MIDDLESEX HOSPITAL.
1
35 Pulse quick, and weaker than it had been since the 6th. Ordered sulphuric acid and morphia in large doses. 13th.-Very slight return of hæmoptysis since last visit; pulse stronger and less frequent. Repeat mixture. 14th.-No return of haemoptysis. Repeat mixture. 15th.-Sudden but slight return of haemoptysis. Repeat mixture. 16th.-Slight haemoptysis ; pulse weaker. Ordered gallic acid and morphia; increased the wine to eight ounces, it having been decreased to four ounces. From this time there was no return of the hæmorrhage, and the patient continued to improve steadily until the 10th of September, when he was discharged from the hospital quite well. The patient’s chest was now carefully and repeatedlyexa- mined, but did not exhibit a sign of tuberculosis of the lungs. I consider the above case of interest on account of the rarity of haemoptysis as a sequela of typhus. I do not consider it was one of those cases (by no means uncommon) where hypo- static congestion had occurred; and on the return of the patient’s strength, he was enabled to expectorate the effused matters. In such cases the crepitus pervades the whole of the back of the chest; it is not confined to a single spot, as in the case of James M-; and the blood in the expectoration is limited to slight streaks, never appearing in large quantities at once, as in the case just reported. It appears to me that the haemorrhage in this case was caused by ruptured capillaries. Molesworth-street, Dublin, Dec. 6th, 1865. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. MIDDLESEX HOSPITAL. A CASE IN WHICH TRACHEOTOMY AND CÆSAREAN SECTION WERE PERFORMED. (Under the care of Dr. STEWART and Mr. HULKE.) Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, tum proprias collectas habere, et inter ae comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proceminm. WE recently published (" Mirror," Dec. 23rd and 30th) the details of a case in which Cæsarean section was performed in this hospital on account of occlusion of the vagina by cancer, when a living child was extracted, who is now thriving. By a remarkable coincidence, the operation was again required to be performed within forty-eight hours. In this latter case, particulars of which we subjoin, the mother was dead; and the procedure was adopted to save, if possible, the life of the child. The propriety of the practice in such circumstances has long been recognised. It was known to the ancient Romans. By a decree of Numa Pompilius, no woman who died pregnant was suffered to be buried ere her body had been opened, with the view of preserving the infant for the use of the State. A still more stringent law was made in 1749 by the King of Sicily, who decreed the punishment of death to those medical men who omitted to perform the Cæsarean ope- ration on such women as died in the advanced stages of preg- nancy. (See "Cooper’s Surgical Dictionary," vol. i., p. 368.) Numerous instances have been published, on good or indif- ferent authority, of the extraction of a living fcetns from the dead body of its mother. Amongst them, one will be found recorded in the " Medico-Chirurgical Transactions," vol. xii., p. 46; where the late Mr. Green, of St. Thomas’s Hospital, extracted from a woman, who had been suddenly killed, a fcetus which survived thirty-four hours. A blonde, aged twenty-six, in the ninth month of pregnancy, was admitted into Murray ward, with sore-throat, on the 4th of December, at half-past nine P.M., under the care of Dr. Stewart, who had seen her at her own house in consultation that afternoon, and advised her removal to the hospital. She was voiceless; but, when lying still, had not much dyspnœa. Respiration 30 ; a slight, harsh, inspiratory laryngeal sound ; vesicular murmur audible throughout the chest; pulse 130; expression calm. She had been seriously ill a week, but for several days before had not felt quite well; and her throat had become sore while she was nursing a child, who died of sore-throat the morning of her admission into hospital. The absence of previous chronic laryngeal disease, together with her embonpoint and previous excellent health, were unfavourable to the supposition of a tubercular or syphilitic laryngitis; while its contagiousness, inferable from its accession while nursing her child similarly affected, afforded a strong presumption in favour of diphtheria. When she was again seen by Dr. Stewart, about two hours after admission, her dyspncea had become so great that bronchotomy could not be deferred. Very little air entered the chest, and her face was livid. At twelve P.M., Mr. Hulke opened the upper part of her trachea, and put in a double Trousseau’s canula. There was unusually free bleeding, owing to venous turgescence, to the increased vascularity produced by blistering, and to the depth of the trachea, due to the stoutness and swelling of her neck. Much blood escaped from the mouth, as well as from the external wound, and much was ejected through the tube with some shreds of false membrane. Air in full volume en- tered the chest, and the respiratory murmur was everywhere audible. She passed a quiet night; but at four A.M. had a paroxysm of apnoea, caused by some membrane getting into the tube. This was removed by Mr. Bayley, the resident clinical assistant, who had watched her most assiduously, and she again breathed freely. At half-past eight A.M. another paroxysm of apnoea occurred. More shreds of membrane and some membranous coagula of blood were removed, but she died. The mode of death being comparatively slow, it was diffi- cult to fix the very moment when life ceased. As soon as it was evident that respiration could not be restored, Mr. Hulke, who happened to be in the hospital at the time, removed the child from the uterus by a long incision. It kicked while being taken from the womb, but could not be resuscitated. The proceeding did not occupy longer than a minute. It was necessary to extend the incision in the abdominal walls above the navel, and to make that in the uterus equally extensive. The uterine walls were only about two lines and a half thick. The placenta was attached to the front of the body of the uterus, its middle lying directly in the line of the incision. It was at once recognised by its spongy texture and avoided. The hand was quickly pushed between it and the uterine walls to its edge where the membranes were torn, and the child reached. The thinness of the uterine wall-in which this case differed so strikingly from Mr. De Morgan’s-was probably owing to the greater distension of the uterus, the liquor amnii being present, and to the absence of contraction. At the post-mortem examination, the laryngeal mucous mem- brane was found congested, œdematous, and coated with mem- branous diphtheritic exudation. The trachea and bronchi were e congested, and clogged with mucus. ST. GEORGE’S HOSPITAL. AMPUTATION THROUGH THE KNEE-JOINT BY FLAPS ; FATAL RESULT. (Under the care of Mr. POLLOCK.) THE first of the two cases which we here note is one which says nothing either for or against the value of the kind of amputation performed. The woman was in a sinking state from disease; her only chance lay in the removal of the limb, and there can be no doubt that a similar result would have followed any other procedure. Amputation through the knee-joint has not until of late years received so much attention in this country as might, .perhaps, have been expected. Of late, however, there has been a growing impression in favour of the operation, and it has been frequently performed. The fears which were at first entertained respecting the effects of opening up so large a joint as the knee have been shown to be groundless, especially by the results of excision of the joint. The objection, too, that the smooth surface of the cartilage covering the condyles could not unite with the flaps has been proved, at least in most cases, to be unfounded. The advantage of leaving the carti- .
Transcript of MIDDLESEX HOSPITAL.
35
Pulse quick, and weaker than it had been since the 6th.Ordered sulphuric acid and morphia in large doses.13th.-Very slight return of hæmoptysis since last visit;
pulse stronger and less frequent. Repeat mixture.14th.-No return of haemoptysis. Repeat mixture.15th.-Sudden but slight return of haemoptysis. Repeat
mixture.16th.-Slight haemoptysis ; pulse weaker. Ordered gallic
acid and morphia; increased the wine to eight ounces, ithaving been decreased to four ounces.From this time there was no return of the hæmorrhage, and
the patient continued to improve steadily until the 10th ofSeptember, when he was discharged from the hospital quitewell. The patient’s chest was now carefully and repeatedlyexa-mined, but did not exhibit a sign of tuberculosis of the lungs.
I consider the above case of interest on account of the rarityof haemoptysis as a sequela of typhus. I do not consider itwas one of those cases (by no means uncommon) where hypo-static congestion had occurred; and on the return of the
patient’s strength, he was enabled to expectorate the effusedmatters. In such cases the crepitus pervades the whole of theback of the chest; it is not confined to a single spot, as in thecase of James M-; and the blood in the expectoration islimited to slight streaks, never appearing in large quantities atonce, as in the case just reported. It appears to me that the
haemorrhage in this case was caused by ruptured capillaries.Molesworth-street, Dublin, Dec. 6th, 1865.
A MirrorOF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
MIDDLESEX HOSPITAL.A CASE IN WHICH TRACHEOTOMY AND CÆSAREAN SECTION
WERE PERFORMED.
(Under the care of Dr. STEWART and Mr. HULKE.)
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, et interae comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proceminm.
WE recently published (" Mirror," Dec. 23rd and 30th) thedetails of a case in which Cæsarean section was performed inthis hospital on account of occlusion of the vagina by cancer,when a living child was extracted, who is now thriving. Bya remarkable coincidence, the operation was again required tobe performed within forty-eight hours. In this latter case,
particulars of which we subjoin, the mother was dead; andthe procedure was adopted to save, if possible, the life of thechild. The propriety of the practice in such circumstanceshas long been recognised. It was known to the ancientRomans. By a decree of Numa Pompilius, no woman whodied pregnant was suffered to be buried ere her body had beenopened, with the view of preserving the infant for the use ofthe State. A still more stringent law was made in 1749 bythe King of Sicily, who decreed the punishment of death tothose medical men who omitted to perform the Cæsarean ope-ration on such women as died in the advanced stages of preg-nancy. (See "Cooper’s Surgical Dictionary," vol. i., p. 368.)Numerous instances have been published, on good or indif-ferent authority, of the extraction of a living fcetns from thedead body of its mother. Amongst them, one will be foundrecorded in the " Medico-Chirurgical Transactions," vol. xii.,p. 46; where the late Mr. Green, of St. Thomas’s Hospital,extracted from a woman, who had been suddenly killed, afcetus which survived thirty-four hours.A blonde, aged twenty-six, in the ninth month of pregnancy,
was admitted into Murray ward, with sore-throat, on the 4thof December, at half-past nine P.M., under the care of Dr.
Stewart, who had seen her at her own house in consultationthat afternoon, and advised her removal to the hospital. Shewas voiceless; but, when lying still, had not much dyspnœa.Respiration 30 ; a slight, harsh, inspiratory laryngeal sound ;vesicular murmur audible throughout the chest; pulse 130;expression calm. She had been seriously ill a week, but forseveral days before had not felt quite well; and her throathad become sore while she was nursing a child, who died ofsore-throat the morning of her admission into hospital. Theabsence of previous chronic laryngeal disease, together with herembonpoint and previous excellent health, were unfavourableto the supposition of a tubercular or syphilitic laryngitis; whileits contagiousness, inferable from its accession while nursingher child similarly affected, afforded a strong presumption infavour of diphtheria. When she was again seen by Dr.Stewart, about two hours after admission, her dyspncea hadbecome so great that bronchotomy could not be deferred.Very little air entered the chest, and her face was livid.At twelve P.M., Mr. Hulke opened the upper part of her
trachea, and put in a double Trousseau’s canula. There wasunusually free bleeding, owing to venous turgescence, tothe increased vascularity produced by blistering, and to thedepth of the trachea, due to the stoutness and swelling of herneck. Much blood escaped from the mouth, as well as fromthe external wound, and much was ejected through the tubewith some shreds of false membrane. Air in full volume en-tered the chest, and the respiratory murmur was everywhereaudible. She passed a quiet night; but at four A.M. had aparoxysm of apnoea, caused by some membrane getting intothe tube. This was removed by Mr. Bayley, the residentclinical assistant, who had watched her most assiduously, andshe again breathed freely. At half-past eight A.M. anotherparoxysm of apnoea occurred. More shreds of membrane andsome membranous coagula of blood were removed, but shedied.The mode of death being comparatively slow, it was diffi-
cult to fix the very moment when life ceased. As soon as itwas evident that respiration could not be restored, Mr. Hulke,who happened to be in the hospital at the time, removed thechild from the uterus by a long incision. It kicked whilebeing taken from the womb, but could not be resuscitated.The proceeding did not occupy longer than a minute. It was
necessary to extend the incision in the abdominal walls abovethe navel, and to make that in the uterus equally extensive.The uterine walls were only about two lines and a half thick.The placenta was attached to the front of the body of theuterus, its middle lying directly in the line of the incision. Itwas at once recognised by its spongy texture and avoided.The hand was quickly pushed between it and the uterine wallsto its edge where the membranes were torn, and the childreached.The thinness of the uterine wall-in which this case differed
so strikingly from Mr. De Morgan’s-was probably owing tothe greater distension of the uterus, the liquor amnii beingpresent, and to the absence of contraction.At the post-mortem examination, the laryngeal mucous mem-
brane was found congested, œdematous, and coated with mem-branous diphtheritic exudation. The trachea and bronchi were econgested, and clogged with mucus.
ST. GEORGE’S HOSPITAL.
AMPUTATION THROUGH THE KNEE-JOINT BY FLAPS ;FATAL RESULT.
(Under the care of Mr. POLLOCK.)THE first of the two cases which we here note is one which says
nothing either for or against the value of the kind of amputationperformed. The woman was in a sinking state from disease; heronly chance lay in the removal of the limb, and there can beno doubt that a similar result would have followed any other
procedure. Amputation through the knee-joint has not untilof late years received so much attention in this country asmight, .perhaps, have been expected. Of late, however, therehas been a growing impression in favour of the operation, andit has been frequently performed. The fears which were atfirst entertained respecting the effects of opening up so large ajoint as the knee have been shown to be groundless, especiallyby the results of excision of the joint. The objection, too,that the smooth surface of the cartilage covering the condylescould not unite with the flaps has been proved, at least in mostcases, to be unfounded. The advantage of leaving the carti- .
