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LIVERPOOL EYE AND EAR INFIRMARY.
143 four pints of milk in twenty-four hours, with eight better, but still pale and looking ill. No dyspnoea of importof whisky.-17th: Temperature at 7.30 last night ance. Cardiac dulness is still a little large and too easily 104:’5°; after sponging for twenty minutes it fell to 101.4°. defined. Temperature 990; pulse 100; respiration 24. Has passed a restless night. Had three grains of opium, March 8th : Allowed to get up for an hour. With the but slept only two hours. Now lying on the left side. No exception of a rather severe attack of vomiting, he conchange in the physical condition of the right chest.- tinued to improve rapidly, and left the hospital on May 18th, 23rd : There has been steady improvement during the last 1882. four or five days. This morning he is pale, and breathing Remarks.—The drugs employed in the case were various, rapidly; pupils not dilated. Not in any great pain, but a and given, with the exception of salicylate of soda, rather Heart: Cardiac dulness with the idea of little discomfort in breathing. combating the tendency to death than with much increased. It begins at the third rib, and extends and consequently have not been noted. notion, any specific down to the sixth, and is much increased to the right of It may be well to note that blistering was discarded. Among sternum (absolute dulness) ; apex not localised ; distinct the of interest in the case, the following may be many points friction fremitus felt over the upper part of dulness. On noted :-1. The rather doubtful rheumatic nature auscultation friction sound distinctly heard over the upper specially of the case at the commencement, and the failure of salicylate half of the dulness, the systolic portion of which is double. of soda to relieve. 2. The total absence of all joint affecPulse 130; temperature 99° ; evening temperature 100 6°.it to have been a case of rheumatic fever. tions, assuming 29th : Cardiac dulness about same as on the 23rd. Friction 3. A so difficult to display in the notes, but so obvious sound unaltered at base. General condition about the same. to all point who saw the case from day to day ; the rapidly downPulse 142 ; temperature 99° ; evening temperature 101°. ward course of the case immediately prior to the aspiration, Feb. 2nd : Pericardial effusion rather increased than and the unaided part the operation played in saving life. otherwise. The praecordial region has a full distended 4. The rapid absorption of the effusion after comparatively look, there being a want of interspace markings. The ab- the withdrawal of so small a portion of it. solute dulness begins now almost at the second rib and extends down to the seventh laterally; the dulness measures at the level of the fourth rib eight inches. Sounds obscure LIVERPOOL EYE AND EAR INFIRMARY. .and distinct. No friction sound heard. Patient is pale and A PIECE OF STEEL IN THE CRYSTALLINE LENS ; AT-anxious. To-day, for the first time, a change in the abdoTEMPTED REMOVAL ; DEATH DURING THE ADMINISmen is noticed. The epigastrium is full and tender, and TRATION OF DICHLORIDE OF ETHIDENE. dull on gentle percussion. Edge of liver is easily felt at WM. -, aged twenty-pix, a weakly-looking man, was about the level of umbilicus. Temperature 100° ; pulse 128 ; evening temperature 1016°.—4th: Patient better. Pulse, admitted on the morning of Nov. 21st last, sunering from although rapid, is much steadier. Breathing 36, much a wound of the right eye, inflicted with a chipping of steel, .freer. There is some slight improvement in physical signs. half an hour previously. On examination the foreign body The cardiac dulness is not so great. Epigastric swelling and in the lens. Mr. Edgar Browne decided that seen could be tenderness gone. Temperature 102° ; pulse 152.-5th : Intense pain in back of chest during the night, with great an attempt should be made to extract the body. The housedyspncea. Sweating profusely. This morning he is better. surgeon, Mr. Charles Shears, on auscultation of the patient Temperature 101° ; pulse 142 ; respiration 52. The præ- could detect no cardiac murmur, but the sounds at the base cordial dulness is a little increased.—7th : General and local were not distinct, and it was not thought sufficient to condition about the same. It is evident that he cannot hold out much longer if present condition continues. At 4.30 P.M. contra-indicate the administration of an anaesthetic. Diaspiration of the pericardium was performed by Mr. Ward, chloride of ethidene was then given on a small flannel the house-surgeon, according to the plan followed by inhaler, and the patient came under its influence slowly Dr. Clifford Allbutt and Mr. Wheelhouse in a similar case but quietly. In ten minutes the man was fully under under the former’s care about ten years ago. The fine the influence of the anaesthetic, and Mr. Browne made aspirator needle was entered obliquely in the fourth left the corneal section. Almost immediately the pulse (which space, two inches and a half from the middle line, and had been carefully noted all through) became very pushed upwards and backwards towards the middle of the feeble, and the patient very pale. The head was right scapula until a cavity was clearly entered at a depth lowered, the tongue drawn well forwards, and artificial of about an inch and a half. Only about an ounce respiration was commenced without delay. Air passed - of bloody turbid -serum was drawn off (more could not freely in and out of the chest. Nitrite of amyl was then be obtained). It’was intended to withdraw as much fluid as applied to the nostrils, and the patient was inverted. He, possible. The patient struggled a good deal at first, but the however, showed no signs of returning consciousness. operation did not really give rise to any special distress. Artificial respiration was carried on for nearly half an hour, Temperature 102° ; evening temperature 101 ’8°; respiration but without any beneficial result. Between three and four 56.—8th : Passed a good night. Says he feels much better. drachms of the etbidene were used. Breathing still short (40). No marked change in cardiac By order of the coroner, a post-mortem examination was physical signs.-9th: Temperature 99° ; pulse 120 ; respira- made thirty-six hours after death by Dr. Alexander Davidtion 32.—10th : Temperature 100° ; pulse 96 ; respiration 3’. son, physician to, and lecturer on pathology at, the —11th: Much better. Temperature 100° ; pulse 88; respira- LiverpoolRoyal Infirmary. On removing the heart, it was tion 32. Area of cardiac dulness much less. Absolute found to be in a flabby condition, and the walls were very dulness commences now at lower border of third costal thin ; all the valves were healthy. On the lining membrane cartilage, and extends downwards to sixth rib. It measures of the aorta, one inch above the valves, and extending for transversely at fourth cartilage (its widest part) six inches. some distance, small fatty patches were seen, as also on the Distinct cardiac impulse can now be seen and felt in fourth thoracic aorta, and in one place there was the appearance and fifth spaces. Sounds thumping and dull, but free from as of a healed atheromatous ulcer. The heart muscle was friction or bruit. General condition much improved. (The examined microscopically, and found to have undergone marked fall in pulse-rate may be due to digitalis, eighty extensive granular degeneration, the nuclei especially drops of tincture per diem, which he has been taking since being surrounded with granules. The right lung was deeply 5th inst. It is therefore discontinued.) He is now taking congested. solid food, with eight ounces of whisky, and milk ad libitum. At the inquest, evidence was given to the effect that the Evening temperature 102°.-l2th : The cardiac dulness has man died from cardiac syncope, produced by the adminisfallen to nearly its natural size. The main increase is now tration of an anaesthetic to a patient whose heart was in a to the right. Temperature 101’2°; pulse 120; respiration 32. condition of commencing fatty degeneration, which condiHe complains of pain in his back. There has been nc tion could not have been discovered during life, and which difficulty in swallowing throughout. Lungs clear. —15th: Car- certainly was not suspected in so young a man. The jury diac dulness continues well defined. Commences above at gave their verdict accordingly, adding that they thought lower border of third cartilage and extends to sixth rib. " everything was done that could possibly be done, or that Transversely it is limited by middle line and a point fom was customarily done." Since the early part of 1879 diinches to the left of this. Heart-sounds are of a thudding chloride of ethidene has been largely used at the infirmary, it character. No friction or bruit. Base second sound is split having been administered between four hundred and five General condition improving. Temperature 99°; pulse 120 hundred times, and, up to this present unfortunate occurrespiration 32. Pulse of no marked character.-22nd: Mud] rence, without any mishap. The absence of struggling,
three
or
ounces
144 with which patients come under its influence, its pleasant smell, and the very little sickness following its administration, caused ethidene to be regarded as a specially suitable anaesthetic for operations on the eye.
had been removed by the author. These latter were examples of a disease which is inevitably fatal unless removed by operation ; the signs and symptoms of their presence were discussed. Great care is necessary in examining the state of the patients before having recourse to operation. The two conditions, the absence of which are so important to be assured of before interfering, are : renal disease and Hæmaturia from either of these sources of cancer. course absolutely contra - indicates an operation. The PRESIDENT, after alluding to the specimens and instru. ROYAL MEDICAL & CHIRURGICAL SOCIETY. ments exhibited, and in proposing a vote of thanks to the author, remarked that the subject opened up points on the Cases of Polypoid Tumour of the Bladder removed by diagnosis and nature of vesical tumours, and praised the tion.—Operation for Exploring the Bladder by Perineal paper for its clear and practical character.-Mr. LUND Section of the Urethra, and for removing Vesical Tumour, (Manchester) bore testimony to the practical value of the paper, treating of a class of cases difficult of diagnosis and Impacted Calculus, &c. now be decided to deal with by THE ordinary meeting of this Society was held on the 23rc treatment, which it could external urethrotomy or median lithotomy in place of the more inst., John Marshall Esq., F.R.S., President, in the chair. risky procedure of a lateral lithotomy or cystotomy. By this The evening was occupied with the reading by Sir Henry method Sir H. Thompson had shown that it was as easy to male bladder as the female; and he would Thompson of two papers, bearing on the operation for- ex- explore the that the main difficulty in the digital exploration ploration of the bladder and removal of tumours from that imagine with deep perineums. He would be’in cases of fat viscus, and the prolonged discussion that ensued. A large had seen cases in whichsubjects the bladder had been opened for collection of preparations was exhibited from the museums tumours by the lateral incision. Two of them were cases of of the Royal College of Surgeons, St. George’s Hospital, and malignant disease, but the third was one he had seen University College Hospital, also specimens by Sir H. recently with Mr. Whitehead of Manchester, who, in a letter Thompson, including microscopical preparations by Mr. Boyd which Mr. Lund read, says that he first explored the bladder and Dr. H. Gibbes. At the close of the meeting Mr. Pearce through an incision of the membranous urethra seven years ago, not deeming it a novel proceeding, and that within the Gould demonstrated Dr. Bigelow’s latest modification of his past year he had performed the same operation six times; !-instrument for litholapaxy. in four of the cases finding and removing growths from the J Sir HENRY THOMPSON read a paper on four cases of Poly- bladder. In all of the cases the chief symptom was alarming Ypoid Tumour of the Bladder removed by Operation. The and uncontrollable hæmaturia. The case seen with Mr. :paper consists of the history of symptoms, the removal by Lund was that of a medical man seventy years of age, who operation, and the results, in four cases of vesical tumour, had suffered from persistent haemorrhage for seven years, each of large size, one of them extremely so, and filling the with frequent expulsion of villous shreds. The growth was bladder. In three the patients recovered, in the fourth, with scraped away with Volkmann’s spoon, and the patient has the large tumour, the issue was fatal. A carefully made resumed his practice without any further symptoms. In the - microscopical examination is described, and the report is second case there was much relief from pain and haemorrhage, but death occurred three months after the operation frotn appended in each case. Sir HENRY THOMPSON also read a paper on an Opera- causes independent of the bladder. The third case was contion for Exploring the Bladder by Perineal Section of the valescent two months after the operation. The last case ‘Urethra, and for removing Vesical Tumour, Impacted Cal- was much relieved, but had only been recently operated culus, &e. ; with cases. The author desired to ask the upon. Mr. Whitehead concludes that the operation is free attention of the Society to a new method of investigating from risk, that it affords in most cases ample facility for obscure diseases of the bladder, which promises to be valu- complete digital examination of the bladder ; but that in very able in certain conditions occasionally met with. Every- stout subjects partial exploration could only be effected, and one sometimes meets with a case in which the symptoms of that it was of great benefit even in cases of malignant disease, vesical disease are severe and obstinate, and although for it afforded good drainage and physiological rest very careful examination has been made, he is unable to to the bladder. Mr. Lund added that in cases where mnch arrive at a rational diagnosis. The occurrence is doubtless haemorrhage followed removal of a tumour, perchloride of not a common one ; in the great of cases carefully iron could be injected, the vesical mucous membrane being made observations demonstrate the nature and seat of very tolerant of strong astringents.-Mr. REGINALD HARthe disease. But for the exceptional cases, always impor. RISON (Liverpool) related a case recently under his care at tant-cases generally marked by frequent or persisting the Liverpool Infirmary. The man had long suffered from harmaturia of some standing, manifestly not renal, and persistent hæmaturia, and on examination the prostate was without local sign of cancerous tumour-he proposes to thought to be enlarged and indurated. He cut down upon take decided action, and to submit, further, that such action the prostate and found a hard fungating mass with a hard should not be unduly postponed. The essential step in the base, which he succeeded in enucleating. There was not method proposed is to examine the entire internal surface of much after-bleeding, and the haematuria has not since rethe bladder with the finger, by which means we can reco- turned (now four or five months). Partial incontinence of gnise the presence of any tumour, large or small, the urine followed, but was met by a " urinary truss "-i.e., an The method of doing ordinary truss adjusted to the root of the penis. Mr. Paul, existence of encysted calculus, &c. ’ this was illustrated, and shown to be a proceeding simple and who examined the growth microscopically, reported that it easy of performance, and at the same time one which in- was a specimen of scirrhous carcinoma.-Mr. DURHAM convolves little if any danger to life. It consists in making a gratulated Sir H. Thompson upon his successful removal of small opening from the raphe of the perineum to the mem- tumours of the male bladder, but as regards the method branous urethra, which is opened on a grooved staff just described in the second paper he failed to see its novelty. enough to admit the left index-finger to enter the canal and He had performed it’at least a hundred times in treating to be pushed on to the neck of the bladder. Provided bladder disease, and could confirm Sir Henry’s statement as the ansestheaia of the patient is so complete that the to the ease with which the bladder could be explored by it. The abdominal muscles are perfectly relaxed, every portion operation was well known to Guy’s men as Cock’s operation, of the internal surface of the bladder may be brought which was intended to afford relief to an inflamed bladderin consecutively by suprapubic pressure into close contact cases of intractable stricture. In some cases he had found with the tip of the finger, and any deviation from tumours, cancerous in nature, which he had partially the natural condition, however slight, may be rioted. The removed. But Cock’s operation was performed without the operation is an external urethrotomy only, and involves staff as a guide ; the commencement of the prostatic urethra neither the prostrate nor the bladder. The application of being determined by the left index finger in the rectum ; and the proceeding not only to diagnosis but subsequently to the urethra incised through the middle line of the perineum treatment, was then discussed. It was shown to offer facility in front of this point. It was the same operation as Sir H. for the removal of tumour, impacted calculus, &c. Seven or Thompson’s with the exception of the use of the staff. In a eight cases in which the operation had been performed were case supposed to be one of impermeable stricture that he so dealt cited, and several examples of tumour were exhibited which with, Mr. Durham found the obstruction to be due to an elon.
Medical Societies.
-
Opera-
-
majority
three
or
ounces
144 with which patients come under its influence, its pleasant smell, and the very little sickness following its administration, caused ethidene to be regarded as a specially suitable anaesthetic for operations on the eye.
had been removed by the author. These latter were examples of a disease which is inevitably fatal unless removed by operation ; the signs and symptoms of their presence were discussed. Great care is necessary in examining the state of the patients before having recourse to operation. The two conditions, the absence of which are so important to be assured of before interfering, are : renal disease and Hæmaturia from either of these sources of cancer. course absolutely contra - indicates an operation. The PRESIDENT, after alluding to the specimens and instru. ROYAL MEDICAL & CHIRURGICAL SOCIETY. ments exhibited, and in proposing a vote of thanks to the author, remarked that the subject opened up points on the Cases of Polypoid Tumour of the Bladder removed by diagnosis and nature of vesical tumours, and praised the tion.—Operation for Exploring the Bladder by Perineal paper for its clear and practical character.-Mr. LUND Section of the Urethra, and for removing Vesical Tumour, (Manchester) bore testimony to the practical value of the paper, treating of a class of cases difficult of diagnosis and Impacted Calculus, &c. now be decided to deal with by THE ordinary meeting of this Society was held on the 23rc treatment, which it could external urethrotomy or median lithotomy in place of the more inst., John Marshall Esq., F.R.S., President, in the chair. risky procedure of a lateral lithotomy or cystotomy. By this The evening was occupied with the reading by Sir Henry method Sir H. Thompson had shown that it was as easy to male bladder as the female; and he would Thompson of two papers, bearing on the operation for- ex- explore the that the main difficulty in the digital exploration ploration of the bladder and removal of tumours from that imagine with deep perineums. He would be’in cases of fat viscus, and the prolonged discussion that ensued. A large had seen cases in whichsubjects the bladder had been opened for collection of preparations was exhibited from the museums tumours by the lateral incision. Two of them were cases of of the Royal College of Surgeons, St. George’s Hospital, and malignant disease, but the third was one he had seen University College Hospital, also specimens by Sir H. recently with Mr. Whitehead of Manchester, who, in a letter Thompson, including microscopical preparations by Mr. Boyd which Mr. Lund read, says that he first explored the bladder and Dr. H. Gibbes. At the close of the meeting Mr. Pearce through an incision of the membranous urethra seven years ago, not deeming it a novel proceeding, and that within the Gould demonstrated Dr. Bigelow’s latest modification of his past year he had performed the same operation six times; !-instrument for litholapaxy. in four of the cases finding and removing growths from the J Sir HENRY THOMPSON read a paper on four cases of Poly- bladder. In all of the cases the chief symptom was alarming Ypoid Tumour of the Bladder removed by Operation. The and uncontrollable hæmaturia. The case seen with Mr. :paper consists of the history of symptoms, the removal by Lund was that of a medical man seventy years of age, who operation, and the results, in four cases of vesical tumour, had suffered from persistent haemorrhage for seven years, each of large size, one of them extremely so, and filling the with frequent expulsion of villous shreds. The growth was bladder. In three the patients recovered, in the fourth, with scraped away with Volkmann’s spoon, and the patient has the large tumour, the issue was fatal. A carefully made resumed his practice without any further symptoms. In the - microscopical examination is described, and the report is second case there was much relief from pain and haemorrhage, but death occurred three months after the operation frotn appended in each case. Sir HENRY THOMPSON also read a paper on an Opera- causes independent of the bladder. The third case was contion for Exploring the Bladder by Perineal Section of the valescent two months after the operation. The last case ‘Urethra, and for removing Vesical Tumour, Impacted Cal- was much relieved, but had only been recently operated culus, &e. ; with cases. The author desired to ask the upon. Mr. Whitehead concludes that the operation is free attention of the Society to a new method of investigating from risk, that it affords in most cases ample facility for obscure diseases of the bladder, which promises to be valu- complete digital examination of the bladder ; but that in very able in certain conditions occasionally met with. Every- stout subjects partial exploration could only be effected, and one sometimes meets with a case in which the symptoms of that it was of great benefit even in cases of malignant disease, vesical disease are severe and obstinate, and although for it afforded good drainage and physiological rest very careful examination has been made, he is unable to to the bladder. Mr. Lund added that in cases where mnch arrive at a rational diagnosis. The occurrence is doubtless haemorrhage followed removal of a tumour, perchloride of not a common one ; in the great of cases carefully iron could be injected, the vesical mucous membrane being made observations demonstrate the nature and seat of very tolerant of strong astringents.-Mr. REGINALD HARthe disease. But for the exceptional cases, always impor. RISON (Liverpool) related a case recently under his care at tant-cases generally marked by frequent or persisting the Liverpool Infirmary. The man had long suffered from harmaturia of some standing, manifestly not renal, and persistent hæmaturia, and on examination the prostate was without local sign of cancerous tumour-he proposes to thought to be enlarged and indurated. He cut down upon take decided action, and to submit, further, that such action the prostate and found a hard fungating mass with a hard should not be unduly postponed. The essential step in the base, which he succeeded in enucleating. There was not method proposed is to examine the entire internal surface of much after-bleeding, and the haematuria has not since rethe bladder with the finger, by which means we can reco- turned (now four or five months). Partial incontinence of gnise the presence of any tumour, large or small, the urine followed, but was met by a " urinary truss "-i.e., an The method of doing ordinary truss adjusted to the root of the penis. Mr. Paul, existence of encysted calculus, &c. ’ this was illustrated, and shown to be a proceeding simple and who examined the growth microscopically, reported that it easy of performance, and at the same time one which in- was a specimen of scirrhous carcinoma.-Mr. DURHAM convolves little if any danger to life. It consists in making a gratulated Sir H. Thompson upon his successful removal of small opening from the raphe of the perineum to the mem- tumours of the male bladder, but as regards the method branous urethra, which is opened on a grooved staff just described in the second paper he failed to see its novelty. enough to admit the left index-finger to enter the canal and He had performed it’at least a hundred times in treating to be pushed on to the neck of the bladder. Provided bladder disease, and could confirm Sir Henry’s statement as the ansestheaia of the patient is so complete that the to the ease with which the bladder could be explored by it. The abdominal muscles are perfectly relaxed, every portion operation was well known to Guy’s men as Cock’s operation, of the internal surface of the bladder may be brought which was intended to afford relief to an inflamed bladderin consecutively by suprapubic pressure into close contact cases of intractable stricture. In some cases he had found with the tip of the finger, and any deviation from tumours, cancerous in nature, which he had partially the natural condition, however slight, may be rioted. The removed. But Cock’s operation was performed without the operation is an external urethrotomy only, and involves staff as a guide ; the commencement of the prostatic urethra neither the prostrate nor the bladder. The application of being determined by the left index finger in the rectum ; and the proceeding not only to diagnosis but subsequently to the urethra incised through the middle line of the perineum treatment, was then discussed. It was shown to offer facility in front of this point. It was the same operation as Sir H. for the removal of tumour, impacted calculus, &c. Seven or Thompson’s with the exception of the use of the staff. In a eight cases in which the operation had been performed were case supposed to be one of impermeable stricture that he so dealt cited, and several examples of tumour were exhibited which with, Mr. Durham found the obstruction to be due to an elon.
Medical Societies.
-
Opera-
-
majority