THE AMERICAN MEDICAL INTELLIGENCER. Vol. III. November 1, 1839. No. 15. For the American Medical Intelligencer. ART. I.-PHILADELPHIA HOSPITAL, (BLOCKLEY.) DR. DUNGLISOn, attending PHYSICIAN. Case of Tubercular Peritonitis, with Perforation of the Intestines. Reported by A. M. VEDDER, M. D., Senior Resident Physician at the time. Elizabeth M'Cann, æt. 24, entered Women's Medical Ward, No. 2, June 14, 1838; born in Ireland; in America five years; seamstress; was never sick, that she recollects, in Ireland, and even till October, 1835, when she was affected with what she termed pleurisy of the right side; had pain in her side; could not take a full breath; was treated for it three weeks in Medical Ward, No. 4. After the cure of the pleurisy, she left the house; had a cough at that time; none previously. The cough ceased entirely after some time; expectoration was frothy, no blood. In October, 1836, entered the hospital with syphilis; had no chancres at her entrance; they appeared, however, on the labia and thighs two weeks after; had a discharge from the vagina six or seven weeks before her admission. It occurred four weeks after "exposure." Was under treatment for four months in the Venereal Ward. Took a great deal of mercury, but was never salivated. In March, 1837, left the hospital. In July, entered the Surgical Ward with ozama; was quite well in the interim; no return of her former "complaint." Was under treatment for ozæma till February, 1938, (seven months.) Several pieces of carious bone were discharged from her nose, from which a copious and sanious fluid issued. The nose became less prominent, and her voice characteristic. Various astringent and antiseptic washes were used: chloride of soda, &c. At the time of her discharge, (February 28,) was well, and able to work; and continued so until the 1st of May last, with the exception of a sore throat, which persisted for a few days. Took blue mass. About the 1st of May last, a small, hacking" cough began, with soreness in the epigastric region; vomiting at times. Cough continued until the 10th of June; about the same time had a "sharp" pain near the short ribs. Expectoration at first white and frothy, but it became yellow about the 1st of June; it was small in quantity. Her cough was most severe at night; has had cold sweats for two weeks past; no chills; ædema of feet a week since. About the middle of May diarrhoea commenced, which was at times severe; has never been free from it since; six or seven stools daily. No blood till within the last three days; stools were composed of slime. Soreness of abdomen became more severe at the same time (niiddle of May,) particularly at the hypogastric region. Was taken with vomiting before the purging commenced, which has continued ever since, more or less. Could not retain even water at times. Was quite fleshy before the commencement of the present attack (May 1st.) Emaciation has progressed gradually since. Acidity of stomach since the beginning. A few days before her entrance, took an emetic, and afterward castor oil and laudanum. Present state, June 14th, 1838.-Expression of feebleness; anxious, pale, emaciated. Feels very feeble, but walked into the ward; prefers lying on the right side; voice feeble; cephalalgia; tongue moist, of a pale red; anorexia complete; thirst great; vomiting after taking food or liquids, none at other times; cough slight, worse at night; no chill, but sweated last night; did not sleep, on account of pain and the open condition of her bowels; expectoration rare, yellowish; dyspnoea; no pain in the chest, but some in the abdomen, which is tender on slight pressure throughout, particularly in the hypogastric region; abdomen not distended, or retracted; has had fifteen or twenty stools in the last twenty-four hours, watery, with blood and slime, not fetid now; tenesmus and griping; skin warm, moist; pulse 96, small and feeble; cedema of the feet. Applicentur cucurb. cruentæ ad f3vi. regioni hypogastr., et postea cataplasma humuli. Applic. sinapisma regioni epigastricæ. B. Hydrarg. chlorid. mit. gr. i. Pulv. ipecac. et opii, gr. ii. Quater in dies. June 15th.-Expression as before; less short breathed; less feeble; vomited three times before the cupping, twice since the last paroxysm, continuing twenty minutes after taking ice, which was ordered last evening. Took the ice again, but did not vomit; anorexia; cough less; expectoration one ounce in twenty-four hours, in part watery, with masses of yellowish mucus floating in it; tongue pale, red, moist; thirst continues; complains of great pain at the hypogastric region, and a burning sensation at the epigastrium; vomited last evening about a quart of fluid of a brown colour, very sour, setting her teeth on edge;" six stools in twenty-four hours, watery, mixed with blood, no clots, not fetid, but have an acid smell: stools small in quantity, with tenesmus and tormina; no burning sensation at the anus; no dysury; pulse 84, small and feeble; skin cool, natural temperature, moist; abdomen somewhat distended with gas. General tenderness of abdomen; very much so at hypogastrium, not less than on 14th. Slept for about two hours in early part of night; after the severe fit of vomiting, was restless during the remainder of the night. Decubitus dorsal; limbs slightly drawn up. Continuentur remedia. June 15th, P. M.-No vomiting, and but one stool since morning. Pain in epigastrium less, but more severe in lower portion of abdomen. Has taken ice and milk to-day. June 16th, P. M.-No stool until this morning, six since then; no vomiting; griping and tenesmus continue; complains now of an intense pain at hypogastrium; thirst continues; no blood in the stools, but they are greenish and fetid; tongue moist, shining; pulse 108, small, quick; skin dry, about nalural temperature. Applicentur hirudines xx., parti dolenti, et postea cataplasma. Continuentur pilulæ. June 19th.-Yesterday, a small tumour was observed in the hypogastrium, about four inches above the symphysis pubis, tense, very painful, to which was applied the unguentum hydrargyri. Pain continues, but less severe; expression more lively; strength rather increased; abdomen generally less tender; appetite bad; thirst; vomited last evening. On 18th, four or five stools; in last twenty-four hours, fifteen to twenty; tormina and tenesmus less; no blood or mucus; stools are now yellowish; dysury; secretion of urine small, deep-coloured; sleeps better, but is often awakened; tongue pale red; pulse 100; skin cool; less abdominal tenderness; gums slightly touched, but no salivation. Continuentur pilulæ. June 20th.-Tumour more pointed; pain in it much increased; chill this morning; evident fluctuation in the tumour; a lancet was passed in three eighths of an inch, but no pus followed. Lies with her legs drawn up; constantly moaning. Omittatur unguentum hydrargyri. Applicetur cataplasma cum tinctura opii. B. Opii, gr. i. Camphor. gr. iii. M. Et fiat pilula quater in die sumenda. Continuentur pilulæ ut antea. June 22d.-Abscess broke this morning, discharging about fiij. of thick greenish-yellow pus. Much less pain in the part. Slept better. June 26, P. M.-All treatment was discontinued on the 24th. Since last note, patient has been improving, appetite having increased; pain in abdomen nearly gone; no vomiting or coughing for the last three days. On the 25th, P. M., vomiting became very severe, for which the following prescription was ordered : , Tinct. kreosot. gtt. v. Aq. menth. 3ss. Pro re nata. Great dyspnoea, with lower extremities drawn up; a blister was applied to epigastrium, and ice ordered. At 9 r. M., the vomiting having become more severe, the patient was much exhausted; pulse 120, small, feeble. She was ordered iced wine whey. The vomiting has continued until this evening, but less severe; has taken in addition to the whey, beef essence; slept none last night; is more feeble; vomiting continues; moaning at times; decubitus partly on the right side, with knees drawn up; respiration high, abrupt, frequent; cough slight; pulse 132, small and feeble; vomits a greenish thin fluid; tongue shining, moist; thirst; no cephalalgia; skin above natural temperature, dry; complains of a burning sensation in palms of hands, and coldness of feel; no pain, except in region of abscess, and in small of back; abscess continues to discharge pretty freely the same greenish-yellow fetid matter. (Vomiting began on the 14th, for which she took tinct. opii gtt. v. aq. cinnam. 3ss. pro re nata.) Abdomen somewhat distended, gaseous, and painful on percus sion. Continue beef essence, wine whey, and ice. Poultice to abscess. Blister to be kept open. June 28th, P. M.-Vomiting has continued since last note; worse in the afternoon, scarce half an hour passes without a paroxysm, which continues about five minutes; vomits a fluid resembling water, of greenish character. Says she has no pain; complains only of feebleness; more emaciated; sleeps somewhat better; vomited less last night, the matter ejected was very "sour;" feels a burning sensation at the epigastrium. Three stools in twelve hours, in part resembling the matter discharged from the abscess. No evacuation on the 27th. On the 27th, bubbles of foul air issued from the opening, the discharge nearly ceasing at the same time; discharge is now extremely fetid, green, almost of a gangrenous odour; pulse 120, small; skin dry, cool; almost no tenderness in abdomen, except in lower portion; on pressing these, bubbles of foul air issue from the abscess; abdomen moderately distended with gas; breathes more easily; lies on her back, with lower extremities extended; cough slight; almost no expectoration; tongue dry, red at the edges, slightly coated at the centre; can retain nothing on her stomach. June 29th.-Cannot even retain the ice; two stools; a very fetid smell about the patient; abscess of a gangrenous odour; much more feeble; pulse cannot be counted at the wrist; extremities cold; speaks with difficulty; says she has pain in the hypogastrium; abscess has nearly ceased discharging; bubbles of air still issue from the opening; stools of the same character as on the 27th. Give iced brandy punch. The other treatment was discontinued. Necroscopy, June 30th, seventeen hours after death.-Exterior: Emaciation extreme; limbs not rigid; small frame. In the hypogastric region the integuments are of a dark blue colour, in the centre of which the abscess opens. A probe is passed into it, and is found to communicate with the abdominal cavity, by a winding canal between the folds of the parietes. Abdomen.-On laying open the abdomen the external orifice is found to communicate with a complete circumscribed cyst, formed by the agglutination of the omentum to the anterior wall of the abdomen and by the intestine. It extends quite into the pelvis, and as deep as the vertebræ, dipping between the folds of the intestines. The cyst does not communicate with the rest of the abdomen. The walls are ulcerated, and in parts almost gangrenous, containing a greenish fetid matter. On pressing the intestines, bubbles of air issue from two or three openings; they all look into the cavity of the cyst. On examining it more closely, three perforations are found lying near each other in the lower portion of the ileum, and one in the colon, rounded with a light yellow tinge, varying from two to four lines in diameter. The corresponding portion of the intestine is here inflamed. The intestines are glued in spots to each other and to the anterior walls of the abdomen, partly by old organised adhesions and partly by new ones. Surface of the intestines, as well as the omentum and peritoneum lining the walls of the abdomen, thickly studded with tubercles, varying in size from a pin's head to that of a small pea. No lymph or serum in the cavity of the peritoneum. Small intestine.—Pale ; mucous membrane softened with a few scattering (six or eight) tubercles in the submucous tissue. Glands of Peyer not developed. Large intestine.-Presents several blue spots in the inferior portion. Stomach.-Rather pale; contains a green fluid, fetid, resembling fæces. Bladder.-Corrugated, contracted, its mucous coat much injected. One small tubercle is found in the submucous tissue near its fundus. (The bladder formed part of the walls of the cyst.) Spleen.-A few tubercles are seen beneath its external membrane; tissue firmi. Liver.-No tubercles; fatty. Mesenteric glands.-Normal. Kidneys.-Rather pale, not tubercular. External membrane not adherent. Lungs.-No serum in either pleura. Left lung bound down by a few old adhesions; tissue soft. One or two tubercles are found in it. Right lung strongly adherent below; can with difficulty be removed. Tissue soft; a few masses of tubercles near its summit, where there is a cavity the size of an almond, lined by a smooth false membrane. No tubercle observed in the rest of the lung. Bronchial glands tuberculated; some of them filled with a cretaceous deposit. A. M. VEDDer. ART. II.-CLINICAL OBSERVATIONS ON THE USE OF THE AIR-DOUCHE IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE EAR. BY T. WHARTON JONES, ESQ.' (Continued from page 225) No. III. CASE III-Chronic inflammation of the lining membrane of the tympanic cavities, with accumulation of mucus-No obstruction of the Eustachian tubes-Auditory passages natural. 27th Jan. 1839.-The subject of this case was sent by Mr. Quain, of University College, with the following note: "My dear sir, Mr. E. F., the bearer of this, has been more or less deaf for a considerable time, and, from a short examination, I am inclined to think the Eustachian tubes at fault. "I shall be much obliged if you will be so good as to examine him and give me your opinion. The tendency of my own opinion is, that the local means-catheterism, &c.—may be beneficial; yet, judging from his appearance, the diathesis, so to say, it is probable they will not alone be of any great utility. "I am, &c. "R. QUAIN." Mr. E. F. is 19 years of age; had scarlet fever when he was six; after that the deafness came on. Is subject to attacks of ear-ache. His sister was born quite deaf, but after having scarlet fever she acquired hearing! Skin coarse, with sebaceous follicles of the face much developed; habitually costive. The climate in which he usually resides is very moist. In September and October, 1826, was treated in Paris, by M. Deleau, who applied the air-douche about fourteen times, but only with temporary benefit. Took iodine last summer, according to the prescription of Dr. Elliotson. During the last autumn, hearing improved of itself considerably, but has been diminishing since he came to London. It is now-left ear, 3 inches ; right ear five inches. Left membrana tympani and handle of the malleus appear natural; the right also. The skin of the auditory passages slightly red and tender. The secretion of wax natural. Applied the air-douche to both ears, as an exploratory means. On the left side the air entered freely, but with great gurgling; ou the right side not so freely, and with less gurgling. After the air-douche, the hearing distance of the left ear was nine inches, of the right ear six or seven inches. The hearing was further raised on both sides to one foot, by making forced expirations with the nose and mouth closed. Tuesday, 29th Jan.-In consultation with Mr. Quain, and Mr. Gasquet, of Burton Crescent. Hearing distance to-day-on the left side, eight inches; on the right side, one foot. After the application of the air-douche, the hearing distance on the left side was raised to one foot four inches, on the right side to one foot and a quarter. Prescription. To continue the treatment with the air-douche, and endeavour to improve the state of the constitution by attention to diet and regimen. To resume the use of the iodine. 1 Lond. Med. Gaz. Aug. 17, 1839, p. 754. |