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incontinence of urine, and that she could not then retain it. Shewas directed to bring the child back to the hospital without furtherdelay. Some days, however, having elapsed without her doingso, and my attention having been directed to a statement whichshe had made a day or two previously at the Bow-street Police-office, that the child still suffered from incontinence of urine, andwas probably injured for life, I deemed it my duty to visit thechild at her own home, particularly as the child did not show anysigns of this malady whilst in the hospital. I accordingly went,on Monday, the 17th of January, in company with Mr. Adkins,to Old Pye-street, Westminster. We found the child in perfecthealth, playing about the room; and upon examining her, andquestioning the mother, ascertained that the incontinence of urinedid not then exist; and, from the appearance of parts, I feel veryconfident that it never did so.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.

Ulcer of the Stomach.(Under the care of Dr. BUDD.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, turn aliorum proprias, collectas habere et inter secomparare.—MoRGAGNI. De Sed. et Cuus. Morb., lib.14. Procemium.

THE diagnosis of gastric affections is sometimes easy, and atother times fraught with difficulties of no trifling kind. The

ordinary derangements of the stomach brought on by a super-abundance or an improper kind of food, symptomatic irrita-bility, deficiency of chemical action, muscular debility, &c.,are pretty easily recognised and treated. But affections ofanother class - viz., chronic inflammation, ulceration, andcancer, present groups of symptoms which have so much

analogy with each other, that it is often a puzzling problem togive a decided opinion as to the actual nature of the disease.

Pain, loss of appetite, vomiting, haematemesis, and flatu-lency, are generally present, with more or less intensity, in theaffections to which we have just alluded; but it would appear,from the statistics which have been made public, and from ourown experience, that the common ulcer of the stomach is moreseldom met with than either chronic inflammation or carci-noma of the gastric cavity. As far as hospital practice is con-cerned, we are bound to say that we have noticed more casesof simple ulcer of the stomach in Dr. Budd’s wards than inany other institution, and we hope to serve a useful purposeby pointing out the treatment which Dr. Budd adopts in thesecases-viz., the avoidance of all irritating substances, and theuse of boiled flour and milk for ordinary nourishment. Thecourse thus pursued is in complete harmony with the methodsusually employed for favouring the cicatrization of ulcerssituated on the surface; for soothing applications, except incases of very languid and indolent ulcers, are, in general, themost likely to benefit the patient. It is highly probable, thatin this way Dr. Budd has succeeded more than once in pro-curing the healing of ulcers of the stomach; and it would

perhaps be well, whenever ulceration of the mucous mem-brane of other portions of the alimentary canal is suspected,that the above-mentioned facts be kept in view, for it maybe supposed that such emollient applications might sometimesbe more beneficial than preparations of opium or othersedatives. Nor need the diagnosis of these affections he

strictly correct, for adopting the farinaceous diet cannot failto be of much use, both in carcinoma and chronic inflamma.tion without ulceration.Some doubts have been raised as to the actual cicatrization

of ulcers of the stomach; but autopsies have clearly revealedthe existence of such cicatrices, though these are perhaps asfare as cicatrized yomicæ in the lungs. It is worthy of notice,

that pressure on the epigastric region does not generally givesevere pain over a circumscribed spot, and that it is thussomewhat difficult, in most instances, to say where the ulceris actually situated; and it certainly may now and thenhappen, that chronic inflammation with exudation of blood,may be confounded with ulceration and lesion of some arterialor venous branch.We feel the more inclined to put the following case upon

record, as it presented the more striking symptoms of the twoaffections which we have just named. Most of our readers-will most probably side with Dr. Budd, and consider the case-as a bonâ fide instance of ulcer of the stomach. The details ofthe case were obtained from the notes of Mr. Marchant, oneof Dr. Budd’s clinical clerks.William F---, a bricklayer, aged forty years, was admitted ;,

October 12, 1852, under the care of Dr. Budd. The patientalways enjoyed good health until about eight years ago, whenhe began to suffer from pain in the head and limbs; he then ’for a few days vomited his food, and noticed that it was tingedwith blood. Soon after these symptoms had shown themselves,he brought up (as he says) seventy-two ounces of blood, of avery dark colour. The man is of intemperate habits, but doesnot recollect whether he had been drinking to excess a short-time previous to this latter attack. No pain after the ingestion,of solid food was at that time experienced, nor had actual andcopious vomiting of the contents of the stomach taken place -until about a week before the occurrence of hsematemesis.The patient was at this period laid up for about ten weeks,and during the subsequent eight years had, up to the day ofhis admission, onlv four attacks of sanguineous vomiting, eachto the amount of about six ounces of blood. The latter wason these occasions very fluid, and of dark colour; and thevomiting used to occur after a fit of coughing, though theblood never came with the sputa.

. Up to nine days before admission, the patient had expe-’

rienced no pain in the stomach, and no difficulty of takingfood; but he now began to complain of headache, uneasiness’ in the bowels, slight cough, and loss of appetite. Solid food- was occasionally rejected, but not streaked with blood. The.

gastric pain was always increased upon taking aliments of af consistent kind; and the suffering seemed to extend from the

middle of the stomach to the pyloric extremity. The patientstated that he felt very weak in the afternoon of the day onwhich he was admitted, and vomited (according to his calcu-

) lation) between three and four pints of dark, coagulatedblood. He thereupon became very faint, and was brought to

_

this hospital.His state on admission is thus described:-Extremely

pallid, lips blanched, lightness and giddiness of the head, withgreat pain in that organ, and flashes of light before the eyes.The uneasiness over the epigastrium, and to the left of thatregion, has diminished, but the part still feels sore. Therehas been no vomiting of blood since admission, nor any re-jection of food. The bowels are confined, and the patient saysthat he has never noticed anv blood in his stools. No rest atnight, and great pain on pressure on the right side of the lineaalba, as far as the level of the umbilicus. Liver not enlarged.On auscultation of the heart, slight systolic roughness is heardat the apex; pulmonary sounds normal.

Dr. Budd diagnosed ulcer of the stomach, and ordered iceto be sucked, and the food to consist of boiled miik and flour.The progress was extremely slow for a few days, but no otherattacks of haematemesis took place.

Six days after admission, Dr. Budd prescribed three grainsof citrate of iron to be taken three times a day. Four daysafterwards, a blister was applied to the pit of the stomach;this relieved the tightness felt in that locality. No vomitinghad taken place, but the bowels were relaxed, and the patientstill felt giddy. There was also some pain in the loins andright flank, but the patient rested better at night, and thefood was taken with pleasure.Up to the fortieth day after admission, the patient remained

extremely weak and giddy, lie had severe pain across theumbilicus, and the bowels were often relaxed, though thediet was chiefly composed of flour, oatmeal, arrowroot, andmilk.At this period, Dr. Dudd prescribed an astringent chalk

mixture, which caused the looseness to cease. The symptomsbecame a little mitigated on the fifty-first day. The man wasthen allowed a slice of meat, and had again an astringentmixture.A week after this, there was still tenesmus, giddiness, and

slight díarrhae, when Dr. Budd ordered a mixture of bismuth,magnesia, and morphia. This gave some relief; but on the

the patient was taken with violent sickness

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and purging, the matters vomited being very sour and green.He now took effervescent draughts, and a mixture composedof opium, catechu, chalk, and logwood, the bismuth being atthe same time continued. The symptoms were now effec-tually controlled, and Dr. Budd now gave creosote and opiumin small doses.The sickness returned, however, in a few days; the epigas-

trium became very tender on pressure, especially after meals;and the headache continued very severe. The creosote wasnow omitted, a blister applied to the pit of the stomach, anda combination of chalk, bismuth, and morphia ordered.From this time the patient began to improve; the sickness

did not recur; the pain after meals diminished; and tender-ness on pressure over the epigastrium gave way. A nourish-ing diet was now prescribed, and the man was discharged athis own request, ten weeks after admission, warned by Dr.Budd to refrain from all stimulating and intoxicatingliquors. Here is a good instance of the degree of irritability which

may be induced by one or more ulcers of the stomach. Thefarinaceous food, used for the first few weeks, certainly con-tributed much in diminishing the distress; but as soon as a lessexclusive diet was allowed, and preparations of steel ordered,the same train of symptoms as had characterized the firstperiod of the case suddenly re-appeared. Bismuth, magnesia,and morphia, form a combination which answered admirably,and which is of great value in these cases, whether there besimply chronic inflammation or actual ulceration. Dr. Buddadvised the patient to avoid stimulating aliments, and torefrain from the use of intoxicating liquors; just on the sameprinciple, we presume, as the surgeon warns a patient on theeve of being discharged with a newly-cicatrized tegumentaryulcer, to shield the delicate structure from violence, or thecontact of irritating substances. We sincerely hope that Dr.Budd’s advice will be followed, and that his patient will notput himself under the necessity of again applying for assistanceat this institution.

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GUY’S HOSPITAL.

Injury to the Ulnar Artery. and Partial Division of the UlnarNerve, from a Lacerated Wound of the Fore-arm; Delegationof the Artery; Improved Method of Continuous Irrigation.

(Under the care of Mr. HILTON.)WE offered, last week, a few illustrations of the practice

followed by some hospital surgeons in cases of ha-morrhagedepending on wounds of arteries, and now continue thesubject the more willingly, as collections of this kind are verylikely to prove of practical utility. The case to which wedesire to call attention affords, besides, an opportunity ofintroducing a mode of irrigating the injured limb in a mannerwhich we have not seen adopted elsewhere; and when it isrecollected how important the continuous application of coldlnay sometimes be, it will not appear useless that the bestmode of doing so be made known. Indeed, we may ventureto say that the application of cold in compound fracture,large wounds of the soft parts, and even in peritonitis andpneumonia, is not so much appreciated and practised as itperhaps should be. But we leave the discussion of this subjectfor another occasion, and at once proceed to enter upon Mr.Eilton’s case.

William R--, aged nineteen, an apprentice to a tobacco-nist, was admitted into Cornelius ward August 21, 1852, witha lacerated wound of the fore-arm, the result of a fall througha window. The accident happened about ten in the morning,and the patient was soon afterwards brought to the hospitalvery faint and pale from loss of blood.The examination of the arm exposed an extensive wound on

the inner side of the anterior apcet of the fore-arm. It ap-peared that the edges of the broken glass, and the frame ofthe wood-work of the window, had cut and torn. from belowupwards a long flap of skin and muscles, reaching from withintwo inches of the wrist-joint to near the elbow, the woundbeing broadest and deepest towards the internal condyle ofthe humerus. The flexor carpi ulnaris was completely divided:the flexor sublimis and profuudis partially so, and much

jagged. The sheath of the ulnar artery, with its associatedveins, was denuded and ecchymosed for nearly two inches, andthe ulnar nerve had been cut obliquely through about itsanterior half. The haemorrhage was slight after the boy’sadmission. it being chiefly venous; lie was put to bed with thefore-arm flexed, raised on pillows, and wetted lint placedaround the seat of injury.Mr. Hilton saw the patient at one o’clock, and obtained a

good view of the extent of injury, by sponging the blood

from the ragged muscles; and, thinking that the sequel tosuch a wound might be some sloughing which would includethe bloodvessels, deemed it right to place two ligatures uponthe ulnar artery, one at the upper, the other at the lower partof its exposed portion. The vessel was then divided in its

centre, so as to allow of retraction at both ends. The flap ofskin and muscle was much retracted, and required some effortsin stretching, so as to make it reach the part of the arm fromwhich it had been separated. This was ultimately accom-plished by numerous interrupted sutures; the hand was flexedat an obtuse angle, so as to allow of the approximation of theends of the partially divided nerve, and to relieve the tensionof the skin and muscles. The fore-arm was then lightly boundto a splint placed upon its dorsal surface, for the purpcse ofsupporting or steadying the limb. The latter was then so

placed upon a pillow, with the hand raised, that the woundedsurface might receive the intended irrigation as soon as localreaction had clearly manifested itself in the flap, as the latter,when first adjusted, was below the temperature of the sur-rounding integument.The irrigating means hitherto employed at Guy’s Hospital

had consisted of a receptacle for water (a glass funnel generally,with a cork inserted in its narrow end), suspended as best itcould be to some part of the frame of the patient’s bed, withworsted threads so placed that one set of ends could be im-mersed in the water, and the others hang over the part to beirrigated, capillary attraction completing the rest of the in-tention. Mr. Hilton, observing the occasional inefficiency ofthis instrument, had constructed, by Mr. Bigg, of St.Thomas’s-street, the apparatus used in this case; and as it seemed toanswer the purpose, we shall just describe it :-The instrument consists of a zinc reservoir, with a vulcanized

india-rubber tube opening from it at its side, close to thebottom. The entrance of water into the tube is regulated bya stop cock; at the other end of the tube is affixed a broadzinc head, resembling a compressed or flattened rose of awatering-pot, a linear series of perforations being cut throughits lower or convex edge. Equidistant from each other, andabout half-an-inch apart, threads of worsted were passedthrough these holes from within, and made to project aboutthree-quarters of an inch below the metal. This end wassuspended over the part to be irrigated; the reservoir chargedwith water placed upon the usual little shelf situated at thehead of the bed, and the stop cock being turned, allowed thewater to escape into the tube. The extent and rapidity ofthe irrigation were, by the aid of the stop-cock, perfectlyregulated. A small sheet of oil-silk was placed under the armand separated from the bed, the oil-silk being so arranged asto conduct the water which had passed over the limb into abasin or Upon the floor of the ward. It is obvious that waterof any temperature, or medicated in a prescribed manner, maybe made, by this simple and cheap apparatus, to distributeitself over any part, however small or extensive it may be.The advantages of this instrument are, that the supply ofwater can be regulated by a stop-cock, so that there may bea definite and equable amount of irrigation to every part ofthe injured structure, or to any particular region, which irri-gation can be regulated according to the sensation of thepatient, or the temperature of the textures under treatment.By enlarging or diminishing, by elongating or shortening, thehead, or varying its form, the drops might also be carriedsimultaneously over a larger or smaller, or any irregularly-formed surface.Mr. Hilton ordered a pill of calomel and opium, and a

sedative to be administered at night. On the next day thearm looked well, and no pain was complained of; the irriga-tion had been continued night and day. Three grains ofmercury-with-chalk, and four of Dover’s powder, were orderedto be given twice a day.On the second day the fore-arm was somewhat red and

swollen, especially around the sutures, the oedema extendingon both sides of them. There was some pain, but the limbdid not put on the appearance of erysipelas, though the tem-perature was a little higher than that of the surroundinguninjured parts.On the next day (third day after the infliction of the wound

and the deligation of the artery), the redness was much less,the am looked well, and the parts seemed inclined to unite.The irrigation kept the arm cool and comfortable to the

patient, the latter in creasing or diminishing the extent of watersupply according to the heat or pain he experienced in thelimb. He slept well; the bowels were open, and the appetitegood.On the seventh day, Mr. Hilton took away four of the

sutures, as the adjacent parts were nicely healed.