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patient (46 years old) suffered only from tympanitis, his system was much debilitated from want of good food, and exposure to the hardships of the past winter. There was no tenderness of the abdomen, no diarrhæa, no constipation; nothing, in fact, but the tympanitis. He was ordered to take, by the house physician, aquæ ammoniæ gtt. x., in water. Mistaking his directions, it was administered undiluted. He called for water immediately, and complained of burning in the throat. He continued restless and moaning until 4, P. M. (five hours after), when he was again seen by the physician, who found him sitting up in bed, laboring for breath. The thought of oedema glottidis at once was suggested as the difficulty. On introducing his finger into the throat, it felt soft and pulpy; no sacs or bags could, however, be felt. While consulting in regard to the case in a distant part of the ward, with another physician, who, after an examination, came to the same conclusion, the man ceased to breathe.
Autopsy.-On inspection of parts after death, on all anterior to the epiglottis, considerable oedema existed; the edges of the openings of the larynx were swollen; and within, the larynx itself was almost completely closed. No irregularities in the way of bags or sacs existed, such as are most commonly observed in this disease. The pharynx was very red, the ædematous swellings not markedly so. The tympanitis was due to chronic tubercular peritonitis, which differed from most cases in there not having been alternations of diarrhæa and constipation. In the lungs diffuse tubercular matter existed, and four or five moderate tubercular infiltrations; contrary to the law of Louis, that tubercles are most abundant and most advanced in the lungs in patients over sixteen years of age.
Dr. Jenkins inquired how far topical applications might have proved of service in this case ?
Dr. Clark replied, that though many cases had occurred under his observation in hospital practice, he had never had the immediate treatment of one.
Dr. Sayre suggested that oedema could always be detected by the eye more readily than by the finger, as the fluid can be crowded away by pressure.
Dr. Clark observed, that this case would not have been relieved by the operation proposed by Dr. Buck—it could perhaps have been relieved by puncturing with a curved needle.
Dr. Foster inquired if nitrate of silver might not have been of use?
Dr. Clark thought not. The danger is not usually appreciated until a few minutes before death. Three of the cases with which he was familiar died at night, nothing being known before the autopsy as to the cause of death-in
one the effusion was consequent upon syphilitic ulceration of the fauces; and in the case operated upon by the lamented Ravenhill four years since at Bellevue, the man seemed as if he could not take a dozen more respirations. He scarified with an ordinary probepointed bistoury, and the next day he was nearly as well as ever.
Dr. Clark next exhibited a bladder, showing certain forms of inflammatory action when paralyzed, viz., fibrous effusion at the commencement of the urethra. It was a case of apoplexy: the urine escaped from the bladder, at times mixed with blood; there was also found purulent matter when examined. The catheter, when introduced, gave a sensation as if passing at certain points along a roughened surface. This is explained by inspection of the urethra, which is covered at intervals by fibrous effusion.
Dr. Clark next presented three kidneys showing fibrous degeneration, their respective weights being 104 02., 3} oz., and 2 oz. Microscopically, they exhibit the same character; neither of them are fatty, the secreting cells in each are healthy, their surfaces slightly granular. In a strong light, on the smallest, with a lens magnifying 1 diameters, can be seen an infinite number of papillary eminences covering the whole surface. These are not the granulations of Bright's disease, which are always of a yellow or grayish white color; these presenting the same color as that of the base. In Bright's disease they are irregular; these are rounded up, standing out half their diameter from the surface. They are in fact Malpighian bodies left standing out from the surface of the kidney by the retraction of the other part of the organ. One of the kidneys is dotted over with scarlet colored spots, wbich are composed of crystalline hæmatoidine ; another is dotted over in its interior with an abundance of the black variety of hæmatoidine, so as to present a marked discoloration on section. He (Dr. C.) is not aware it has been before noticed in Bright's disease. Black vomit contains precisely the same material.
Dr. Cock inquired whether these specimens were not gradations of the same disease ?
Dr. Clark considered them as such.
Dr. Schilling suggested that they were similar to cirrhosis of the liver, which was large or small according to the stage of the disease.
Dr. Sayre presented a specimen of melanosis of the liver, removed from a gentleman 60 years of age. Eight years since an oval tumor was first observed on the left temple, about the size of a small nut, movable under the finger, and unattended with pain. It slowly increased until 1851, when it was first seen by Dr. Sayre, and was then the size of a large egg. The only inconvenience occasioned by it was the difficulty of putting on his hat. He thought it was an ordinary encysted tumor over the temporal muscle, but on cutting down upon it, it was situated below the muscle, and consisted of a perfectly black, jelly-like mass, covered with a thin pellicle ; it extended below the zygoma, and completely filled the temporal fossa. It was easily removed the wound healed by the first intention. The tumor Dr. Sayre considered to be melanotic cancer in its nature. But it was destroyed before a microscopic examination could be made. His general health continued perfectly good, and be attended actively to his business (that of a builder) for three years and more; and Dr. S. began to think bis first impressions as to the nature of the mass were erroneous, as no return in any of the internal organs had 0ccurred. About that time, while carrying a large and long board across the street upon his shoulder, in a severe gale of wind, be was suddenly twisted around, and to prevent himself from being prostrated by the force of the win:l, he was compelled to brace the muscles of his back and limbs with great energy. While in this position he was seized with acute pain in the back and right side over the region of the liver; where, to use his own words, he “distinctly heard something crack, and felt it give way." He was brought home faint and in great pain. When examined by Dr. Sagre, a day or two after the accident, nothing unnatural could be detected. After remaining quiet a few weeks he gradually resumed his business, but never seemed so well or active. In November last, six months after the accident, Dr. Sayre was called in on account of obstinate vomiting; and on examination a nodulated, hardened mass was distinctly felt upon the right lobe of the liver, which extended some distance below the ribs. He informed his son, a physician, that he feared his first impressions, in regard to the nature of the tumor removed from his temple three and a half years since, were correct, and that the disease had returned in the liver. The tumor continued to increase rather slowly; but its progress was so rapid during the last three months, that its enlargement was clearly perceptible at each weekly visit. Three weeks ago it could be felt crowding down into the right iliac fossa, and very near to the crest of the ilium on the left side. The thorax was distended laterally to its fullest capacity, and the lungs forced upwards, so that respiration could not be heard below the fourth rib, on the anterior and lateral parts of the chest. He had not been able to assume the recumbent position for some weeks. On the 2d May, a severe attack of vomiting occurred, and he rapidly began to sink, and died on the 3d, at 4, P. M. The post-mortem examination was made on the 4th inst., forty-two hours after death, assisted by Drs. Thebaud and Lattimore; the body having been preserved in ice for the last twentyfour hours. External appearance-face much emaciated ; legs, penis, and scrotum, adematous. On opening the cadaver and removing the sternum, the diaphragm was found crowded above the fourth rib, and only 34 inches below the clavicle, thus compressing the lungs and heart into a very small space. The right and left iliac fossa were completely filled with tumors from the two lobes of the liver; the lower border of the fissure of the liver was below the umbilicus, and the intestines were crowded into the small triangular space between that and the pubis. The liver weighed, immediately after removal, 23 pounds.
Weight-23 pounds. Measurement--Vertical diameter right lobe, 17 inches ; vertical diameter left lobe, 161 inches; vertical diameter at the fissure, 81 inches; transverse diameter at the middle, 20 inches ; transverse diameter at the base, 22 inches ; oblique diameter from right to left, 23; inches; oblique diameter from left to right, 201 inches ; greatest thickness, 4 inches. 1. Dr. Finnell presented a stomach removed from a man eighteen years old, who took an unknown quantity of oxalic acid-it was much contracted, of an intense red color. The lungs and brain were much congested.
Dr. Finnell next exhibited an hypertrophied heart, weighing 14 oz.,
with thickening of the mitral valve. The man died suddenly in the street, and was not known to have labored under disease of the heart.
Regular Meeting, May 25, 1854.-Dr. Griscom presented a specimen of tumor of the liver removed from a man 29 years of age. The patient, of robust constitution, general good health, was admitted into the City Hospital with ascites, attributed to cirrhosis, on the 24th April last. He has been at one time somewhat intemperate. Five weeks ago he first noticed abdominal dropsy, which did not at the time cause him any inconvenience, nor compel him to discontinue labor; two weeks before admission he also noticed some oedema of the lower extremities. No pain whatever preceded these symptoms, nor any derangement of his general health, with the exception of a somewhat troublesome diarrhoea. When admitted, the belly was much distended, the superficial veins enlarged, but to a less degree than is common in cirrhosis of the liver. Dullness over the hepatic region somewhat less extensive than natural ; belly evenly distended, but tympanitic over the whole central portion, where, the patient lying on his back, no fluctuation could be detected. Over the lateral portions were dullness and fluctuation, changing with position, the quantity of fluid not appearing very considerable. The tension of abdominal parietes occasioned marked distress in breathing. The feet and legs were considerably ædematous, pitting on pressure. The quantity of urine passed was greater than natural, normal in appearance, containing no albumen, depositing no lithates specific gravity, 1021.
There was diarrhæa, bowels moving four or five times in twenty-four hours, passages thin, watery, light colored, without tenesmus. Pulse 96, fair strength, tongue moist, clean, skin natural. He complained of no pain, simply of the distress and uneasiness occasioned by distension; the degree of which varied from day to day. The quantity of water was from three to four quarts in twenty-four hours; no diuretics were employed. On the 4th of May paracentesis abdominis was performed. (On introduction of the canula only a small quantity of fluid escaped ; the orifice of the tube being obstructed, an elastic catheter was introduced through the canula, by which about three quarts of remarkably clear serum was withdrawn.) He was somewhat relieved by the operationtwo days after, on the morning of the 6th, respiration short, pulse accelerated, friction sound at base of right lung laterally and anteriorlydiaphoretics ordered. The next morning pulse 108, hard, moderate fullness, respiration 30; skin natural in temperature, moist, expression less indicative of suffering. Is more comfortable and complains less of pain in the side ; of no pain over abdomen, except at the point of operation. Percussion anteriorly natural over both sides. Apex of heart beats below fifth rib, and four and a half inches to left of sternum. Posteriorly, percussion over right side dull, up to a point two inches below the posterior angle of scapula, especially over the lower half of the lung, where dullness is complete. Over left side, percussion natural. Over upper part of right lung posteriorly, respiratory sounds natural, becoming more indistinct about commencement of lower hals. At the lower part of lung, respiratory sound almost entirely absent; and laterally and anteriorly is heard a distinct, dry friction sound, accompanying inspiration and expiration. Vocal sounds ægophonic. Over left lung, distinct mucous râles. Expectoration very slight, not characteristic of pneumonia or bronchitis. *13th May. From this time onward there was no improvement in the patient's general condition; the pulse ranged from 96 to 112, the same in character; the dyspnoea increased and was caused almost entirely by the great distension of the abdomen ; his rest was bad, change of position afforded little relief; appetite poor, the stomach with difficulty retaining food; the bowels at times loose, and strength slowly failing. These conditions were met by palliatives, and support. He died on the 18th.
Autopsy.-On opening the chest, the whole right side was found to be full of serous fluid, containing but a small quantity of fibrin. No deposit of false membrane upon the surface of lung or pleura. The right lung small, collapsed, not adherent to ribs, but forced toward the spine and floating in the serous fluid, of a dark gray color, non-crepitant, except at the apex, containing no tubercles nor cancerous masses, only several calcareous bodies. Left lung crepitant, paler than natural, free from tubercles, but containing several calcareous masses. Heart, to left of natural position, but healthy. Scattered over the inner surface of pleura were quantities of large, firm, white bodies, covering the pleural lining, the ribs, and diaphragm, and mediastinum of right side. There were none of these found on the left side. Liver about natural size, very firm and hard; and scattered over its surface were found a number of hard, white nodules from the size of a pea up to an inch in diameter, imbedded in the liver; and on section, these are found abundantly scattered through that organ, appearing to be of a cancerous nature. The color of liver a pale red, mottled with white or gray points. Its weight four pounds twelve ounces. On opening the peritoneum there was no escape of gas; no fibrinous deposit; considerable fluid within the cavity. The stomach and intestines large, and enormously distended with gas, lying in such manner that the stomach, colon, and one convolution of small intestine, form one even convexity. At the angle formed by the transverse and ascending colons, pressing firmly against the ascending colon, which lay partly posterior to it, and against the liver at the transverse fissure, covered in by the right lobe of the liver and the short ribs, adherent to the liver, and the lateral and posterior abdominal muscles, and to the colon through the attachments of its investing membrane, and having its true point of attachment to the mesentery, the divergent lines of which could be distinctly made out at its inner posterior side, -was found an enormous tumor. It was firm, hard, elastic, and cartilaginous to the feel and the knife, somewhat nodulated, surface pearly white, smooth and polished. Weight, two pounds eight ounces. (Case in full, in Archives.)
Dr. Clark remarked, that the large tumor appeared to be fibrous in character ; the masses on the pleura he thought were cancerous.