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Lessons f~'om General P~"actice. By Dm KNAGGS. 27 ART. III.--Lesso~,~ fl'om (;e~e~'ai P~,ctice. By SAMUEL T. K~aGGS, M.B., Ch.M., F.R C.S.I., L.K. & Q.C.P.I., Honorary Surgeon Newcastle tto~pital, N.S.~u Assistant-Surgeon N.S.W. Naval Forces. CASE I.--Case of Rete, tion, followed by Su,p2)ression, of' U~ine, lasting Seven Days--Recovery--Observations. J. G., shoemaker, aged forty-five ycars, living in a suburb near the city of Newcastle. He had been drinking for six or eight weeks. On Sunday, 31st March, 187"2, he found himselffinable to micturate, but did not suffer any inconvenience until the Tuesday evening following, when at seven p.m. [ was hurriedly requested to see him, the case being described as ~ most urgent one. I fbund him lying on his back in bed, suffering great distress; pulse 90; respiration hurried; the skin moist and clammy; countenance pale and anxious, tie was complaining of great distension in the region of the bladder. He had been vainly endeavouring to urinate, and he described the agony that he suffered as being unbearable. I at once put him into a warm hip bath, which seemed to relieve the most urgent symptoms; while there I made him try to pass water, but the endeavour was fruitless. I then attempted catheterism, first trying most cautiously to insinuate No. 9 gum elastic catheter. It passed as fi~r as the prostate gland without obstruction, and there it stopped. All the usual mam~euvres, such as inserting the finger into tile rectum, wittidrawing the stilette (Hey), depressing the hand, &c., were tried fruitlessly. After a most patient trial I likewise failed to pass Nos. 6, 4, and 2. The warm bath, however, seemed to cause an abatement of the most urgent symptoms. _At nine p.m. I again saw the patient, in eonsuhation with Dr. Harris. Though somewhat distressed with the feeling of distension about the cystic region, the more urgent symptoms had not returned. The cystic dulness reached almost up to the umbilicus, the prostate gland was found to be very much enlarged, and the cystic tuinour was plainly perceptible through the anterior wall of the rectum. Catheterism again failed. We decided upon trying to induce a free action of the bowels; in the event, of this failing the propriety of operative interference could be considered next day. Urgent symptoms, if arising duling the night, to be treated by hot stupes and warm baths.

Lessons from general practice

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Lessons f~'om General P~"actice. By Dm KNAGGS. 27

ART. III.--Lesso~,~ fl'om (;e~e~'ai P~,ctice. By SAMUEL T. K~aGGS, M.B., Ch.M., F .R C.S.I., L.K. & Q.C.P.I., Honorary Surgeon Newcastle tto~pital, N.S.~u Assistant-Surgeon N.S.W. Naval Forces.

CASE I.--Case of Rete, tion, followed by Su,p2)ression, of' U~ine, lasting Seven Days--Recovery--Observations.

J. G., shoemaker, aged forty-five ycars, living in a suburb near the city of Newcastle. He had been drinking for six or eight weeks. On Sunday, 31st March, 187"2, he found himselffinable to micturate, but did not suffer any inconvenience until the Tuesday evening following, when at seven p.m. [ was hurriedly requested to see him, the case being described as ~ most urgent one. I fbund him lying on his back in bed, suffering great distress; pulse 90; respiration hurried; the skin moist and clammy; countenance pale and anxious, t ie was complaining of great distension in the region of the bladder. He had been vainly endeavouring to urinate, and he described the agony that he suffered as being unbearable. I at once put him into a warm hip bath, which seemed to relieve the most urgent symptoms; while there I made him try to pass water, but the endeavour was fruitless. I then attempted catheterism, first trying most cautiously to insinuate No. 9 gum elastic catheter. It passed as fi~r as the prostate gland without obstruction, and there it stopped. All the usual mam~euvres, such as inserting the finger into tile rectum, wittidrawing the stilette (Hey), depressing the hand, &c., were tried fruitlessly. After a most patient trial I likewise failed to pass Nos. 6, 4, and 2. The warm bath, however, seemed to cause an abatement of the most urgent symptoms. _At nine p.m. I again saw the patient, in eonsuhation with Dr. Harris. Though somewhat distressed with the feeling of distension about the cystic region, the more urgent symptoms had not returned. The cystic dulness reached almost up to the umbilicus, the prostate gland was found to be very much enlarged, and the cystic tuinour was plainly perceptible through the anterior wall of the rectum. Catheterism again failed. W e decided upon trying to induce a free action of the bowels; in the event, of this failing the propriety of operative interference could be considered next day. Urgent symptoms, if arising duling the night, to be treated by hot stupes and warm baths.

28 Lessons from General Practice.

Twenty grains of calomel were at once given in four [)ills, to be followed hourly by two-ounce doses of" black draught until the bowels should be moved.

Fourth day: Wednesday, 3rd April.--I visited the patient at daylight, and found that the pills remained down, but every attempt to take any of the draughts was frustrated by incessant vomiting. The patient had been up se.veral times during the night in great pain, unavailingly endeavouring to pass water. After each fl'uifless effort he found considerable relief by remaining half-an- hour in the warm bath. Upon examination I found that the cystic tumour had considerably subsided. H e complained less of the feeling of distension than he had done the (lay before. I made a careful examination of the bedding and clothing, but could detect no evidences of his having unconsciously passed water. Symptoms of ur~emic poisoning appeared to be setting in, the pupils becoming contracted, an inclination to drowsiness, slight wandering of the mind, and great irritability of the stomach. At ten am., according to appointment, I again met Dr. Harris in consultation with reference to the case. By this time the symptoms of ur~emla had become more decided. The patient could with difficulty be roused from the comatose state into which he had fallen. There was incessant vomiting of u greenish watery fluid in copious quantities, having a f(etid urinous odour. The skin was moist and clammy; also exhaling an odour similar to the vomit.

We decided that the time for operation had passed, the abdominal tumour having all but subsided. Catheterism again failed. It being considered very desirable to produce free action of the bowels, croton oil, in two-nfinim doses, was ordered every hour until the bowels should be moved, the oil to be placed upon the tongue. This caused such aggravation of the vomiting and thirst that it had to be discontinued after the second dose. In the afternoon the patient was still stupid and comatose, yet could be aroused on his attention being attracted. He said that he had had a beautifully quiet sleep, and now had no pain in the bladder. Catheterism was again tried while he wa~ in a warm bath, but failed. He expressed himself to be greatly relieved every time he go~ the bath, but in this instance he t[finted ou getting out of it to go to bed. I now made what I feared wotlld be the last ,~ttemp~ t;,) evacuate the bowels, administering at outea turpentine injection, I)~t his weak state was such that it e~msed no action of the bo~vels. i, accordingly, tbiluwcd it. u l) with about t.~vo pints of warm water,

By DR. KI~'AGOS. 29

which so distended the bowels that it was almost instandy ejected. Half-an-hour afterwards lie was relieved oF a thir solid motion, but he fainted on getting off the stool. This so dejected him that he settled his worldly affairs, having a firm conviction on his mind that, he could not possibly outlive the night.

Fif th day: Thursday, ~til April . --Patient very weak and low spirited ; slept during the night, but wandered greatly in his mind ; excessive watery vomiting; profuse clammy perspirations, the excretions having all the same urlnous odour. He has not had a morsel of fbod since last Saturday, and has not passed water since Saturday morning. He has a firm conviction on his mind of approaching death, and says that he will surely die this evening. He is so weak that the least effort produces fainting. There is an inclination to stupor, no actual pain, and the bladder is flaccid.

Sixth day : Friday, 5th Apr i l . - - I tried to induce him to consent to go to the hospital, but his friends objected, preferring him to die amongst them. His appearance much the same as yesterday, but he was much weaker, and hardly able to raise his hand. Another enema was administered, which returned stained greenish bl~ek. He said that this relieved him greatly, but the increased vomiting, cold perspirations, and stupor appeared worse.

Seventh d'~y: Saturd'ty, 6th Apri l . - -Had a quiet night. Begged to be Ief~ quiet on his back, as each movement produced excessive retching. A t two p.m. injected per rectum a pint of strong beef-tea and two glasses of brandy. He fhlt almost immedi- ately much stronger. To be continued every four hours.

A t seven p.m. he passed ~ chamberful of water, giving a strong alkaline re-action, after which there was less inclination to vomit. I ordered a draught, containing two grains of oxalate of cerium, one minim of creosote, two minims of dilute hydrocyanic acid, and two dracimls of mucilage of gum arabic, with water, to be taken every hour.

The above draught was designed to allay the vomi"cing and irritability of' the stomach. I again saw the patient that night, when he expressed himself as feeling like a " new man." I te rapidly improved from this out, and in a week was able to walk about.

Observatlons.--This case in itself is remarkable, from the fact that the patient, a broken-down, debilitated subject, survived seven days without passing a drop of water from his urinary bladder, and ultimately recovered. It possesses a further interest, from the flint

30 Lessons from General Practice.

timt nature came to the rescue of the physician, and indicated a rational procedure in the treatment. The gastro-intestinal tract and the skin took on vicarious action, as was indicated by the copious watery vomltlngs and profuse perspirations exhaling a peculiar urinous odour. These organs (stomach, intestines, and skin) voluntarily gave their assistance to the kidneys, and performed their functions while their (the kidneys') portals were stopped, and thus relieved the blood of urea and such effete products as would have accumulated in the system, and have litcrt~|ly polsoued the patient.

The mechanism by which the bladder was relieved of its contents on the fourth day can, I think, be fairly explained, as well as illus- trated, by our physiological researches in the study of Asiatic cholera. In Asiatic cholera a prominent symptom is the copious rice water evacuations by mouth and rectum ; these are thrown out in such vast quantities, and so greatly exceed the ingesta, as thereby to excite surprise as to where the fluid all comes from. Actual experiment has proved that several changes take place in the blood which supplies this fluid. Being deprived successively of its water, its salts, and albumen, then the properties of the corpuscles become changed, and they in turn rob the tissues through which the~ permeate of their water S co~stituents. There is no obstacle to our assuming that a somewhat analogous change took place in the blood of the patient whose case is under consideration. The gastro-intestinal tract and sldn by energetically taking on vicarious action deprived the blood of water, urea, chloride of sodum, as well as other effete matters. The blood having become physically changed in its properties, the corpuscles absorbed the necessary watery consti. tuents from the tissues; the bladderful ot ~ fluid in its turn became a reservoir, and, for the time being, recouped the tissues with the necessary moisture by yielding up its contents. Titus can be explained why, though the bladder does not physiologically possess absorbent properties, the absorption of its contents actually took place in this instance.

This case I deem a most instructive one, and if the lesson which it inculcates be carefully studied, and the hints which it suggests be tbllowed out in a spirit of scientific inquiry, it cannot but be productive of much good, and materially modify our treatment of urinary retention and suppression.

By DR. KNAGGS. 31

CASE II.--Case of Hydc~tids of tM Liver--Ope~'ation--Relief-- Observatio~s.

R. P., engine driver, aged forty years, was in perfect health about four years ago. Since then he has noticed a gradual and painless enlargement of' the abdomen, which first commenced on the left side. The growth appeared orlginally to have extended ti'om above downwards; of that he was quite confident. Never had any disturb- anee of the liver. Has occasionally had loss of eyesight and vertigo, which came on suddenly without being induced by violent exertion, or any such cause. In March, 1872, he had a fall which made him feel faint, and then a change occurred in the shape of the turnout; it used before to give him a sensation as though dragging down ti'om his right side; he now feels as though he were filled from below upwards. Is troubled with wearying pains in the loins and local pains across the back, but attributes all this to the weight he is carrying in his abdomen, which now feels so tense that he has a difficulty in drawing his breath. Has been in the habit of drinking varieties of water from water-holes, when out shooting with his dogs. Remembers one instance which happened about seven years ago. He was lost on the Kela Plains, and when in an exhausted condition from want of water, his dog found a water-hole for him. He drank greedily of this, though alive with vermin, which were preying on the debris of dead and decaying animals which had perished in it. He has lived always freely and well, but never took fermented or spirituous liquors to excess.

The personal appearance of the patient is that of one possessing a well-built frame firmly put together. The complexion is sallow, some- what swarthy, the hair and eyes dark. On close examination a slightly jaundiced tinge of the skin and conjunetiva~ can be detected. The chest is ample and symmetrical, expanding freely and equally in the process of respiration, exhibiting no abnormal signs to auscul- tation and percussion. The pulsations of the heart are quite natural in rhythm but weak in force, both sounds distinct and natural. Pulse 76 to 80, weak, but not unnaturally so. Over the abdomen some veins are prominent, and a fulness is noticeable in the veins of the lower extremities, but nothing of a varicose condition observ- able. There is no history of any form of hmmorrhage having occurred fi'om any of the outlets.

The urine is copious in quantity, pale in eolour, of slightly acid re-action; specific gravity I008, and has the most remote trace of albumen. The tongue is thickly coated with thick brown fur; he

32 Lessons from Ge~eral P~actiee.

complains of continual thirst, and great loss of appetile ; the bowels are obstlnatcly costive. The most characteristic feature presented by the patient's personal appearance is the abdominal tumour, which gives him a peculiar carrltlgc and gait, causing him to hold his shoulders well back, so poising his person as to counter-balance the load in his abdominal cavity. The general contour of the tumour is identical with that of an enormous ovarian tumour in the female.

The abdomen was carefully examined while he was in the supine position. The circumference of' the body at the umbilicus was forty inches. Four distinct tumours could be detected, threein the right side and one in the left. Those in the right were almost vertically situated with reference to one another. They were some- what oval in shape, their longer axis lying transverse to the axis of the body. The following were respectively the extent of surface perceptible to palpation and palmation by each turnout on the right side, enumerating them from above downwards : --Five inches by three and a half inches ; four and a half inches by three inches ; three and a half inches by two inches. The uppermost turnout was in the right lumbar region, its lower margin just above an imaginary zone bisecting the umbilicus; the lowest tumour was so situated as to be equally divided by the imaginary line that separates the r ight inguinal fi'om the hypogastric region. The intermediate turnout was midway between the other two, but more towards the median llne of the body. The fourth tumour, which presented to pahnation a surface of four and a half bv three inches, was situated on the left side, lying in the left inguinal and hypogastric regions, having its long axis lying obliquely and in a line almost parallel with Poupart's ligament. All these tumours appeared to have a uniform smooth surface, and on palpation conveyed an impression of soliditv no doubt deceptive. Now, though for convenience of description, these have been described separately as tumours, carefill examination proved them to be portions of a large fluctuating tumour that occut)ied the whole abdomen of" the !)atient. No definite outline could be detected so as to map out, the full extent of this tumour. The whole abdomen was equally tense and elastic, affording a dis- tinct sense of fluctuation, and it did not alter its shape on the patient changing his posture. There was dulness to percussion on the anterior aspect, slight resonance on the let't side, and high up beneath the diaphragm. At the right side in front the dulness caused by the tumour merged into the n(~rmal liver dulness, and extended up almost to a line with the fourth rib.

By DR. KNAGGS. 33

On l l th July ('72), I saw the patient with Dr. C. W. Morgan, of Bathurst, who being interested in the subject of hydatids, very kindly acceded to my request fbr a consultation, and coincided with me in the diagnosis of the case. Symptoms of pressure were now becoming so urgent that tbe patient begged fbr relief' by operation, which he willingly consented to undergo, after the object and risks of tapping were fully explained to him.

On the 14th July I performed the operation at the patient's residence. Drs. Morgan and Harris were kind enough to be present and to assist me. I proposed to tap the abdominal parieties through the linea alba, two and half inches below the umbilicus, and with that object made a small incision tilrough the cutls vera with a lancet, and then plunged in a trocar, sheathed in a cannula a quarter of an inch in diameter.

It passed freely through the abdominal pariedes, and the point impinged upon a hard resisting body, through which no amount of reasonable force seemed capable of propelling it. The trocar was withdrawn, and a few drops of ascitic fluid flowed out through the orifice of the eannula. The hard substance was carefully probed through the eannula with the stilette of a No. 9 catheter, and it conveyed such a sense of fibrous hardness that it was decided not to use undue violence in order to perfbrate it. The cannuta.being withdrawn and the wound closed up, I next proceeded to tap through the linea alba, one inch above ltle umbilicus, first making a pilot incision with an ordinary bleeding lancet, which I plunged into the hilt; withdrawing this I rapidly introduced the re,ear and eannula, and was rewm'ded by seeing a thick, dirty, brown, opaque fluid gush from the cannula on withdrawing the troear.

Twelve pints of this fluid were evacuated to the patient's relief. I was fortunate enough to secure a collapsed hydatid sac measuring two and a half inches long, which insinuated itself through the cannula. Some little difficulty was experienced by a slight hernia of omentum which protruded through the incision on the with- drawal of the eannula. Finding its red.ction impossible, I snipped it off with a pair of scissors; the slight t)leeding diat fbllowed soon stopped, and then the wound was closed with a wet pad, which was securely fixed by a bandage round the body. The patient was left, in a recumbent position, and six hours afterwards a hydragogue purge containing scammony andjala I) was administered. No disagreeable after effects resuhed from the operation; the only unpleasant sequel being excessive thirst, which lasted several days. Four or

D

34 Lessons from Ge~eral Practice.

five days afterwards the patient was able to get up and walk about, I fear rather to() soon, as on the sixth day I was requested to see him in consequence of excessive itchiness about the orifices of the wounds, which were surrounded by an erysipel'~tous rash. Rest and attention to the bowels soon relieved him of this; he gradually got better, and was soon able to resume his post at 5he locomotive engine. I saw him lately, and he, though not much reduced ill size, expressed himself to be quite comfortable, and well able to perfbrm his duties.

Contents of the cyst.--I carefully examined the fluid evacuated from the tumour. The quantity was exactly twelve pints, specific gravity 1020; it gave a slightly acid reaction, was so highly albumin- ous that it thoroughly coagulated on boiling; a large quantity of bile was present, the fluid staining white surf[rues a bright yellow colour, and rcadily reacting to the nitric acid and ~Pettenkofer's tests. I made a most searehlng microscopic examination of the fluid, but could not find the slightest trace of" booklets, or other debris of broken down ecchinococci. All that could be notiecd were a quantity of" granular matter, oil globules, and numerous crystals of phosphate of llme. When lei~t standing fbr some considerable time, a light coloured sediment was deposited which, on chemical exami- nation, proved to be an adnfixture of sebaceous granular substance and phosphate of lime. I should have had no positive evidence of the turnout bcing a hydati~l one, were it not for the cyst wall that so fortunately insinuated itself" through the cannula during the operation of tapping.

Observatlons.--This case is a very good illustration of a multiple hydatid tumour, the principal cyst of which had undergone the atheromatous transformation described by Laennee, Brewster, Cruveilhler, Charcot, and others, and which was first observed by l~uysch of Amsterdam, in the seventeenth century. Davaine has looked upon the presence of eholesterine as being of general occurrence in such cases, but here it was absent. Neither could I find any trace of h~ematoidlne or sugar, the former of which is described as being peculiar to hydatids of the liver.

Taking into consideration the circumstances of the ease, they are compatible with the supposition that this is an instance in which nature had attempted a spontaneous cure by the introduction of bile into the interior of the cyst. The bile, no doubt, obtained admission through a communication set, up between the tfiliary duets and the cyst wall, and its prolonged contact with the contents of

By Da. KNAaGS. 35

the cyst was ~atal to the existence of the hydatids. This action ol bile on the vit~tlty of the ecchinococcus is so well known that the injection of ox-bile into such turnouts has been proposed as a radical cure tbr the disease.

Notwithstanding the unfavourable prognosis in hydatid disease, I deem this to be a most favourable case of its kind, and in which the principle of non-intervention in the way of further operation is strongly indicated. Atheromatous degeneration having commenced, layer after laver of" sebaceous matter is deposited on the cyst wall, and by concreting, it so thickens the wall as to make it rigid and non-distensile. By tapping there could be no prospect of causing contraction of the cyst wall, which would soon again be filled with the albuminous fluid secreted by its lining membrane, and thereby weaken the patlent's system by robbing his blood of some of its most useful constituents. At the same time this rigidity of the cyst wall does good, as its non-distensibility prevents a further increase in the size of the tumour. In this case I have decided on no further operative interference as long as pressure symptoms do not occasion serious inconvenience.

A lesson to be deduced from this case is, the necessity of making a careful chemical and microscopical examination of the contents of abdominal cysts when they have been tapped. Had this case occurred in a female, its ahnost identical appearance with an ovarian tumour might have misled even a cautious practitioner, and an erroneous diagnosis would be apparently verified on tapping by the appearance of a "dark coloured highly albuminous fluid," which is considered by some to be pathognomonic of the ovarian disease.

CaSE III.--lnterestlng Sequel to Operation jbr Ovarian Disease.

With reference to tile successful case of ovariotomy reported by me in a previous number of the Journal (February, 1873), I wish to state that the patient enjoys most perfect health, and has regular painless menstruation every month. A t that period the lower part of the wound (where the pedicle was clamped) re-opens, and from it there is an oozing of' blood during the *hree days that the catameuia last.