipelatous inflammation having been produced upon the upper part of the thigh, and anterior part of the abdomen, from the pressure caused by the instru- ment, it was removed.
27th. On this morning I took away all the sponges and lint, which were soaked in purulent matter, and came away without any difficulty. The wound looks healthy, and is gra- nulating.
December 1. A small abscess formed on the upper and outer part of the thigh where the instrument pressed.
3d. About three o’clock this day (being thirteen days from the first attack of hemorrhage) a second took place; he lost only a few ounces of blood, as it was immediately arrested
Mr. Collis’ Cases of Popliteal Aneurism. 5
by our intelligent apothecary, Mr. Parr, who instantly filled the wound with sponge, and applied the screw, which was left on until the 7th, when it and the sponges were removed. During this period the state of the patient seemed nearly hopes less. His countenance was almost hippocratic ; he resembled. a person in a low stage of typhus, and a gangrenous smell ex- haled from the body. He was freely supported by wine, bark, and animal food. He had no further bleeding, and began to recover rapidly. On the 4th of January he was sent home, and soon after resumed his labours.
The instrument which I made use of was one previously employed by Mr. Crampton, the Surgeon General, in a similar case, and with good success. Jt consists of an iron hoop, about an inch and a half in breadth, and sufficiently large to encom- pass the thigh ; it opens behind, so as to admit of such dilata- tion as to suit a limb of any dimensions. This hoop has a slit in the anterior and internal part, into which is placed a move- able screw, with a pad attached. This pad is to be applied immediately over the compress, which has been put upon the artery, and then by turning this screw, any degree of compres- sion can be made upon the artery, whilst little or no pressure is made upon the other parts of the limb, and consequently no great obstruction, if any, is given to the collateral circulation. The hoop produced much inconvenience to this man, and was also the cause of inflammation, which terminated in abscess. ‘This arose from the instrument being too narrow upon the part on which the limb rested, and J have now got one constructed with a broad flat surface ; this is padded, and fits the under and outer part of the limb accurately, and on which the thigh rests without any inconvenience. To this are added two straps, one to surround the pelvis, and another the thigh, by which means the instrument is kept more firmly in its situation.*
* This instrument was made by Reynolds, of the Coombe, who has shown
much intelligence in constructing this and other instruments.
36 Dr. Joere’s Researches on Solidification of the
My chief object in recording this case is to show the advan- tage to be derived from pressure properly made, in arresting secondary hemorrhage, from such a vessel as the femoral ar- tery, and the greater benefit likely to arise from such a mode of proceeding, than from tying the artery higher up, which, in the majority of the cases in which it has been tried, has failed in saving the life of the patient.
Arr. VII.— Researches on Solidification of the Lungs in New- born Infants. By Epwarp Jorre, P. D., C. M.B. Leipsig.
Tue greater number of new-born infants die of convulsions, apoplexy, or suffocative catarrh; so, at least, we are told by the parents, and even by the medical attendants, who are often unable to give us any clearer account of the matter, or unwil- ling to take the trouble of finding out a more accurate explanation of it. And yet the sudden death, or remarkable wasting away of so many children, should incite every observer to do his ut- most to investigate the hidden causes of such melancholy occur- rences. According to some experiments and observations made in the Leipsic School of Midwifery,* the various conditions and accidents which so frequently endanger or destroy the life of new-born infants, depend on one and the same organic dis- ease of the lungs, resulting from either too difficult, or too rapid and easy a delivery. |
It appears that the infant, immediately after its expulsion from the uterus, has to make a strong and deep inspiration, in order at once to commence and to continue effectually the new vital process connected with the great change in the circulation which then takes place. Nor has nature neglected to make
* Dissertatio inauguralis pro summis in medicina et chirurgia honoribus ca- pessendis: ‘* De morbo Pulmonum Organico, ex Respiratione Neonatorum Im- perfecta orto ;” auctore Edvardo D. Joerg, AA. LL. M. Philos. Doctore, et Med. Baccal. Lipsie, 1832, sumtibus Barthi.
Lungs in New-born Infants. BT
every requisite provision for this; since by the diminished vi- tality of the membranes towards the close of pregnancy, and the gradual compression of the placenta during parturition, the former circulation of the foetus is obstructed, and the scarcely born infant compelled to compensate by inspiring, for the de- ficiency of oxygen thereby produced. The first inspirations are, in consequence of this deficiency, (a state resembling asphyxia by carbonic acid or other poisonous gases,) naturally the most powerful, and at once expand the lungs to admit the rush of blood ; so that the foramen ovale and ductus arteriosus may close and become obliterated : in which case the child continues to respire regularly, oxygenizes his blood, and is able to ery and to drink.
Thus the first cry of the infant, while it indicates its anxious, suffocating condition, serves at the same time to open and ex- pand its lungs, and is consequently more analogous to the deep sighing and groaning of persons taken out of cellars or caves contaming irrespirable air, than to a real expression of pain. Now, when any noxious influence prevents the development of this natural condition of the lungs, and produces the opposite one, it is evident that the consequences must be highly in- jurious.
Two cases have been observed, in which the respiration of new-born infants is rendered irregular, and organic disease of the lungs produced ; namely, Ist, too difficult, and 2d, too ra- pid and easy a delivery. The former by too great compression of the head, and consequently of the brain, (whether in the pelvis during violent pains, or by the forceps,) weakens the in- fant to such a degree, that it is absolutely unable to relieve it- self, and can only respire imperfectly, so that its lungs are but partially distended. The condition thus produced, is precisely similar to that to be presently described, except that in the latter, the pressure on the brain frequently produces inflamma- tion of that organ, and thereby renders the case more compli- cated.
38 Dr. Joerg’s Researches on Solidification of the
2. Too rapid and easy a delivery, in consequence of its short duration, and the inferior degree of compression of the placenta, does not produce the requisite obstruction to the foetal circulation, nor the due want of oxygen which makes res- piration necessary. The consequence is, that the infant only respires imperfectly, expands and fills its lungs with air but partially, and is never able subsequently to remedy this without the aid of art.
Under the circumstances above mentioned, we have often seen infants suddenly seized with illness, and sometimes die in spite of every exertion made to save them, before the real cause of the attack and the proper method of treatment were discovered ; and on examination the following appearances were observed, arising all from the same causes, though differ- ing greatly among themselves in many respects.
In every case in which we made a post mortem examination for several years past, a portion only of the lungs, from the greater half to merely an eighth or tenth part, was found filled with air, and of a red colour; while the remaining portion con- tinued in the same state in which it had been in the foetus, and was of a liver colour. When the infant had died..soon after birth, the condensed portion was susceptible of inflation; but where death did not occur till several weeks after that event, it was found carnified and incapable of being inflated ; sometimes the partition between the healthy and diseased portion was in a state of inflammation, and the latter contained vomice: the bronchi, too, were often inflamed and filled with mucus. The great contrast between the bright red of the healthy, and the liver brown of the diseased portions, struck the eye imme- diately on opening the thorax. In most cases, the foramen ovale was still open, and there were very firm polypi in the heart and large vessels. The brain was frequently gorged with blood, which was sometimes even effused between its mem- branes and over its surface: it also occasionally contained ab- scesses corresponding to others on the cranium, or fontanelle,
Lungs in New-born Infants. 39
that had been produced by the use of instruments, or by vio- lent pressure against the pelvis during delivery. In the rest of ‘the body, there was no particular morbid phenomenon con- stantly present: however, in the greater number of cases, the skin, particularly on the face, had a bluish cast ; while in some it was withered and emaciated, and the whole body, especially the intestines, pale and bloodless.
Krom these facts, and from observations made of late years during the progress of the disease, we are warranted in describ- ing its nature and terminations in the followmg manner: The solidification, or continuation in the foetal condition of a greater or less portion of the lungs, so that during inspiration their substance cannot be penetrated by the air. The blood, being still more incapable of penetrating, cannot be supplied with oxygen, and must consequently continue venous, and produce obstructions and dangerous congestions; while at the same time, from its being unable to afford the stimulus requisite to the system for the continuation of its functions, an atonic senile condition obtains, attended with the utmost weakness, and com- plete atrophy, and terminating in death in hectic fever. The general morbid condition is, consequently, difficulty of respira- tion and impeded circulation, producing dangerous and even fatal congestions. Its terminations are: Ist, recovery; 2d, se- condary diseases ; and 3d, death.
I. Recovery ensues when the efforts of the infant to inspire are assisted by proper treatment, and the subsequent symptoms properly managed.
Il. Secondary diseases :—(a) obstruction of the lungs, inas- much as a portion of them remains condensed, which, without actually producing death, is very oppressive and dangerous : (6) chronic cyanosis, the foramen ovale continuing open, and the infant being lable to constant suffering.
Ill. Death :—(a) from apoplexy; in consequence of ob- struction and congestion: (5) from suffocative catarrh, when the feeble respiration is not able to expel the mucus secreted in
40 Dr. Joerg’s Researches on Solidification of the
the bronchi, and the violent efforts at full inspiration produce bronchitis, and an over-abundant secretion of mucus, which the patient has not strength to get rid of: (c) from fever, the result of bronchitis: (d) from atrophy ; the production of animal heat being prevented by the deficiency of oxygen, and the whole sys- tem paralyzed by the want of its requisite stimulus.
Symproms.—When the infant comes into the world, the head is either found greatly swollen, (in which case abscesses often form in the part that has suffered from pressure, and in- flammation or violent congestion of the brain ensues,) or else, though quite uninjured, and the delivery having been rapid and easy, it cries but feebly, breathes very short, and exerts the muscles of the thorax greatly ; it is presently attacked with a faintness, and if it had been capable of drinking previously, now loses that power, the voice becomes hoarse and weak, and scarcely audible. Stertor and convulsions soon follow, the little patient becomes quite blue, the eye-balls turn, and the respiration remits, sometimes for so long as five minutes, till the scene at last closes with death. Should the illness continue for some days or weeks, a little short cough, the most certain sien of violent bronchitis, comes on; together with total weak- ness, atrophy, and hectic fever; and the child, at the very latest four or five weeks after birth, sinks under a violent attack of cyanosis, or bronchitis, or from the effects of the fever and atrophy.
The best method of preventing the organic disease of the lungs is, Ist, on no account to hasten the birth unnecessarily, because this never can be done without endangering the child ; and 2d, as far as possible to prevent too violent pressure on the head. The respiration of the new-born infant should be accu- rately observed, and the strength of its voice and manner of sucking attended to; and the moment we find the breathing too short, or the voice hoarse or feeble, and plaintive, or that the infant cannot suck properly, we must immediately exert ourselves to set matters to rights. In the first place, the me-
Lungs in New-born Infants. 41
dical attendant should immediately endeavour to blow air into the lungs, till the thorax is properly expanded. The navel- string must not be cut too soon ; the chest and back should be stimulated by friction with the hand ora brush; they might also be sprinkled with cold water and sulphuric ether, and the soles of the feet well rubbed with a flesh brush. The child should be put in a warm bath, and the friction continued till it is able to cry loud and breathe properly: should these means not succeed, recourse must be had to internal remedies. An emetic consisting of a few grains of ipecacuanha, a drachm of oxymel of squills, or a quarter or third of a grain of emetic tartar, should be immediately exhibited. Afterwards a quarter, or, In urgent cases, half a grain of calomel should be given, for the purpose of producing general excitement by stimulating the intestinal canal, as well as of diminishing the too copious secretion of mucus in the bronchi, and diminishing the cere- bral congestion. The repeated employment of warm baths, either simple, aromatic, (by the addition of thyme or marjoram, and calamus aromaticus,) or restorative, (composed of milk or some mucilaginous fluid,) contributes greatly to revive the sys- tem, and restore and promote the circulation. Simapisms of about an inch in diameter are occasionally to be applied to the chest or neck. ‘The most unwearied attention is requisite to restore and maintain the health of the little patient. By the proper application of the above remedies, by avoiding all the ledentia, and even by delaying as much as possible every birth that appears to be proceeding too rapidly, a great many lives may be saved: still the disease is a dangerous one from the very first, and requires great care and watchfulness through- out.*
* We beg to acknowledge our obligations to Dr. West, for his translation from the German of this original memoir. —Ep.
VOL. Vv. No. 13. G
42 Dr. Houston’s Case of a Tooth in the Trachea.
Art. VIII.—A Case in which a large Molar Tooth entered and passed through the Larynx during the Operation of Extraction. By John Houston, M.D. M.R.I.A., Demon- strator of Anatomy in the Royal College of Surgeons in Ire- land. Surgeon to Baggot-street Surgical Hospital, &c. &c.
(Read before the Surgical Society of Ireland.)
Joun Crare, etat. twenty-nine, a servant of the Rev. Mr. Brownrigg, of temperate habits and good constitution, had occa- sion, in the month of May, 1830, to get the second molar tooth of the right upper jaw extracted. On the first application of the instrument to the tooth, a fragment of the crown was chipped off, and removed from the mouth by the operator. By a second attempt, the tooth was started from its socket ; but on being loosened from the claw of the instrument, it suddenly passed down the throat, and was not seen afterwards by either the patient or the operator. Owing to the large size and firm hold of the tooth in the jaw bone, considerable dexterity and force were found necessary for its extraction.
I saw the man about four hours after the operation, when he presented me with the fragment which had been broken off in the first attempt, and gave me the following account of the sensations experienced at the time of the accident, and after its occurrence. He felt at the instant on which the extraction was completed, a momentary, sharp, prickling pain at the top of the windpipe. This was instantly followed by a severe fit of cough- ing, which soon went off, but recurred again several times with- out any evident cause, and at each time with less and less seve- rity, until, after a few hours it ceased to produce any further annoyance. ‘The man stated most positively, that he had not, for a considerable time previously to the accident, been subject to any cough, or other affection of the chest ; and that at the mstant of its occurrence, both he and the dentist attributed the sudden ac- cession of the symptoms, to the passage of the bone down his
Dr. Houston’s Case of a Tooth in the Trachea. 43
throat. He complained, also, that from the time of the perform- ance of the operation, he could not get rid of a feeling of unde- finable uneasiness in the chest ; a sensation of weight in breath- ing ; anda tendency to draw heavy sighs, which haunted and which kept his mind in a continual state of inquietude. Occa- sionally, but not at any regular intervals, he coughed up a little frothy mucus, perfectly untinged with blood or purulent matter. He had no hoarseness, no acceleration of breathing though he had walked nearly two miles, no pain in any part of his chest, and no relative difference in the facility with which he inspired, or breathed out the air.
In a consultation with several eminent professional gentle- men, held on him twenty-four hours after the accident, his con- dition was found to be the same as that just described, and the following stethoscopic signs were noted down: there was a mu- cous rattle in the lower part of the trachea, audible even to the naked ear, but very distinct when heard through the stethoscope. Both sides of the chest gave a perfectly and equally clear sound on percussion ; but notwithstanding their similarity in this re- spect, there was a marked difference in the intensity of the res- piratory murmur—the sound of the air entering into, and expanding the right lung, being obviously more feeble than that heard at the same moment in the left. ‘There was, likewise, under the right clavicle a slight sonorous rale, a deviation from the natural sound of breathing not discoverable in any part of the left lung. These signs were fixed and not modified or re- moved by any alteration in the position of the body; nor by causing the patient to expire with violence, or to take a full breath. In the consultation, various opinions were delivered respecting the course of the tooth, viz. whether it had entered the trachea, or passed into the cesophagus. Some gentlemen, whose faith in stethoscopic signs were not, at that time, (now nearly four years ago,) so strong as it has become since, placing little weight on that part of the investigation, and rely- ing solely on other symptoms, could not bring themselves to
AA Dr. Houston’s Case of a Tooth in the Trachea.
believe, that a large, splintered, and doubly fanged. tooth, could find so easy an entrance through the rima glottidis, and lie in the trachea, or bronchial tube, without causing distress of a more urgent nature, than that complained of by the patient ; seeing that so small a body as even a cherry stone, can produce so much disturbance there. The fit of coughing, induced at the moment of the accident, might, in their opinion, have been caused by a scratch of the tooth on the epiglottis, while passing through the pharynx into the cesophagus ; and it was considered that the transient existence of this symptom, gave confirmation to such a view of the matter. Then, as to the feeling of uneasi- ness, and tendency to draw heavy sighs which the man com- plained of, they were accounted for by supposing them to have arisen more from the alarm produced by the marked attention paid to the patient, on account of the singularity of the accident, than from any serious injury he had sustained.
On the other hand, it was urged by those present who happened to be greater believers in the value of the stethoscope, that the fact of the respiratory murmur being feeble and indis- tinct in the right lung, whilst the sound on percussion thereon was equal to that produced by striking over the left, taken in connexion with the rattle in the lower part of the trachea and top of the right lung, indicated the existence of an obstructing body in the right bronchus. ‘They were ready, however, to admit, that of these symptoms, no single one, nor indeed all taken together, could, of themselves be considered unequivocal evidence of the presence of the tooth in that situation; but, when viewed in conjunction with the other immediate conse- quences resulting from the operation, in an individual, too, pre- viously in good health, viz. the sudden and certain disappear- ance of the tooth; the violent fit of coughing which occurred at the instant of its extraction ; and the uncomfortable and op- pressed state of breathing remaining after, all in their opinion seemed to demonstrate the presence of the suspected body, cither in whole or in part in some of the air-passages, and
Dr. Houston’s Case of a Tooth in the Trachea. 45
most probably in the right bronchial tube. The case, how- ever, being of a very unique description, and the evidence in proof of the presence of the foreign body in the windpipe not being, in the minds of all, sufficiently decisive, it was deter- mined, that for the present, no hazardous operation could, with propriety, be undertaken. ‘The man was accordingly placed in hospital, in order that farther observations on his condition might be made.
Not having had from this period more than occasional in- terviews with the patient, as he had passed from under my care, and not being in full possession of the changes and treatment he underwent, I must content myself with stating, that he passed successively through the several stages of pneumonia, bronchitis, and pleuritis, first of the right, and secondarily of the left lung; that the early period of the illness having been allowed to pass over, without the performance of any operation for its relief, in consequence of the uncertainty and obscurity hanging over the case, it was deemed prudent not to make any unavailing attempt when the prospects of benefit from an ope- ration had passed away ; and finally, that he died on the ele- venth day from the occurrence of the accident.
The great interest excited by this case on account of the novelty attached to it, and particularly on account of the differ- ence of opinion respecting its nature, gave rise, of course, to a desire among all persons acquainted with its occurrence, to know the result of the post-mortem examination. Numbers were assembled to witness the opening of the body, when, un- expectedly, the friends refused their assent. No persuasion, no entreaty, no bribery, could change their determination ; and accordingly the corpse was removed from the hospital. How- ever, having watched the procession, and traced the body to the house in which it was laid, I at length, through the per- suasion of the Rev. Mr. Brownrigg, and by his consenting to remain present, obtained leave to make the wished for exa- mination.
46 Dr. Houston’s Case of a Tooth in the Trachea.
The following is an account of the post-mortem, as noted down at the moment of its performance.
Examination sixteen hours after death.—When the anterior part of the chest was removed, and the pleura opened, the lungs retained their natural fulness; no collapse on either side took place. The right lung was adherent on every side to the parietes of the chest, except posteriorly, where a considerable quantity of thin bloody fluid lay between the pleure. The pleural cavity on the left side was also obliterated by an univer- sal adhesion. The lymph effused between the pulmonary and costal pleuree of the right lung was in considerable quantity, firm and opaque, and evidently of several days standing; that especially, where the fluid noticed above was lodged, for an extent of seven or eight inches, was very abundant and tena- cious. The lymph which caused the adhesions on the left side was in smaller quantity, and appeared only as a thin semi- gelatinized stratum. In both, the pleura pulmonalis, when stripped of the artificial membrane, exhibited a highly vascular surface; on the base of the right lung it was red even to livi- dity. All the adhesions were, however, easily broken through, by pressure with the hand; they were obviously the product of the recent attack of inflammation.
The substance of the right lung was hepatized in every part ; its structure readily gave way under pressure with the finger: and when cut into, the surfaces of the section dis- charged a quantity of serum and dark fluid blood. The left lung, though less advanced in disease, exhibited all the marks of intense inflammation, its integral structure was dense, heavy, and swollen with engorgement.
Such was the condition of the pleura and pulmonary tissue ; the next and most interesting part of the dissection Jay in the examination of the air-passages. On slitting open the tra- chea from the larynx down to the lung, the obnoxious tooth was discovered lying in the right bronchial tube, about one inch beyond its commencement; the fangs were directed to-
Dr. Houston’s Case of a Tooth in the Trachea. 47
wards the lung, the broken crown looked up towards the larynx. The bone lay loose in the tube, and came away rea- dily when caught between the points of the scissors. It had two long fangs, and when tested with the splinter, which had been broken off in the first attempt at its extraction, and pre- sented to me by the man while alive, was found to fit most ac- curately to it, and make a perfect tooth.
1. The portion of tooth found in the lung, with the fragment at a short distance. 2, The tooth and fragment, of the natural size, joined together.
The mucous membrane of the air-passages, from the larynx to the finest ramifications all through both lungs, was in a state of intense inflammation ; it was tumid and softened in consist- ence, and of a deep red colour, as if injected, ‘The tubes were occupied by a muco-purulent fluid ; but there was no abscess around the tooth, nor even did the structures in the immediate vicinity of the foreign body exhibit a much higher degree of inflammation than those which were more remote.
None of the organs in the chest presented any marks of the existence of previous disease. The pleuritic adhesions were not of longer standing than the period occupied in the course of the late fatal attack; and there were neither tubercles, nor tubercular cavities in any part of either lung.
This case deserves to be recorded for several reasons :— First, on account of its rarity. Secondly, as it shows that a body, apparently much larger than the aperture of the rima glottidis, and one even of different form, can find a passage
48 Dr. Houston’s Case of a Tooth in the Trachea.
through that fissure. Thirdly, because it proves that so ob- noxious a foreign body as a full grown molar tooth may lie for a time in the windpipe, without being productive of much inconvenience. ourthly, on account of the additional evi- dence which it supplies of the justness of Mr. Key’s statement, that the right bronchus is the usual resting place for foreign bodies, which have passed the larynx. J%fthly, on account of the practical observations made soon after the accident on the state of the respiration, by percussion and the use of the stetho- scope. And sixthly, because by the sectio cadaveris, the cha- racter of inflammatory action induced by the presence of a foreign body in the bronchial tubes is demonstrated.
Respecting the first of these positions, viz. the singularity of the case, nothing such to my knowledge is on record. It is probable that such an accident was never dreaded by any one setting about the extraction of a tooth: and as the like may never occur again, the registry of it may rather be placed among the “ cas rares,” than held out as a caution against the prac- tice of tooth drawing.
Secondly : to understand aright how a body of greater ap: parent dimensions than the rima glottidis could have found a passage through that aperture, it is only necessary to reflect for a moment on the nature of the process of inspiration. ‘The in- troduction of air to the lungs with every breath, is consequent upon the enlargement of the chest—the weight of the atmosphere pressing the adjacent column into the cavity with a rapidity proportioned to the suddenness and extent of the dilatation, and with a force sufficrent to carry along in the current any light moveable body, which may happen to come in the way. A small body so intercepted, will readily pass with the air through the rima, and be lodged in a part of the tube lower down. A body of inordinate dimensions may stick so firmly in the aperture, that the full weight of the atmosphere is un- equal to its propulsion onwards, and death from suffocation will be the inevitable consequence, if the foreign body be not
Dr. Houston’s Case of a Tooth in the Trachea. AG
instantly shot back again by a powerful expiratory effort, or removed by operation. And, a body of intermediate size, viz. one of such moderate dimensions, as to be capable of passing through the rima, by stretching and divaricating the sides. of that aperture, may, when pressed heavily by the atmosphere, as it would during a forced inspiration, be driven past the ob- struction, and thence into the trachea or bronchial tubes.
Such latter was, no doubt, the mode by which the tooth. . in the case above related, found a passage into the bronchus. The man, holding his breath during all the time of the opera- tion, suddenly at the moment in which the extraction was com-’ pleted, took a full inspiration; upon which, the tooth, partly by its gravity, (the head being at the time thrown back,) and partly carried by the air rushing to the windpipe, fell over the aperture leading into that tube. The obstruction caused thereby to the further entrance of air, induced a spasmodic increase of action in the muscles of imspiration, and a consequent increase of pressure by the air at the opening, by which the tooth was driven with force through the fissure.
Thirdly: as to the freedom from pain or irritation from the presence of the foreign body, during the early part of the pa- tient’s illness, it constitutes an important fact to be borne in — mind in making a diagnosis in such cases: the absence of this sign had certainly much influence on the diagnosis of the case in question. It has been long ago observed by Louis, and the accuracy of the observation has been since confirmed by others, that foreign bodies in the air passages produce more irritation when lying in the neighbourhood of the larynx, than when low down in the trachea ; and that according as they are carried up er down by the air in breathing, so will the patients be afflicted with cough and dyspneea, or have freedom from such sufferings. The accuracy of the observation receives additional proof from the history of this case. The tooth, a large heavy body, not admitting of elevation by the expired air, lay uninterruptedly m
VOL, v. NO. 13. H
50 Dr. Houston’s Case of a Tooth in the Trachea.
the bottom of the trachea, and, as Louis significantly observes, “‘ lay easy.”
Fourthly: the case here related tends to confirm the opi- nion now generally entertained, that the right bronchus, in pre- ference to the left, is that usually occupied by a foreign body carried by the air through the trachea. It was into this part that Mr. Key found a sixpence to drop, when let fall in the dead body through the rima glottidis ; and it was here that he discovered the sixpence which caused the death of the indivi- dual whose case led to the performance of such experiments. The multiplication of proofs in favour of an important patholo- gical fact, and one which may lead to greater accuracy of diag- nosis, and greater precision in the performance of any opera- tion, undertaken for the safety of human life, is of great value ; and it is obvious, that such must be the tendency not only of Mr. Key’s highly interesting communications, but of that just offered by me in corroboration of his statements. With re- spect to the possibility of saving, by an operation, the life of the individual in question, no more can at present be said, than that some attempt would most likely have been made, had the presence of the tooth in the right bronchus been clearly ascertained ; and that the forceps recommended by Mr. Key, consisting of two long narrow blades, capable of being passed down the trachea through an artificial opening, might have been those to which a trial would have been given. It is clear, that the ordinary operation of making an opening in the wind- pipe, through which the offending body might be expelled by the efforts of expiration would not have been sufficient. ‘The tooth should have been actually lifted from the right bronchial tube by mechanical means; otherwise its removal could not have been accomplished. The weight of the body would have opposed its elevation from the bronchus by any force which the expired air could exert upon it; and its size and irregularity of form would have been unfavourable to its discharge through such an opening as the calibre and connexions of the trachea would admit of.
Dr. Housten’s Case of a Tooth in the Trachea. 5k
Fifthly: the application of the stethoscope to the detection of foreign bodies in the air passages, is a recent improvement in the use of that valuable instrument. ‘The absence of respiratory murmur in one lung during inspiration, when, by percussion, it is proved that the cells of the organ are healthy, and filled with air, is, in a case of this nature, a clear proof of the presence of an obstructing body in the bronchial tube leading to the af- fected organ ; and the circumscribed mucous rale, audible in the same place, may be considered as indicative of an increase of se- cretion, caused by the presence of the local irritation. These phenomena, so intelligible consequences of the accident, and so characteristic of its nature, were first observed in this city, in two patients in the Meath Hospital, and their presence alone justified and led to the performance of successful operations for tracheotomy.* |
Sixthly: the pathological condition of the thoracic organs of this patient presented some points of interest. The morbid changes induced by the late inflammation, were not all of equal standing; they had, on the contrary, commenced in different parts in succession, and might be traced as from a centre, re- ferrible to the right bronchus the seat of the tooth—through the mucous membrane, pulmonary tissue and pleura, first of the right, and subsequently of the left lung, until all these textures were involved in the same disease. Ordinary instances of bronchitis induced by cold, are not prone to run rapidly into pneumonia, and much less to spread to the serous membrane covering the lung ; the case, however, appears to be very different where the inflammation of the mucous membrane is caused by the presence of a foreign body, as is shewn by the dissection of the lungs in the individual, the subject of this communi- cation.
* These two highly interesting cases are recorded in the 5th vol. of the Dublin Hospital Reports, by Professor M‘Namara. |
32 Dr. Montgomery on the occasional Occurrence of
Art. [X.—On the occasional Occurrence of Mental Incohe- rence during Natural Labour. By W. F. Monrcomery, M.D., Professor of Midwifery to the King and Queen’s College of Physicians in Treland.
Pernaps I cannot more appropriately introduce the remarks which I have to offer on this subject, than by quoting, as a pre- liminary observation, one prefixed to a highly instructive and valuable paper on vaccination, lately published by Dr. Maun- sell in this Journal, his words are: “a very limited experience must be sufficient to expose to any thinking person the fallacy included in the supposition, that the difficulties and perplexities of a practitioner are chiefly to be met with in the more danger- ous and rare cases of disease.” Now, if there be one subject more than another, to which such a fallacy is found to extend its influence injuriously, it is that of natural labour, the laws, circumstances, and phenomena of which are usually considered as matters of such constant and common-place uniformity, that it is deemed quite enough to have ascertained, that a labour is natural, to enable us to anticipate every symptom that will arise, and understand every circumstance likely to occur during the whole of the process; in short, that as soon as we have been pre- sent at a few cases, we may with a safe conscience rest satis- fied, that we know all that is to be known of the matter, and adopt the comfortable maxim, “ ex uno disce omnes,” a rule of discrimination which we might, with just as much propriety, attempt to apply to the human head and face, and assert their universal similarity, because there is in all an assemblage of the same parts ; but even in those which are to the careless ob- server indistinguishably alike, how easily does the quick and practised eye of the anatomist detect imperfection of structure or irregularity of arrangement, or the phrenologist or physiog- nomist recognize the characteristic differences which distin- guish the philosopher from the sensual voluptuary or the vil-
Menta! Incoherence during Natural Labour. 53
lam; so also will the skilful painter discover and appreciate varieties in proportion or expression, which as perfectly dist'n- cuish one individual from another, as if they belonged to diffe- rent species; and by such nice discrimination of these more delicate points, and his power of treating them correctly, does he earn for himself well-merited praise and high reputation ; and so it is or ought to be in our profession; and my belief is, that there are not to be met with any two cases of labour, which, if carefully observed, will be found precisely alike ;* nor any one case which, when attentively watched, will not pre- sent to us some interesting variety of circumstance, or suggest some new idea, thereby adding to that stock of knowledge, which is to render us afterwards more certainly useful to our patients, and consequently assist us in advancing to professional eminence, by means which are at once the most creditable, safe, and certain. It is by no means my intention to trespass on the time of the reader or weary him, by even an enumera- tion of the symptoms or aggregation of circumstances, which usually present themselves in natural labour, with which, I will take for granted, that he is already perfectly familiar; but I may be permitted to advert to one fact vitally connected with our subject, for the purpose of shewing how slowly some, even of the circumstances apparently easily known, became objects even of consideration, much, less of knowledge. I allude to the relations which the head observes with regard to the pelvis, as it descends through that cavity and issues from its outlet : now, strange as it may appear, it is nevertheless not more strange than true, that although men of great talent and observation were employed in the practice of midwifery, and distinct trea- tises were written on the subject, so far back as the beginning
%* Such also, and even more decided, was the conclusion to which Denman’s experience and talents led him ; ‘¢ we may,” says he, “ probably never meet with
any two labours in any respect exactly similar.” p. 284. ed. 5.
54 Dr. Montgomery on the occasional Occurrence of
of the seventeenth century,* when the works of Ambrose Paré were collected and translated, when the great Harvey prac- tised midwifery, and wrote his “ Ewercitationes de partu,” and when Ruysch was elected Professor of Midwifery by the States of Holland, still no idea was entertained of the true me- chanism of the passage of the head, nor was even an attempt made to explain it, until the middle of the eighteenth century, when Sir Fielding Ould, then master of the Dublin Lying-in- Hospital, published his view of it in 1742;+ in fact, we had no full, clear, and satisfactory account of it, until Negelé of Heidelburgh published his “ Mechanism of Parturition” in 1829.t And yet I need not here insist, that on the correct and intimate acquaintance which we possess of these relations, and our expertness in detecting them by examination, depends al- together our capability of managing or correcting malpositions, and of applying and using instruments with advantage and safety. Still I regret to believe, that there are many, very many who consider it quite sufficient to have ascertained the present- ing part to be the head, to satisfy them that all is right, and who, to use the words of Dewees, “ committhe whole charge of the labour to the management of nature, if the head present, no matter how, and as she is usually successful, however hard the struggle, never stop to inquire whether they could have aided her efforts or abridged her toils ;”§ never considering
* I am aware, that there were publications of even earlier date, as for in- stance, ‘‘ The Byrthe of Mankynde, or the Woman’s Booke,”’ in 1540, but they are not of any authority.
+ Before that period it appears to have been taken for granted, that because the head issued from the pelvis with the occiput towards the pubis, and the face to the sacrum, it passed into and through the pelvic cavity in the same position, which was accordingly designated as the “ situs capitis rectus et equus.”’ See figure in Mauriceau, vol. i. edit. 1712, p. 243, and also Deventer’s 8th and 9th plates, French edit. 1734, pp. 95-6.
¢ Negelé’s book was printed in Germany in 1822, but it was not known in this country until the publication of Dr. Rigby’s translation in 1829.
§ Compendium of Midwifery, page 237, par. 577.
Mental Incoherence during Natural Labour. 55
that there are at least five varieties of relation between the head and the pelvis, each of which is accompanied with a corres- ponding difference in the circumstances of delivery, and, of course, may require a very different mode of management.
If in dwelling even thus long on matters so familiar to most of my readers, I have trespassed on their patience, I can only urge in extenuation, the extreme importance of the subject of natural labour, which Denman tells us, “‘ was the last thmg well understood in the practice of midwifery ;” * and the engrossing interest with which it is invested, as being not alone a delicate branch of professional inquiry, but also a process whose results so powerfully influence our domestic happiness, and are associated with some of the purest and tenderest feelings, which spring from and cement the most sacred of our social relations.
I shall now proceed to notice the particular symptom of in- coherence during natural labour, to which I wish to call atten- tion ; and I am the more anxious to do so, because, as far as I am aware, it has not been described by any writer on mid- wifery. It is well known, I presume, to every one who is con- versant with the management of labour, that the period of that process at which the os uteri becomes fully dilated, and is put severely on the stretch by the head passing through it, is one of extreme distress and pain to the patient, who generally at that time is much agitated, experiences a smart rigor, and vomits ; but in addition to these and other symptoms of almost constant occurrence, I have observed, that the impression thus made on the system is in so many instances accompanied by incoherence or temporary delirium, that I have ceased to re- gard its occurrence as a matter of surprise ; and yet I confess, that I was six years engaged in the practice of midwifery, hav- ing also attended the Lying-in-Hospital for two years and a half, before I took notice of this fact, which was at length
* Introduction to Midwifery, ed. 5, p. 268.
56 Dr. Montgomery on the occasional Occurrence of
presented to my observation in characters so forcible, as not to be overlooked or easily forgotten: since then, I have watched closely, and have frequently met with it; sometimes strongly marked, at others so slight as almost to escape observation ; but perhaps the best description I can give of this circum- stance, will be collected from a brief detail of some of the cases in which it was observed. I shall therefore select three out of those in which it occurred under my own observation, and three others which were communicated to me in conse- quence of my having discussed the subject in my lectures. Case J.—A. 8. in labour of her second child, of very irri- table temper, was going on favourably, and without any symp- tom calculated to excite attention, until the rupture of the membranes, which took place before the os uteri was fully di- lated, the pains increased. in strength, and the head began to press hard into and stretch the os uteri: in a few minutes after- wards, on my asking her some indifferent question, she popped her bare leg out of the bed, and requested that IT would unlace her boot and take it off, for that it made her very uncomfortable, and was insupportably hot in such warm summer weather ; then a pain or two passed over, and she again reiterated the request about my taking off her boots, or that I would allow the nurse to do so, and if not, that I would at least pour the contents of the water jug over her to cool her; then two or three pains more passed over, and she started on a new theme, “ Doctor, don’t you think Mr. him a charming man, I wish I was married to him, and S name she mentioned, was, perhaps, the ugliest man to be found any where : all this lasted about a quarter of an hour ; the head then passed the os uteri, and she presently dozed a little; the
is a very handsome man, I think
might marry any one he liked.” The gentleman whose
labour afterwards went on for several hours, and rather severely, but she had not the slightest return of the incoherence, and re- covered well. ‘This was the first time I had observed this oc- currence, and it alarmed me exceedingly.
Mental Incoherence during Natural Labour. 57
Cass IL.—Mrs. D. aged 25, of very irritable habit, and ra- ther ardent temper, sent for me at ten o'clock, rp. M. ; it was her first labour, and was proceeding actively with powerful pains. At half past one the membranes ruptured, and the head began to bear upon and into the os uteri ; at two o’clock, when this part was fully on the stretch, and she was covered with perspiration, she turned to me and said, that she “ would not go down to the drawing-room ; for what would visitors think if they saw her sit-_ ting there, and she in labour? and that I need say no more on the subject, for that she would not do it, but that she would have no objection to step into the coach and start off for Ballybay ;” here she concluded, began to doze a little, and wandered no more; the head soon after came down upon the perineum, and a little after three o’clock she was safely delivered of a very large and healthy boy, and recovered well. I since attended this lady, and she had no return of this symptom.
Case III.—Mrs. S. aged about 40, remarkably healthy and even tempered ; in her ninth labour, which began on the 14th by the dribbling away of the waters, she had a few slight pains in the course of that day, but the labour did not increase or become active till nine o’clock, p. m. of the 15th, when the pains were quick and forcing, and about twelve o’clock mid- night, she turned to me and said, that she “ thought it would be time for her to get up and see the children dressed and sent to school, otherwise they would be late ;” then she ex- pressed great surprise as to what could be preventing her mo- ther from coming to town, to be with her during her confine- ment, which, she said, she knew would take place before her arrival ; her mother was at the moment standing by her bed- side and holding her hand: presently the head descended fully into the cavity of the pelvis, and the incoherence ceased after having lasted about five minutes. She was safely delivered at twenty minutes before two o’clock, a.m. of the 16th.
Case TV.—An extremely intelligent gentleman, son of a physician in England, who was attending my lectures in
vol, v.. No. [a I
58 Dr. Montgomery on the occasional Occurrence of
1831, told me, that my account of this matter was very satis- factory to him, as explaining a circumstance which had hap- pened in his father’s practice, which had been at the time of its occurrence a source of extreme alarm, and had always appeared to them both totally unaccountable. He had been attending a lady of rank in labour, she was remarkable for the gentleness of her disposition and propriety of conduct ; every thing appeared to him to be going on perfectly well, and the labour promised to be speedily terminated, when the lady, in reply to some question from the doctor, desired him to go be damned for a scoundrel; and then followed up this singular address by language not less remarkable for its indecency, than for the inappropriate circumstances under which it was in- troduced ; this, however, lasted only a few minutes, when she became quite calm, and observed, that she believed she had been talking nonsense, but did not know of what kind: her labour was happily terminated in a very few hours, and she recovered well; but from that time, Dr. and his son always considered her as a person liable to insanity, until the latter heard me describe such occurrences as not unusual.
Casz V.—The account of this case was very kindly com- municated to me by Dr. Young, of Ormond-quay, in conse-
quence of hearing me lecture on the subject. I shall give it in his own words :—
‘“ Upper Ormond-quay, “My Dear Sir,
“ Agreeably to your request, I furnish you with an outline of a case which fell under my observation, and which you seemed to think deserving of attention, as far as,regards a peculiar symptom, which has not, I believe, been noticed by practical writers. The symptom I allude to is, the slight but marked delirium, which sometimes attends natural labours, just as the head of the foetus is passing through the os uteri, which is then forcibly distended and exccedingly on the stretch.
Mental Incoherence during Natural Labour. 59
“On the 14th of March I was called upon to see Mrs. R. H. of Mabbott-street, aged 20, then about to be confined with her first child. The labour was perfectly natural, and con- tinued active for at least eight hours; I thought it necessary to leave her room for a few minutes, and on my return, I found that the membranes had been ruptured, which I attributed to the interference of the nurse. The pains now became more violent, the head forcibly pressing through the os uteri, when at this moment I was greatly alarmed by her incoherent ex- pressions, (as if in conversation with her relations, who were at that time in the country,) and was induced to suppose, that these were the premonitory symptoms of an attack of convul- sions; but I was agreeably relieved in about two minutes from my great anxiety, by the complete subsidence of these (as | then thought) alarming symptoms; in fact, the child was en- tirely expelled after a few pains, and the lady’s recovery was uninterrupted.
« Faithfully your’s, “ Ken*. Youne.”
Case VI.—For this case I am indebted to Dr. Paterson, of Blessington-street, whose account of it I shall transcribe, to- gether with his very judicious preliminary observations :—
‘¢ 32, Blessington-street. “ Dear Sir,
“ As the reputation of the physician is as much endangered by being alarmed without cause, as from not observing danger when it really exists; and as in the practice of medicine, a knowledge of the causes of disease in general, renders our prognosis clear, our treatment decided and efficient ; so in that of midwifery, every fact founded on observation, which elucidates the causes of symptoms, and which tends to prevent unnecessary alarm in the mind and conduct of the me- dical attendant, ought faithfully to be recorded. In accordance with this sentiment I send you the annexed case, in whose first
60 Dr. Montgomery on the occasional Occurrence of
stage symptoms occurred, which, during their contmuance, oc- casioned me considerable anxiety.
“In the month of October, 1831, Mrs. S., a lady aged 30 years, of a strong but nervous constitution, pregnant of her first child, and at the full period of utero-gestation, was at two o’clock, a. M., awoke with the precursory symptoms of labour. There was neither headach nor fever, and little, if any excite- ment of the pulse, but she was now, as she had been during the greater part of gestation, unusually anxious and despond- ing as to the result. Her diet, exercise, and bowels, had been carefully regulated, and every proper means to remove her ap- prehension adopted. The os uteri was contracted and sleghtly rigid; an emollient enema was administered, and rest—sleep if possible, advised.
“‘ Five o’clock, a. m. She had not slept, but expressed her- self soothed by the enema which produced the desired effect ; the pains were sharp and frequent ; the voice characteristic, and the os uteri now dilated to nearly the size ofa shilling ; she com- plains much of cutting pain in her back; no headach; pulse quiet; little thirst. Her bed-chamber was large, well venti- lated, and cool ; no fire nor any stimulant allowed.
«¢ Seven o’clock, a.m. Os uteri dilating gradually though slowly ; when my patient began to talk incoherently, and ulti- mately to sing a favourite Italian air, which, I understood, she had been playing the day previous. She had spoken collectedly the minute preceding; from this error mentis she was at once recalled, by applying cold to her forehead and speaking mildly to her, when she expressed herself aware of
> in the interval she
having “ done or said something foolish, complained of the lancinating pains, and again resumed the wild melody ; from which I always with ease recalled her. Al- ternate moments of sensibility and delirium occurred, till half past eleven o’clock, a.m., when the os uteri being almost fully dilated, the membranes and head. presenting, the tendency to
wander ceased, and though the external parts did not dilate
Mental Incoherence during Natural Labour. 61
kindly, the delirium did not again recur ; her recovery was fa- vourable.
“ T candidly acknowledge I was at first alarmed ; but the quiet state of the circulation; the freedom from fever or local determination ; the ease with which I recalled her to perfect re- collection and sensibility; by leading me to consider the inco- herence as the effect of pain in a highly hysterical individual, (as my patient undoubtedly was,) allayed my fears, and enabled me to think with coolness and to act with deliberation. I have not mentioned what perhaps I should, that I could not then ac- count why the delirium, if arising from the pains, did not con- tinue as long as they did, nor did I distinguish between the ef- fects of the pain of dilatation of the os uteri and of expulsory action, till my conversation with you on the subject gave me reason to attribute the mental affection to the former.*
“« Very truly yout’s, ‘¢ Henry Paterson.”
Such are the characters and accompanying circumstances of this species of incoherence, which it appears to me of great importance to have known, and properly appreciated, espe- cially by those who have had but little experience in prac- tice, but who may have learned, that delirium in labour is to be regarded as a dreadfully dangerous occurrence, which it undoubtedly is, when it comes in the train of other bad symptoms, accompanying a difficult and protracted case ; but this form of incoherence of which I speak, has no affinity with such7a*condition; it comes on suddenly, during per- fectly natural and favourable labour, and most frequently at the particular stage of the process which I have pointed out ; it is not accompanied or followed by any other unpleasant or sus- | picious symptom ; it occurs, perhaps, immediately after the ROTEL A. OGG R ie Joie TARO 1O Syren 2 be
* This lady was since confined a second time under Dr. Paterson’s care, with-
out any return of incoherence,
62 Dr. Montgomery on the occasional Occurrence of
patient has been talking cheerfully, and having lasted a few minutes, disappears, leaving her perfectly clear and collected, and returns no more, even though the subsequent part of the labour should be slower and more painful. In every instance which came under my observation, the patients were afterwards conscious that they had been wandering, and occasionally apo- logized for any thing wrong they might have said, although they were not aware of what the exact nature of their obser- vations might have been, their condition, so far, exhibiting that mental embarrassment observed by Dr. Gooch,* as occasion- ally occurring “ in women who had been debilitated by nursing,” in which “ the mind was wrong, yet right enough to recognize
9
that it was wrong.” Now should the practitioner in attendance not happen to be aware of this fact, his fears would almost cer- tainly be alarmingly excited, and might, perliaps, induce him to pronounce an opinion, or adopt a course of treatment, under the apprehension of imminent danger, which the subsequent circumstances of the case would not justify, and which might even be highly injurious. Thus, one gentleman states, that he was sure his patient was about to be seized with convulsions, and had the symptoms continued, he would probably have felt himself called on to bleed her, or request further advice, neither of which is desirable when unnecessary: another told me that he fully anticipated the approach of puerperal mania, anda third, that although from the time of the occurrence, he never recognized any further symptom of derangement, he had always considered the lady as of unsound mind, until I men- tioned to him what I had observed ; and precisely the same dis- tressing impression was made on the husband and family of another lady, until I relieved them by describing the circum- stance as one which I had several times met with, and to which I attached no consequence; an assurance which was received _with almost a transport of delight and satisfaction. I have al-
* Account of the Diseases of Women, p. 114.
Mental Sevens during Natural Labour. 63
ready said that this occurrence is not described by authors, and I did not venture to make that assertion until I had carefully examined the works of Denman, Burns, Merriman, Gooch, Hamilton, Smellie, Dewees, Gardien, Velpeau, Desormeaux, Baudelocque, Boivin, Mauriceau, La Motte, Deventer, and Stein, of whom, only two* mention such an occurrence at all, and they merely state generally, with regard to labour, that sometimes, when it is violent and under peculiar circumstances, (which they do not describe or specify), the woman “ becomes delirious, or suffers a transient disturbance of the intellectual functions ;” but they have given no account of the form such incoherence assumes, its distinguishing characters, or the accom- panying circumstances ; nor have they or any body else, as far as I know, reported any case calculated to call attention to the subject ; and although I find, upon inquiry, that it has occurred to other professional men, (as in the cases already related,) they stated to me at once, that they recollected it only as having greatly surprised and alarmed them, and that until they heard my account of it they had never thought of connecting it with any particular cause, or part of the process, or in fact had re- garded it as anything more than one of those strange and un- accountable incidents which occasionally spring up to astonish and embarrass us in practice.
I should also observe, that I have known the same circum- stance happen in abortion, when the ovum was forcing through the rigid cervix and os uteri; but more frequently the effect then produced is extreme faintness, and a degree of exhaustion totally disproportioned to any appreciable cause, such as ha- morrhage. TI lately attended a lady, who was miscarr ying in the second month, with slight hemorrhage, and during the distention of the lower part of the cervix uteri, such a degree of faintness and exhaustion prevailed, that she was almost
ng rt rn EL
* Gardien, Traité d’Accouchmens, tom. ii. p. 224, and Desormeaux, Dict. de Med. tom, i. p. 170.
64 Dr. Montgomery on the occasional Occurrence of
completely insensible for more than an hour; but no sooner was the ovum expelled into the vagina and removed, than she revived again and felt quite well, a very satisfactory proof that the symptoms of exhaustion had been the result of the pe- culiar impression made at the time on the brain and nervous system. The subjoined fact also appears to me of considerable interest, as illustrative of our subject. A professional friend in- formed me, that an attempt made by him to dilate the os uteri for the cure of dysmenorrhcea, as recommended by Dr. Mackintosh, was accompanied by excessive distress, and such complete incoherence on the part of the patient, that he was afraid ever to renew the operation.
It should not be forgotten, that there are many other cir- cumstances connected with pregnancy and parturition, which are so much in unison with the occurrence of the symptom now spoken of, as to render its appearance a matter of less surprise or singularity. It is well known that in almost all women, but especially in those of an irritable habit, con- ception is followed by very obvious alterations in their moral temperament, apparently depending on a state of exalted ner- vous sensibility, or, as Dtenman* well expresses it, “ m conse- quence also of this general and perpetual irritation, the temper of pregnant women is sometimes rendered less gentle and pa- tient, than is consistent with their usual character, and this claims compassion instead of resentment ;” in some the irrita- bility assumes the extraordinary and protean forms of hysteria, and occasionally the patient’s condition is such, that it would be no easy matter to draw the line of separation between it and absolute mental aberration, or, at least, what is usually called an unsettled state of mind; while in others complete de- rangement takes place. A patient of my father-in-law’s, the late Dr. Connor, became deranged in eight successive pregnancies, and very lately a woman was received into the Richmond Lu-
* Introduction to Midwifery, p. 216.
Mental Incoherence during Natural Labour. 65
natic Asylum, who was three times similarly affected during _ gestation, but always became sane a short time before delivery, and continued so until the re-oceurrence of pregnancy. It is also a fact universally acknowledged, that the nervous system of all parturient women, is in a state of peculiar excitement and impressibility, by which they are rendered most painfully sensitive to the slightest moral or physical disturbances, and the very circumstance of the dilatation of the os uteri in labour, is In some a source of irritation sufficient to induce that fearful affection of the brain, which we believe to constitute in many cases the essential cause of puerperal convulsions; and the appearance of mania during the state of child-bed, is of too frequent occurrence to require more than to be mentioned. Nor shall we be ata loss for some very close and striking ana- logies if we leave this particular system altogether, and turn our attention to other organs and their functions : thus it must be familiar to many, how frequently children become incohe- rent, especially at night, after having paid a visit to the pastry cook’s shop, and received into their stomachs a quantity of in- digestible matters; an effect which I once saw remarkably _ exemplified in an adult: the gentleman was then a medical student, went to the theatre, and after his return supped on lobster and mutton kidneys, after which he drank two or three glasses of wine and nothing more; the following morning he got up as usual, and went to a gentleman who was preparing him along with others for his examination ; he was, in general, as I was informed, remarkable for the extent of his information and good answering, but on this occasion his replies were the most unqualified nonsense: in consequence of which, he was advised to return home and rest himself ; which he did; but shortly after his arrival at his lodging, I was sent for in great haste, in consequence of his having fainted. On his re- covery I asked him if he felt sick ? he said not: I asked if his bowels were out of order ? he said not; that they were confined, but that if he had diarrheea it would cause an effusion of coagu-
VOL. v. No. 13. K
66 Dr. Montgomery on the occasional Occurrence of
lable lymph, which would put an end to the insenstble perspira- tion: he was very cold and shivering. I got him ito bed, gave him a little warm wine and water, and applied heat to his feet. While these measures were in progress, I ascertained what f have already stated, about the supper he had eaten, which it seemed also was a very unusual thing with him to do, as he was of remarkably temperate and regular habits; his tongue was foul, and his abdomen felt full and doughy, as if the bowels were much loaded. J ordered an active purgative, to be fol- lowed by an injection. Ina few hours afterwards, I had the advantage of Mr. Colles’ advice, to whom he was serving his time ; he advised the aperients to be repeated, as the for- mer dose, &c. had acted only slightly: he was quite aware that he had been talking nonsense to us in the morning, for which he apologized ; but he was, nevertheless, still quite inco- herent; anda moment afterwards, in answer to a question from Mr. Colles, as to what wine he had drank the night before, he said he had taken “ only three glasses of intertrochanteric wine, which you know, Sir, is the proper name for port.” In the course of the evening the bowels were: relieved plentifully, and the previous night’s supper discharged almost exactly in the state it had been swallowed; he got several hours good sleep during the night, and in the morming was as perfectly collected as ever, nor had he ever to my knowledge any return of the annoyance. Since then he passed his. examination with distinguished credit before the College of Surgeons.
Dr. Gooch relates a still more remarkable case, in which mania after delivery was induced by disorder of the alimentary canal, and subsided immediately upon the expulsion of the offensive matter from the bowels.*
In conclusion I may observe, that an explanation of this phenomenon seems to me to arise naturally from_a considera-
aa nnn en a
* On the Diseases of Women, p. 156.
Mental Incoherence during Natural Labour. 67
tion of the anatomical structure of the part principally engaged, the changes which it undergoesat the time, and the physiological condition of the uterus resulting from pregnancy. With regard to the former, we know that the lower part of the cervix, or that surrounding the os uteri, has the structure, and performs the func- tions of a sphincter, and that forcible or extreme dilatation of such parts is always productive of great distress ; and in the present instance, we have an aperture, which, this hour, would hardly admit the point of our finger, before the end of another hour, dilated to such a degree, as to give passage to a body, measuring at least from ten to twelve inches in circumference ;* in doing which, it is sometimes so stretched, as to tear in seve- ral parts, and thus gives rise to the jagged or notched state of the part, so constantly found in women who have borne several children. I think also, I have sufficient evidence to believe that this incoherence will most frequently be observed in cases where the membranes have given way, or have been imprudently rup- tured, too early in labour, by which the expulsive action of the uterus suddenly acquires increased force, and impels prema- turely, the hard, bulky, and unaccommodating head against the os uteri which it carries down before it, untila portion of the lower part of the cervix is caught and severely pressed between the head, and the bony wall of the pelvis, which greatly adds to the pain and distress experienced, and besides throws the part into a condition still more unfavourable for dilatation. This theory (if it deserve such a name) is fortunately one, which, whether true or false, may be entertained with safety, inasmuch as the conduct to which its reception would lead, could have no other than a good effect, since it merely furnishes an additional precaution
* It may be proper to observe here, that this is not the greatest circumference of the child’s head, which is that measured from the occiput, over the parietal pro- tuberances, and round the forehead, which amounts to from thirteen to sixteen inch- es ; but that is not the one presented to the os uteri in natural labour, in which the head passes in such a position, that its outline is nearly a circle, whose diametet is the bi-parietal or transverse dimension of the cranium, or nearly so.
68 Dr. Montgomery on Mental Incoherence during Labour.
against a premature interference with the membranes. Lastly, we know that the part of the cervix around the os uteri re- ceives a very abundant supply of nerves from the great hypo- gastric plexus, and thereby establishes intimate connexions with the branches of the renal and spermatic plexuses ; which nervous supply becomes not only physically increased during the time of gestation,* but (in common with the other constituents of the organ) has its functional activity or its peculiar sensibility greatly exalted, manifesting its irritative influence, not only by the derangement caused in the action of certain viscera, as the bladder, stomach, and intestines, but in anmy instances disturb- ing seriously the whole system, and inducing effects already adverted to.
Such an explanation appears to me not only reasonable in itself, but the more satisfactory from its corresponding so closely with that offered by Dr. Gooch, to account generally for the dis- orders of the mind in lying-in women, which is the following: “ the sexual system in women is a set of organs, which are in ac- tion only during half the natural life of the individual, and even during this half, they are in action only at intervals, During these intervals of action, they diffuse an unusual excitement throughout the nervous system; witness the hys- teric afiections of puberty, the nervous susceptibility which occurs during every menstrual period, the nervous affections of breeding, and the nervous susceptibility of lying-in women. I do not mean,” he adds, “ that these appearances are to be observed in every instance of puberty, menstruation, pregnan- cy, and child-bed, but that they occur sufficiently often, to show that these states are liable to produce these conditions of the nervous system ;”+ but he makes no mention, either in his essay on that subject or elsewhere, of the occurrence which we have been here considering, and which appears to me a forcible illustration of the general law just referred to, while, in the
* Vide Tiedeman’s Tabula, et Nervorum Uteri Descriptio. t Op. jam cit.
Dr. Little on the Treatment of Diseases of the Lungs. 69
particular instance before us, we can moreover ascertain the connexion or at least the coincidence between the mental affec- tion and the existence of a powerful impression made, at the time, on a peculiarly sensitive and irritable part of a system, which we know does, even under ordinary circumstances, exert so decided an influence over not alone the physical, but also the moral and mental constitution of the female.
P.S. Should any facts, illustrative of the subject of the fore- going observations, have presented themselves to the reader, I beg to say, that I would consider their communication as a favour.
18, MoLEsworTH-STREET.
Art. X.—Practical Observations on the Treatment of some of the Diseases of the Lungs, §c. By Roxserr Lirriz, M.D., Lecturer on the Institutes and Practice of Medicine in the Belfast College. Physician to the Belfast Hospital. Phy- sician Accoucheur to the Belfast Lying-in Charity, &c. &c.
Ir is more particularly in extensive hospital practice that the physician has it in his power to form a just estimate of the comparative merits of different remedies for the mitigation or cure of disease. The want of an opportunity of observing a sufficient number of cases, has led practitioners of much merit into great errors, respecting the advantages of various remedies, for it is, in fact, only by the most careful comparison of those curative means, recommended as most salutary in the treatment of any disease or class of diseases, that it is possible to assign to each its peculiar advantages ; and as the situation of physi- cian to the Belfast hospital, which I have held for several years past, has afforded me every facility of studying practically pul- monary affections, I now think it right to submit to the pub- lic a brief account of the result of my experience. ‘The situation of Belfast is remarkably low, and also extremely damp, so that
70 Dr. Little on the Treatment of Diseases of the Lungs.
those pulmonary affections, common to such situations, prevail init, asmight be expected, toa very considerable extent. Pul- monary consumption is certainly of very frequent occurrence here, but that disease is, in all probability, favoured as much by the numerous manufacturing establishments, as by the damp- ness of the atmosphere. I am led to believe that acute nflam- matory diseases do not prevail in a greater degree in Belfast, than in less damp situations during the winter months, but in the spring months, owing to its not being, to any considerable de- eree, defended from the East and North winds, which usually prevail at that season of the year, I think acute pulmonary dis- eases occur more frequently, than in almost any town of the same extent with which I am acquainted.
In the treatment of no single class of diseases, has there been greater diversity of opinion with regard to the most suita- ble curative means, than in that of the pulmonary organs ; some practitioners trusting almost exclusively to one plan of treat- ment, and others, again, relying on that of an opposite nature. This, however, is only what has always been the case, in a cer- tain degree, when the nature of the disease is, as im many instances, incapable of improvement. There are some pulmo- nary affections that are scarcely susceptible of palliation when they have arived at a certain stage, but there are others, again, at all times capable of receiving the greatest benefit from suita- ble remedies. I therefore think it would be quite unreasonable for any physician to recommend the same plan of treatment to be exactly followed, under all the changes that this dangerous class of diseases is liable to present ; and although it is my inten- tion, in this paper, to dwell most on the advantages of counter- irritation, still, it will be seen, that I am not insensible to the sreat benefit of other means.
Turpentine is the counter-irritant I employ most in the treatment of pulmonary affections, more particularly in those of the air tubes, and as it is one that has not been hitherto re- commended, as far as I know, to any considerable extent in
Dr. Little on the Treatment of Discases of the Lungs. 71
these diseases, I will take as extensive a view as possible of its peculiar advantages, when compared with other remedies of the same class.
I was first led to the extensive application of turpentine to the chest in pulmonary affections, from what I knew respecting its advantages, as an antispasmodic and counter-irritant in other diseases: and I found on each trial the most satisfactory re- sults as to its advantages in soothing morbid irritation, and at the same in subduing (in proportion to the extent and duration of its application) internal diseased action. ‘The two counter- irritants in most common use in the treatment of pulmonary diseases, are tartar emetic and cantharides. Now with regard to these, no person can deny, but that they are both capable of producing powerful irritation on the parts to which they are applied. This, however, is not exactly all that is re- quired in the treatment of pulmonary disease, but more parti- cularly in that of the air tubes, when there is much acute in- flammatory action present. The irritation of the surface, unless that irritation gives rise to a change in the sensibility of the respiratory muscles, cannot in these affections be productive of more than partial benefit, for in all cases where the respiratory organs are in a state of acute inflammation, there is spasmodic action of the muscles immediately connected with these or- gans, but more particularly those of the air tubes, and it is very common to find cough, which is merely a spasmodic action of these parts, continue for a considerable time after all inflam- matory action has been completely overcome, so that whatever counter-irritating application is used in these cases, should have also, if possible, an antispasmodic effect. I certainly do con- sider the antispasmodic powers of the turpentine application in pulmonary diseases, of the greatest consequence ; but keep- ing that effect out of view altogether, I would prefer it as a counter-irritant to any other with which I am acquainted.
Sometimes pulmonary diseases are accompanied with great local and general excitement of the system, and at other times
72 Dr. Little on the Treatment of Diseases of the Lungs.
the very reverse of this is the case,—there is great local and ge- neral debility. Now I am quite convinced, from much expe- rience in the application of turpentine as a counter-irritant, that it may be carried to any reasonable length, without the least danger of either increasing internal inflammatory action or fever in these cases; or internal or general debility. Tartar emetic is much too slow and too irritating an application, when the pulmonary organs are in a state of acute inflammation, and the application of a blister to the chest is of very doubtful efficacy, even when blood-letting has been premised. I am quite convinced, when these organs are in a state of acute inflamma- tion in children, that blisters are, in nine cases out of ten, more injurious than useful. But such is not the case with the ap- plication of turpentine, no matter whether blood-letting be pre- mised or not. The vascular system in children is very easily roused, and this is a thing that I fear is generally kept too little in view, in the treatment of the internal inflammatory af- fections which I have been considering. When turpentine is applied freely to the chest of a child, labouring under acute pulmonary disease, it soon excites inflammation of the skin, but this excitement of the skin is not immediately succeeded by increased frequency of pulse, and increased difficulty of breath- ing, as is frequently the case after the application of a blister ; but, on the contrary, brings down, in proportion to the external excitement that is produced, the frequency of the pulse, and at the same time affords relief to all the internal inflammatory symptoms. I am therefore well satisfied, that the proper ap- plication of turpentine to the chest will be found in many cases of pulmonary inflammation, but especially in that affecting the air tubes, infinitely more useful than either tartar emetic or blisters, on account of its antispasmodic as well as its stimulat- ing effects. I would not merely give a preference to turpentine over all other stimulants when applied to the chest, in acute inflammation of the pulmonary organs, but would prefer it much in those of a chronic nature; because it has no tendency
Dr. Little on the Treatment of Diseases of the Lungs. 73
like the others to increase debility, both local and general, a too common accompaniment of such affections. I am quite convinced, that the purulent discharge that is frequently kept up in these cases by means of tartar emetic and blisters for weeks, nay, sometimes even for months at a time, is productive of the very worst effects in certain cases. When any chronic pul- monary affection has subsisted for a length of time, the system generally is brought to a state of debility, and it is, in nine cases out of ten, making bad worse to bring it down by any curative means still lower. I think I have seen in old age in particular, when the system is altogether m a state of great debility, the worst possible effects from the application of blis- ters. I have seen, for instance, the bronchial secretion sud- denly increase so much by their application, as to give rise to suffocation, and I am certain I have observed the same thing occur in infancy and childhood repeatedly. I have how- ever, applied turpentine to the chest as a counter-irritant at all ages, and in the lowest states of the system, and I can safely say, I never saw any debilitating effects produced by it, no mat- ter to what extent it was carried.
For some time past, the inhalation of chlorine and iodine gases has been much extolled for the cure of chronic affections of the air tubes of the lungs; and the inhalation of the same gases has been even strongly recommended by medical men of great respectability, for the cure of pulmonary consumption. I have given avery extensive trial to these gaseous inhalations, and I am sorry to say, that they have not proved so successful in the cases where I have tried their curative powers, as I had expected from the very strong manner in which they had been recommended by many individuals to public notice. I have certainly found these gaseous inhalations of use in chronic af- fections of the air tubes of the lungs, but again I have found them, by their stimulating effects on the mucous lining of the same tubes, convert a chronic affection into one of an acute kind. The difficulty in the use of these gases is the regulation
VOL. Vv. NO. 13. L
74 Dr. Little on the Treatment of Diseases of the Lungs-
of their stimulating effeets, and this is a thing that is quite im- possible to do, even after the most extensive experience in their use. In pulmonary consumption, I have never been able to cure, or even relieve a single case by their use, and I have found them, even in many eases, produce so much excitement, as to render it necessary to discontinue their further application. With respect to the comparative merits of these gases, the one has always appeared to me to be possessed of nearly the same effects as the other, both in consumptive cases, and also in cases: of chronic inflammation of the air tubes of the lungs.
Although I consider the inhalation of chlorine and iodine not by any means safe, or generally useful, and although I do not consider any other counter-irritant to be at all compared with turpentine in the treatment of pulmonary affections, still 1 do not wish to be understood as advocating the exclusive use of that application ; and in order to point out its advantages clearly, and at the same time to explain the various auxiliary remedies I frequently employ in conjunction with it, I will now proceed to give a full detail of the various pulmonary affections in whick. I have found it most beneficial.
Hooping cough is one of those epidemic diseases, from which most children suffer an attack, and that before they have arrived at their tenth year. It is unfortunately onthe pulmonary organs more particularly, that this epidemic disease commits its ravages: every person who has watched the progress of hooping cough, must admit that it owes its peculiar characters,, in a great measure, to spasmodic action of the muscles of respiration, but more particularly those surrounding the aper- ture of the larynx. There is, however, in addition to this spas- modic action, almost alwavs a congested state of the mucous: lining of the air tubes: this, however, appears always in the first instance, to be greater about the larynx than any other part. Sometimes, instead of what might be denominated a simple congestion of the mucous lining of the air tubes, there isa more: active inflammatory state, and this is even occasionally found to
Dr. Little on the Treatment of Diseases of the Lungs. 75
pervade the substance of the lungs. Now in this disease, the © danger would appear to be partly owing to spasmodic action, and partly to inflammatory action, the former being most dange- rous in very young infants, and the latter in children of all ages, possessing full habits of body. From these circumstances, the physician should keep two things strictly in view in the treat- ment of hooping cough, the one is the reduction of spasmodic, and the other that of inflammatory action.
I do not know any single remedy in which I could place so much confidence, in the treatment of this disease, as the appli- cation of turpentine, owing to its antispasmodic and counter-irri- tating effects, when used freely to the surface of the chest or throat. In all cases, after the chest or throat has been freely moistened with the turpentine, a piece of flannel should be closely applied, so as to exclude all access of air, and at the same time assist in keeping up the irritation on the surface. When it is deemed necessary to increase the antispasmodic powers of the turpentine, a proper proportion of camphor or laudanum 1s ad- ded. I have seldom found it necessary to repeat these appli- cations more than once or twice a day, unless the symptoms were very urgent, so as to require active counter-irritation. In addition to the turpentine application in the treatment of hoop- ing cough, [ invariably detract blood from the chest or region of the larynx, when I find any feverish state, pain of chest, hur- ried breathing, or any other symptoms indicating inflammatory action in the air tubes or substance of the lungs. Inchildren of full habits, I employ leeches, independently of the pressure of inflammatory symptoms. When leeches are applied in hooping cough, the bleeding should never be promoted by sponging with warm water after they are detached: it is better, instead of sponging in this way, to apply as many leeches as will be equal to take away the quantity of blood required, so that there may be no exposure of the parts after their removal.
By proceeding with the applications I have just stated, and at the same time attending to the state of the bowels, I ge-
76 Dr. Little on the Treatment of Diseases of the Lungs.
nerally find the spasmodic cough, and all the other morbid symptoms which usually accompany the disease I have been considering, subside, even in the worst cases, in the course of eight or ten days. Internal antispasmodics of different kinds, are very generally employed in the treatment of hooping cough. I have tried a very great variety of remedies of this class, and I must candidly confess, that they have, inalmostall cases, very much disappointed me; but although I cannot recommend them as being equal in efficacy to the turpentine application, still there are some of them useful auxiliaries to it in the relief of the spas- modic cough. The internal antispasmodics which are most useful, are opium, hemlock, and henbane, in the form of tinc- ture, either given separately, or in combination with each other, and with a suitable proportion of hippo or antimonial wine. At the commencement, and even during the entire progress of hooping cough, it is very common for physicians to order squills in doses sufficient to excite vomiting several times daily ; now this, [ think, is a most reprehensible plan of proceeding, on ac- count of the great tendency it has to produce, in some instances, and in others to increase, inflammatory congestion of the mucous lining of the air tubes of the lungs, a thing that the practitioner should take particular care to prevent or remove. Those who order squill emetics, generally do so with the view of promoting the discharge of a quantity of the phlegm which usually abounds so much in this complaint. The removal of the phlegm is cer- tainly a thing most desirable, but it should be remembered that this secretion is merely a product of the spasmodic and inflam- matory action which I have stated as constituting the complaint, and that it can only be moderated or checked by antiphlogistic and antispasmodic remedies.
When hooping cough is not treated on the antiphlogistic and antispasmodic plans I have so strongly recommended, it sometimes assumes a chronic character, and the child becomes hectic: now when such is the case, change of air is recom- mended, and in many instances, this is productive of the very
Dr. Little on the Treatment of Diseases of the Lungs. 77
best effects. I am so much alive to the immense advantages of _ certain states of the atmosphere, to the recovery of children af- “fected with this disease, that I would, if possible, keep them breathing from its very commencement, in tolerably moist air, at a temperature never lower than sixty-six degrees of Fahrts thermometer.
Asthma.—This is another disease that is characterized by great spasmodic action of the respiratory muscles, but more par- ticularly those of the air tubes. It is, however, only as far as spasmodic action of the respiratory muscles is concerned, that it bears any resemblance to hooping cough, for as to its exciting causes, general symptoms, progress, and termination, it is totally dissimilar to the last mentioned disease. In asthma, the mu- cous lining of the air tubes of the lungs is sometimes perlectly healthy, and at other times it is in a diseased condition, or at least it possesses, in some individuals, a strong predisposition to assume a diseased action, on the slightest application of cold to the surface of the body, or the least change in the temperature of the atmosphere ; and: hence, sometimes, those paroxysms of difficult breathing which constitute the asthmatic attack, are ac- companied with bronchitis, either in a lesser or greater degree. It would appear, therefore, from these circumstances, that in the treatment of asthma, as far as the paroxysm is concerned, some- times antispasmodic remedies alone will be sufficient, and at other times that these must be combined with such as are pos- sessed of antiphlogistic powers.
I have tried freely antispasmodics of the most powerful kind, in this disease, as internal remedies, and from landanum, which is one of the most powerful of them, I have even been fre- quently unable to procure any immediate relief from the difti- culty of breathing. And with regard to diffusible stimulants, either alone or combined with laudanum, I have in many in- stances been little more successful; but such has not been the case when I have employed to the surface of the chest, the tur- pentine application, until it has produced considerable “inflam-
78 Dr. Little on the Treatment of Diseases of the Lungs.
mation. In order to excite sudden inflammation on the surface of the chest with this application, it should be used as hot as it can be borne, and by means of flannel, I have in very few cases failed to check an asthmatic paroxysm by the application IJ have just stated, in one or at most two hours. I do consider it, therefore, after numerous trials, by far the best antispasmodic that the physician can make use of in the disease in question. When there is either temporary or permanent disease of the mucous lining of the air tubes of the lungs, in addition to spas- modic action of the internal respiratory muscles, as is the case in what is denominated humoral asthma, I would employ once or twice every day, unless too much external inflammation were produced, the turpentine application to the chest, and at the same time, if the disease of the mucous lining of the air tubes were of the inflammatory kind, I would apply leeches as an auxiliary. I wish it to be distinctly understood, that I would in the treatment of spasmodic asthma, either of the purely ner- vous or humoral kind, use occasionally other remedies in addi- tion to those I have just recommended, for it is of all other diseases, one that would require nearly all the resources of the physician.
An attack of asthma is generally produced by a disordered state of the system, of greater or less duration, so that there is time to apply the turpentine freely to the chest, before the spasmodic breathing commences. When the turpentine is em- ployed for the%purpose of preventing the occurrence of a pa- roxysm of asthma, it should be applied to the entire chest by means of flannel, and at as high a temperature as it can be borne by the patient, for unless there is very extensive redness and smarting produced, it will not answer the purpose.
Croup is an inflammatory affection of the air tubes of the lungs, extending in most cases from the larnyx to the ex- treme ramifications of the bronchie. It is the mucous lining that is more particularly affected in this complaint, but there is also very considerable spasmodic action of the internal res-
Dr. Little on the Treatment of Diseases of the Lungs. 79
piratory muscles, so that it should be always considered as a disease partly consisting of acute inflammation, and partly of spasmodic action. Thisis a disease peculiar to infancy and childhood, and like many other maladies of these periods of life, it runs its course with great rapidity, and very frequently to a fatal termination. It requires, therefore, that whatever re- medies are employed for its treatment, should be possessed of considerable activity, both for the relief of inflammation and spasmodic actions. The plan I usually follow, in the treatment of croup, is to detract a quantity of blood as soon as possible after its commencement, the quantity of blood always to be in proportion to the state of the system and the violence of the disease. When children are very young, or not possessed of very strong constitutions, I would prefer the detraction of blood from the chest or throat by means of leeches, and when chil- dren are from eight to ten years of age, I would employ the lancet. After the free detraction of blood, the next step is the production of counter-irritation over the chest and neck by means of the turpentine application. When the turpentine has produced a considerable degree of cutaneous inflammation, I generally find the dry barking cough considerably relieved, and by a little further perseverance, all the morbid symptoms subside. Besides this application and the blood-letting, I in- variably, at as early a stage as possible, establish perspiration, which I keep up freely, at the same time that I employ the turpentine to the chest and throat. As a diaphoretic I gene- rally prefer an infusion of hippo, to which I add a small quan- tity of nitre and henbane. The strength of this infusion must vary according to the age of the child, and the effect that is required, ‘The dose should always be such in the first instance, as to give rise to a considerable deal of nausea, but at the same time, care should be taken not to carry it so far as to excite vomiting. In the treatment of all acute affections of the respi- ratory organs, sweating is a remedy of the greatest importance. It requires, however, to be kept up for several hours at a time,
80 Dr. Little on the Treatment of Diseases of the Lungs.
in order that it may be useful, and I do not know any one dis- ease of this class, in which its curative powers are greater, if carried a sufficient length, than that of ‘inflammatory croup. ‘The salutary effects of sweating remedies are seldom or ever obtained by the common plan of conducting that process ; for instead of keeping the skin moist for one or two hours, as is usually the case, it should be kept freely moist for fifteen or twenty hours. Bleeding, early counter-irritation with turpen- tine, and free sweating, are the remedies on which I would al- most exclusively rely in the treatment of croup, not forgetting, at the same time, the necessity of keeping the bowels free with cooling laxatives. By some practitioners calomel is thought to possess wonderful powers, when given to a considerable extent in croup, I have used it it in many cases of this complaint to a very great extent, and again I have used it in smaller quan- tities, and from the numerous trials I have made of its curative powers, I do not think it is a remedy that can be at all de- pended upon, no matter in what dose it is given. I could therefore wish, that the use of this medicine were dispensed with altogether in the treatment of inflammatory croup.
There is no acute affection of the respiratory organs more liable to suffer a relapse, than the one I have just been con- sidering, so that it is necessary during convalescence to guard against any exposure to cold. In order to prevent any bad effects from exposure to cold, I would advise during the conti- nuance of the acute symptoms, and even for some weeks after these have subsided, that the patient be kept constantly in an atmosphere such as I have stated to be most useful in hooping cough.
Bronchitis.—This is a morbid affection of the respiratory organs, of still more frequent occurrence than any of these I have hitherto considered, and as it is produced by atmospheric changes, particularly from heat to cold, it merits, m a variable, damp climate such as this, the very particular attention of the medical practitioner. In Belfast I am convinced that colds
Dr. Little on the Treatment of Diseases of the Lungs. 81
prevail more than all other pulmonary affections, and as they are frequently complicated, in this and all other places where they prevail to a great extent, with many other morbid conditions of the system, they are the immediate cause of death in far more cases than is generally supposed. Bronchitis, being a disease that attacks at allages, and even in the most opposite conditions of the system, requires far more attention than almost any other disease of the respiratory organs, as far as treatment is con- cerned. Its progress in infancy, childhood, manhood, and old age, are all different, and it therefore requires, at each of these particular periods of life, remedies in some degree different from those that would be suitable at any other period. All the eruptive fevers are accompanied with a bronchial affection, and this is in many instances of a very dangerous kind; but that which is so generally complicated with continued fever in the winter season, is productive in very many instances of the most disastrous consequences. This, however, is more particularly the case in those who are advanced in life, or who are possessed of delicate constitutions. I might safely say, that the one-half of those who die of fever in the Belfast hospital, being ad- vanced above thirty-three years of age, die from asphyxia, in consequence of disease of the mucous lining of the air tubes of the lungs. Although bronchitis, complicated with fever, is not so dangerous in manhood or childhood as in old age, still at the two former periods of life, it is not by any means to be con- sidered as a trifling morbid affection, when complicated with that disease. I fear it is too much the case in the treatment of continued fever, to look upon bronchial disease as a secondary affection of no great consequence. Such, however, should not be the case, for at any period of life it is one of the most fre- quent, insidious, and dangerous complications of fever with which I am acquainted. This is the case particularly during the winter and spring months.
In the treatment of bronchitis occurring at different ages,
and in different conditions of the system; I have found no single
VOL. V. No. 13. M
82 Dr. Little on the Treatment of Diseases of the Lungs.
plan of treatment at all to be compared with that of counter-ir- ritation of the surface of the chest, by means of turpentine. The antispasmodic powers of this application are of the greatest consequence, when the respiratory muscles are in a state of ir- ritation, and such is the case in the disease of the mucous membrane I am just considering, to a very great extent. It is, — besides, an application that as I have already stated, is not hable either to increase the bronchial inflammation, or the ac- companying symptomatic fever, as is too often the case with blisters and other stimulating applications, so generally applied to the chest in cases of bronchitis. In the treatment of acute bronchitis occurring in youth or middle age, and not accompa- nied with continued fever, I would advise, next to the detrac- tion of blood, free counter-irritation of the surface of the chest by means of flannel well moistened with turpentine, and ct the same time copious sweating for several hours. In slight attacks of cold I would never think of bleeding, but trust simply to the turpentine application to the chest, free perspiration, and keeping the bowels free by means of some cooling laxative.
In the treatment of acute bronchitis in children, there should never be a large quantity of blood abstracted either by the lancet or leeches, even in the most severe cases, on account of the sudden and dangerous relaxation it is liable to produce in such patients. The safest and most successful plan of treating bronchitis in children, consists in early and moderate bleeding, early counter-irritation with turpentine, and early and free perspiration, together with the use of the mildest laxatives.
When acute bronchitis occurs in old age, the application of turpentine to the chest so as to excite cutaneous inflammation, together with mild diaphoretics and gentle laxatives, will, at an early period of the disease, afford by far the best chance of success. Blood-letting is a remedy that I would not at all re- commend, and it is, in my opinion, in most cases very danger- ous, when inflammatory action of the mucous lining of the air
Dr. Little on the Treatment of Diseases of the Lungs. 83
tubes of the lungs occurs in a relaxed state of the system, which is almost always the case in persons far advanced in life.
The acute bronchitis which occurs so frequently in this town, in connexion with continued fever, should be treated in almost all cases without the loss of blood, either by means of leeches or the lancet. I do not know how the loss of blood js borne for the relief of acute inflammation of the mucous lining ‘of the lungs in other places, but in this I am quite satisfied, that it is a dangerous practice in nine cases out of ten jn con- tinued fever. The great danger from the loss of blood in bron- chitis occurring in old age and in continued fever, is the pro- duction of relaxation of the system to such a degree, as to give rise to asphyxia, from the accumulation of mucus in the air tubes. I would, therefore, in almost every case of bronchitis, accompanied with continued fever, overcome the inflammatory action by the early and free application of turpentine to the chest. The use of sweating remedies, so valuable in the gene- neral treatment of acute bronchial inflammation, is of some- what doubtful efficacy in the treatment of that complicated with continued fever ; and when bronchitis is accompanied with the last mentioned disease, I would treat it in the great majo- rity of cases by the turpentine application alone. It is neces- cessary for medical men who take charge of patients labouring under continued fever, to be most attentive to the state of every internal organ of the body, and there is no part that requires more attention than that of the mucous lining of the air tubes of the lungs. As soon as I ascertain the existence of dis- ease in the mucous lining of the lungs of persons labouring under fever, I cause the chest to be well sponged with turpentine, and to be afterwards closely covered with flannel. The extent to which I carry the turpentine application varies according to the amount of diseased action to be overcome. In severe casesof inflammation, I would repeat the sponging with the turpentine every second or third hour, and in more mild cases I would not, in all probability, repeat it more than
84 Dr. Little on the Treatment of Diseases of the Lungs.
three or four times a day. In the treatment of chronic bron- chitis, I find the free use of turpentine to the surface of the chest, generally more decidedly useful, than any other external application, or any internal remedy with which I am ac- quainted, and it should, at least in that disease, always be considered a necessary part of the curative means that are employed.
From what has been said respecting the advantages of tur- pentine as an antispasmodic and counter-irritant in bronchitis, , I need not dwell at any length on its employment in the treatment of pneumonia and pleuritis. In the last mentioned diseases, I employ it as a counter-irritant from the very com- mencement of the inflammatory action, and with the very best effects. When it is desirable to excite by the turpentine ap- plication to the chest sudden cutaneous inflammation, it 1s used at as high a temperature as the patient can bear it, and by means of flannel. The plan I follow in most cases in the treatment’of pneumonia and pleuritis, when the person is of a strong constitution, is to detract blood freely at as early a stage as possible, and at the same time excite sudden and extensive inflammation on the surface of the chest by means of warm turpentine. ‘The only other remedies I use in addition to these are diaphoretics and cooling laxatives.
Before I conclude this paper, I cannot omit making a few observations on the treatment of pulmonary consumption, which is a disease of very frequent occurrence, and at the same time, one that is less easily managed than any of these diseases of the pulmonary organs I have hitherto considered. ‘The number of cases of pulmonary consumption constantly under my care in the Belfast hospital, is very great, so that I have an extensive opportunity of treating it at every stage. It is precisely the same with consumption, as it is with all other diseases of the pulmonary organs, the physician can do most good, when he is consulted at an early stage, and by the assist- ance of the stethoscope, he will be able, in the great majority of cases, to detect the presence of tubercles in the lungs, before
Dr. Little on the Treatment of Diseases of the Lungs. 85
they have made much progress. There was a time when the cough, which is usually produced by the presence of tubercles in the lungs, at a very early period of their growth, was, in most instances, attributed to bronchial disease, and hence its real cause was not, in all probability, discovered, until very ex- tensive disorganization of the pulmonary substance had taken place.
In the treatment of pulmonary consumption at an early stage, the”physician has two important objects to fulfil, by whatever curative means he may employ ; the one is to promote the ab- sorption of the tubercles, and the other is to retard their growth as much as possible. I do not know any thing so useful for the purpose of promoting the absorption of tubercles, or re- tarding their growth, as frequent small bleedings, and coun- ter-irritation to the chest by means of turpentine. I prefer the application of a small number of leeches to the chest, to any other mode of detracting blood: the number, in persons of full habit, should never exceed eight at a time, and the bleeding from the bites should never be promoted by sponging with warm water. ‘The best way of proceeding, after the leeches are detached, is to cover the bites with adhesive plaster, and im- mediately afterwards, apply over the entire chest, a piece of flan- nel, well moistened with turpentine. In young persons of pretty full habit, six or eight leeches may be applied] to fthe chest twice a week, and in persons of rather delicate constitution, the same number may in general be applied with advantage once a week. The best time to apply the turpentine to the chest in a general way, is at bed time, and one good application at that time, will generally be quite sufficient to keep a slight, but con- stant irritation on the surface.
By proceeding with the bleeding and application of the turpentine in this way, I have, in several cases, when I had eve- ry reason to believe that tubercles were in considerable number in the lings, been able to remove, completely, the symptoms of pulmonary disease ; and again I have been able, by prosecuting
86 Dr. Little on the Treatment of Diseases of the Lungs.
the same plan with steadiness, to retard, in many cases, the progress of the disease.
In all cases where there are either tubercles present in the lungs, or a strong tendency to their development, the greatest advantage is gained by defending the surface of the chest from cold during the winter season. The chest may be defended from cold in various ways, but I think there is nothing that an- swers the purpose better, than a very thin layer of cotton wool, fixed in such a way, as not to be liable to shift by the different motions of the body. The application of blisters to the chest, is in very general use at the commencement of pulmonary con- sumption, for the purpose of affording relief to the pain of chest, cough, and other early symptoms. Iam convinced, how- ever, that instead of affording relief, these applications, in very many cases, hurry on the disease to a fatal termination, owing to their excessive irritation, favouring, instead of retarding the secretion of the tubercles. Besides, blisters, if frequently re- peated, have the effect, in most cases, of producing great gene- ral debility, a thing that should be avoided as far as possible, in every stage of the disease. ‘The debility, and excessive irritat- ing effects produced by the protracted use of tartar emetic to the chest, renders it also an objectionable remedy. There isone stimulating application, besides the turpentine, that I have used to a very considerable extent, in the treatment of the first stage of pulmonary consumption ; it is iodine ointment. This appli- cation, however, aswell as that of the turpentine, must beattended with leeching. . With regard to the use of internal remedies in the first stage of pulmonary consumption, I know none on which I could place more confidence. When the cough is very trouble- some, however, the antispasmodic power of the turpentine may be assisted by hemlock, hyosciamus, and hippo, combined toge- ther, and given in proper doses.
It is certainly necessary at the commencement, and even during the entire progress of pulmonary consumption, to attend to the food, drink, and above all, to the keeping the body in
Dr. Little on the Treatment of Diseases of the Lungs. 87
an equable, and at the same time, moderately high temperature. These, however, are only auxiliary to the plan of treatment I have so strongly recommended.
With respect to the advanced stages of consumption, I need say nothing, as, after the progress of softening has commenced in the tubercles, the physician can scarcely palliate the various distressing symptoms. There is, however, in the progress of consumption, an affection of very frequent occurrence, that merits a little attention, it is pleuritis. The pleura, when inflamed, produces most acute pain ; and when attacked in the last stage of consumption, has a most distressing effect. Now for the relief of pleuritis, under such circumstances, the turpentine ap- plication will be found most valuable, on account of the sudden relief it affords. |
I intended, at the commencement of this paper, to illustrate the advantages of turpentine in the treatment of pulmonary. af- fections, by a number of cases; but I found, before I had. pro- ceeded far, that such a plan would have rendered it far too voluminous. |
EXPLANATION OF PLATE.
This plate exhibits an accurate representation of the calculi removed by Dr. G. O’Brien. (See Case II. p. 8, of this Num- ber.)
Fig. I. Represents the calculus first extracted, and which broke before being removed. The tooth is seen with the fang turned upwards, the crown being fixed in the calculus: the appearance of the enamel is quite distinct. The fissure be- neath marks the commencement of the fracture, where the stone broke.
Fig. I. The calculus subsequently obtained. The superior, extremity exhibits the fang of the tooth, protruding, as it was seen, after some of the matter had been scraped away.
Fig. Il]. A section of this calculus, shewing the situation, and the several parts of the tooth within. The fang, crosmn;'! as é and enamel, are distinctly marked ; with the canal, contaits ~ ing a substance, that appears to be the remains of the
nerve.
These representations are of the exact size of the originals.
DUBLIN MEDICAL JOURNAL
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& on Stone by William Lover
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BIBLIOGRAPHIC NOTICES.
Observations on Obstetric Auscultation, with an Analysis of the Evidences of Pregnancy, and an Inquiry into the Proofs of the Life and Death of the Foetus in Utero. By Evory Kennepy, M.D., Licentiate of the King and Queen’s College of Physicians in Ireland, Lecturer on Midwifery and the Dis- eases of Women and Children, at the Richmond Hospital School, and late Assistant to the Dublin Lying-in Hospital.
(Continued from Vol. IV. ». 265.)
WE now come to a most important part of Dr. Kennedy’s work, the application of auscultation, as one of the evidences of preg- nancy, and of the means of ascertaining the life or death of the foetus in utero. In some of the most difficult and doubtful cri- ses which occur in midwifery, a knowledge of the life or death of the foetus may often save the life of the child or mother, and will always materially influence, and to a great degree guide, the practitioner in the performance of one of the most revolting operations in medicine.
The discovery of auscultation, as a means of diagnosis in sus- pected pregnancy, is due to Maior of Geneva, who heard the action of the foetal heart, by applying his ear to the abdomen of a pregnant woman. Kergaradec put this discovery into prac- tical application, and detected the placental soufile; and the attention of the profession in this country was, we believe, first called to the value of auscultation in doubtful pregnancy, by two papers, published in the Medical Transactions, and Dublin Hospital Reports; the first by Dr. Ferguson, Professor of Prac- tice of Medicine to the Apothecaries’ Hall of Ireland, the second by Dr. Kennedy, the author of the work before us.
Dr. Kennedy, in combating the objections to the use of the stethoscope, notices a German writer, Siebold, who asserted, that notwithstanding all the pains he took, he was unable to dis- . cover any sound with the “hearing trumpet,” as he calls the stethoscope. Siebold, however, admits that he could easily de-
VOL. V. No. 13. N |
90 Bibliographic Notices.
tect the required sounds with the naked ear, while Dr. Jobn- son, of Edinburgh, inthe ninth number of this Journal, speaking for himself, and, as he states, authorized to the same purport by others, assures us he could never hear the foetal heart, and modestly says, that he does not believe the assertion of a re- spectable member of the profession, as to Ais ever having heard it. We should like, as a curiosity, to have a statistical table of the ages of the disbelievers in auscultation. We would venture a wager, that as in the instance of the sceptics on Harvey's discovery of the circulation, their ages would average above 40, unless, perhaps, with an exception of insuperable ignorance or self-conceit that scorns to learn. Within the circle of our own observation, we have observed men holding a respectable rank in the profession, who first publicly sneered at what they called the quackery of the stethoscope, then prophesied that its use as a toy would not outlive a year, next became silent on the subject, and now, with more cunning than honesty, carry the instrument about with them, pretending to understand its ap- plication, and knowing as much of its use as a state trumpeter in one of our city pageantries, knows of the use of the instru- ment of music which he idly carries as part of the show. When an individual comes forward, and stating himself as speaking the sentiments of a number, says that the persons on whose part he speaks could not believe that “ the foetal heart is audible before birth,” we have only one of these alterna- tives to offer, either, Ist, that the individuals on whose part he speaks, are all deaf, forming a party brought together by a freak of accidents, like the party of dervishes in the Arabian Tales all blind of an eye, or 2dly, that having the possession of the fa- culty of hearing, they will not exercise it, and there are none so deaf as those that wild not hear; or lastly, that all those in France, Germany, Italy, and our own countries, who say they can hear and have heard the foetal heart, are all linked toge- ther to uphold an imposture. The last supposition 1s too monstrous to be entertained for a moment: the first, Dr. John- son and his supporters will, from their self-esteem, at once re- pudiate. In possession of the second, the only remaining alter- native, we leave them in the full enjoyment of all their self-gra- iulations.
The placental souffle, or sound produced in the neighbour- hood of the placenta, is the first sound noticed. ,
‘¢ If we examine, either with the naked ear or the stethoscope, the abdomen of the pregnant woman, we shall (provided the preg- nancy be sufficiently advanced) observe a peculiar blowing or hissing spun This sound is to be met with in almost every case, and is
Dr. Kennedy on Odstetric Auscultation. 91
observed at different parts of the uterine tumour. It does not al- ways exhibit the same characters ; yet these are sufliciently striking to render it recognizable in almost every case. It assumes the dif- ferent varieties which Laennec describes under the term bellows’ sound, namely, the bellows’ sound, properly so called, likened by that author to the continuous murmur, similar to that of the sea, familarly exemplified by the application of a large shell to the ear; the rasping or sawing sound, which is occasionally found so exactly imitated as to lead, the listener to imagine an artisan at work quite close to him; and the musical or hissing sound, so well described. by the same author. A sound, resembling the cooing of a dove, is sometimes observable, but this is comparatively rare. A more fre- quent peculiarity to be noticed, is, a strange drone resembling that of a bagpipe accompanying the sound, but yet without interfering with it. The most constant form we meet with, however, is a com- bination of the bellows or sawing with the hissing sound, com- mencing with one of the former, and terminating with the latter; and this is in general so protracted, that the last souffle is audible when the subsequent one commences.
‘‘ These sounds are, from the distention of the uterus, and con- sequent facility of examination, easily detected in advanced preg- nancy ; and although not so loud or sonorous in the earlier stages, yet to the practised ear they become equally distinct. None of the above mentioned varieties are peculiar to particular stages of preg- nancy, being detected indifferently in them all. The extent of sur- face over which the sound is observable, varies much according to circumstances ; in some it is confined to a small circumscribed spot, in others it is audible over a greater surface, perhaps two or three inches square ; and in a few it is to be met with over the greater part of the uterine tumour, although there is in many cases one spot in par- ticular, perhaps not larger than the end of the instrument, where the sound is vastly more distinct and sonorous than elsewhere. The soujjle is most frequently found in the lateral and inferior parts of the uterus, but it may have its seat in any part of it; and it must be added, that cases will occur, although, if proper precautions be had recourse to, very rarely, where we shall not be able to detect it. ‘The cause producing the sounds in question requires explanation, with a view to which, we must briefly inquire into the nature of the vascular structure and circulation of the uterus.”
Dr. Kennedy examines the structure of the uterus where the placenta is attached, to explain the production of the souffle. He observes, that the portion of the uterus to which the pla- centa isattached, is a circumscribed portion, changing abruptly from the remaining texture of the uterus, and consisting of “a congeries of vessels, tortuous, ramifying, and expanding into cells or sinuses, whilst the remaining part exhibits the parenchy- matous structure of this organ, with merely occasional vessels
interspersed.”
92 Bibliographic Notices.
After an examination of the facts observed relative to the placental souffle, and a repetition of De Haiis’s opinion, that the sound is in the aorta or iliac arteries, our author states his own conclusion, that the souffle depends on the transmission of blood through the arterial tubes of the uterus.
The immediate cause of the production of souffle is next discussed, and Dr. Kennedy adopts the explanation of its pro- duction offered by Dr. Corrigan.
‘The manner in which the souffle, when situated in the other arteries of the body, is produced, does not as yet appear to have been quite agreed upon. Laennec, after discussing the subject at con- siderable length, arrives at the conclusion that it depends upon spasm. Dr. Corrigan ascribes the phenomenon to the currents pro- duced by the passage of blood from a narrow orifice into a wider tube. It certainly appears more reasonable to explain what we may, with propriety, at least in the instance of placental souffle, term a constant phenomenon, upon the principle of fixed physical causes, than that of spasm, which we can only term a casual and changing vital operation ; but besides this, Dr. Corrigan’s views would rather appear to be corroborated by the phenomenon in question. Let us bear in mind the difference that exists between the virgin and the pregnant uterus. That, in the latter, a new system of vessels be- comes rapidly developed, capable of furnishing with the means of growth a new being, and the appendages peculiar to it. The organ which heretofore received merely a sufficiency of blood to sustain its own vitality, and admit of a slight periodic discharge, in consequence of the alteration in size which has taken place, and as well the com- parative increase in the vessels already existing as the development of new ones, now receives a quantity of blood, bearing a very large proportion to that circulating in the rest of the system, while the great vessels supplying this organ do not appear sensibly altered in size. With this view of the circulation we can find no difficulty in admitting, that between this system of vessels and the main trunks supplying it, a disproportion in calibre exists. If we take into con- sideration with this the peculiar distribution of the vessels of the uterus at the placental part, and the free anastomosis which takes place here and in the lateral parts, the vessels meeting and converg- ing there, and that a comparatively small stream is now rushing from one or two arteries into an extensive system of tubes, the aggregate calibre of which is infinitely greater than that of the vessel or vessels from which it flows ; the inference of Dr. Corrigan with regard to bruit de soufflet generally, may with every justice be drawn, namely, ‘ that the motion (of the blood) is that of a current; the sides of the arteries, instead of being acted upon by a body of fluid moving forward almost as a solid mass, receive the impulse of a stream whose particles are in motion with different degrees of velo-
Dr. Kennedy on Obstetric Auscultation. vo
city.’ * The existence of the sound here, beyond the point where the artery is comparatively narrow, tends, as in Dr. Corrigan’s expe- riments, to prove its dependence upon the above causes.”
There are some very useful directions given on the means of avoiding mistakes, which might be made by the tyro in the use of the stethoscope, when seeking for the placental souffle. For these we must refer to the work. It is scarcely necessary to say, that Dr. Kennedy relies very much on the placental soulile as an evidence of pregnancy.
‘“The co-existence of the foetal pulsation with the souffle, of course decides the question ; but with regard to the latter, taken se- parately, we shall even go so far as to say, that were all the symptoms of pregnancy absent, and this sound could be distinctly perceptible, we should at least withhold our opinion until a sufficient time had elapsed to place the matter beyond a doubt.”
And two very convineing cases are given in support of this opinion.
The placental souffle may be detected at a very early period of pregnancy.
‘‘ We have not succeeded in detecting the placental sound in any case until after the second month from impregnation ; but have frequently done so in the tenth, eleventh, and twelfth weeks.
‘¢ August 15th, 1829.. A woman named Devereux, who had been under my care in labour eighteen months before, called to consult me for a slight attack of pneumonia. She mentioned that her menses had not appeared for the last two months: I therefore ex- amined her with the stethoscope, and detected clearly the placental souffle, although no uterine tumour was observable. Dr. Collins, who also examined her, expressed his astonishment at its distinct- ness at that early period. I gave this woman reason to suppose it possible that she was pregnant, of which she had not the slightest anticipation. However, the accuracy of the diagnosis was attested by her coming into hospital on the 7th of March, 1830, in labour, and being delivered of a living child the day following, exactly twenty-nine weeks from the period at which we had examined her.”
In concluding his observations on the placental souffle, he observes judiciously as to the reasons for demanding confidence in it.
“* Considering the souffle as an evidence of pregnancy, in an ab-
stract point of view, we should be inclined to inquire what ought more strongly to verify the opinion we arrive at on this subject, or
* Lancet, vol. 1, N.S. p. 1.
94 Bibliographic Notices.
ailord us more assistance in our investigation, than a phenomenon pro- duced by the passage of blood through the vessels constituting the connexion between the parent and the embryo; on the supply of vi- tal fluid, through which, however mysterious that connexion may appear, the actual existence of the latter as an embryo, its develop- ment as a foetus, and maturity as a child, depend ?”
The next auscultatory sign taken up is the pulsation of the heart of the foetus.
‘“‘ In exploring with the stethoscope the abdomen of a woman at the full period of pregnancy, whose child is alive, we shall detect over a surface, more or less extensive according to the position of the child, and disposition of the foetal and maternal organs, a pulsatory sound generally much more rapid than the pulse of the mother, and exhibiting the characteristic marks of a distinct and independent circulation.”
The pulsations of the foetal heart are about 130 or 140, but are considerably influenced by the state of the circulation in the mother, by hemorrhage from the maternal vessels, by the muscu- lar efforts of the foetus, and by the action of the uterus in labour. Some interesting cases are related, illustrative of these points, and very full descriptions are given as to the circumstances in- fluencing the position of the foetal heart, and as to the rules for discovering its pulsations.
The position of the foetal heart is never discovered so early as the placental souffle ; the latter is occasionally detected as early as the tenth week, while the foetal heart can only with difficulty, and by an experienced stethoscopist, be discovered be- fore the period of quickening. Those who, after a perusal of the following case, can be content to remain ignorant of auscul- tation, deserve to remain for ever in the bliss of ignorance.
“The author is indebted for the following case to his friend Dr. Byrne, Physician to the University. ‘Mary M., ztat. thirty-four, married, of a pale, leucophlegmatic appearance, the motier of three children, of bad health for the last nine months; had no child for the last three years; catamenia irregular for the same period, both as to quantity and time of appearance. Has been much distressed in mind of late, by a tumor rising out of the pelvis into the hypogastrium, as she cannot satisfy herself with regard to its nature. ‘The physi- cian under whose care she was, had an accoucheur to examine her per vaginam, before my seeing her; who pronounced the case to be one of a tumor, about the size of a clenched fist, growing from the superior fundus of the uterus, and involving the fallopian tubes, and ovaries : he further condemned it as cancerous, from a supposed no- dulated feel, when examined through the parietes of the abdomen. The treatment usual in cases of cancer had been resorted to, but
Di. Kennedy on Odstetric Auseultation. 95
without any good effect. On May 29th, 1830, I examined her, be- ing requested to do so, in order to make myself acquainted with the feel of cancerous tumors growing in this situation. Her present symptoms are, occasional sickness of stomach, pains about the loins, appetite bad, tongue clean, bowels free, pulse quick, weak, and small : the catamenia have been suspended for five or six months. The tu- mor is soft, elastic, and circumscribed, without pain on pressure, and occupying the pelvis and lower part of the abdomen. I can find no nodules on relaxing the abdominal muscles in the usual way ; but as- certained that when these were in a contracted state, as in the sitting posture, such a sensation was communicated to the hand in a slight degree. On applying the stethoscope immediately below the umbili- cus, I heard a masked murmur, very different from the borborygmus of the intestines : on changing to the right side, on the same plane, the placental murmur was tolerably distinct, but this sound singly was not sufficient to make me pronounce on the nature of the tumour. On removing the instrument to the opposite side, I heard the fatal heart pulsating one hundred and forty in the minute, whilst the mo- ther’s pulse was only ninety. This I pointed out to an accoucheur present, who had previously examined her, without coming to any satisfactory conclusion. We therefore, without hesitation, informed her that she was pregnant; on which glad tidings I have seldom seen more joy depicted in the countenance of any individual. This poor woman was delivered of a healthy child about two months af- terwards.’”
There is, obviously, a great difference in the value of the pulsation of the foetal heart, according as positive or negative evidence may be sought for; its presence is at once indicative both of the existence of pregnancy, and of the life of the foetus, , but its absence, unless under circumstances which are fully considered by our author, is not conclusive in the opposite way.
Compound pregnancy, complicated pregnancy, pseudo-preg- nancy, nervous or ideal pseudo-pregnancy, and premeditated or simulated pseudo-pregnancy, are discussed, and a mass of in- formation and instructive cases given under each head. We must, however, refer our readers to the work for the information required, and we pass on to the chapter containing “ the Inqui- ry into the Proofs of the Life and Death of the Foetus in Utero.” This chapter is ushered in with a page or two of flourishing sym- pathy on the “ common fate of mankind,” and a conclusion 1s logically arrived at, that “a foetus may die at any time :” we did not require to be told that, and where we have the long and rugged road of science to travel, the less of the mud of mawkish sentimentality we have to wade through, the better.
It is scarcely requisite to tell our readers how necessary it
96 Bibliographic Notices.
often is, to be able to tell confidently, whether the foetus be alive. We cannot easily forget the delight with which a mo- ther heard the assurance of the life of the child she carried, after the occurrence of an accident which she feared had de- stroyed it. Our author adduces a number of instances to shew how necessary such knowledge is, both during pregnancy and the progress of labour; its importance in medico-legal ques- tions is self-evident. The usual symptoms supposed to indi- cate the death of the foetus, whether furnished by the mother or foetus, the true value of these symptoms and their insuffi- ciency are shewn with a masterly hand, and the following cases given in illustration.
“June 3rd, 1830, I was requested by Dr. Hutton to visit a young woman named Lock, who was advanced in pregnancy, and supposed her child dead. She had been married on the 9th of November preceding, and had not since menstruated. She had suffered from morning sickness, and her abdomen had been gradually enlarging, until within the last three weeks, when it became, as she stated, flac- cid, and something weighty was to be felt falling from side to side in it. She had never either quickened, or felt the motions of the child ; and now complained much of a feeling of coldness in the abdomen, with general debility, and as she expressed it, heart sickness. Her breasts appeared small, scarcely at all distended, and devoid of milk ; but she stated them to have been larger and fuller until latterly. Under these circumstances, the patient and her mother naturally concluded the child to be dead. On applying the hand to the abdo- men, no motion was to be felt, but the stethoscopic evidences indicated that the child was alive, a fact which, (to the great astonishment of the patient and her friends), was attested by the birth of a living child, within six weeks from the period of examination. Several similar cases could be adduced, as well as cases in which females supposed they experienced the motions of the child, and asserted, that it exhibited the usual evidences of its vitality, at the very