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XIV. CASES OF ACUTE DISEASE IN THE THROAT AND LARYNX. By Dr. James Arthur Wilson, Physician to St. George's Hospital.

There can be no doubt that many lives are lost by the above inflammations for want of tracheotomy. In Nov., 1830, Dr. Wilson, with Dr. Nevenson and Mr. Keate, attended a gentleman who died of cynanche supervening on erysipelas. On examination, the epiglottis and posterior membrane of the tongue were found to be highly vascular and thickened, and pus was infiltrated in the cellular membrane of the fauces. The larynx, below the cordæ vocales, and the trachea, were free from disease or obstruction. Here was a case where tracheotomy would have saved life, almost to a certainty. The event made a deep impression on Dr. W.'s mind, and was of service thirteen years afterwards.

Case. Mr. W. C. aged 27, full habit, got heated at a ball, and caught cold going home. He was unable to sleep, from general uneasiness and sense of choking on attempting to swallow. Leeches, calomel, and other measures, were employed; but the breathing was not relieved, even by the abstraction of twenty-four ounces of blood from the arm. In the evening of July 8, 1843, he was in extremis, and Mr. Keate exposed the trachea below the thyroid gland, and made an opening into it, inserting a canula in the aperture. Instantaneous relief was the consequence.

"On the first rush of air into the trachea, the patient appeared to feel instant relief, and his countenance began at once to resume its natural expression; but from this time not two minutes could have elapsed, when he was suddenly attacked by most violent spasms of his whole frame, with a struggle for breath, as if threatening immediate suffocation. All consciousness directly ceased, the eyelids closed, the face was livid, the features were distorted, the blood, still bubbling from the wound, became suddenly black as ink. The breath was drawn convulsively, and at long intervals. All movement, excepting that of the pulse, had ceased, and the patient appeared, literally, at his last gasp. During this awful crisis of the young man's fate, which lasted for perhaps a minute, (seemingly for a much longer time,) his head was held forcibly back,-the canula was withdrawn, and the orifice in the trachea cleared from blood, and kept widely open. The breathing at length became more natural; the face, no longer ghastly, began to resume the character and tint of life. Not long after this most fearful convulsion, a large quantity of mucus, mixed in part with blood, was rejected, in long viscid ropes, from the mouth; and it was then found that the patient again breathed through the larynx. Upon this, the canula was finally withdrawn. A profuse perspiration now burst forth from the face, neck, and chest of the patient, who gradually recovered his consciousness, and expressed by writing that his breathing was quite easy.' He slept at intervals during the night, and was convalescent from this time." 140.

Although, as Dr. Wilson remarks, the operation can hardly be too late, yet the chance of success is greatly lessened by delay, because the patient is being poisoned by his own blood. There is a good deal of management necessary in preventing the blood from flowing down the trachea into the lungs. The operation of tracheotomy has now been so often performed with success, that no patient should be allowed to be suffocated by obstruction about the throat, without opening the wind-pipe. A gentleman of our acquaintance breathed more than twenty years through a tube.

XV. ON THE PRESENCE OF OXALATE OF LIME IN
Henry Bence Jones, M.A., Cantab.

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The author observes that the appearance of octohedral crystals in the urine appears first to have been described by M. Vigla. Dr. Bird in England, and afterwards M. Donné in France, recognised the very frequent occurrence of such crystals, and by re-actions observed by the microscope, inferred that these crystals were oxalate of lime. A case occurred to Dr. Jones, in which, from the quantity of octohedral crystals passed, he was able to examine the sediment in nearly the usual method. He remarks:

"The states of the system in which octohedral crystals are seen, vary exceedingly. In acute rheumatism and gout, chronic rheumatism, aggravated hypochondriasis and hysteria, and diabetes, I have found such crystals. In one case in which the rheumatism was slight, the influence of diet and exercise on the mixed deposite of urate of ammonia and oxalate of lime was made the subject of experiment. In other cases in which these octohedral crystals occurred, the symptoms were altogether different; irritation of the urinary organs being the most prominent. The concretion of the crystals, into oxalate of lime-gravel, seemed in one patient to be the cause of this diversity of symptoms.

"The connection observed by MM. Donné and Rayer, between seminal weakness and oxalate of lime, I found in two cases; and in a third, where three small oxalate of lime calculi had been passed at long intervals, and octohedral crystals were constantly found in the urine, on one examination a few dead spermatozoa were seen." 147.

John Saunders, æt. 47, formerly a soldier, was admitted an out-patient of St. George's Hospital. The deposit which had been continually observed in the urine was examined in March, 1843, and found to consist of innumerable crystals of uric acid mixed with octohedral crystals. For twenty years he had suffered more or less from urinary disorders. In 1828 he had rheumatic fever, and was confined to bed eleven weeks. The small joints of the fingers are larger and stiffer than natural, and occasionally very painful.

"The urinary sediment was thrown on a filter and washed with distilled water. The red residue was dried, reduced to a fine powder, and treated with dilute hydrochloric acid, which left most of the uric acid undissolved. The acid liquid was filtered, and ammonia gave a very considerable precipitate, when added in excess. When evaporated to dryness, and heated on platinum, the muriate of ammonia was driven off, and the residue effervesced strongly when thrown into dilate acid, and left an alkaline ash when heated more highly. The ash was with difficulty soluble in water, and gave a precipitate with oxalate of ammonia. Hence some organic acid salt of lime was present; and as oxalate of lime is known to occur in octohedral crystals, the conclusion that these crystals were oxalate of lime is most probable." 148.

The author examined the urine of a patient of Mr. Cutler's, and at the same time three small renal calculi which passed in July, August, and September, and afterwards another which passed in October. The urine under the microscope contained multitudes of octohedræ mixed with some crystals of uric acid. All calculi were found to consist of oxalate of

lime mixed with uric acid. He examined the urine in cases of acute rheumatism, and always detected the presence of these octohedral crystals. This deposit is also frequently found mixed with urate of ammonia in chronic rheumatism. In one case he was enabled to make some experiments regarding the effect of diet and exercise on the deposit, and he observed that the octohedral crystals seemed to vary in quantity at different periods of the day. Then follow the daily results of this experiment, which are given very minutely for the four weeks during which it lasted. The author states that it would be easy to multiply examples of the connection between octohedral crystals and rheumatism; but, as no variation in the treatment of ordinary rheumatism seems to be thereby indicated, the fact seems only interesting, as showing the close connection between the red deposit and octohedral crystals. He adds, " octohedral crystals in the urine, and symptoms of a totally different kind, frequently occur together. The patient complains of pain in one or both loins, of frequent desire to pass his water, which is sometimes in very small quantity; at other times so much as to simulate diabetes. There are sudden calls to empty the bladder, and if it is delayed, considerable pain is produced. The urine when examined contains only a slight cloud, which does not disappear with heat. In other respects it appears natural. When examined with the microscope, the cloud is seen to consist sometimes entirely of octohedral crystals. More frequently of these crystals mixed with globules of mucus, and sometimes with large and small scales of epithelium."

The above symptoms closely resemble those produced by a small calculus in the kidney, and in one case they suddenly ceased after sharp pain in the course of the right ureter, and slight retraction of the testicle.

Dr. Jones concludes by remarking, that the treatment which proved most beneficial in these cases of irritation was that which improved the general health. In two of Mr. Cutler's patients the symptoms followed mental anxiety. Medicines had little effect, but as the causes for anxiety disappeared, the symptoms ceased.

This paper is a valuable contribution to our knowledge of urinary disorders. We shall return to this important volume in our next number.

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. By Samuel Ashwell, M.D., Member of the Royal College of Physicians, London; Obstetric Physician and Lecturer to Guy's Hospital. 8vo. Part III. London, 1844. Highley.

HAVING formerly spoken of this work very highly, our task will not now be a difficult one, especially as the present and concluding part is not only equal but superior in practical excellence and research to its predeWe have often had occasion, during the last twelve or fifteen years, to remark, that there was no lack of diligence or talent in the obstetric department of medicine; and the book of Dr. Ashwell, although we do not always agree with him, fully sustains its reputation. It is clear

cessors.

he intended it to be a safe guide in practice, and while he has proved himself thoroughly acquainted with the controverted pathology of female disease, he has avoided obscuring his own views by any forced attempt to make them harmonize with the opinions of others. His work is eminently his own; he has seen frequently that about which he has written; he has tested the worth of his diagnostic precepts by constant and accurate observation, and his treatment of the various maladies is evidently the result of most extensive and often very successful practice. Nor is there any dogmatism or vanity about his writing. The style is plain and forcible; without any dark passages, incomprehensible either by himself or his readers. In some places, however, Dr. Ashwell takes a little too much for granted; he supposes that others are as fully acquainted with female disease as he is, and therefore occasionally neglects a full exposition of his prognosis and remedial management.

We are glad Dr. Ashwell has had courage and candour enough to confess that, even with all the advantages of Guy's Hospital and a very extensive private practice, he has seen but few examples of some of the very rare diseases: this is as it should be, and affords a striking and instructive contrast to some of the French writers, who, as in M. Lisfranc's instance, exhaust the credulity of their readers by announcing the startling fact, or rather falsehood, that they have seen "hundreds of cases of a disease," (anteversion of the womb,) which, even in the largest fields of observation, occurs only extremely rarely.

We congratulate the author on another important point-the authentication of his cases. We are aware this cannot always be done, but certainly it is a matter of great moment. The case is the portraiture of the history of the disease, and as there are false facts in philosophy, so there may be false cases in medicine. Dr. Ashwell has given great additional authority to his work by an admirable selection of cases; the truth and reality of which no one can doubt. Let us not be misunderstood: we say again it cannot always be done; but we are sure it is often neglected where no real difficulty exists. Dr. Bright, a distinguished colleague of the author, and some other writers, have advantageously availed themselves of a similar verification of their reported cases, and we trust ere long to see it far more generally adopted.

The chapter on polypus contains an excellent summary, not only of the practice, but likewise of the pathology, of this important disease. Dr. Ashwell has not failed to embody some of the peculiar views of Lisfranc, nor has he hesitated to express his disapprobation of some of his measures. We agree with him in his incredulity about such frequent "enucleation," and in his condemnation of severe and violent efforts to abstract polypi while still high up in the uterine cavity. There is much force in Dr. Ashwell's remark, "such things don't require to be done in Eng'and." But we think the author is yet too cautious and careful about removal by the knife, as we are confident, in many instances, it is far better and safer than the ligature. We shall, as in our former reviews, allow the author to speak for himself in an extended analysis, assenting or dissenting as we proceed.

The following is his definition of polypus:

“A firm and insensible tumour, usually round and smooth, and growing by a No. 99.

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stalk either from the mucous lining of the uterus, or the structure beneath; its. chief symptom being hæmorrhage. It commences in the cavity of the womb, in the channel of the cervix, or from the os. It is often of fibrous texture, not malignant, and rarely ulcerates. It is covered by mucous membrane, and sometimes by an adventitious coat, the product of inflammation. There is little pain, menstruation is excessive, and conception may occur."

Dr. Ashwell observes that polypus of the uterus, while it is not an uncommon disease, is certainly far more rare than cancer. In the following remarks we entirely concur.

"There is no malady more certainly curable than polypus, although many patients have died from its accompanying bleedings, without its existence ever having been suspected, much less ascertained. The necessity for vaginal examination, where profuse uterine bleedings resist the remedies employed for their suppression, cannot be too strongly urged. In the hæmorrhages of polypus,.. astringents are useless-the only effectual remedy is removal.

"Pain can scarcely be said to be a symptom, and the first suspicion of the disease is excessive menstruation, or bleeding occurring in the catamenial intervals. Although the evacuation of the bladder or intestines is seldom prevented, it is not impossible that a large polypus, by pressure on the urethra or rectum, or both, may obstruct their functions. Hence, if the patient be strong, the loss of blood seldom attracts notice, till some of its injurious effects begin to be realized. When the digestion becomes impaired, and there is leucorrhoea, deadly sallowness, difficult respiration, and other evils,-then anxiety begins, and it is not long till a reluctant permission is granted to examine the state of the womb."

There is considerable variety in the size of these growths. Some, not larger than a garden bean, have bled alarmingly; while a polypus exceeding a Seville orange in size, scarcely bled at all, ultimately producing irritation by its pressure on the neck of the bladder, and great exhaustion by constant and large secretions of pus. We are glad Dr. Ashwell has dwelt on this fact, as the continuance of purulent discharge, and the almost entire absence of hæmorrhage, has induced most injurious delay in ascertaining, by a proper examination, the existence of the disease. The protracted inclusion of a polypus within the uterine cavity is perplexing and dangerous; as a small one, especially if it be soft and vascular, may give rise to alarming and even fatal losses of blood. We insert the following, case entire, as it is an instructive one, and conveys a good idea of the author's clear and forcible style of writing.

"Such instances have occurred in my practice, and a hard polypus of moderate size, now in Guy's Museum, removed when it had very partially descended through the cervix, fully attests the truth of the preceding observations. This polypus grew so slowly, probably because the hemorrhages had been frequent and excessive, that three years elapsed prior to its coming within the reach of the finger. During this period, the patient had been frequently seen by eminent obstetric physicians, who in vain attempted to restrain the bleedings. At first, as she believed it to be entirely useless, I was not permitted to make an examination; but, on my assuring her, that although the growth had not yet descended into the vagina, it might speedily do so, she consented; and I had then the opportunity of touching a small, hard, and insensible tumour, just emerging from the os. The bleeding which followed alarmed me so much, that,. before leaving the house, I attempted its removal. Excision was out of the question, and with a very long instrument, I made two unsuccessful efforts before I could apply the ligature. When completed, the canule were some way within the channel of the cervix. It was an anxious case, for there were several

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