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THE LONDON HOSPITAL MEDICAL SOCIETY.
488 the plan of treatment he has found most and being present, would perhaps favour them with his views He states, that as the deviation occurs in a curve, on this subject. with its centre upon the fracture, it is desirable to counteract Mr. SHAw was aware that this fracturo had been termed in the deformity by extension acting in a direction according to Dublin, Colles’ fracture, having, many years ago, been dethe tangent of that curve. This end he thinks is best attained scribed by that distinguished surgeon ; but as it seemed that by acting through the medium cf the hand and of the capsular Mr. Colles had not enjoyed an opportunity of performing any ligament which is attached to the lower end of the radius. post-mortem examinations of this fracture, he believed nothing The hand is first to be brought into a position of strong flexion, new concerning its pathology had been made public by that and the forearm is then placed on an oblique plane, with the gentleman. Petit, Dessault, Sir Astley Cooper, and others, carpus highest, the hand being permitted to hang freely down had likewise treated it in their works ; but until the year the perpendicular end of the plane. The tendons of the ex- 1834, its pathology had remained comparatively unknown. tensor muscles are thus brought into a position which enables In that year, Gogrand, Malgaigne, and about the them to assist in keeping the reduced fragments of the bone same time, made known the results of their experience, and in proper relation. Where the deformity requires it, the dis- called the attention of surgeons more especially to the placed lower fragment is to be pressed into its position by the pathology of this fracture. The frequency of its occurrence, thumb of the operator, after sufficient extension has been and the difriclllty attending the diagnosis, had been admitted. made, and when the hand is bent on the forearm. The pa- When existing in a slight degree, it was liable to be mistaken tient is to be kept in bed, but the hand is not confined, the for a distortion or dislocation of the wrist, and when in a seat of fracture being covered only by an evaporating lotion. greater degree, for a luxation of the same. In the London Out of the thirty-nine cases under the Professor’s care at the Hospital, from which alone he had been able to procure staFrederick’s Hospital, he failed but in one in effccting a cure. tistical data for any lengthened period, the fractures of the He has found a similar plan of treatment equally successful in radius, ulna, and of both bones together, were reckoned as fractures of the forearm, without distinguishing them from fractures of the radius higher up the arm. Mr. PARTRIDGE presented a dissection of a fracture of the each other. Knowing, however, how very much the number lower extremity of the radius, the fracture having passed of fractures of the radius predominated over those of the obliquely through the lower end of the bone, cutting off the ulna, or of both bones together, the frequency of this fracture styloid process.and passing into the articulation. The man had might be easily conceived. In 1842, there were treated at been admitted an out-patient in King’s College Hospital, with the London Hospital 840 fractures, of which 153 were of the comminuted fracture, which was treated on the usual principles, forearm. In 1843, there were 899 fractures, and 156 of the but in a few days after the accident, he came into the forearm. In 1845, 952 fractures, 200 of which were of the hospital, abscesses having formed, and pieces of bone having forearm; and in 1846, there were 954 fractures, with 176 of the forearm. In the five months, from May to October, 1846, come away, and he had ultimately been obliged to perform amputation of the arm. Mr. Partridge believed that the !, at the King’s College Hospital, there were treated eightyfracture was most frequently oblique, and considered it as four fractures, fifteen of which were of the forearm, twelve of radius, and three of ulna. Acknowledging, then, the freone very difficult to treat satisfactorily. Mr. SoLLY remarked, that the Society were under a great quency of this fracture, and the repeated failures attending obligation to Dr. Hodgkin for having brought the results of its treatment, (Velpeau cures but thirty out of fifty,) thus Professor Fenger’s experience beforethem. No fracture causing a partial, if not total, loss of the use of the hand and so frequently occurred, and none, perhaps, was so little fingers to a great number of our fellow-beings, it will be understood. He mentioned the recent case of an expe- readily conceded that any rational plan, by which a more rienced surgeon, who had been proceeded against by his favourable result may be attained, is worthy the notice of the profession. Mr. Shaw hoped, therefore, that the method patient for damages, in consequence of some deformity followed the treatment of a fracture of this kind. This adopted by Professor Fenger, by which such pleasing results The treat- had been obtained, and of which a modification had already case had at the time excited no little interest. ment of this injury was attended with so much difficulty, that been successfully tried by Mr. Busk, Mr. Hamilton, and even with the greatest care, and in the most experienced others, would meet a kind reception and fair trial among hands, it often failed. In this country, attention had, but of English surgeons. As it had been remarked by Mr. Busk, comparatively late date, been directed to the peculiarities at- that it would be no easy thing to keep patients so long in bed with this fracture, Mr. Shaw thought that a splmt, in which tending this fracture. Mr. BusK had seen several cases of fracture of the lower the arm could be supported, permitting the hand, at the same extremity of the radius, close to the joint, and had lately tried time, to hang freely down, or rather, to be fastened down, a method somewhat resembling that of Professor Fenger. He might be used, and the patient could, under certain restricalso placed the arm in a state of complete pronation, elevated tions, be allowed greater liberty. To the other objection, the hand, and depressed the elbow, but supporting the carpus, that the patient would not be able to sustain the weight of permitted only the fingers to hang down. The results arrived the hand so long a time hanging down, as would be necessary at by him, under this treatment, appeared satisfactory. The for the consolidation of the fracture, he remarked that this weight of the hand would, he considered, prove too fatiguing position seemed to him the most natural-at any rate, less for the patient, if continued in the position used by Professor constrained than in starch bandages, Dupuytren’s splints, &c.; Fenger for any length of time, nor did he think it possible or and that the patients, in the numerous trials made by Pronecessary to keep the patient in bed so long. In his own fessor Fenger, had not experienced more difficulty than cases the patient kept the arm in a sling and went about. He might be reasonably expected under such circumstances. could not think that when the whole hand hung over the end of the splint, as recommended by Dr. Fenger, the stretched tendons would act as "a natural splint." THE LONDON HOSPITAL MEDICAL SOCIETY. Mr. ARNOTT said, the nature of this accident was described MARCH 12, 1847.—MR. DALDY IN THE CHAIR. thirty years ago, by Colles, of Dublin, whose description had been reproduced by Smith, of Dublin, in his recently published Mr. ToMKINs read a case of work.*’ Dr. Smith described the fracture from an examination POISONING WITH NITRIC ACID, WITH RECOVERY. of twenty specimens, and has given nineor ten illustrations of On Tuesday, August 11th, 1846, at about one in the morning, He was fully aware of the difficulty ! the appearances. attending the diagnosis and treatment of this, having him- Iwas called up to see a prostitute, twenty-six years of age, self suffered, many years since, from having had his arm who, as I was informed, had attempted self-destruction, by broken not far above the articulation, and could bear witness swallowing half an ounce of aquafortis. Three quarters of to the pain and extremely disagreable sensations attend- an hour had elapsed before medical assistance could be obI arrived, I found that thedruggist at whose ing the application of Dupuytren’s bandage. He was tained,theand when had been obtained, and who had called me inclined to think favourably of Professor Fenger’s method, shop poison by which the extension was produced by the weight of the up, had been endeavouring to administer calcined magnesia, hand acting through the medium of the capsular ligament, suspended in water. She appeared in a state of helpless and was glad that Dr. Hodgkin had made it known to them. intoxication, and was vomiting a quantity of dark fluid, Dr. IIonGKarr disclaimed any other merit than that of having resembling porter in colour, and mixed with viscid mucus. received the paper from Mr. Norton Shaw, the translator. Face somewhat congested; lips bluish and swollen, with a Mr. Shaw had studied many years in the north of Europe, yellow stain, and two or three small blisters in the middle of the under one; these being the only external signs of any corrosive liquid having been swallowed. Pulse scarcely per* A Treatise on Fractures and Dislocation in the Vicinity of Joints. Dublin, 1847. ceptible, and very rapid; extremities cold; pupils contracted,
proceeds to describe successful.
Dupuytren,
having
489 I endeavoured to pour the The first severe symptoms he experienced (about nine magnesia and water down her throat, but soon found it im-months back) were those of the food seeming to rest at a point possible, on account of-first, the strong spasmodic closureopposite the upper border of the sternum, requiring a draught of the jaws, which only intermitted during the act of vomiting, of fluid to force the mass downwards: this was frequently this being immediately succeeded by violent grinding of the succeeded by regurgitation, with violent retching and coughteeth, and then, immovable closure of the jaws; secondly, ing. Upon applying to a surgeon in the neighbourhood for when an opportunity offered itself of putting some fluid into assistance, his throat was examined witha probang ; and the mouth, the attempt to swallow directly excited vomiting, leeches and blisters having been applied for a short time and this increased greatly, so that, at length, the further admi- without much relief, he was referred to the hospital, into nistration of anything became impracticable. She was then put which he was admitted Jan. 13th, under the care of Mr. Anto bed, and bottles of hot water applied to her feet, and I sat drews. He never remernbers having had any uneasiness in down to watch for the first sign of reaction. She lay for his throat previous to the present symptoms, or to have swalseveral hours, in a state of profound insensibility, interrupted lowed scalding liquids, or anything which would have induced only at intervals of four or five minutes, by violent retching, an inflammatory attack. but she made no effort to raise or move herself. At length, Jan. 17th.-Four days after his admission into the hospital, her pulse became stronger, and the surface of her body Mr. Adams, at the request of Mr. Andrews, cautiously passed warmer, and she raised her hands to her throat, and gave a small-sized probang; slight resistance appeared to be offered other signs of returning consciousness. Pressure on the about the situation of the lower constrictor of the pharynx. throat gave her great uneasiness, and immediately excited After passing this, the instrument was again obstructed in its vomiting, while much firmer pressure on the epigastric region progress some inches lower down the tube; with slight presonly excited slight expression of pain. Ordered twelve sure, this also was overcome, and the probang appeared to leeches to the throat, and eighteen to the epigastrium.- pass’into the stomach. This operation, however, occasioned Noon : The leech-bites have bled very freely, especially those cons derable pain, which continued for some hours, and was referred to the cardiac end and upper border of the stomach. over the throat; is now sensible, though incapable of speaking No further application of the probang was directed, and the even in a whisper; breathes naturally; the retching continues At this as frequently as at first, and is provoked, on attempting to patient was put upon middle diet, with strong broth. swallow her saliva; this she is unable to accomplish; and her stage of the disorder, and for some weeks subsequently, he face and attitude are expressive of excruciating agony; could swallow solid food, cut up finely, with greater ease than neither bladder nor bowels have acted; very little tenderness liquids. Upon a careful stethoscopic examination of the in epigastric region; but the slightest pressure on the throat thoracic organs, no abnormal condition could be detected, nor gives great pain, and excites attempts to vomit. Ordered was any enlargement, hardness, or tenderness upon manipulatwenty leeches to the throat, and five minims of dilute hydro- tion, observable in the neck or cervical glands; the stomach cyanic acid, in two drachms of syrup, every four hours; barley also appeared free from any induration at either orifice. water or linseed tea, cold, in case of her being able to swallow. But slight variation occurred in the symptoms during the - Ten P.M.: Tenderness of throat diminished, and retching succeeding months. The probang was but rarely had recourse less frequent, but still incapable of swallowing; feels faintish; to, and it was always observable that greater difficulty was castor oil and oxymel enema administered; this caused a experienced in passing it after each successive application. Feb. 7th.—His general health appears good; and were it copious faeculent evacuation, and a small quantity of urine was passed at the same time. not for the gradually increasing difficulty of deglutition, he 12th.—Has passed a restless night, in much pain, and seems would be able, he thinks, to pursue his accustomed engagemuch exhausted; has with great effort swallowed a tea- ments. His diet is altered to milk, with light pudding, which spoonful of cold water; can answer briefly in a whisper, when he is compelled to eat very gradually by small spoonfuls at a spoken to; tenderness and pain without considerably dimi- time. More solid food will not now pass the lower stricture. nished, but slight pressure excites retching; pulse 110, and His voice is reduced to a loud whisper. weak; blistered her on each side of the larynx, with acetum 14th.—During the last week, his constitution seems to cantharides. Repeat enema.-Eight.P.M.: Feels better, but sympathize with the disease. Much pain is complained of very restless, and cannot sleep; pain and tenderness, and dis- over the stomach, with general disturbance of the functions. position to vomit, have much subsided; effort to swallow The face, nose, and lips, have assumed a bluish hue ; his exceedingly painful, but has taken a little barley water and breath is offensive, and he is unable to pass food of any kind milk. To have fifteen minims of laudanum, in half an ounce into the stomach. After having passed a teaspoonful of fluid, of water, at bed-time, and to use a gargle, consisting of an it appears to remain in the oesophagus a few seconds, and is then violently rejected by coughing. ounce of honey of borax, and five ounces of water. Three days were 13th.-Has slept comfortably at intervals, and feels better in passed with little if any food being taken. Under these cirevery respect. The false membrane in the mouth is beginning cumstances, the stomach-pump was resorted to, and the to come off in shreds of considerable size, one of them being smallest being passed down to the stricture, (through which moulded into the shape of part of the fauces, pharynx, and it could not pass,) the pump was attached, and in this manner upper part of the cesophagus; feels extremely weak; tender- he was fed three times daily with milk and beef-tea, containness and pain in throat diminishing. Ordered, beef-tea, with ing finely grated bread. Notwithstanding the nourishment arrow-root, barley-water, and milk, of which she now drinks he took, and his apparently increasing appetite, it was too frequently; repeat blisters, lower down on each side, to throat; evident that his health was rapidly giving way. His breath became horribly offensive ; mucus collecting in his throat repeat enema. From this time, she continued improving and gained strength gave him uneasiness; but neither purulent matter nor blood rapidly. In a week, she could enjoy a mutton chop, and taste was observable in his sputa. her food; bowels kept regularly evacuated by means of ene22nd.-Complains of being ill all over; cannot rise from mata, and a light tonic administered. At the end of the fort- his bed, as usual; pulse is accelerated, 118; skin hot and dry; night she was removed to a penitentiary, where she remained cough excessively troublesome, keeping him awake all night; only a fortnight. I have seen her recently, and she looks well, his mouth is parched, obliging him constantly to moisten it and has gained health. with acid drinks, or by sucking wet lint. More resistance Mr. Tomkins considered that very little acid (which was ofthan usual is formed upon passing the upper stricture; but the strength of that ordinarily employed) had reached the yet no pain is occasioned. The lower passage, however, is stomach, and that that was so diluted by the gin and beermore contracted, rendering it extremely difficult to pass a which the patient had taken as not to cause any distinct in- small quantity of his accustomed diet; and this can only be done between intervals of coughing. flammatory affection of the organ. 23rd.-No food has been passed to-day; he looks anxious and emaciated; lips anscmic; the colour of his nose is dark Mr. BARRETT read a case of and livid; the thick mucus gurgles in his throat, appearing to MALIGNANT STRICTURE OF THE (ESOPHAGUS, WITH ATROPHY OF impede the respiration, and at times almost threatening suffoTHE RECURRENT LARYNGEAL NERVE, GIVING RISE TO ALMOST cation; pulse 136, wiry, and small; tongue slightly furred ENTIRE SUPPRESSION OF THE VOICE. and dry; breath offensive; mouth parched; skin of lips D. B-, aged forty-one, a bricklayer, has been accustomedi cracked, dry, and swollen ; loud bronchial rale obscuring for the last few years to live somewhat intemperately. States,:, every other sound in the chest. About four o’clock this that within the last two years lie has lost flesh considerably. afternoon, whilst talking to some friends who were standing This he attributes to the constant difficulty he has found iniby, he was seized with a fit of coughing, ejected a quantity of swallowing. His voice, also, has recently become altered ini dark, foetid matter from the mouth, fell back, and died. Post-mortem examination, twenty-two hours after death.tone to a deep, gruff base.
and feebly affected by the light.
.
!
-
.
490
Body considerably emaciated.—Brain : lymph effused between the layers
A small quantity of of aracluzoid, but not adherent to either; more fluid than usual in the subarachnoid spaces and lateral ventricles. In every other respect the brain appeared healthy.—Cavity of thorax: The lungs rose up on removing the sternum; no adhesions. The whole contents were removed for a more minute exaniiiirtion.Cavity of abdomen : Nothing abnormal was observed in the contents of this cavity. Stomach perfectly healthy; the liver also; no enlargement in the mesenteric glands. The oesophagus and neighbouring parts presented the following appearance:—Upon the anterior surface of trachea, extending downwards from the thyroid gland on to the pericardium, was a dense layer of soft, imperfectly developed fatty tissue. Upon removing this, the lower part of thyroid gland was condensed, by means of a much condensed mass, (of what appeared to be the original tissue,) to a number of indurated rounded bodies, somewhat resembling enlarged glands, slightly varying in size, and extending backwards rather more to the left side than the right, involving the carotid vessels, and partly separating the oesophagus from the trachea. Upon a section being made of one of these indurated bodies, a white, cream-like substance exuded from the dense fibrous structure of which it seems composed ; but the structure itself did not present that gritty character upon cutting it which is usually met with in scirrhus. The interior of some parts of the bodies was softened; others
’ result
firm
contained cavities, partly filled with a foetid, unhealthy-looking matter. Between the oesophagus and trachea, immediately behind, and a little below the thyroid cartilage, was a large abscess,
or
cyst, filled with matter somewhat similar
to
the
of considerable force, as the parts in the vicinity of the stricture appear excessively thickened, as they invariably are, thus serving to prevent the occurrence of such mischief. In the case of the man now before you, his appearance when he first entered the hospital was certainly indicative of malignant disease, neither had he any symptoms at the seat of the disease, showing that so destructive a process was going on. From the suspicious and dangerous character of the disease generally, Mr. Andrews, 1 believe, was led to adopt the more passive treatment: the result of a post mortem has proved the advantage of such a course. Dut, on the other hand, had the case been one of stricture from thickening of the sub-mucous cellular tissue only, as might probably have been the condition of this stricture in the first instance, before the malignant disease was induced by the constant and unchecked irritation, then I cannot help thinking that the mechannical treatment, if carefully applied, would have brought the case to a more successful termination. The gradual loss of voice must no doubt be attributable to the total destruction of the recurrent laryngeal nerve, the gradual diminution of the circumference of the trachea by the increasing pressure of the abscess materially tending to lessen the volume of sound; the attempt to speak towards the close of the man’s life being accompanied by considerable exertion, and requiring frequent respiratory efforts.
Foreign Department. FOREIGN PERIODICALS.—FRENCH.
preceding. and containing several detached rings of the traTincture of Iodine as a Collyrium in Hypopion. chea, in a state of partial absorption. This abscess was In L’ Union Médicale of April 6th, li. RIVAUD-LAUDRAN, of found to communicate, (as is seen in the preparation on the recommends the use of the tincture of iodine as a coltable,) on one side, by an oblong opening in the oesophagus, Lyons, to bring about absorption in cases of hypopion. He about the lower border of the inferior constriction, and on the lyrium two cases in which he employed it successfully. narrates anterior surface with the trachea, the rings of which had One, a lady, aged 61, had violent inflammation of the internal given way, their place being supplied by a thickened conti- tunics, with ulceration of the cornea, at its lower part, and a nuation of the fibrous membrane; through this membrane the into the anterior chamber, accomeffusion of considerable opening had taken place. A little below this opening in panied with violent painspusin the eye and head. The disease the oesophagus was the commencement of a stricture, scarcely had lasted, when it came under the writer’s observation, nearly admit a small and surrounded to large enough goose-quill, by a month and a half, and mild antiphlogistic measures had been
a condensed state of the submucous cellular tissue; its situation corresponded with the bifurcation of the trachea. The carotid vessels appeared to be implicated in the diseased mass, but the walls had been strengthened by a considerable thickening of the surrounding tissues. Their internal coats presented a highly vascular appearance, and small spots of lymph were visible, as well as upon the inner coat of the tuberal jugular vein. The left subclavian and vena innominata were evidently compressed by the gradually extending mass. Whether the orifice of the thoracic duct was closed, I am unable to state, as the heart was divided in the removal at the post-mortem; but from the immediate contiguity of the disease to this duct, I could hardly imagine it could escape some morbid influence. Upon tracing upwards the recurrent laryngeal nerve on the left side, it was found to terminate upon the internal surface of the lower part of the larger cyst, in a rounded nodule, the continuance of which had evidently been destroyed by the progressive absorption. I am indebted to Dr. Davies for the microscopical investigation of the diseased structure, which was found to consist of cancerous de.
posit. -I
have been induced to bring this case before the Society, much in consequence of the peculiar interest it possesses, or under the idea that it contains many new circumstances corroborative of ascertained facts, neither from any novelty or success in the treatment, or even relief of any of the symptoms, but simply because it appears to present the following questions for consideration-viz., Whether, in a case of stricture of the oesophagus, in which the presence of malignant disease was doubtful, it were better merely to direct our attention to the relief of general constitutional symptoms as much as possible, leaving the stricture untouched; or, on the other hand, as in the case of stricture elsewhere, to attempt a radical eure by means of probangs or bougies, armed or Votherwise, combating any inflammatory symptoms which might arise in the usual manner. The cases recorded by Sir Everard Home give ample evidence of the success of the latter treatment. I am aware that one objection to this mode would be the danger of passing out of the oesophagus into the other important strictures, as is the case in one of the preparations before you, in which the probang was passed through the oesophagus into the anterior mediastinum: this, however, must certainly have been the not
so
used, but without amelioration. M. Laudran immediately submitted the patient to active antiphlogistic treatment, bleeding from the arm, leeches to the mastoid process, active purging, and low diet, with an ointment to the eyelids containing belladonna. By these means the internal inflammation was soon got under; the pain ceased, the redness of the sclerotica vanished; the hypopion only showed no signs of decrease, and the iritis, dependent on it, remained stationary. The ulcer on the cornea slowly but sensibly improved. He then thought to try iodine in a collyrium, knowing it was not productive of inflammation, from
previous experience, and ordered four or five drops of a collyrimn made of fifteen drops of tincture of iodine to six drachms of distilled water, to be dropped into the eye three times a day. After this treatment had been pursued for four days, the hypopion, which had at the outset occupied a large portion of the anterior chamber, became reduced in size to a pin’s head; nearly three-fourths of it being absorbed. Cicatrization of the ulcer of the cornea went on rapidly. At the end of seven days absorption was complete. A white speck occupied the site of the ulcer of the cornea, the iris was rather irregular, and the sight was impaired. The other case was that of a gentleman, aged 71, of sanguine temperament, who had suffered from inflammation of£ the right eye for a month. Similar symptoms were present as in the former case: the vessels of the conjunctiva and sclerot,ica were congested: there was keratitis, and ulceration of the lower part of the cornea, with iritis, hypopion, and violent headach coming on in paroxysms several times during the day. Antiphlogistic treatment was adopted, and overcame the inflammatory symptoms in six days; but the hypopion was unrelieved. Recourse was had to the iodine collyrium, as above, which brought about complete absorption in eight days. -Remar7cs.-It seems impossible to doubt the good effects of the iodine in the preceding cases; no sign of the removal of the hypopion being noticed till its employment. The remedy was employed only against the purulent effusion, not against its cause-the active inflammation, which was previously combated by antiphlogistic means. Indeed, At. Laudran does not consider iodine to be antiphlogistic, but only as a medicine which favours absorption, by exciting the absorbents to functional activity. He would not insist on the two cases given,
proceeds to describe successful.
Dupuytren,
having
489 I endeavoured to pour the The first severe symptoms he experienced (about nine magnesia and water down her throat, but soon found it im-months back) were those of the food seeming to rest at a point possible, on account of-first, the strong spasmodic closureopposite the upper border of the sternum, requiring a draught of the jaws, which only intermitted during the act of vomiting, of fluid to force the mass downwards: this was frequently this being immediately succeeded by violent grinding of the succeeded by regurgitation, with violent retching and coughteeth, and then, immovable closure of the jaws; secondly, ing. Upon applying to a surgeon in the neighbourhood for when an opportunity offered itself of putting some fluid into assistance, his throat was examined witha probang ; and the mouth, the attempt to swallow directly excited vomiting, leeches and blisters having been applied for a short time and this increased greatly, so that, at length, the further admi- without much relief, he was referred to the hospital, into nistration of anything became impracticable. She was then put which he was admitted Jan. 13th, under the care of Mr. Anto bed, and bottles of hot water applied to her feet, and I sat drews. He never remernbers having had any uneasiness in down to watch for the first sign of reaction. She lay for his throat previous to the present symptoms, or to have swalseveral hours, in a state of profound insensibility, interrupted lowed scalding liquids, or anything which would have induced only at intervals of four or five minutes, by violent retching, an inflammatory attack. but she made no effort to raise or move herself. At length, Jan. 17th.-Four days after his admission into the hospital, her pulse became stronger, and the surface of her body Mr. Adams, at the request of Mr. Andrews, cautiously passed warmer, and she raised her hands to her throat, and gave a small-sized probang; slight resistance appeared to be offered other signs of returning consciousness. Pressure on the about the situation of the lower constrictor of the pharynx. throat gave her great uneasiness, and immediately excited After passing this, the instrument was again obstructed in its vomiting, while much firmer pressure on the epigastric region progress some inches lower down the tube; with slight presonly excited slight expression of pain. Ordered twelve sure, this also was overcome, and the probang appeared to leeches to the throat, and eighteen to the epigastrium.- pass’into the stomach. This operation, however, occasioned Noon : The leech-bites have bled very freely, especially those cons derable pain, which continued for some hours, and was referred to the cardiac end and upper border of the stomach. over the throat; is now sensible, though incapable of speaking No further application of the probang was directed, and the even in a whisper; breathes naturally; the retching continues At this as frequently as at first, and is provoked, on attempting to patient was put upon middle diet, with strong broth. swallow her saliva; this she is unable to accomplish; and her stage of the disorder, and for some weeks subsequently, he face and attitude are expressive of excruciating agony; could swallow solid food, cut up finely, with greater ease than neither bladder nor bowels have acted; very little tenderness liquids. Upon a careful stethoscopic examination of the in epigastric region; but the slightest pressure on the throat thoracic organs, no abnormal condition could be detected, nor gives great pain, and excites attempts to vomit. Ordered was any enlargement, hardness, or tenderness upon manipulatwenty leeches to the throat, and five minims of dilute hydro- tion, observable in the neck or cervical glands; the stomach cyanic acid, in two drachms of syrup, every four hours; barley also appeared free from any induration at either orifice. water or linseed tea, cold, in case of her being able to swallow. But slight variation occurred in the symptoms during the - Ten P.M.: Tenderness of throat diminished, and retching succeeding months. The probang was but rarely had recourse less frequent, but still incapable of swallowing; feels faintish; to, and it was always observable that greater difficulty was castor oil and oxymel enema administered; this caused a experienced in passing it after each successive application. Feb. 7th.—His general health appears good; and were it copious faeculent evacuation, and a small quantity of urine was passed at the same time. not for the gradually increasing difficulty of deglutition, he 12th.—Has passed a restless night, in much pain, and seems would be able, he thinks, to pursue his accustomed engagemuch exhausted; has with great effort swallowed a tea- ments. His diet is altered to milk, with light pudding, which spoonful of cold water; can answer briefly in a whisper, when he is compelled to eat very gradually by small spoonfuls at a spoken to; tenderness and pain without considerably dimi- time. More solid food will not now pass the lower stricture. nished, but slight pressure excites retching; pulse 110, and His voice is reduced to a loud whisper. weak; blistered her on each side of the larynx, with acetum 14th.—During the last week, his constitution seems to cantharides. Repeat enema.-Eight.P.M.: Feels better, but sympathize with the disease. Much pain is complained of very restless, and cannot sleep; pain and tenderness, and dis- over the stomach, with general disturbance of the functions. position to vomit, have much subsided; effort to swallow The face, nose, and lips, have assumed a bluish hue ; his exceedingly painful, but has taken a little barley water and breath is offensive, and he is unable to pass food of any kind milk. To have fifteen minims of laudanum, in half an ounce into the stomach. After having passed a teaspoonful of fluid, of water, at bed-time, and to use a gargle, consisting of an it appears to remain in the oesophagus a few seconds, and is then violently rejected by coughing. ounce of honey of borax, and five ounces of water. Three days were 13th.-Has slept comfortably at intervals, and feels better in passed with little if any food being taken. Under these cirevery respect. The false membrane in the mouth is beginning cumstances, the stomach-pump was resorted to, and the to come off in shreds of considerable size, one of them being smallest being passed down to the stricture, (through which moulded into the shape of part of the fauces, pharynx, and it could not pass,) the pump was attached, and in this manner upper part of the cesophagus; feels extremely weak; tender- he was fed three times daily with milk and beef-tea, containness and pain in throat diminishing. Ordered, beef-tea, with ing finely grated bread. Notwithstanding the nourishment arrow-root, barley-water, and milk, of which she now drinks he took, and his apparently increasing appetite, it was too frequently; repeat blisters, lower down on each side, to throat; evident that his health was rapidly giving way. His breath became horribly offensive ; mucus collecting in his throat repeat enema. From this time, she continued improving and gained strength gave him uneasiness; but neither purulent matter nor blood rapidly. In a week, she could enjoy a mutton chop, and taste was observable in his sputa. her food; bowels kept regularly evacuated by means of ene22nd.-Complains of being ill all over; cannot rise from mata, and a light tonic administered. At the end of the fort- his bed, as usual; pulse is accelerated, 118; skin hot and dry; night she was removed to a penitentiary, where she remained cough excessively troublesome, keeping him awake all night; only a fortnight. I have seen her recently, and she looks well, his mouth is parched, obliging him constantly to moisten it and has gained health. with acid drinks, or by sucking wet lint. More resistance Mr. Tomkins considered that very little acid (which was ofthan usual is formed upon passing the upper stricture; but the strength of that ordinarily employed) had reached the yet no pain is occasioned. The lower passage, however, is stomach, and that that was so diluted by the gin and beermore contracted, rendering it extremely difficult to pass a which the patient had taken as not to cause any distinct in- small quantity of his accustomed diet; and this can only be done between intervals of coughing. flammatory affection of the organ. 23rd.-No food has been passed to-day; he looks anxious and emaciated; lips anscmic; the colour of his nose is dark Mr. BARRETT read a case of and livid; the thick mucus gurgles in his throat, appearing to MALIGNANT STRICTURE OF THE (ESOPHAGUS, WITH ATROPHY OF impede the respiration, and at times almost threatening suffoTHE RECURRENT LARYNGEAL NERVE, GIVING RISE TO ALMOST cation; pulse 136, wiry, and small; tongue slightly furred ENTIRE SUPPRESSION OF THE VOICE. and dry; breath offensive; mouth parched; skin of lips D. B-, aged forty-one, a bricklayer, has been accustomedi cracked, dry, and swollen ; loud bronchial rale obscuring for the last few years to live somewhat intemperately. States,:, every other sound in the chest. About four o’clock this that within the last two years lie has lost flesh considerably. afternoon, whilst talking to some friends who were standing This he attributes to the constant difficulty he has found iniby, he was seized with a fit of coughing, ejected a quantity of swallowing. His voice, also, has recently become altered ini dark, foetid matter from the mouth, fell back, and died. Post-mortem examination, twenty-two hours after death.tone to a deep, gruff base.
and feebly affected by the light.
.
!
-
.
490
Body considerably emaciated.—Brain : lymph effused between the layers
A small quantity of of aracluzoid, but not adherent to either; more fluid than usual in the subarachnoid spaces and lateral ventricles. In every other respect the brain appeared healthy.—Cavity of thorax: The lungs rose up on removing the sternum; no adhesions. The whole contents were removed for a more minute exaniiiirtion.Cavity of abdomen : Nothing abnormal was observed in the contents of this cavity. Stomach perfectly healthy; the liver also; no enlargement in the mesenteric glands. The oesophagus and neighbouring parts presented the following appearance:—Upon the anterior surface of trachea, extending downwards from the thyroid gland on to the pericardium, was a dense layer of soft, imperfectly developed fatty tissue. Upon removing this, the lower part of thyroid gland was condensed, by means of a much condensed mass, (of what appeared to be the original tissue,) to a number of indurated rounded bodies, somewhat resembling enlarged glands, slightly varying in size, and extending backwards rather more to the left side than the right, involving the carotid vessels, and partly separating the oesophagus from the trachea. Upon a section being made of one of these indurated bodies, a white, cream-like substance exuded from the dense fibrous structure of which it seems composed ; but the structure itself did not present that gritty character upon cutting it which is usually met with in scirrhus. The interior of some parts of the bodies was softened; others
’ result
firm
contained cavities, partly filled with a foetid, unhealthy-looking matter. Between the oesophagus and trachea, immediately behind, and a little below the thyroid cartilage, was a large abscess,
or
cyst, filled with matter somewhat similar
to
the
of considerable force, as the parts in the vicinity of the stricture appear excessively thickened, as they invariably are, thus serving to prevent the occurrence of such mischief. In the case of the man now before you, his appearance when he first entered the hospital was certainly indicative of malignant disease, neither had he any symptoms at the seat of the disease, showing that so destructive a process was going on. From the suspicious and dangerous character of the disease generally, Mr. Andrews, 1 believe, was led to adopt the more passive treatment: the result of a post mortem has proved the advantage of such a course. Dut, on the other hand, had the case been one of stricture from thickening of the sub-mucous cellular tissue only, as might probably have been the condition of this stricture in the first instance, before the malignant disease was induced by the constant and unchecked irritation, then I cannot help thinking that the mechannical treatment, if carefully applied, would have brought the case to a more successful termination. The gradual loss of voice must no doubt be attributable to the total destruction of the recurrent laryngeal nerve, the gradual diminution of the circumference of the trachea by the increasing pressure of the abscess materially tending to lessen the volume of sound; the attempt to speak towards the close of the man’s life being accompanied by considerable exertion, and requiring frequent respiratory efforts.
Foreign Department. FOREIGN PERIODICALS.—FRENCH.
preceding. and containing several detached rings of the traTincture of Iodine as a Collyrium in Hypopion. chea, in a state of partial absorption. This abscess was In L’ Union Médicale of April 6th, li. RIVAUD-LAUDRAN, of found to communicate, (as is seen in the preparation on the recommends the use of the tincture of iodine as a coltable,) on one side, by an oblong opening in the oesophagus, Lyons, to bring about absorption in cases of hypopion. He about the lower border of the inferior constriction, and on the lyrium two cases in which he employed it successfully. narrates anterior surface with the trachea, the rings of which had One, a lady, aged 61, had violent inflammation of the internal given way, their place being supplied by a thickened conti- tunics, with ulceration of the cornea, at its lower part, and a nuation of the fibrous membrane; through this membrane the into the anterior chamber, accomeffusion of considerable opening had taken place. A little below this opening in panied with violent painspusin the eye and head. The disease the oesophagus was the commencement of a stricture, scarcely had lasted, when it came under the writer’s observation, nearly admit a small and surrounded to large enough goose-quill, by a month and a half, and mild antiphlogistic measures had been
a condensed state of the submucous cellular tissue; its situation corresponded with the bifurcation of the trachea. The carotid vessels appeared to be implicated in the diseased mass, but the walls had been strengthened by a considerable thickening of the surrounding tissues. Their internal coats presented a highly vascular appearance, and small spots of lymph were visible, as well as upon the inner coat of the tuberal jugular vein. The left subclavian and vena innominata were evidently compressed by the gradually extending mass. Whether the orifice of the thoracic duct was closed, I am unable to state, as the heart was divided in the removal at the post-mortem; but from the immediate contiguity of the disease to this duct, I could hardly imagine it could escape some morbid influence. Upon tracing upwards the recurrent laryngeal nerve on the left side, it was found to terminate upon the internal surface of the lower part of the larger cyst, in a rounded nodule, the continuance of which had evidently been destroyed by the progressive absorption. I am indebted to Dr. Davies for the microscopical investigation of the diseased structure, which was found to consist of cancerous de.
posit. -I
have been induced to bring this case before the Society, much in consequence of the peculiar interest it possesses, or under the idea that it contains many new circumstances corroborative of ascertained facts, neither from any novelty or success in the treatment, or even relief of any of the symptoms, but simply because it appears to present the following questions for consideration-viz., Whether, in a case of stricture of the oesophagus, in which the presence of malignant disease was doubtful, it were better merely to direct our attention to the relief of general constitutional symptoms as much as possible, leaving the stricture untouched; or, on the other hand, as in the case of stricture elsewhere, to attempt a radical eure by means of probangs or bougies, armed or Votherwise, combating any inflammatory symptoms which might arise in the usual manner. The cases recorded by Sir Everard Home give ample evidence of the success of the latter treatment. I am aware that one objection to this mode would be the danger of passing out of the oesophagus into the other important strictures, as is the case in one of the preparations before you, in which the probang was passed through the oesophagus into the anterior mediastinum: this, however, must certainly have been the not
so
used, but without amelioration. M. Laudran immediately submitted the patient to active antiphlogistic treatment, bleeding from the arm, leeches to the mastoid process, active purging, and low diet, with an ointment to the eyelids containing belladonna. By these means the internal inflammation was soon got under; the pain ceased, the redness of the sclerotica vanished; the hypopion only showed no signs of decrease, and the iritis, dependent on it, remained stationary. The ulcer on the cornea slowly but sensibly improved. He then thought to try iodine in a collyrium, knowing it was not productive of inflammation, from
previous experience, and ordered four or five drops of a collyrimn made of fifteen drops of tincture of iodine to six drachms of distilled water, to be dropped into the eye three times a day. After this treatment had been pursued for four days, the hypopion, which had at the outset occupied a large portion of the anterior chamber, became reduced in size to a pin’s head; nearly three-fourths of it being absorbed. Cicatrization of the ulcer of the cornea went on rapidly. At the end of seven days absorption was complete. A white speck occupied the site of the ulcer of the cornea, the iris was rather irregular, and the sight was impaired. The other case was that of a gentleman, aged 71, of sanguine temperament, who had suffered from inflammation of£ the right eye for a month. Similar symptoms were present as in the former case: the vessels of the conjunctiva and sclerot,ica were congested: there was keratitis, and ulceration of the lower part of the cornea, with iritis, hypopion, and violent headach coming on in paroxysms several times during the day. Antiphlogistic treatment was adopted, and overcame the inflammatory symptoms in six days; but the hypopion was unrelieved. Recourse was had to the iodine collyrium, as above, which brought about complete absorption in eight days. -Remar7cs.-It seems impossible to doubt the good effects of the iodine in the preceding cases; no sign of the removal of the hypopion being noticed till its employment. The remedy was employed only against the purulent effusion, not against its cause-the active inflammation, which was previously combated by antiphlogistic means. Indeed, At. Laudran does not consider iodine to be antiphlogistic, but only as a medicine which favours absorption, by exciting the absorbents to functional activity. He would not insist on the two cases given,