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CASE 2. In January last, I was summoned by a lady member of our Society for advice in regard to a severe and irritating cough, which she said was provoked by the accidental drawing into the larynx of an orange seed. There was a very irritative, continuous cough, and sibilant râles in both lungs, but no area of dullness. I called in consultation Dr. H. C. Clapp, who verified the result of the physical examination. The cough continued with more or less severity, and the patient kept about and attended to her professional duties. At the end of six weeks the foreign body was expelled.
REMARKS. The surgical treatment of foreign bodies in the air passages is very unsatisfactory, for the reason that if the foreign body has entered either bronchus, and become lodged there, it is absolutely impossible by any means now at our command, to reach and dislodge it. Sometimes foreign bodies are lodged for a long time in the bronchus, and are finally expelled by Nature. At other times, very rapid and severe inflammatory processes are set up and death rapidly ensues. There is no means of reaching the location of the foreign body so lodged, through the anterior or posterior chest wall, and all instruments so far devised for thrusting down the trachea, and grasping a foreign body have proved useless. If inversion of the patient and percussion of the anterior and posterior chest walls, and expulsive coughing efforts fail to dislodge it, it is useless to make further attempts. Foreign bodies lodged in the larynx of course can be reached and be extracted either per mouth or by making laryngotomy; but unfortunately, as a rule, such do not stop in the larynx, but pass on into the trachea, and become lodged in one or the other bronchus.
A very exhaustive article can be found in the New York Medical Journal for July 25, 1891, by J. D. Rushmore, M.D. This relates the case of a clergyman, who got a cork lodged in a bronchus, and upon whom every conceivable method was tried for relief, without avail. Autopsy showed the cork in the lower bifurcation of the left bronchus. The article closes with the following conclusions :
That a foreign body in a bronchus is always a source of danger to the patient.
That its spontaneous expulsion is very exceptional and may be long delayed.
That the danger is from inflammation and its results, and less frequently from asphyxia.
That its earliest possible removal ought to be attempted.
That the dangers of operative interference ought not to prevent the attempt to remove the foreign body.
That to attempt the removal without a preliminary opening into the larynx or trachea is unwise.
That after a reasonable search through the trachea and bronchus, opening the thoracic cavity in front, or the mediastinum or pleural cavity posteriorly is justifiable.
That all operative measures for relief ought to be taken at a single operation if possible.
That the chåracter of the foreign body and the patient's condition are important factors in deciding on the time and character of the operative measures to be employed.
PORTAL OBSTRUCTION AND ITS RELATION TO DISORDERS OF THE UTERUS AND ITS ASSOCIATED ORGANS.
BY EMILY A. BRUCE., M.D. [Read before the Boston Homæopathic Medical Society.] In discussing the etiology of diseases of the uterus and its associated organs, authorities rarely mention or only briefly refer to the influence of obstructive derangements of the liver in their development and perpetuation; while they dwell often at length upon factors which are only operative in exceptional cases. Yet a very large per cent. of all pelvic diseases, whether organic or functional, are associated with some form of hepatic disturbance. The question naturally arises which is the primary disease and how the secondary is excited. In a large majority of the cases the weight of evidence is against the liver, the other organs seeming to be the victims of an unfavorable position in the economy.
It has often occurred to me to question the wisdom of the arrangements of the abdominal and pelvic viscera with relation to each other, especially in the female. When we consider the delicate and sensitive organs suspended by their frail supports in a yielding mass of tissues, with nothing reliable beneath them, and borne down by the weight of superincumbent organs, we are surprised, not that healthy pelvic organs in the adult-female are the exception, but that they ever exist.
The evolutionist tries to help us out of our perplexity regarding what seems to be such an unsuitable arrangement of important organs, by telling us that this relation was all right while the race was getting about on all fours, and that there has not yet been sufficient time for these organs to adjust themselves to the changed position and mode of locomotion. Let us hope that evolution will make a special effort in this direction, so that a
few million years hence our sisters will not suffer from the same or equal defects of anatomy.
In order to explain the evident intimate relations existing between viscera so far separated and so unlike in structure and function as those in question, it will be necessary to ascertain their means of inter-communication, anatomical and physiologi
We will, therefore, first briefly recall some prominent points in the anatomy and physiology of the great gland which has been well called the chemical laboratory of the body; since the pathology of any portion of the body can be intelligently studied only while the mind holds a distinct impression of its normal condition.
This important viscus seems at first sight to have a very simple structure, being composed of four different anatomical elements, namely, cells, connective tissues, vessels of various kinds, and nerves; and we are surprised when we realize how many different kinds of work are carried on with the one apparatus.
It has a double vascular supply, arterial blood for the nourishment of the tissues and portal blood for its laboratory work.
The peculiar negative structure, or rather want of structure of the hepatic vein-having 'neither coats nor valves-has no inconsiderable influence over the development of passive hepatic congestions.
This great vital workshop, with its manifold and mysterious industries, occupies a very important position in the economy, surrounded as it is on all sides by vital organs. It is attached to the abdominal wall and diaphragm by folds of its investing peritoneum, sinking with each inspiration and rising with each expiration in harmony with the movements of the diaphragm.
This piston-like action of the diaphragm and liver acting together produces a suction force which aids greatly the circulation of the liver itself, as well as that of the outlying portions of the portal tract; and also helps in sustaining the pelvic viscera in normal position. In this we find a beneficent relation between the hepatic gland and the pelvic organs. Having had a glimpse of this interesting organ as a whole, let us look at some of its component parts.
The minute and most versatile hepatic cells are closely packed into five- or six-sided lobules, which are invested by Glisson's capsule, in which ramify blood vessels lymphatics, bile ducts, and nerves, forming a dense complex network. The cells themselves are supported by a delicate web of connective tissue continuous with the inter-lobular reticulum. In this web are the radicals of the bile ducts, capillary blood vessels from both sources and minute lymphatic spaces ; so that each little cell is enveloped in a closely woven net of vessels, each carrying off its legitimate burden to its proper destination. Nerves also are distributed to the cells, modifying their activities according to the work in hand.
Keeping this little outline of the hepatic structure in mind, let us observe for a moment some of the processes which normally go on there.
The arterial blood brought by the hepatic artery nourishes the tissues of the gland; but for their industries the cells must have the portal blood rich in food products newly obtained from the alimentary tract by the selective power of an infinite number of epithelial cells, and of capillaries which have their origin in the mucous membrane lining its whole extent. We are ready now to pass in review some of the manifold products these same industrious cells are able to obtain from this, to the unaided eye, homogeneous fluid, and to recall to mind some of the transformations they effect.
The ancients attributed to the hepatic gland the one function of excreting the bile. Nearer to our time it was thought to be the chief blood-making organ, and source of animal heat, as well as emunctory for the bile. In our day, thanks to recent research, it has reached a position of vast importance, being credited with carrying on a great number of complex processes, both chemical and vital, among which may be mentioned the transformation of sugar to glycogen by a process of dehydration, and changing the glycogen later into glucose by the action of a ferment produced by the glands; also the destruction as well as the production of blood-corpuscles, and the transformation of the hematine of the dead discs into bilirubin wherewith to give its rich tint to the bile, which is now known to be not merely an excrementitious substance, but one destined to be reabsorbed, in part, at least, to do further service in the economy, after having been poured into the intestine. One of the most important accomplishments attributed to the organ recently, is the power of detaining and modifying certain toxic substances, such as the alkaloids, atropine, morphine, narcotine and others. The existence of this function satisfactorily explains some facts previously not a little puzzling to observers concerning the action of these poisons when administered by different methods; as the more prompt and pronounced effect and the smaller dose necessary when administered hypodermically than by the mouth or rectum. In the first instance they are introduced at once to the general circulation, and in the others they must first be subjected to the modifying and delaying power of the liver, and afterwards be set free with diminished energy to do their work in the system.
The hypodermic method of administering remedies then owes
its chief advantages to this power of the hepatic cells over the alkaloids and other toxic medicinal substances; nor is this influence limited to poisons introduced from without, but includes some which are manufactured in the body, such as ptomaines and the products of various morbid processes.
Thus we have a faithful sentinel at the portal of the body, ready to grapple with our foes from within as well as those from without, working unceasingly and often against great odds to secure our immunity from harm.
This gland is also credited with producing urea in common with most of the other organs and tissues of the body, and with making glucose from proteids and fats; with furnishing iron to the blood; and has even been accused, by one experimenter at least, of producing uric acid.
Remembering the intimate relation between the hepatic lobule and the elements in which it lies embedded, and the many agencies capable of setting up disturbances in their interlobular spaces, where, in fact, many of the disorders which eventuate in portal obstruction have their origin, it is easy to comprehend why diseases of this viscus are frequent, and their consequences so disastrous oftentimes.
Whatever increases the blood supply of this organ beyond the normal limit, whatever retards the flow of blood, bile or lymph through it favors obstruction ; whatever causes hypertrophy or atrophy of the inter or intra lobular tissue, whatever causes degenerations or new growths of this organ, leads to engorgement of the portal system of vessels and to obstruction. This being the case, and the number of agencies capable of producing these disturbances legion, it seems almost wonderful that a liver can be found through which the fluids flow freely.
Perhaps the most common of these causes is indulgence in luxurious habits of eating and drinking, especially when united to inactive lives. Other very frequent causes are excessive or prolonged use of alcoholic or other stimulating drinks, violent physical exercise or intense mental application soon after meals, by which digestion is delayed, and fermenting, irritating substances sent to the liver instead of properly elaborated material. Gastro-intestinal catarrh and dilatation of the stomach are sure to produce hepatic derangement sooner or later, and in the same way as delayed and imperfect gastro-intestinal digestion from other causes. Malaria and continued high temperature, chronic heart and lung diseases, tumors of the mediastinum and disturbed innervation, direct or reflex, may induce hepatic stasis and its evil consequences. Sudden and even gradual cessation of habitual losses of blood, as when bleeding hemorrhoids or the menses are suppressed, is often followed by portal obstruction, and gout and rheumatism are often complicated by it.