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Page 1: WESTMINSTER MEDICAL SOCIETY

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consequences. For instance, Louis and Petit relate a case,where a piece of gold remained lodged in the trachea duringfour years, when the patient died phthisical. Royer Collardmet with the case of a lunatic, at Charenton, who swalloweda nail an inch and a half long, with a large head. On exami-nation after death, the nail was found sticking in the leftbronchus. The lung was not injured, and only slightly in-flamed; but the nail was very much oxidized, and coveredwith all animal matter, the centre of the nail being still hard;thus proving the foreign body had remained a long time inthe lungs. M. Collard gives an account of another case, like-wise in a maniac, at Charenton, who swallowed the bone of a- mutton-chop, without producing any severe symptoms, or even’inconvenience. Six years afterwards this patient died, with-out, however, any apparent pectoral disease. On dissectionthe bone was found fixed in the bronchi; but there were nomorbid appearances whatever in any part of the lung. He

(Dr. Webster) might quote other cases, but would only now.allude to two-viz., that of John Stevenson, an old Covenanter;whose life was published in 1728. This person swallowed apiece of bone, about the size of half a hazel-nut, which gotinto his bronchi, and produced much pectoral disease, likea decline. At the end of fourteen years and nine months,the bone was expectorated, when the patient recovered. Theother case was one which the late Mr. Barrow, of Davies-street, told him, (Dr. Webster,) being that of a gentleman hehad attended for some time, with severe pectoral symptoms,so much like phthisis, that the patient was not expected tosurvive. However, early one morning he coughed up a pieceof ginger, thickly encrusted with a hard mucous-lookingmatter, when recovery soon followed. On seeing the ginger,the patient told Mr. Barrow that formerly he often went tosleep with a piece of that substance in his mouth for a stomachcomplaint, and at the very commencement of his pulmonaryaffection he had done so, but missed the ginger in the morn-.ing; and he now had no doubt but it had then slipped into hiswindpipe, and produced all the subsequent symptoms. Thecases now related, to which many others might be added, atleast proved that foreign bodies might remain in the bronchifor a very long period, and were even ultimately got rid ofwithout an operation. Regarding the case now detailed to theSociety, he did not offer any opinion.Mr. HEWETT agreed with the last speaker, that in Mr.

-Brunel’s case, the escape of the coin in the manner that it en-tered was due to accident entirely. A case of a similar kindhad come into St. George’s Hospital some time since. Anomnibus conductor swallowed a fourDennv bit: he was close.to St. Thomas’s Hospital, and was taken in there. Theturned him on his head; rapped him on the back and chesiand produced great coughing. He did not like these proceedings, and left the hospital. Finding afterwards that his voicebecame husky, he applied to St. George’s Hospital. Mr. Hewetfound him with irritation about the chest, and a roughenecvoice, but no obstruction to the health. He had attacks o:bronchitis, and remained in the hospital. It was determinecto operate upon him; but the day previous to that selected foithe proceeding, he coughed up the coin. He (Mr. Hewett)did not agree with Dr. Williams that the stethoscope wouldalways indicate the presence of a foreign body. It was not soin Mr. Brunel’s case; it was not so in the case just detailed.It was interesting that in Mr. Solly’s case there was a large.abscess in the mediastinum, and pericarditis. Now were these.changes the result of the influence of the foreign body; or.did they exist previous to its presence in the air-passages ? He.asked these questions because lie had heard of two cases ofpericarditis, which had occurred after attempts had been madeto remove foreign bodies from the bronchi by means of theforceps.

Mr. SoLLY said that the man in his case was well beforeswallowing the pebble.

Mr. MAcrLWAiN made some observations, the purport ofwhich was to inculcate the prudence of making an incision in.the trachea in cases of foreign bodies in the air-tubes, and to,leave the rest to Nature. Oificious and meddlesome surgeryin these cases was injurious.

Dr. BARBER spoke at some length, to show that all the phy-sicians at St. Thomas’s Hospital agreed in believing that aforeign body was impacted in the right bronchus, althoughthey might have differed in describing the sounds that werepresent.Mr. HENRY LEE said he believed that the principle upon

which this operation had first been introduced, had not beenfairly stated during the discussion. He believed that theoperation had not, in the first instance, been undertaken witha view either of allowing the foreign substance to escape

through the opening, or with the idea that the glottis wouldno longer retain its irritability after the opening had beenmade. Dut he believed that the operation was undertakenwith the viow of allowing the patient to breathe during thetime that the excitability of the muscles of the glottis washe coming exhausted. It was a principle recognised in surgery,that involuntary muscles, after a time, became less and lesssensible to any stimulus which was applied to them; and if aforeign substance was allowed to remain a sufficiently longtime in contact with the muscles of the glottis, they would’gradually relax, and allow it to pass. The opening the trachea,lie apprehended, was made for no other purpose than to allowthe patient to breathe during the time that this was takingplace.

WESTMINSTER MEDICAL SOCIETY.

SATURDAY, APRIL 21, 1849.—MR. HIRD, PRESIDENT.

POSITION OF THE VISCERA IN DISEASE.

DR. SIBSON made a communication on the Position of theViscera, the Configuration of the Body, and the Movements ofRespiration in Chest Disease. These had been the subjectsof his researches during the last twelve years, and his objectwas to bring them before the Society in a connected form.The three subjects, apparently separate, really and naturallycombine to form a preliminary method of examination in ascer-taining the presence and nature of chest disease. The com-munication was based upon, and illustrated by, a series ofnearly forty diagrams, which had been taken from the deadand living body by Dr. Sibson, by means of a tracing-frame,suggested to him by Dr. Hodgkin. It is self-evident that theknowledge of the normal is essential to that of the abnormal.In the healthy man, the important organs are all so placed inrelation to each other and to the Darietes. that there is acommon centre, around which they all, as it were, clilster.That centre is the lower end of the sternum, and the recollec-tion of it’is at once easy and important. Just above the lowerend of the sternum is the lower boundary of the heart, andthe lower margin, coming to an angle, of the right lung; justbelow the part indicated is the upper boundary of that portionof the liver which is immediately behind the parietes. Aline

drawn from the lower end of the sternum to the right, runsalong the lower margin of the right luag; a line from the samepoint to the left indicates the lower boundary of the heart;the liver and stomach being immediately beneath those lines.The configuration of the chest, happily, indicates the size andoutlines of the internal organs, so that they can be distin-guished by the ocular inspection of the body, the bulk andsize of the organs being made apparent by certain prominences,and their boundaries by certain depressions. The lowermargin of the right lung and the lower boundary ofthe heart correspond to depressions passing across the

sixth costal cartilages to the right and left of the lowerend of the sternum. The costal cartilages immediatelyin front of the heart are more prominent than thoseover the middle lobe of the right lung. The ribs over

the liver and stomach to each side are more prominentthan those over the right and left lungs; the hepaticand gastric bulges are thus formed, the existence of whichwas first pointed out by Dr. Edwin Harrison. Duringinspiration, the position of all the viscera is changed, the dia-phragm, in its descent, drawing downwards the base of eachlung and the lower boundary of the heart, and pushing down-wards the liver, spleen, stomach, and, indeed, all the abdo-minal and pelvic organs. At the same time, the costal areaof the chest everywhere enlarges. During a tranquil inspira-tion, the superior ribs, which perform thoracic respiration,move forward from two to six-hundredths of an inch, whilethe abdomen advances about three-tenths of an inch, indica-ting diaphragmatic respiration; at the same time, the loweror floating ribs move outwards about one-tenth of an inch,their motion being greater than that of the superior ribs.Their action is to expand the lower part of each lung simul-taneously with the descent of the diaphragm, and they aretruly diaphragmatic ribs. During a deep inspiration, the de-scent of the diaphragm and the advance of the whole of thefront of the chest and abdomen is about one inch; consequently,while the thoracic respiration is increased twentyfold, thediaphragmatic is only increased threefold. The base of eachlung and the lower boundary of the heart are about an inchlower, when the diaphragm is at the lowest; at the end of adeep inspiration, the liver, stomach, and spleen are pusheddown to a like extent. To observe the respiratory move-ments with greater nicety, the speaker devised the chest-

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measurer, an account of which is contained in the last volumeof the Medico-Chirurgical Transactions. If the organs be inthe position, and the chest be of the configuration indicated,a.nd if the respiratory movements be symmetrical and normalin extent, we have the assurance, so satisfactory both to themedical man and the patient, that there is no organic diseaseof the heart and lungs. This important information canusually be gained with sufficient accuracy by means of ocularinspection and percussion,by the application of the hand duringrespiration, and, if needful, by the use of the chest-measurer.When the stomach and intestines are much swollen withflatus, they push up the diaphragm, and compress the lungs andheart upwards into the chest. The lower boundary of the heartand the lower margins of the lungs are unusually high, being,in cases of extreme distention, about an inch higher than usual.The form of the chest and abdomen is changed in proportionto the distention, the abdomen being full, rounded, and tense,while the chest is flattened in front, and widened sideways.In cases of the class referred to, a chain of morbid sensationsin the chest is often referred by the patient to disease in the- chest itself, though it is really due to the abdominal distention;dyspncea and palpitation being both caused by the physicalcompression upwards of the heart and lungs; and in the trainof symptoms, headaeh, dizziness, and even unconsciousnessis often occasioned by the difficulty with which the blood re-turns from the head to the right side of the heart. If thestomach and intestines be unusually empty, the diaphragm, in-stead of being raised, is lowered, and the lungs and heart, in-stead of being compressed upwards and shortened, arelowered at their base and lengthened. In bronchitis, and vesi-cular emphysema, the lungs and the heart, especially its rightcavities, are enlarged. In extreme cases they are larger, andtlieirlower boundaries are lower than they are in health duringthe deepest possible inspiration; these boundaries being insome cases from an inch to an inch and a half lower thanthey are in health. The whole diaphragm being lowered, theliver, stomach, and spleen, and indeed all the abdominal viscera,are correspondingly low in their position. The configurationof the chest is at the same time correspondingly changed.The enlarged condition of the lungs and heart is indicated bythe marked and barrel-like roundness and fulness of the chest,especially at its upper part, for while that part is prominent,the lower end of the sternum and the upper part of the abdo-men are unusually hollow. In the emphysema of boyhood,the sternum is most prominent, some little way above thelower end in that of manhood; the greatest projection is at thejunction of the two bones of the sternum, while in that of old.age the lower end of the sternum and the xyphoid cartilageare the projecting parts. The respiration of persons affectedwith emphysema is very characteristic; they are already, as itwere, almost at the top of their breath, and they breathe withlabour. The motion of the upper part of the chest is usuallysomewhat increased, but the lower end of the sternum, andthe adjoining cartilages, instead of advancing actually fallback. The same remarkable phenomenon is observed in casesrequiring tracheotomy, when the obstruction to respiration inthe larynx is extreme; in one case of that class, the whole ofthe walls of the chest fell backwards, instead of advancingduring inspiration, at the same time that the abdominalmotion was unusually marked. The cause of this fall-ing back of the walls of the chest, during inspiration, is- evident; the diaphragm, by its descent, lengthens the lung,and as air can only enter the air cells with difficulty,the lung collapses, and the costal walls over them collapsealso, being forced backwards by atmospheric pressure.1n extreme laryngitis, as in emphysema, the lungs arelengthened, owing to the action of the diaphragm; but whilethe lungs are amplified in emphysema, they are narrowed inlaryngitis, and the chest is consequently lengthened, flattened,and narrowed; at the same time, the heart, being denuded oflung in front, comes into extensive contact with the walls ofthe chest, and the heart’s impulse is therefore felt ex’ e;.sively;whereas, in emphysema, it is only to be perceived behind andbelow the xyphoid cartilage. When much fluid is effused I,into one side of the chest, (as has been observed and well ’,described by several authors,) the fluid necessarily compresses ’ithe lung on the affected side, and all the neighbouring organsare pressed aside from their usual position. If the effusionbe on the left side, the heart is displaced to the right of thesternum, and the stomach, spleen, and liver, are displaceddownwards and to the right; at the same time, the ribs arepushed outwards and separated farther from each other bythe contained fluid; consequently, the whole of the affected.side is enlarged. The respiratory movements are remarliablyaffected; while those of the whole of the healthy side are

exaggerated, those of the affected side are either lessened,arrested, or reversed. When the effusion disappears, it isinteresting to notice the progressive return of the viscera.towards their normal position, as is now being instanced in acase which the speaker had seen with Dr. Hodgkin and Dr.Aldis. If, while the fluid disappears, the lung does not regainits power of expansion, but remains permanently condensed,the displaced organs will return beyond their former position,and in part occupy the place previously occupied by the con-densed organ; consequently, the margin of the healthy lungand the heart will be drawn abnormally to the affected side,and the abdominal organs will rise unusually high into thatside of the chest; at the same time, while the opposite side i3enlarged, the affected side is narrowed and flattened. Therespiratory movements are at the same time restrained orannihilated on the affected, while they are exaggerated on thehealthy side. If the upper lobe be the seat of tuberculouscavities, while the lower lobe is comparatively healthy, theposition of the viscera is not materially changed; but the ribsover the affected part are flattened, and their respiratorymotion is diminished. If the lower lobe be the seat ofpneumonia, while the other parts are healthy, the affectedlobe is permanently enlarged ; the thoracic organs are

not materially displaced ; the walls of the chest on theaffected side are somewhat fuller than usual; and the re-spiratory movements of the ribs, especially the diaphragmaticor lower ribs, and of the abdomen on the affected side, are re-strained,while those of the whole opposite side are exaggerated.Dr. Sibson concluded his communication by indicating theposition of the viscera, the form of the chest, and the move-ments of respiration in pericarditis; enlarged heart, withoutpericardial adhesions, and enlarged heart with pericardialadhesions. He afterwards exhibited before the Society twomen, one healthy, the other affected with tubercular disease ofthe whole left lung. In the former, the position of the viscera,the form of the chest, and the movements of respiration weresymmetrical and normal. In the latter, (he was kindly broughtforward by Dr. Burslem,) the inner margin of the right lungencroached on the affected side, being considerably to theleft of the sternum; the whole of the left side was narrowedand flattened, while the right side was unusually developed;and the respiratory movements, both thoracic and abdominal,of the whole of the affected side, were almost annihilated,while those of the opposite side were, throughout, exaggerated.The respiratory movements in both of these cases were ob-served by means of the chest measurer.

SATURDAY, APRIL 28, 1849. ’

INFLAMMATION OF THE PROSTATE, FRODI INJECTION OF THENITRATE OF SILVER.

Mr. HENRY SMITH related the following case:-A man,agedtwenty-eight, applied to him on the 4th ultimo, suffering fromextreme pain about the bladder. He was constantly passinga few drops of water, accompanied with great pain afterwards.About three weeks since, he said he had a gonorrhoea, forwhich he took medicine, and afterwards used an injection ofthe nitrate of silver. This caused him intense pain, the urinebecame bloody, and the discharge stopped. About a weekago, he first experienced these symptoms, which had graduallyincreased until the present time. Conceiving that the manhad irritation or inflammation of the neck of the bladder, Mr.Smith ordered fomentations of hot water to the part, and gavehim five grains of calomel, with half a grain of opium. Healso prescribed a draught containing balsam of copaiba, tine.ture of henbane, and liquid potash, every four hours. Thenext morning, he had experienced only slight and temporaryrelief from the bathing and the first few drops of medicine;his symptoms now were unabated. During the night, he hadbeen in great pain, walking up and down the room, and hadpassed his water by a few drops, as many as seventeen times.Tongue furred; pulse rapid. The finger was now introducedinto the rectum, and the prostate discovered to be increasedin size, very tense, and pressing strongly upon the gut. Theexamination produced great pain; fluctuation could not bedetected. He was ordered to bed; six leeches were to beapplied to the perinaeum, followed by fomentations and theapplication of a warm poultice. He was ordered five graiu5of calomel and one of opium, with the following draught,every four hours. Tincture of henbane, twenty minims; halfa drachm of sweet spirits of nitre; ten minims of liquid potash,and an ounce of camphor mixture. Plenty of diluents. Onthe next morning, it was found that the leeches had givenhim temporary relief. He has been in great pain all night, andhas passed his water every quarter of on hour; this was ae-

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companied with great pain. The prostate was still enlargedpainful, and tender. He had a severe rigor last evening. Bowel:confined. Pulse full; tongue furred; countenance anxiousA catheter was easily passed into the bladder, but scarcelyany urine was found there. The man cried out with pain althe instrument passed over the prostatic portion of the urethra. Urine passed to-day, and with copious mucous depositSix drachms of castor-oil directly; after the bowels have beeropened, an opium suppository to be placed often in the rectumFive grains of calomel, and ten of Dover’s powder, at bedtimethe following draught every four hours-an eighth-of a grairof tartar emetic, twenty drops of tincture of henbane, arounce of water. Linseed-tea acl libitum. From this time hegradually improved, and in a few days was quite well. Thecase was related with the view of showing the necessity oj

using injections of the nitrate of silver with some care. Thhman had been an out-patient of a hospital, and had an injection of the nitrate given him to use; this he did with theeffects stated; no doubt the injection was of proper strengthas he was under an eminent surgeon. No one doubted thevalue of nitrate of silver generally; but this case; with four OJfive others, had convinced the narrator of the necessity ojsome cautions in the use of that agent.Mr. AcTON defended the proper use of the nitrate of silveI

in cases of gonorrhoea. He questioned, in this instance, if theprostatic inflammation resulted from the injection ; at allevents, such an untoward proceeding would not have occurredfrom nitrate of silver when used by a surgeon.

Dr. TILT read a paper on

SUBACUTE INFLAMMATION OF THE OVARIES AND OF THE FALLO-

PIAN TUBES AS ONE OF THE CAUSES OF STERILITY.

After dividing the causes of sterility iuto those which are selfevident, those which are disputable, and those which are of amysterious nature, Dr. Tilt drew the attention of the Societyto subacute ovaritis as a frequent cause of sterility. Hefounded this assertion-

I.—On physiological data.II.—On the testimony of authors.III.—On the cases which he brought forward.He began by establishing the paramount importance of the

ovaries in the hierarchy of our organs, showing that the ana-tomical phenomena of ovulation were identical to those termedinflammatory, and thus led us to believe that in morbid ovula-tion the healthy process might often pass into the inflammatory,and furnish a satisfactory explanation of the increase of pains

’ and of heat in the ovarian regions-symptoms so frequentlymet with in difficult menstruation. He considered that sub-acute inflammation of the ovaries might produce all thosesymptoms which are called by the common name of dysmenor-rhcea, although they may also depend on the disorder of otherorgans. He also admitted that the symptoms of subacute ova-ritis might vary according to the nature of the patient’s consti-tution, producing hysterical symptoms in nervous and highly-excitable females, and morbid products and sterility in thoseof a strumous constitution. -II.-Dr. Tilt proved by the testimony of authors, the fre-

quency of unaccounted for ovarian lesions, and as these lesionsare admitted by all to be the products of inflammation, hedrew, as an evident conclusion, that the ovaries and their peri-tonasal covering were frequently subjected to inflammation,though not recognised as such during the patient’s life, nortreated accordingly. Respecting the production of dysmenor-rhoea, Dr. Tilt admitted, that in some instances all the symp-toms of that disease were produced by subacute ovaritis, whilein others, as it has been well established by Dr. Oldham, ova-ritis determines dysmenorrhœa by the inflammatory congestionof the uterus to which it gives rise; but he did not agree withDr. Rigby that membraniform exudations in the catameniawere always the proof of ovaritis. Having thus establishedthat subacute ovaritis is a frequent cause of dysmenorrhoea,Dr. Tilt observed that dysmenorrhcea and sterility being ad-mitted as concomitant facts, depending on each other, or onthe same cause, he had a right to infer that subacute ovaritiswas a cause of sterility, and that this imperfection was theresult-

1. Of morbid lesions of the stroma, or of the vesicles ofthe ovula therein contained.

2. Of a false membranous deposit lining the ovaries so asto preclude the exit of the ovula.

3. Of lesions in the tube destined to convey the ovulato their uterine abode. He likewise stated that sterility wassometimes produced by the uterine extremities being blockedup by a glutinous deposit, and asked-whether there was any

possibility of doing for these organs what Mackintosh andSimpson have done in similar cases of temporary occlusion ofthe neck of the womb.

In concluding the enumeration of morbid lesions, Dr. Tiltremarked that as our physiology of the ovaries dates onlyfrom yesterday, we need not be surprised if the knowledge oftheir pathology is also in an embryotic state.

III. The paper was concluded by Dr. Tilt’s giving threecases in which the diagnosis of the disease was fully con-firmed, by an accurate examination of the patient throughthe rectum, and wherein the treatment recommended broughton the cessation of sterility after it had lasted five, six, and sevenyears. The remedial measures prescribed were leeches, todiminish the chronic ovarian congestion; blisters, to break thechain of a morbid nervous action, fostered by long habits ofsuffering; mercurial ointment, combined with narcotic extractsand camphor, to reduce pain and vascular action; and medi-cated enemata were administered with the same intention.In the discussion which ensued, Mr. BROWN made some re·

marks on the causes which induced a pathological change inthe condition of menstruation; among the foremost of which,he regarded cold, more particularly applied to the feet fromthin shoes. He mentioned, in reference to the examinationby " double touch," that Dr. Blundell had twenty years sincetaught and practised it.

Dr. MURPHY eulogized the paper, and mentioned that insome cases the condition of the uterus itself, as contraction ofthe neck, &c., appeared to be the chief cause of dysmenor-rhosa. In some of these cases, mechanical means to relievethe stricture had cured the disease; in other cases, no suchbenefit had followed. He mentioned that of ten cases ofovaritis, none affected the left ovary. He spoke of the neces-sity of using bougies and the speculum, with care,in some casesof dysmenorrhooa, as occasionally they did harm.Mr. GREAlII attributed sterility in some cases to the luxu-

rious habits of young girls in the higher walks of life. Healluded to sterility as the result of contraction of the cervixuteri, and of its cure by dilatation with bougies.

Dr. WEBSTER, among his friends, knew 140 couples who hadno children.Mr. GREENHALGH mentioned cases of dysmenorrhoea which

were cured by marriage. How was this ? Did ovarian ex-citement act on the similia similibus curantur ? He had foundthe left ovary affected more frequently than the right. Howdid we diagnose sub-acute ovaritis ?’ Mr. ACTON made some remarks on the value of thespeculum, and on the safety with which the uterus might beinjected with nitrate of silver. He questioned the ease withwhich ovaritis was said to be diagnosed.

Dr. TILT, in answer to Mr. GREENHALGH’S observationrespecting the difficulty of diagnosis in these cases, stated thathe was so convinced of the value of the objection, that he hadfirst appealed to physiology, to show that the disease waslikely to occur, and then to morbid anatomy, to certify howfrequently inflammatory lesions were found in and around theovaries, thus proving a corresponding frequency of previousinflammation, though not noticed nor treated as such. Headmitted that the ovaries have their neuralgic affections, likeother organs, and that it was impossible to affirm unhesitatinglythe existence of sub-acute ovaritis, without an accurate exa-mination, which could neither be enforced by a medical mannor would be consented to by the family, unless the patientwere actuated by some such strong motive as the desire ofprogeny. When a rectal examination was made, the ovarieswere found increased to double or triple their usual size, andpainful to pressure, which is not the case in health; the-vagina,on being explored, is found hot; the womb is healthy but itslateral movements induce pain. Such evident symptoms ofinflammation being observed, when it was possible closely.toinvestigate the disease, Dr. Tilt thought it might not un-reasonably be inferred that the same lesions likewise existedwhen it was not possible to make so accurate an observation,the correctness of the inference being confirmed by the effi-cacy attending the use of the same remedial measures in bothcases.

EPIDEMICS.—The epidemic of typhus, lately prevalent in theValley of Aosta, Sardinian States, has ceased there, but isnow making sad havoc in the province of Lomellina, (Pied-mont.) The Board of Health of Turin have received infor.mation that the disease is mainly to be attributed to the use ofbread-of bad quality, composed of maize, wheat flour, and rye,that is to say, containing very little gluten, or nutritivematter.