IV. ON THE TREATMENT OF SEROUS CYSTS. "The essential differences that we observe, in the structure of cysts, and the nature of their contents, would lead us to suppose that the same principles of treatment cannot be applicable to all cases of encysted tumours. In some instances the cyst is like the thinnest serous membrane, and contains a clear fluid of watery consistence, in others it is a fibrous structure more or less compact and thick, perhaps with a cuticular or horny lining, or with portions of cartilaginous or osseous texture, and containing either a thick fluid, or from that to the most compact kind of fat or other matter. The fibrous cysts must be either left alone or completely removed by the knife. To irritate them, either by seton, by stimulating injections, or by incision and escharotics, is not only ineffectual as a means of cure, but very dangerous. Measures of the latter kind may be adopted without much risk in the serous cysts. We may make an incision into the swelling and keep it open; inflammation and suppuration of the membrane will ensue, and will lead to permanent obliteration of the cyst. Excision is applicable to the fibrous cysts, which are generally seated in the subcutaneous stratum of adipous texture; while the other mode of proceeding is more convenient in those of serous structure, which are seated more deeply, in the intermuscular cellular tissue, and generally covered at least in part, by some superficial muscle. These, when neglected, often become so extensive, and are so closely connected to blood-vessels and other important parts, that complete excision would be either extremely difficult or impracticable.” 43. Case. A lad, t. 14, had a swelling on the left side of the neck, which had commenced eight years previously. It was nearly as large as the fist, situated under the sterno-mastoideus, extended from the sternal end of the clavicle to the ear, passed to the side of the trachea, larynx and œsophagus in front, and towards the ligamentum nuchæ behind. It obviously contained fluid. On Sept. 17th, 1830, Mr. Lawrence made an incision, between two and three inches long, over that part of the swelling behind the sterno-mastoid, and laid bare the cyst, punctured it, and let out a few ounces of light-brownish, watery fluid. The denuded portion of the cyst had a smooth surface, and in it were other smaller cysts, most of them communicating with the general cavity, which was generally smooth. The carotid artery was felt through the thin membrane of the cyst, in the whole length of the neck, as if it had been dissected. Mr. L. introduced four slips of lint, spread with spermaceti cerate, into the cavity, leaving their ends out at the wound, which was lightly covered with a similar dressing. A good deal of tendency to inflammatory action occurred after the operation, and antiphlogistic treatment was necessary. The cavity was obliterated at the beginning of November, when the patient left town. The patient continues well, without a vestige of the former disease. Mr. Lawrence refers to two cases related by the late M. Delpech. The cysts were very extensive. M. Delpech cured the disease by puncturing the cysts, and introducing bundles of charpie, in such a manner as to come in contact with every part of the internal surface. One case was cured by the 19th day, the other by the 40th. Case of Cyst in the Orbit, containing Hydatids. C. R. æt. 42, admitted into the London Ophthalmic Infirmary, Jan. 3d, 1820, with protrusion of one eye from the orbit by a tumour, situated between the upper and inner portion of the eyeball and the lid. The upper lid was greatly stretched, the lower everted, the conjunctiva of the globe thickened, the iris motionless, vision gone. The tumour was firm, and apparently fixed to the orbit; it fluctuated obscurely. It had commenced seven years previously. He had applied at the infirmary when the disease was less advanced, and when only a small firm protuberance could be felt obscurely under the superciliary arch. He then refused to submit to an operation. Mr. Lawrence made a puncture into the most prominent part of the swelling; a dessert-spoonful of clear watery fluid escaped. Two days afterwards a soft white substance appeared in the puncture; it was removed-it was a hydatid, and a few others escaped when pressure was made on the swelling. The whole collection was cleared out by enlarging the puncture, and injecting water forcibly into the sac. Inflammation and suppuration of the cyst followed, and in about a month the opening closed, the eye returning to its natural situation. In March, a little motion of the iris and slight perception of light had returned. Professor Delpech relates two cases of serous cyst in the orbit, one containing clear fluid, the other a large hydatid. M. Delpech introduced charpie into both, practice which Mr. Lawrence criticises in the instance of the hydatid, as being unnecessary, and likely to excite too much inflammation. The profession will feel obliged to Mr. Lawrence for this paper. The publication of the experience of men who have seen much, and particularly of those who, like Mr. Lawrence, are well able to reason on what they see, is always valuable. Perhaps Mr. Lawrence's example may induce others to contribute towards the elucidation of a subject, the importance of which is commensurate with its difficulties. V. ON SOME EFFECTS OF INFLAMMATION OF THE MEMBRANOUS LINING OF THE LARYNX, &c. &c. By John Wood, late House Surgeon to St. Bartholomew's Hospital. [Med. Chir. Trans. Vol. XVII.] THIS is a very long paper, exhibiting very creditable research and much judgment on an important point of medical surgery. Laryngitis is not uncommon, and every one knows what a fearful and formidable inflammation it is. In many cases it comes on almost insensibly and proceeds slowly, and is not usually complicated with inflammation of the tracheal or bronchial lining, or with much symptomatic fever. It is attended with more or less dysphagia, by which our author thinks it may be distinguished from croup. Pathologically too, he avers that it differs from the latter disease, inasmuch as the change of structure consists of interstitial deposition, and not of effusion, in the form of an adventitious membrane upon the surface of the inflamed mucous membrane. "The distinctions of croup from other forms of inflammation of the larynx, and an accurate knowledge of the seat of obstruction in each instance, are essential to successful treatment of the different affections. General bleeding, so highly beneficial in croup, seems often to have aggravated the sufferings, and hastened the death, of those affected with oedema of the glottis. Had the pathology of croup been better understood, laryngotomy would never have been declared to be the most efficacious means of relief." 142. It is often impossible to determine, during life, whether acute inflammation has caused serous effusion into the submucous tissue, or whether this is swollen and thickened by gradual interstitial deposition. "It appears to me that the term SPASM is often used unwarrantably to explain the deaths of persons who have shewn symptoms of diseased larynx, and that the common notion of spasmodic asphyxia is dangerous, as it leads to the use of opiates and antispasmodics in disorders essentially inflammatory, and only to be treated with success by those who early discover and appreciate their nature and tendency. Dissection, certainly seldom discloses in the larynx a complete obstacle to the transmission of air: this is not necessary to produce death. If the passage be gradually narrowed, so as to prevent at each inspiration the ingress of a proper quantity of air, the properties of the blood are consequently altered. The circulation of the fluid in an unhealthy state, produces a general debilitating effect; this is augmented by the fatigue resulting from the increased exertions which breathing requires. The imperfect expansion of the lungs causes in them a state of vascular conjestion and consecutive serous effusion, which impedes the return of blood from the head, and gives rise to turgescence of the vessels of the brain with effusion into the cerebral cavities. Although,' says Dr. Cheyne, in his remarks on croup, apparently the first of the vital functions which is arrested by respiration, yet this seems to arise from a want of muscular strength in consequence of failure of the sensorial power, the invariable result of defective supply of pure arterial blood in the brain.' These patients, I believe, die more frequently from cerebral disorder and gradual exhaustion than from sudden or spasmodic suffocation." 147. Our author questions the propriety of the term "spasmodic asthma," concluding that the dyspnoea observed in the paroxysm results from “vascular conjestion of the lungs, and particularly of their mucous membrane." He acknowledges that when a permanent lesion exists, it is difficult to explain how the symptoms should be only occasional, the intervals of the attacks being quite free from suffering. Irregularity of the circulation, he thinks, offers a better solution of the difficulty than spasm. "In whatever textures inflammation occurs, we notice periods of exacerbation and remission. May not, then, the occasional aggravation of the symptoms in laryngitis be as fairly ascribed to a temporary increase of the inflammation as to an extraordinary action of the muscles of the larynx? Are the distressing paroxysms in peritonitis ever attributed to spasm of the abdominal muscles? In tetanus, or in hydrophobia, where violent spasms of the throat are remarkable, do they ever produce asphyxia? To con. clude these desultory remarks on spasm, I have only to say, with the late Dr. Albers, of Bremen, Neque adhuc vidi tracheitidem spasmodicam."* 154. Lib. cit. p. 153. Several cases of the disease, as occurring in St. Bartholomew's and elsewhere, are detailed, but most of them have appeared in the periodicals at the time they took place. We come therefore to the second part of the paper. ON BRONCHOTOMY. Obstruction to respiration, in cases of the above description, generally finds relief from bronchotomy; but where the obstruction is in the bronchial tubes, the operation is necessarily useless, if not worse. Whether bronchotomy may ever be serviceable in certain affections of the larynx, which have been termed spasmodic, cerebral, or sympathetic, our author does not pretend to determine, nor has he found any thing very satisfactory in his researches among written testimonies. "Dr. Albers, of Bonn, speaks of a state of disease, observable particularly in girls who are subject to irregular menstruation, in which the larynx is so irritable, that, on the slightest occasion, and usually towards evening, it becomes affected with spasm, which is to be quieted by nothing, not even by musk and opium. It is attended with a dry cough, which will continue for two or three hours without interruption, and not cease until the patient falls into a swoon, or even into convulsions. I have seen,' says Dr. Aibers, these symptoms regularly repeated every evening for two months together. In this case, as also in every instance where such spasm is produced, should not tracheotomy be employed to remove this troublesome and highly dangerous condition? Particularly as this affection continues to be regularly repeated even when the menstrual functions are performed, and as the patient is liable every moment to be sufocated."* 170. Mr. Wood says he would prefer, in such cases, a trial of some powerful revulsive agent, such as sudden immersion in cold water, the shower-bath, croton-oil, or an emetic. The propriety of bronchotomy, in laryngeal disease, will much depend on the state of the lungs, which must be determined by an accurate investigation of the history and phenomena of the disease. We extract the following passage, which is founded on the authority of Bonetus, though we have great doubt of its accuracy. "There are, perhaps, no symptoms that more frequently puzzle practitioners than those which seem to depend on affections of the larynx. Disease of the liver is sometimes attended with symptoms of cynanche laryngea, although no morbid appearances are presented in the larynx after death."+ 173. We verily believe that there is not in medicine a more widely extended error than this belief in cough and other affections really appertaining to the chest, being sympathetic of liver disease and dyspepsia. We have endeavoured, on many occasions, to point out the error, and the serious consequences thence resulting, but in vain. The evil appears on the increase rather than on the wane. As example is more potent than precept, we shall briefly allude to one or two melancholy cases illustrative of this point. There are some medical practitioners, not one hundred miles from Tunbridge, who can vouch for the truth of the following fact. A fine young gentleman became affected with cough, and apparently slight pul * Graefe and Walther's Journal, Bd. XV. Heft 4. monary affection. He brought up a little blood, and one of the most eminent of our metropolitan surgeons, happening to be in the neighbourhood, was consulted. He pronounced the complaint to be merely hepatic congestion, and ordered calomel, as a matter of course. The symptoms not giving way, the patient was brought up to town, when a very superficial examination of the chest shewed almost the whole of the left lung disor ganized! He died a few weeks afterwards, and dissection proved the truth of the diagnosis. The family has been left in the greatest distress, and the false diagnosis of the surgeon has damaged his reputation through a very extensive circle of society. This day (10th of January) we saw a young lady just arrived from the country, with "stomach-cough," of seventeen months standing. Not the slightest idea was entertained by some metropolitan and provincial physicians of any disease in the chest. Yet a pupil at any of our great hospital might have discovered the existence of chronic inflammation of the lungs to an extent which now leaves little hopes of recovery. Muttonchops for breakfast-meat and wine for dinner-bitters, nay tonics, were employed for many months to reduce the "stomach-cough"-with, we need hardly say, no benefit-but, on the contrary, with the loss of time, that can never be compensated for by any antiphlogistic measures! We could fill a whole number of our Journal with similar cases; but they would make no impression on the public-and "stomach-cough" will have its way. Mr. Wood notices certain errors of diagnosis of a different kind. “A child, eight months old, died with symptoms of cynanche laryngea, which were evidently occasioned by the pressure of an abscess in front of the thyroid cartilage, and bounding nearly the whole extent of the os hyoides. The internal lining of the air-passage was found healthy. The narrator of this case regrets, with much propriety, that the abscess was not discovered before death. Mr. Lawrence has related the case of a young woman, under twenty years of age, who died suffocated from an aneurism behind the sternum, pressing on the trachea. Her symptoms were so deceptive that it was supposed bronchotomy would be required. The sixth case detailed in the important Memoir of Bayle, is that of an aneurismal tumour, compressing the left bronchia, and simulating oedema of the glottis. I did not' says Bayle, see this case, but am persuaded that I should have taken the disease for oedema of the glottis.'* I know an instance where this mistake led to the performance of tracheotomy, which was attended with bursting of the aneurism into the trachea : and, from a preparation which I lately saw in the College of Surgeons, it appears probable that the same unexpected event must have annoyed another practitioner. In this preparation there is an artificial opening in the larynx; and just above the bifurcation of the trachea another opening is seen to communicate with the cavity of the ruptured sac of an aneurism. Dr. Hope affirms, that bronchotomy has several times been performed with the view of obviating suffocation occasioned by aortic aneurism.t It is unnecessary to multiply instances to prove the importance of minute diagnostic research. The obscurity in which the diseases of the larynx are often involved, and the • Nouveau Journal de Médecine, Janvier, 1819, p. 22. |