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CLINICAL RECORDS

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611 will be at once recognised, for the patient was not only aged, but weak and debilitated. A-fatal syncope was averted by the treatment adopted, but, owing to other causes, he succumbed nine days afterwards. An extremely infirm old man, aged seventy-eight years, was admitted for relief of retention of urine on the 27th of April, 1859. Several attempts had been made before his admission to pass a catheter, but without success. Mr. Thompson, being in the ward at the time, examined him immediately, and found the bladder forming a large tumour, reaching to the umbilicus. The patient was suffering great agony, and was much exhausted. He passed a No. 9 silver catheter without difficulty into the bladder, when a quantity of dark-coloured and fcetid urine flowed. The patient showing signs of increased weakness, and the pulse, which was carefully examined throughout, becoming very feeble, thirty ounces only were withdrawn, and the catheter stopped, and tied into the bladder,-Mr. Thompson remarking that a large quantity of urine remained in the bladder, and that in such a subject it was extremely dangerous to withdraw more than a moderate quantity at a time. He stated that he had known death from syncope to occur through neglect of this precaution. The prostate was found to be considerably enlarged by rectal examination, and the bladder pressing down into the bowel from extreme dis- tension. An hour afterwards, he withdrew rather more than a pint, and four or five hours afterwards, more than two pints and a half, which emptied the bladder. More than five pints had thus been withdrawn in the same number of hours. The catheter was left in. Stimulants and strong fluid nourishment to be taken freely. April 28th.-The silver catheter was exchanged for a gum catheter. The patient much better, and expresses himself as greatly relieved. 29th.-The gum catheter having slipped out in the night, it is found that he has no power to void any urine by his own efforts. It is replaced, and a piece of india-rubber tube, about four feet long, is attached to the mouth of the catheter, the other end of the tube being placed in a vessel beneath the bed. Mr. Thompson is in the habit of adopting this plan, which effectually prevents the bed from being wetted, and carries ofl offensive urine to any distance from the patient which the con. dition of it may make desirable. In this case, the urine is ex- tremely foetid, and loaded with muco-purulent matter. May Ist.-The patient is excessively weak; it is still neces sary to provide for the removal of all his urine by means ol instruments, as he has no power to expel it. 3rd.-He daily grows weaker, refuses nourishment, anc takes only stimulants. It is apparent that at his great age; and with the amount of disease present, he must soon succumb. 5th.-He gradually sank, and died this morning. 7th.-Post-mortem examination. -The whole of the urinar3 apparatus was removed entire. The kidneys were about the natural size, but congested; the ureters not enlarged. ThE prostate was at least four times as large as in the healthy state, and contained numerous rounded bodies, constituted apparentl3 chiefly of glandular substance. There were numerous cavities filled with dark concretions. The bladder was large, an( hypertrophied; the mucous membrane dark in colour an( highly injected. Two sacculi existed, capable of holding fron one to two ounces of urine. The neck of the bladder wa, greatly obstructed by the enlarged prostate. CLINICAL RECORDS. DESTRUCTION OF THE HAND AND FOOT. SOMETIMES the most trivial surgical maladies take on an in- flammatory action, which spreads to important parts, and may involve the loss of a member. Such case we saw at St. Bar- tholomew’s Hospital on the 28th ult., under Mr. Skey’s care. Five weeks before, a woman, apparently in very ill health and of bad constitution, was suffering from an abscess of an ordi- nary character in the thumb and another in the little finger. Both were opened by Mr. Batten, the house-surgeon. The inflammation, however, extended to the wrist, and numerous consecutive abscesses formed, which were treated in a similar manner. The wrist-joint now became involved; and as the mischief seemed irreparable, no resource remained but ampu- tation of the forearm, which Mr. Skey performed at its upper third at the date mentioned, and since the operation we learn the patient is doing well. On the 9th inst. we saw Mr. Adams remove the lower limb of a man in the London Hospital, for general disease of the leg and foot, which originated primarily in a compound fracture of the bones of the leg near the ankle, for which he was admitted on the 10th of April last. Shortly after his admission, a por- tion of the lower end of the tibia was removed; but the heal- ing process did not go on kindly. Infiltrating abscesses formed, with destruction of tissue, which necessitated the amputation of the limb; and this was effected pretty high up, by double rectangular flaps, immediately below the head of the tibia. This was the more necessary as the abscesses had extended freely upwards. The man’s constitution appears to be enfee- bled, but we see no reason to doubt his recovery. The rect- angular flaps adopted in this case by Mr. Adams were not those of Mr. Teale. On the 28th ult. we examined the stump of a boy in St. Bartholomew’s Hospital, whose left thigh had been amputated seven weeks before by Mr. Coote, for disease of the knee-joint of four years’ standing. His health was good, but the long anterior rectangular flap of Teale (which was made on this occasion) had considerably shrunk, thus reducing the stump to the condition of an ordinary antero-posterior flap operation. Experience has yet to show whether this shrinking is likely to prove a common result in Teale’s flaps. FIBRO-PLASTIC TUMOUR. OF THE NECK. THE side of the neck- that is to say, the part of it posterior to the sterno-cleido-mastoid muscle-is subject to every variety of tumour which comes under the notice of the surgeon for re- moval. Our "Clinical Records" have afforded illustrations of the greater number, many admitting of extirpation, and others again involving structures of too great importance to permit of such a proceeding. When a tumour is freely movable, well defined in its general characters, and apparently not too deeply situated, its removal is attended with prospects of success, as in an instance which we saw at Guy’s Hospital on the 24th ultimo in an elderly man under Mr. Hilton’s care. A circular, prominent growth, of the size of an orange, occupied the right side of the neck, a little above the clavicle. It was freely movable, had been growing slowly for twenty-five years up to six or seven months ago, from which time its increase has been more rapid, and hence was likely to involve the more impor- tant parts in this region of the neck. It was therefore taken away, with a second growth, of the size of a walnut, situated above it, and both were found to be somewhat deeply planted between the sterno-mastoid and trapezius muscles. On section, it presented the characters of a fibro-plastic tumour, and since the operation the man has been doing well. FRACTURE OF THE NECK OF THE FEMUR: AB- SENCE OF SOME OF THE USUAL SYMPTOMS. WE lately examined two cases of fracture of the neck of the femur within the capsular ligament, in the Westminster Hos- pital, which were chiefly remarkable for the absence of some of the usual signs diagnostic of this form of injury. The first of these was a woman, fifty-seven years of age, who tripped over a mat, and fell on her side; she became quite helpless, and was brought to the hospital, and placed under Mr. Brooke’s care. On careful examination, distinct crepitus was felt within the capsule ; there was no shortening nor eversion of the limb, and she had the power of drawing it up in bed. There was no tlattening of the hip and no impaction, yet the diagnosis was pretty clear. In two or three days the limb was two-thirds of an inch shorter; the foot was slightly everted, but she could invert it again, and still draw it up in bed. The limb was put up in a long Liston’s splint. The second case was that of a male patient, aged fifty-five years, and was somewhat similar to the preceding. No short- ening of the limb was present; but there were complete eversion of the part, and very indistinct crepitus. The injury seemed to be but a bruise. Seven days afterwards the limb was exa- mined under chloroform, during which shortening occurred, and very distinct crepitus was heard and felt. No splint was employed in this case, and the patient left the hospital some nine weeks afterwards, walking lame, with a crutch. . In relation to the absence of shortening which was observable in both cases, it must be remembered that this is no uncommon occurrence for the first few days, when the neck is fractured within the capsule, and this is mainly due to the (more or less) , integrity of the ligament of Weitbrecht. After a while the shortening becomes more decided, as the ligamental fibres be- come lacerated from the patient’s exertions. A feature of in- terest was the power possessed by both patients of drawing up. their limbs in bed.
Transcript

611

will be at once recognised, for the patient was not only aged,but weak and debilitated. A-fatal syncope was averted bythe treatment adopted, but, owing to other causes, he succumbednine days afterwards.An extremely infirm old man, aged seventy-eight years, was

admitted for relief of retention of urine on the 27th of April,1859. Several attempts had been made before his admissionto pass a catheter, but without success. Mr. Thompson, beingin the ward at the time, examined him immediately, and foundthe bladder forming a large tumour, reaching to the umbilicus.The patient was suffering great agony, and was much exhausted.He passed a No. 9 silver catheter without difficulty into thebladder, when a quantity of dark-coloured and fcetid urineflowed. The patient showing signs of increased weakness, andthe pulse, which was carefully examined throughout, becomingvery feeble, thirty ounces only were withdrawn, and thecatheter stopped, and tied into the bladder,-Mr. Thompsonremarking that a large quantity of urine remained in thebladder, and that in such a subject it was extremely dangerousto withdraw more than a moderate quantity at a time.He stated that he had known death from syncope tooccur through neglect of this precaution. The prostate wasfound to be considerably enlarged by rectal examination, andthe bladder pressing down into the bowel from extreme dis-tension. An hour afterwards, he withdrew rather more thana pint, and four or five hours afterwards, more than two pintsand a half, which emptied the bladder. More than five pintshad thus been withdrawn in the same number of hours. Thecatheter was left in. Stimulants and strong fluid nourishmentto be taken freely.

April 28th.-The silver catheter was exchanged for a gumcatheter. The patient much better, and expresses himself asgreatly relieved.29th.-The gum catheter having slipped out in the night, it

is found that he has no power to void any urine by his ownefforts. It is replaced, and a piece of india-rubber tube, aboutfour feet long, is attached to the mouth of the catheter, theother end of the tube being placed in a vessel beneath the bed.Mr. Thompson is in the habit of adopting this plan, whicheffectually prevents the bed from being wetted, and carries ofloffensive urine to any distance from the patient which the con.dition of it may make desirable. In this case, the urine is ex-tremely foetid, and loaded with muco-purulent matter.May Ist.-The patient is excessively weak; it is still neces

sary to provide for the removal of all his urine by means olinstruments, as he has no power to expel it.3rd.-He daily grows weaker, refuses nourishment, anc

takes only stimulants. It is apparent that at his great age;and with the amount of disease present, he must soon succumb.5th.-He gradually sank, and died this morning.7th.-Post-mortem examination. -The whole of the urinar3

apparatus was removed entire. The kidneys were about thenatural size, but congested; the ureters not enlarged. ThE

prostate was at least four times as large as in the healthy state,and contained numerous rounded bodies, constituted apparentl3chiefly of glandular substance. There were numerous cavitiesfilled with dark concretions. The bladder was large, an(hypertrophied; the mucous membrane dark in colour an(

highly injected. Two sacculi existed, capable of holding fronone to two ounces of urine. The neck of the bladder wa,

greatly obstructed by the enlarged prostate.

CLINICAL RECORDS.

DESTRUCTION OF THE HAND AND FOOT.

SOMETIMES the most trivial surgical maladies take on an in-flammatory action, which spreads to important parts, and mayinvolve the loss of a member. Such case we saw at St. Bar-tholomew’s Hospital on the 28th ult., under Mr. Skey’s care.Five weeks before, a woman, apparently in very ill health andof bad constitution, was suffering from an abscess of an ordi-nary character in the thumb and another in the little finger.Both were opened by Mr. Batten, the house-surgeon. Theinflammation, however, extended to the wrist, and numerousconsecutive abscesses formed, which were treated in a similarmanner. The wrist-joint now became involved; and as themischief seemed irreparable, no resource remained but ampu-tation of the forearm, which Mr. Skey performed at its upperthird at the date mentioned, and since the operation we learnthe patient is doing well.On the 9th inst. we saw Mr. Adams remove the lower limb of

a man in the London Hospital, for general disease of the leg and

foot, which originated primarily in a compound fracture of thebones of the leg near the ankle, for which he was admittedon the 10th of April last. Shortly after his admission, a por-tion of the lower end of the tibia was removed; but the heal-ing process did not go on kindly. Infiltrating abscesses formed,with destruction of tissue, which necessitated the amputationof the limb; and this was effected pretty high up, by doublerectangular flaps, immediately below the head of the tibia.This was the more necessary as the abscesses had extendedfreely upwards. The man’s constitution appears to be enfee-bled, but we see no reason to doubt his recovery. The rect-

angular flaps adopted in this case by Mr. Adams were notthose of Mr. Teale.On the 28th ult. we examined the stump of a boy in St.

Bartholomew’s Hospital, whose left thigh had been amputatedseven weeks before by Mr. Coote, for disease of the knee-jointof four years’ standing. His health was good, but the longanterior rectangular flap of Teale (which was made on thisoccasion) had considerably shrunk, thus reducing the stump tothe condition of an ordinary antero-posterior flap operation.Experience has yet to show whether this shrinking is likely toprove a common result in Teale’s flaps.

FIBRO-PLASTIC TUMOUR. OF THE NECK.

THE side of the neck- that is to say, the part of it posteriorto the sterno-cleido-mastoid muscle-is subject to every varietyof tumour which comes under the notice of the surgeon for re-moval. Our "Clinical Records" have afforded illustrations ofthe greater number, many admitting of extirpation, and othersagain involving structures of too great importance to permit ofsuch a proceeding. When a tumour is freely movable, welldefined in its general characters, and apparently not too deeplysituated, its removal is attended with prospects of success, asin an instance which we saw at Guy’s Hospital on the 24thultimo in an elderly man under Mr. Hilton’s care. A circular,prominent growth, of the size of an orange, occupied the rightside of the neck, a little above the clavicle. It was freelymovable, had been growing slowly for twenty-five years up tosix or seven months ago, from which time its increase has beenmore rapid, and hence was likely to involve the more impor-tant parts in this region of the neck. It was therefore takenaway, with a second growth, of the size of a walnut, situatedabove it, and both were found to be somewhat deeply plantedbetween the sterno-mastoid and trapezius muscles. On section,it presented the characters of a fibro-plastic tumour, and sincethe operation the man has been doing well.

FRACTURE OF THE NECK OF THE FEMUR: AB-SENCE OF SOME OF THE USUAL SYMPTOMS.

WE lately examined two cases of fracture of the neck of thefemur within the capsular ligament, in the Westminster Hos-pital, which were chiefly remarkable for the absence of someof the usual signs diagnostic of this form of injury. The first ofthese was a woman, fifty-seven years of age, who tripped overa mat, and fell on her side; she became quite helpless, and wasbrought to the hospital, and placed under Mr. Brooke’s care.On careful examination, distinct crepitus was felt within thecapsule ; there was no shortening nor eversion of the limb, andshe had the power of drawing it up in bed. There was no

tlattening of the hip and no impaction, yet the diagnosis waspretty clear. In two or three days the limb was two-thirds ofan inch shorter; the foot was slightly everted, but she couldinvert it again, and still draw it up in bed. The limb was putup in a long Liston’s splint.The second case was that of a male patient, aged fifty-five

years, and was somewhat similar to the preceding. No short-ening of the limb was present; but there were complete eversionof the part, and very indistinct crepitus. The injury seemedto be but a bruise. Seven days afterwards the limb was exa-mined under chloroform, during which shortening occurred,and very distinct crepitus was heard and felt. No splint wasemployed in this case, and the patient left the hospital somenine weeks afterwards, walking lame, with a crutch.

. In relation to the absence of shortening which was observablein both cases, it must be remembered that this is no uncommonoccurrence for the first few days, when the neck is fracturedwithin the capsule, and this is mainly due to the (more or less)

, integrity of the ligament of Weitbrecht. After a while theshortening becomes more decided, as the ligamental fibres be-come lacerated from the patient’s exertions. A feature of in-

terest was the power possessed by both patients of drawing up.their limbs in bed.

612

CHIMNEY-SWEEPERS’ CANCER.

Tms well-known, although now less common, disease, whic:was first clearly described by Pott, occasionally presents itselfor treatment at our hospitals. The irritarion produced by thsoot which lodges in the folds of the scrotum gives rise to thformation of a tubercle, or soot-wart, which becomes inflamedcracks, and ulcerates, and assumes the characters of epitheliacancer.

A stout chimney-sweep, about thirty-five years of age, wabrought into the theatre of t. Bartholomew’s Hospital, on th28th of May, with two ulcerated tubercles. situated on th,

right side of the scrotum, towards its most depending partThese had originated in the manner described, and were removed by Air. Stanley, who took up the portion of the scrotullcontaining them between the blades of a pair of curved forcepscutting along their under surfaces with a scalpel. The diseasEwas not extensive, and the present was the first attack of isustained by the patient. He was advised to give up his employment. else a return of the cancer would surely ensue; buhe declared that he &laquo;-as proud of it, and would not resort t<

any other avocation. It is most probable that an early removalike the present, before glandular implication has ensued, woulcbe followed by a perfect cure, were the exciting cause of thEcomplaint to cease; otherwise it will sooner or later returnand ultimately destroy life.The diseased mass was cut into two portions, and presentec

by Mr. Stanley to two distinguished American physicians wh(were present, for their museums. The operation on this occasion was performed without chloroform.

FALL FROM THE TOP OF A HOUSE, AND IMPALEMENT ON THE AREA RAILINGS.

WE have many times recorded the results of falls from a

great height, wherein the patients have either been imme.diately killed or have recovered from their injuries, the latteibeing occasionally comparatively trivial when the nature of thefall has been duly weighed. There’ is a lad, fourteen years ofage, in one of Mr. Erichsen’s wards at University College Hos-pital, who is recovering from some-severe injuries received by anaccident of the kind. On the 9th of May, he fell from the topof a house forty feet high on to some area railings. His fallwas slightly broken by some intervening substance. One iron

spike passed through his left thigh behind the femur, andanother through the right thigh behind the same bone, which,however, was fractured. He was admitted the same day, and,besides the injuries named, the right side of his forehead andthe left temple were found wounded by two other iron spikes,but fortunately not penetrating the bone. He was unconsciousfor five minutes only after the accident. The fractured limbwas put up in starch bandages, and has united; all the woundshave nearly healed up, and he feels pretty comfortable. Hisrecovery has been more rapid than at first sight seemed pro-bable from the nature of the injuries sustained.

R O Y A L SOCIETY.

THURSDAY, MAY 26TH, 1859.SIR BENJAMIN BRODIE, BART., PRESIDENT.

ON THE MODE IN WHICH SONOROUS UNDULATIONS ARE CON-DUCTED FROM THE MEMBRANA TYMPANI TO THE

LABYRINTH IN THE HUMAN EAR.

BY JOSEPH TOYNBEE, F.R.S.,AURAL SURGEON TO ST. MARY’S HOSPITAL.

THE opinion usually entertained by physiologists is, that twochannels are requisite for the transmission of sonorous undula-tions to the labyrinth from the membrana tympani-viz., theair in the tympanic cavity, which transmits the undulations tothe membrane of the fenestra rotunda and the cochlea, and,secondly, the chain of ossicles, which conducts them to thevestibule. This opinion is, however, far from being universallyreceived. Thus one writer contends that "the integrity of onefenestra may suffice for the exercise of hearing ;"* another ex-presses his conviction that the transmission of sound cannottake place through the ossicula;"&dagger; while Sir John Herschel, in

* Mr. Wharton Jones, Encyclop&oelig;dia, of Surgery, "Diseases of the Ear,"p. 23.

t Mr. Brooke. THE LANCET- 1843- D. 380.

speaking of the ossicles, says " they are so far from being essen-tial to hearing, that when the tympanum is destroyed, and the

chain in consequence hangs loose, deafness does not follow."*.

The object of this paper is to decide by experiment how farthe ossicles are requisite for the performance of the function ofhearing. The subject is considered under two heads, viz.:-

1st. Whether sonorous undulations from the external meatuscan reach the labyrinth without the aid of the ossicles as amedium.

2nd. Whether any peculiarity in the conformation of thechain of. ossicles precludes the passage of sonorous undulationsthrough it.

1. Can sonorous undulations reach the labyrinth from theexternal meatus without the ccicl of the ossicles as a medium ?This question has often been answered in the affirmative, appa-rently because it has been ascertained that in cases where twobones of the chain have been removed by disease, the hearingpower is but slightly diminished. In opposition to this view,it must, however, be remembered that the absence of the stapesis always followed by local deafness, while a fixed condition ofthis bone (anchylosis) is accompanied by very serious deafness.The following experiments, selected from several others, de-monstrating the great facility with which sonorous undulationspass from the air to a solid body, indicate that the stapes, evenwhen isolated from the other bones of the chain, may still be amedium for the transmission of sounds to the fenestra ovalisand the vestibule.Experiment I.-Both ears having been closed, a piece of

wood, five inches long and half an inch in diameter, was heldbetween the teeth, and a vibrating tuning fork, C’, having beenbrought within the eighth of an inch of its free extremity, itssound was distinctly heard, and continued to be heard, for be-tween five and six seconds.Experiment 2.-Three portions of wood of the same length

and thickness as that used in the previous experiment wereglued together, so as to form a triangle somewhat of the shapeof the stapes ; the base of this triangle being placed against theouter surface of the tragus, the tuning fork C’ vibrating withina quarter of an inch from its apex was heard for twelve seconds.

2. Is there any peculiarity in the constructiooa of the chain ofossicles to prevent the passage of sonorous undulations throughthem? This question has also Leen answered in the affirmative,on account of the various planes existing in this chain, andof the joints between the several bones composing it.tThe following experiments, selected from a variety detailed

in the paper, indicate that neither the variety of the planesexisting in the chain, nor the presence of joints, prevents thepassage of sonorous undulations through it.Experiment 1.-Two pieces of wood, each five inches long,

were glued together so as to represent the planes of the mal-leus and incus, a triangular piece similar to that used in thelast experiment being glued to one surface of the inferior ex-tremity of the portion representing the incus, so as to imi.tate the plane of the stapes. Three pieces of wood, each fiveinches long, were also glued together, end to end, so as to forma straight rod. The vibrating tuning fork, C’, being placed-at one extremity of the apparatus representing the chain ofbones, and the other end being placed between the teeth, thesound was heard most distinctly for several seconds; and whenit ceased to be heard, the straight rod was substituted, andthe sound was again heard, but only for three seconds.

Exper,iment 2.-Between each of the three pieces of wood,representing the chain of ossicles, similar to those used in theprevious experiment, were placed, instead of glue, two layersof india-rubber, about as thick as ordinary writing paper; thepieces of wood being held together, the tuning fork placed atone end of the chain, was heard as distinctly and as long as inthe previous experiment.The experiments, dissections, and observations recorded in

the paper, induce the author to arrive at the following con-clusions :-

1. That the commonly received opinion that sonorous undu-lations pass to the vestibule, through the chain of ossicles, iscorrect.

2. That the stapes, even when disconnected from the incus,can still conduct sonorous undulations to the vestibule from theair.

3. So far as our present experience extends, it appears thatin the human ear sound cannot reach the labyrinth from themembrana tympani without the agency of two media-viz.,the air in the tympanic cavity, and the chain of ossicles.

’ Encyclop&aelig;dia Metropolitana. Article," Sound," p. 810.&dagger; Mr. Brooke, loc. cit.


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