REMARKS ON CASES OF DEATH FROM AIR ENTERING THE VEINS.

11 He readily assented to a trial; and I success. permitted to quote his own statement of the result. On the remedy being applied, he says, " To my utter astonish-

favourable for must be

ment I heard every sound so loud, that I felt I had never known what it was to hear until that moment. Sir David Davies could hardly have believed it had he not been present.

entering the streets, the noise was so intense, that I was compelled to stop up my ears to deaden the sound; but after a time I became accustomed to it, and can now enjoy the pleasures of social converse without straining my auricular organs, or being obliged to be addressed in a considerable elevation of voice. PersonallyI continue to apply the remedy with the same beneficial effect, and am convinced of its permanent nature, when persevered in, and properly attended to. This extraordinary discovery comes too late to be of that essential service it would have been to me in earlier life, yet it may render the rest of my days more comfortable in my On

or must we look for some other explanation ? Ilowever, ot its relieving this kind of deafness there can be no doubt. Some may feel incredulous at such simple means producing such brilliant results; but in order to substantiate that which I have now written, I propose, in my next paper, to quotn the statements of my patients, appended to histories of their cases.

The question, as to how far this new mode of treatment be made available in cases in which the membrana tympani remains intact, is now occupying my anxious consideration, and forms the basis of a series of experiments, pending which I will, with the editor’s permission, forward to him for publication some observations on " Internal Otorrhœa," and on " Artificial Perforation of the Membrana can

Tympani." Savile-row, Btirlington- gardens, June, 1848.

intercourse with the world." The following brief history of Mr. Griffith’s case, as detailed by himself, is interesting in many points of view:—" The crisis REMARKS ON CASES OF DEATH FROM AIR

ENTERING THE VEINS. of a severe attack of scarlatina in my infancy was attended by abscesses in both ears, which produced deafness, and a (BY A SUBSCRIBER FROM THE COMMENCEMENT OF continual discharge of purulent matter, more or less, until I

THE LANCET.)

IN the editorial observations in THE LANCET on the unfor-Barnes, in the practice of Dr. Willis, you write of that occurrence as being " very rare and remarkable." Permit me to draw your attention, as well as during which my hearing was much improved, again becoming that of the professional gentleman in attendance on the case worse as the discharge ceased. While the discharge lasted, alluded to, to the following extracts:" Numerous experiments have for a long time pointed out I experienced a slight tenderness in my ears, which also ceased with the discharge. I find that your remedy some- the fatal results from the admission of air into the veinstimes does the same thing, and that is my reason for not experiments which go as far back as the time of Morgagni, constantly using it; but if it is not applied, my hearing is not (de udibus et causis, Morb. Epist. 5.) Wepfer seems to have in the least degree remedied! The discharge is always more been the first who discovered that insufflation of air into the profuse when in bed, even without the remedy, and I am jugular vein of the living animal was sufficient to cause instant somewhat puzzled to account for it. My children know as death. His experiment, which was successively repeated by well as I do when the remedy is applied; and when it is, they Redi, Bohn, Ant. Vander-Heyden, R. I. Camerarius, Brunner, remark,’Your ears are too sharp; we cannot now speak too Harder, and Sproegel, exhibited the same results, whether mamma, even in a whisper;’ but they cannot, more than other the air was injected by one of the jugulars, or into one of the people, discover why I should hear so well one day, and the femoral veins; the more forcibly and rapidly the air was innext, perhaps, not better than usual; and the question now is, jected, the more speedy the death. In repeating the expeIIave you got your new ears on to-day, papa?’ The inven- riments of Redi, Vallisnieri remarked that dogs died moretion is invaluable." speedily, and by the injection of a smaller quantity of air, From this communication, written three or four weeks than sheep, lambs, &c., (Morgagni, loc. citat.) In the animals after his visit to town, it appears that the remedy at first set submitted to these experiments the ventricles and auricles of up an irritation in the ear, which occasionally rendered it the heart had been so distended by the air, that the greater advisable that it should be discontinued ; but now I am numbers of the authors mentioned agree in supposing that this enabled to state that such obstacle to its use no longer extreme distention of the parietes of the heart must have exists, and that he applies it regularly, uninterruptedly, and prevented its contractions. It is, then, to the interruption of the functions of the heart that Morgagni attributed these with undiminished success. This case, like the first quoted, proved to be one in which sudden deaths. Langrish, an English physician of the last there was a loss of a great portion of the membrana tympani; century, repeated these experiments with the same results. and I may here observe, that all my experience tends to Chabert has recommended this means as a bloodless method; show that this is an essential condition of the ear for success. of destroying mangy and otherwise diseased horses; and the At the present time I can refer to not very far short of two practice has been adopted by veterinary surgeons on the conhundred cases, in which the new treatment has been suc- tinent. Hitherto it would appear that the knowledge of these facts cessful, and in all of which more or less perforation or dehad no practical bearing on surgery until the year 1818, when struction of the membrane exists. A very small quantity of wool is sufficient. It must be the first instance of the accidental introduction of air into moistened in some fluid without any compression, and gently the veins was noticed by Beauchene, surgeon of the hospital pushed down the meatus with the point of a probe. I have of St. Anthon3-, in Paris. It occurred during an operation had constructed for the purpose a set of instruments, which for the removal of a tumour on the right shoulder. Whilst are calculated to meet and overcome every difficulty; for I detaching with a bistoury a portion of the clavicle which had need scarcely say that it is very easy to talk of passing a been sawn through, a peculiar noise, similar to that of the foreign body down the meatus, but it is not so easily done. penetration of air artificially introduced into the chest of an Besides, it is not sufficient to merely pass it down to the site animal, was heard. Previously to this occurrence the patient, of the membrane; but when there, the spot must be found who had lost but little blood, was not perceptibly weakened; which it is indispensable the wool should occupy and cover; his pulse was full and regular, and his respiration was normal; for then only, and not till then, will success attend the appli- but the moment the hissing noise was heard, the patient cried cation, and the patient regain the hearing. out, "My blood is falling into my heart-I’m dead." He With a few rules, which, of course, vary with the case, the became suddenly pale, his head fell back, his eyes became patient may be taught to manipulate upon himself, and all fixed, vision dimmed, and death ensued in a quarter of an that is required is to remove the dry wool, and replace it hour. with moist, night and morning, or morning only. This is In November,1822, at the Hotel Dieu, a young girl was quite sufficient to maintain the improved hearing in the received for the treatment of an enormous tumour, situated The tumour intervals. on the back and right lateral part of the neck. It will be expected that I should say something of the had been removed by Dupuytren, with the exception of a modus operandi of this new application ; but I can offer small flap, when suddenly a prolonged hissing sound was nothing that is conclusive. It has appeared to me in some heard, the patient was seized with general tremor, fell back, way or other to supply the place of the lost membrane. The and expired almost instantaneously. Dr. Castara, surgeon to the Hopital de Luneville, reports moisture is absolutely necessary to its perfect action; for when the wool becomes perfectly dry it impedes rather than im- another case; so does Delpech; and a case occurred in the proves the power of hearing. Is it possible that moist wool practice of Sir Astley Cooper, during the removal of a placed at the extremity of the meatus can transmit the vibra. mammaryt umour. tions of sound in the same manner as the natural membrane; . Magendie, in his Lectures on the Blood," delivered at the attained my

twenty-second year, when the latter ceased. concretions of wax formed in the passage, increasing the deafness. These were removed by syringing, after which a thin pellucid fluid would issue from the ears,

Occasionally

tunate occurrence at

12 "

College of France in 1837-8, alluding to the veins, says, Too1 "Is it the treatment generally adopted by surgeons in this many examples are unfortunately on record of the occurrence country "-his reply was, " To the best of my knowledge no of fatal results through the accidental entry of air in this case has occurred till the present, (referring, I presume, to manner." He continues: I have published an essay on the his special studies and experiments made in 1837,) to put in subject, and I presume you remember the experiments I practice the results I alluded to." But in the Medico-Chimade before you, in the course of which I explained the best rurgical Transactions for December, 1843, there is recorded a manner of preventing or remedying this formidable occurcase of alarming syncope from the admission of air into a vein Whenever a surgeon practises an operation close to during an amputation at the shoulder-joint, by Bransby B. rence. the thorax, he should take care to be provided with an in- Cooper, Esq., F.R.S. It occurred at Guy’s Hospital, on the strument fitted for the withdrawing of any air that might 17th of May, 1843. The importance of the subject I trust, Mr. Editor, will be a accidentally enter the veins, and through them the right cavities of the heart. The chief symptoms of such entry are, sufficient apology for trespassing thus largely on your columns. a peculiar sibilus, tumultuous pulsation in the chest, and The matter given will also show, that however remarkable the occurrence of air getting into the veins during operations, and spontaneous syncope. "It is not the deleterious action of the air on the living causing death, may be, such an occurrence is by no means tissues that causes death, but the stoppage of the circulation, rare. which takes place in consequence of the ventricle having! London, April, 1848. nothing to contract on but a spurious mass, incapable of traversing the vessels. The sole means of saving the life of the REPORT OF A patient consists in aspiring the froth accumulated in the right side of the heart before too large a quantity has reached the CASE OF SPONTANEOUS RUPTURE OF THE lungs and left side of the heart. I say, too large a quantity, UTERUS BEFORE LABOUR. advisedly; for it is not true that a single bubble of air mixing BY THOMAS F. "

-

with the blood will induce death. I am aware that this assertion makes somewhat light of the organic sensibility of the capillaries, concerning which such marvels are related; but, the fact may be easily verified by any of you. Open the jugular of a dog, and inject air into it, taking the precaution to perform the operation extremely slowly; the animal will continue to live after receiving into its veins not a single bubble, but an entire syringeful of that fluid. Next vary the experiment, by pushing the piston rapidly; you will find that death follows instantaneously; the difference in effect depends on the manner in which you cause the entry of the air. In one case the air reaches the blood gradually by successive bubbles; its presence in the smaller vessels constitutes no obstacle to the continuance of the pulmonary and general circulation. When, on the contrary, you suddenly force in a considerable volume of air, that fluid, dilated by the heat of the organs, distends the walls of the ventricles to such a degree that they cannot contract. The movement which subsequently takes place in the heart depends on contractions of the left ventricle, the right cavities have scarcely any share in it. Hence the importance of causing an assistant to compress, or of tying the cardiac orifice of, any good sized vein that may chance to be opened in the neighbourhood of the chest. And in the application of a ligature there are certain precautions to be taken: you must be careful not to raise the vessel, by introducing one of the branches of your forceps into the interior, and applying the other to its outside; in this way, acting onone side only of the cylinder, you run the risk of permitting the air to enter when you draw the vessel from the wound. The best plan is, obviously, to seize the vein by its external surface, and then tighten the ligature." " So dangerous did M. Bouchon consider operations about the chest, that he recommended them to be performed under water. Bichat long ago pointed out the effects of the admission of air into veins." Further, independently of accidental circumstances which prevent veins from closing after division of their parietes, M. Berard, the present eminent professor of physiology at the School of Medicine of Paris, has pointed out a natural anatomical cause, which merits the special attention of surgeons. This consists in the fact, that the principal branches of the vena cava superior in the vicinity of the heart have connexions with the aponeurotic laminae of the cervical regions, so formed, that the parietes of these vessels are kept in a continual state of tension; so that the veins form so many canals, that are more inclined to remain open than to close. The vast importance of a knowledge of this anatomical peculiarity in operations upon the neck and parts about the chest, will be apparent, and go to show that bleeding in the jugular vein is not so trifling an operation as is supposed by many. In the American Journal for August, 1822, there are observations upon the entry of air into the veins during operations, by John C. Warren, M.D., Professor of Anatomy in the Harvard University, U.S. America. The following eminent men have also written on the subject, giving cases:—MM. Amussat, Mercier, Poisseuille, Denot,

Bouilland, Velpeau, Basse, Mayor, Burley, Godemer, Blandin, Marshal, (de Calvi,) Ribere, Malgaigne, J. Guerin, &c.* With reference to the question put to Dr. M’Cormack at the

inquest

held

on

the

subject of the unfortunate

occurrence,

of death from the entrance of air into the veins, occurring in one of the French hospitals, will also be found detailed in THE LANCET for i. p. 461, and remarks upon the same at p. 475. vol. 1842-3, * A

case

BROWNBILL, ESQ.,

SURGEON TO THE SALFORD WORKHOUSE.

years, was of rather short and had a healthy appearance. She had been married about eight years. In ten months subsequent to marriage, after an ordinary labour of about nine hours’ duration, she gave birth to a full-grown female child, which lived about four months. Soon after labour, which I understand was quite natural, she was seized with conM. A.

G-, aged twenty-eight

stature, well proportioned,

vulsions, followed by delirium &c.,

which, continuing for a days, subsequently resulted in an attack of puerperal mania, for which she was afterwards admitted into week

or

ten

the Manchester Workhouse.

months, and,

as no

sent to Lancaster

Here she remained about two

improvement had taken place, was then Asylum, whence, having been confined

eight months, she was discharged cured; and from that until a recent period had enjoyed uninterrupted good health. Having been separated from her husband during most of the time since her last confinement, she again became pregnant, and was admitted into the Salford Workhouse on the 4th of November last, in order to lie in. She stated that, in the beginning of the seventh month of gestation, whilst hanging out some clothes, she received a fall, which shook her violently, but did not cause her, either then or afterwards, any particular pain. On the 20th of November, at six A.M., after having passed a restless night, with occasional slight uterine pains, she began to vomit. This was followed by several pretty strong pains, during one of which she experienced (to use her own expression) a severe crack in the back, with a feeling of something suddenly giving way in her inside, which was immediately followed by a discharge of liquor amnii from the vagina. The midwife (an intelligent and experienced person) was accordingly sent for, and was soon in attendance. She found, upon examination, the os uteri nearly closed, hard, and incapable of admitting the point of the finger. There was a slight discharge, of a dark brown colour, from the vagina; the patient had vomited the contents of the stomach; and the pains had altogether subsided. Under these circumstances, she left her, and found, on her return, at three P.M., she had had no pain during her absence. The os uteri was lower down, and more yielding, though not in the least dilated, and a slight discharge of water, tinged with blood, escaped whilst making the examination. She had not slept nor felt the motion of the child since soon after the membranes broke. A dose of castor oil was now ordered. On visiting her the following evening, at nine P.M., at the request of Mr. Roberts, the governor of the workhouse, I found the oil had been rejected by the stomach, and the vomiting had more or less continued to the present time, the matter at first being of a greenish yellow, and afterwards of a chocolate colour. Labour had not in the least progressed, the os uteri remaining as before, if anything, more contracted. She had no pains; complained of being weak and poorly; and although several opiates had at short intervals been administered, she had as yet not slept; and with a feeble pulse. Her countenance now began to assume an anxious expression. Nov. 22nd.-About eleven A.M. she began to doze for short periods, but this state soon gave way to extreme restlessness, almost incessantly requiring her position to be altered. She now complained of severe pain in the middle of her back, and her pulse was evidently sinking. Between one and two

seven or