Dr. Mansi Arora University College of Medical Science & GTB Hospital, Delhi.
UNIVERSITY COLLEGE HOSPITAL.
2
447 and spoke to him at 8.30 P.M., and at 9 P.M. a patient called the nurse, and said he could not hear him breathing: he had died apparently without a struggle. At the post- mortem the larynx was removed, and there was practically no opening through the glottis, the parts being so swollen and infiltrated; the larynx was divided with scissors, and I in the middle of the cricoid cartilage, posteriorly, a small abscess the size of a pea was cut through ; this was appa- rently between the cricoid and its perichondrium; its walls were ossified. The vocal cords were tightly strung over the surface of the mucous membrane, leaving a mere chink. This appeared to be all the mischief, but on passing a probe into the right sacculus laryngis, the upper surface of the cricoid was felt bare, ossified, and carious, and on opening the right crico-arytenoid joint, both surfaces were in the same state, resembling the carious surfaces of a diseased knee-joint; much of the cricoid was ossified; the thyroid was totally unaffected. The state of the vocal cords and the general swelling explained why nothing could be seen laryngoseopically. If this man’s trachea had been opened the parts would have been comparatively at rest, the crico-arytenoid joint would possibly have become anchylosed, and the cricoid abscess would possibly have dried up. What voice he would have recovered I do not feel prepared to give an opinion upon, but almost certainly his life would have been saved. As he had attended at two other hospitals, the case was evidently not considered urgent, but it gives a lesson that a patient with persistent stridulous breathing owing to laryngeal mischief, whether ulceration, polypus, or necrosis, is not safe without a tube. It is also remarkable that he never suffered pain even on pressure, or dysphagia. Had laryngotomy been performed instead of tracheotomy, it would inadvertently have been a wrong selection, as the tube would have been in close proximity to the diseased upper margin of the cricoid, and so would have most pro- bably aggravated the disease. CASE OF HYDATIDIFORM DEGENERATION OF THE OVUM COMPLICATED WITH HÆMOR- RHAGE; REMOVAL OF THE MASS. BY WILLIAM C. WISE, M.D. ST. AND., L.R.C.P. LOND., &c. M. A-, aged twenty-eight, married, four children (youngest ten months, still at the breast), last catamenia two months, consulted me on October 3rd, 1871, for a dis- charge of blood from the vagina which had taken place at the same hour for several days prior to her seeking advice. She estimated the quantity discharged each time at from two to four ounces. She had also vomited every morning for two months. The vaginal examination showed the os to be patulous, and the cervix short and plastic, but the speculum revealed no ulceration or other lesion. I diagnosed early pregnancy, directed her to wean the infant, and prescribed rest and the acid infusion of roses with dilute sulphuric acid. As the bleeding continued, in a few days I gave gallic acid in five-grain doses every four hours, and advised her to suck ice and take iced drinks. This treatment being of no avail, I gave ten minims of the solution of extract of ergot (P.B.) with fifteen minims of the tincture of perchloride of iron three times a day, hoping either to stop the bleeding, which had now (Oct. 24th) much increased, or induce the womb to expel its contents ; but neither of these results occurring, I substituted for the ergot and iron ten minims of the tincture of cannabis indica three times a day, and ordered vaginal injections of alum. No improvement taking place, the case was now seen by Dr. Mason, of Finsbury- square, London, who ordered fifteen minims of tincture of perchloride of iron three times a day, and a free supply of Wenham-lake ice, and considered that this treatment per- severed in would eventually stop the bleeding. At the end of a fortnight the general health, which had previously suffered much, was improved, and the haemorrhage, although not stopped, was certainly less. At a second consultation with Dr. Mason, as there was a certain periodicity about the discharge of blood, he suggested that two grains of quinine be given with each dose of the tincture of per- chloride of iron. This was on December 7th, and on the morning of December 8th, on my visiting the patient, she told me she had had bearing-down, forcing pains since 4 A M. at regular intervals. On examination, I found the os dilated to the size of a florin, and a soft, firm, flesh-like substance, which I could not break down, planted over the mouth of the womb. There was still hæmorrhage, though slight, which came and went with every pain. After wait- ing some hours and finding no progress, I gave two half- drachm doses of ergot at an interval of two hours, neither of which appeared to have the slightest effect. I now called in Mr. Mason, F R.C.S., of Woolwich, who placed the patient under the influence of chloroform, while I with great difficulty worked my hand through the placenta-like substance planted over the mouth of the womb, into the cavity of the latter, from which I scooped out a large wash- basin half full of hydatid cysts (so called), which resembled a large number of white grapes floating in claret. There was not the slightest trace of any ovum unless the fleshy mass referred to represented the placenta. We got good contraction of the uterus, the patient slowly regained her strength, and was quite convalescent by the end of a month. Burrage-road, Plumstead, S.E. A Mirror OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. UNIVERSITY COLLEGE HOSPITAL. PSOAS ABSCESS; ACUTE TUBERCULOSIS; DEATH. (Under the care of Mr. ERICHSEN.) Nulla autem eat alia pro certo noscendi via, nisi quamplurimas etmorborum et dissectionum historias, tum aliorum, tum proprias collect as habere, et I inter se comparare.-MORGAGNI De Sed. et Caus. .Morb., lib. iv. Prooemium. THis case is one that throws some light on the origin of tuberculosis. Since Villemin first announced that tubercle may be introduced into the lungs and other organs of the body by inoculation, the views on the pathogeny of tuber- culosis have undergone great changes both in this country and on the continent. It is, however, chiefly owing to the advocacy of Buhl and Niemeyer in Germany, and to the results of experiments carried on by Drs. Burdon-Sanderson and Wilson Fox in this country, that the origin of tuber- culosis from a pre-existing inflammation has come to be regarded as a fact. The only point under dispute is, whe- ther every tuberculosis has such an origin ; some observers answering in the affirmative, while others as positively deny this to be the only mode of origin. In all cases, however, it is acknowledged that there must be a certain predisposi- tion in the patient to the acceptance of this condition; this predisposition Niemeyer calls.a vulnerability of the consti- tution. The facts appear now to be too numerous to allow of the sequence of events being attributed to a coincidence. William T-, aged twenty-three, said that up to two years before admission he was quite well, but that about October, 1869, he suffered rheumatic pain in the hip and lumbar region of the left side. For this he was treated at the Great Northern Hospibal, and in about two months got well. About October, 1870, he felt some weakness in the back, so that he was unable to rise from the horizontal position without using his arms. In January, 1871, he had a severe cough, and spat up a large quantity of mucus, but no blood. He then lost appetite, and suffered pain in the chest. At the end of February of the same year he noticed a swelling in the left groin, and a week after this a swelling in the left lumbar region. These increased in size rapidly for three weeks, but since then have not grown much. At this time he was ordered cod-liver oil. At the beginning of July, 1871, he had a return of the rheumatic pains, but this time in the fingers and in the forearm of the right side. At the end of October he felt pain as of a cord tied tightly round the abdomen. At the time of admission, Nov. 1st,
Transcript of UNIVERSITY COLLEGE HOSPITAL.
447
and spoke to him at 8.30 P.M., and at 9 P.M. a patient calledthe nurse, and said he could not hear him breathing: hehad died apparently without a struggle. At the post-mortem the larynx was removed, and there was practicallyno opening through the glottis, the parts being so swollenand infiltrated; the larynx was divided with scissors, and Iin the middle of the cricoid cartilage, posteriorly, a smallabscess the size of a pea was cut through ; this was appa-rently between the cricoid and its perichondrium; its wallswere ossified. The vocal cords were tightly strung over thesurface of the mucous membrane, leaving a mere chink.This appeared to be all the mischief, but on passing a probeinto the right sacculus laryngis, the upper surface of thecricoid was felt bare, ossified, and carious, and on openingthe right crico-arytenoid joint, both surfaces were in thesame state, resembling the carious surfaces of a diseasedknee-joint; much of the cricoid was ossified; the thyroidwas totally unaffected. The state of the vocal cords andthe general swelling explained why nothing could be seenlaryngoseopically.
If this man’s trachea had been opened the parts wouldhave been comparatively at rest, the crico-arytenoid jointwould possibly have become anchylosed, and the cricoidabscess would possibly have dried up. What voice hewould have recovered I do not feel prepared to give anopinion upon, but almost certainly his life would have beensaved. As he had attended at two other hospitals, the casewas evidently not considered urgent, but it gives a lessonthat a patient with persistent stridulous breathing owingto laryngeal mischief, whether ulceration, polypus, or
necrosis, is not safe without a tube. It is also remarkablethat he never suffered pain even on pressure, or dysphagia.Had laryngotomy been performed instead of tracheotomy,
it would inadvertently have been a wrong selection, as thetube would have been in close proximity to the diseasedupper margin of the cricoid, and so would have most pro-bably aggravated the disease.
CASE OF
HYDATIDIFORM DEGENERATION OF THEOVUM COMPLICATED WITH HÆMOR-
RHAGE; REMOVAL OF THE MASS.BY WILLIAM C. WISE, M.D. ST. AND., L.R.C.P. LOND., &c.
M. A-, aged twenty-eight, married, four children
(youngest ten months, still at the breast), last catameniatwo months, consulted me on October 3rd, 1871, for a dis-charge of blood from the vagina which had taken place atthe same hour for several days prior to her seeking advice.She estimated the quantity discharged each time at from twoto four ounces. She had also vomited every morning fortwo months. The vaginal examination showed the os to bepatulous, and the cervix short and plastic, but the speculumrevealed no ulceration or other lesion. I diagnosed earlypregnancy, directed her to wean the infant, and prescribedrest and the acid infusion of roses with dilute sulphuricacid. As the bleeding continued, in a few days I gave gallicacid in five-grain doses every four hours, and advised herto suck ice and take iced drinks. This treatment being ofno avail, I gave ten minims of the solution of extract ofergot (P.B.) with fifteen minims of the tincture of perchlorideof iron three times a day, hoping either to stop the bleeding,which had now (Oct. 24th) much increased, or induce thewomb to expel its contents ; but neither of these resultsoccurring, I substituted for the ergot and iron ten minimsof the tincture of cannabis indica three times a day, andordered vaginal injections of alum. No improvement takingplace, the case was now seen by Dr. Mason, of Finsbury-square, London, who ordered fifteen minims of tincture ofperchloride of iron three times a day, and a free supply ofWenham-lake ice, and considered that this treatment per-severed in would eventually stop the bleeding. At the endof a fortnight the general health, which had previouslysuffered much, was improved, and the haemorrhage, althoughnot stopped, was certainly less. At a second consultationwith Dr. Mason, as there was a certain periodicity about
the discharge of blood, he suggested that two grains ofquinine be given with each dose of the tincture of per-chloride of iron. This was on December 7th, and on themorning of December 8th, on my visiting the patient, shetold me she had had bearing-down, forcing pains since4 A M. at regular intervals. On examination, I found theos dilated to the size of a florin, and a soft, firm, flesh-likesubstance, which I could not break down, planted over themouth of the womb. There was still hæmorrhage, thoughslight, which came and went with every pain. After wait-
ing some hours and finding no progress, I gave two half-drachm doses of ergot at an interval of two hours, neitherof which appeared to have the slightest effect. I nowcalled in Mr. Mason, F R.C.S., of Woolwich, who placed thepatient under the influence of chloroform, while I withgreat difficulty worked my hand through the placenta-likesubstance planted over the mouth of the womb, into thecavity of the latter, from which I scooped out a large wash-basin half full of hydatid cysts (so called), which resembleda large number of white grapes floating in claret. Therewas not the slightest trace of any ovum unless the fleshymass referred to represented the placenta. We got goodcontraction of the uterus, the patient slowly regained herstrength, and was quite convalescent by the end of a month.
Burrage-road, Plumstead, S.E.
A MirrorOF
HOSPITAL PRACTICE,BRITISH AND FOREIGN.
UNIVERSITY COLLEGE HOSPITAL.PSOAS ABSCESS; ACUTE TUBERCULOSIS; DEATH.
(Under the care of Mr. ERICHSEN.)
Nulla autem eat alia pro certo noscendi via, nisi quamplurimas etmorborumet dissectionum historias, tum aliorum, tum proprias collect as habere, et
I inter se comparare.-MORGAGNI De Sed. et Caus. .Morb., lib. iv. Prooemium.
THis case is one that throws some light on the origin oftuberculosis. Since Villemin first announced that tubercle
may be introduced into the lungs and other organs of thebody by inoculation, the views on the pathogeny of tuber-culosis have undergone great changes both in this countryand on the continent. It is, however, chiefly owing to theadvocacy of Buhl and Niemeyer in Germany, and to theresults of experiments carried on by Drs. Burdon-Sandersonand Wilson Fox in this country, that the origin of tuber-culosis from a pre-existing inflammation has come to beregarded as a fact. The only point under dispute is, whe-ther every tuberculosis has such an origin ; some observersanswering in the affirmative, while others as positively denythis to be the only mode of origin. In all cases, however,it is acknowledged that there must be a certain predisposi-tion in the patient to the acceptance of this condition; thispredisposition Niemeyer calls.a vulnerability of the consti-tution. The facts appear now to be too numerous to allowof the sequence of events being attributed to a coincidence.William T-, aged twenty-three, said that up to two
years before admission he was quite well, but that aboutOctober, 1869, he suffered rheumatic pain in the hip andlumbar region of the left side. For this he was treated atthe Great Northern Hospibal, and in about two months gotwell. About October, 1870, he felt some weakness in theback, so that he was unable to rise from the horizontalposition without using his arms. In January, 1871, he hada severe cough, and spat up a large quantity of mucus, butno blood. He then lost appetite, and suffered pain in thechest. At the end of February of the same year he noticeda swelling in the left groin, and a week after this a swellingin the left lumbar region. These increased in size rapidlyfor three weeks, but since then have not grown much. Atthis time he was ordered cod-liver oil. At the beginning ofJuly, 1871, he had a return of the rheumatic pains, but thistime in the fingers and in the forearm of the right side. At
the end of October he felt pain as of a cord tied tightlyround the abdomen. At the time of admission, Nov. 1st,
448
1871, he had severe cramp-like pain, which radiated fronthe right hip down the outside of the thigh to the uppepart of the calf. On Nov. 3rd he was examined, and it wafound that he had a large, soft, but not circumscribedswelling in the left groin below Poupart’s ligament, an(outside the femoral vessels. The swelling could be reduce(by pressure, and fluctuation detected by palpation over thregion of the psoas muscle above Poupart’s ligamentThere was another soft swelling as large as an orange itthe left lumbar region, extending between the last rib anithe iliac crest, and about one inch from the spinal columnWhen this was compressed, the swelling in the groin in.creased in size and tension, and vice versd,. When standingthe patient kept the left thigh slightly flexed, although b(could straighten it. Over the tenth dorsal vertebra, whictwas prominent, and at the lower lumbar region, there wasgreat tenderness. Impulse on coughing was perceptible irthe psoas abscess, but not in the lumbar; but on emptyingthe lumbar abscess by gentle pressure, an impulse given tcthe psoas abscess could be felt in the lumbar one.Nov. 6th.-In the afternoon the lumbar abscess wa"
opened under carbolic spray, and about six ounces of pusevacuated; the psoas abscess was partly emptied throughthe lumbar.
7th.-11.30 A.M.: Temperature 995° F.-8 P.M.: Tempe.rature 1007°. To have a purgative pill at bedtime.8th.-11 A.M.: Temperature 98-7°.13th.-Very slight discharge of a serous character.14th.-Complains of dragging pains along the spine and
in the supra-clavicular region on taking deep inspirations.15th.-The pain in breathing has gone. Last night the
cough was troublesome, but it is better to-day. Tempera-ture normal ; breathing rapid.16th.-For the last three mornings, at about four o’clock,
there have been severe sweatings. Breathing easier. Tohave two grains of sulphate of quinine and ten drops ofdilute sulphuric acid three times a day.20th.-Breathing more oppressed ; cough troublesome ;
large quantities of mucus expectorated ; great pain in
epigastrium.22nd.-Cough about the same. Ordered a mustard poul-
tice to be applied to the chest, and to take a draught con-sisting of fifteen drops of ipecacuanha wine, ten of spiritsof chloroform, ten of tincture of squills, and five grains ofcarbonate of ammonia, three times a day.24th.-Cough still troublesome. The discharge from the
abscess in two days is only about a teaspoonful of serous fluid.27th.-Cough nearly all gone ; no pain in the chest. The
sweating is not so profuse.Dec. 9th.-No discharge in the dressings. There is still
tenderness in the spine, but it is less. Patient sat up fortwo hours yesterday.12th.-Sits up daily; cough slight ; sweating much
diminished.30th. -A pain which he complained of for several weeks
at the inner side of the thigh has gone, but there is stilltenderness along the spine.
Jan. 19th.-Bowels confined ; complains of headache. Tohave a saline aperient draught.23rd.-Has had a headache for a week. On the 20th he
was sick, and has continued so.. The vomited matters arebitter and clear ; appetite bad ; some tenderness below thecostal cartilages in the right hypochondriac region. Thesaline aperient draught to be repeated.26th.-The quinine mixture has been vomited for some
days past ; there is a very severe occipital headache ;tongue moist, pink, and only slightly furred; countenancedull and earthy-looking; vomiting continues. Temperatureat 11.30 A.M., 99°; at 1.30 P.M., 992°.27th.-Headache and vomiting persist.-11 A.M.: Tem-
perature 99°. The patient sees double; there is no evidentstrabismus, but there is slight ptosis of the right eyelid.The pain in the head runs round in the line of the eyebrowsfrom the back of the head; now and then there are pa-roxysms of pain. The sickness is not relieved by vomiting.Ordered a cantharides blister to the nape of the neck, ice tothe head, an enema daily, to have ice to suck, and to taketwenty drops of the solution of morphia at bedtime.28th.-The diplopia continues; the images are of equal
intensity, but one is placed just above the other. The
patient lies with the legs drawn up; abdomen somewhatretracted.-11.30 A.M. : Temperature 100°; pulse 58.
29th.-He seems to be semi-comatose; answers whenspoken to; is constantly muttering to himself, and drawsup the bed-clothes and bites them.-11 A.M.: Temperature99°; pulse small, 80.30th.-The patient died at 2 A.M. Just before death he
had hiccough and vomited blood. After death the pupilswere noticed to be unequally contracted.Autopsy.-On removing the dura mater the surface of
the brain was found to be dry; veins greatly distended andconvolutions flattened. The ventricles were greatly dis-tended with fluid, and on opening them the septum lucidumwas seen as a delicate membrane. The grey matter was
very dark, and contrasted strongly in colour with the whitesubstance. There were abundant grey granulations along thevessels in the fissure of Sylvius, and a few were to be seenelsewhere. There was a large quantity of lymph at the baseof the brain, especially about the nerves. The heart andpericardium natural; both pleurse adherent throughout byrecent lymph, which was easily torn ; lung-substance denseand congested. On section grey granulations were seenuniformly distributed from apex to base. There was someconsolidation and caseous matter at the right apex. Theperitoneum, especially over the surface of the liver, spleen,and mesentery, was scattered over with grey granulations.Grey granulations were found in and on the liver, and hereand there some larger masses of yellow tubercle were to beseen. Spleen large, vascular, and soft. The kidneys weresoft and friable, and some grey granulations were scatteredthrough the right one. The stomach contained about apint and a half of chocolate-coloured fluid. Mucous mem-brane congested and soft, with numerous patches of capil-lary haemorrhage, especially in the region of the pylorus;no ulceration could be detected. In the intestines a fewtubercular ulcerations were seen. The testicles and bladderwere healthy, but a cheesy mass was found in the prostate.On removing the peritoneum the psoas abscess on the leftside was seen immediately beneath the fascia of the psoasmuscle, and could be traced along the outer border of thismuscle to the brim of the pelvis, where it crossed to theinner side and ran along the femoral artery as far as theprofunda. About the middle of this course an offset passedbackwards above the iliac erest; this was the abscess thatwas opened in the back. Joining this was another abscesswhich passed under the psoas, and ran along the brim ofthe pelvis below the muscle, till it joined the first one. Onthe right side was another abscess, reaching from the thirdlumbar vertebra downwards to half way along the brim ofthe pelvis. This abscess communicated with that of the
opposite side, at the level of the body of the fourth lumbarvertebra. An abscess also passed down the front of thesacrum as far as the third piece. The bodies of the third,fourth, and fifth lumbar, and upper three sacral vertebras werealmost bare, being covered with only a thin layer of granu-lations, through which spicula of bone could be felt. Theintervertebral substance between the three upper lumbarvertebrae seemed healthy, but that between the last lumbar’and first sacral had disappeared, there being in its place alarge cavity containing masses of diseased bone. Theabscesses contained a thick creamy matter of a yellowishcolour, and of the consistence of cream-cheese.
HOMERTON FEVER HOSPITAL.THE COLD BATH IN THE TREATMENT OF ENTERIC AND
TYPHUS FEVERS.
(Under the care of Dr. ALEXANDER COLLIE.)WE now complete the cases treated by the cold bath at
this hospital. The following cases do not argue so much infavour of the cold-bath treatment as those we publishedlast week, yet they are not without interest, and at leasthint a caution. The subject is worthy of a much morecareful investigation than it has hitherto received; it is,however, to those who have charge of large hospitals, wherethis treatment can be easily carried out, that we must lookfor information.
Case 5 was a woman, aged thirty-eight, suffering fromtyphus fever. On the eleventh day of the disease she hadhad hardly any sleep from the commencement of the attack;eruption abundant; tongue dry; a few râles were to be
