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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

ST. GEORGE’S HOSPITAL.

Symptoms of Stone; no Calculus in the Bladder.(Under the care of Mr. CUTLER.)

THE symptoms of stone in the bladder are so accuratelydescribed in most works on surgery, that the diagnosis of thiscomplaint cannot be looked upon as difficult; still the wholetrain of signs accompanying the presence of a calculus may beevident, and yet, as these signs may be connected with otherconditions of the bladder, we are not justified in pronouncing i

upon the case, except the stone has been felt and heard. This Iis a most excellent rule, and the following case will show howcautious surgeons should be in instances of this kind. Thedetails were noted down by Mr. Holmes, surgical registrar tothe hospital.

Charles P-, eleven years old, was admitted, Nov. 9,1853. This boy presented many of the symptoms of stone inthe bladder : he had suffered for a year with frequent calls topass urine, which fluid sometimes stopped suddenly while hewas evacuating the bladder. Blood hjjd occasionally beenpassed with the urine, the symptoms were aggravated byexercise, and he had at such times pain in the course of theurethra. The urine was alkaline and very thick, from thepresence of pus, the prepuce long, and the patient pale andthin. He suffered extremely from frequent and painfulmicturition, and could not abstain for longer than tenminutes.Mr. Cutler ordered a draught of infusion of buchu, with

dilute nitro-muriatic acid, and tincture of columbo, three timesa day, and morphia at night. No instrument was passed forthe investigation of the state of the bladder, Mr. Cutler pre-ferring to wait until the irritation had a little subsided. Inabout a fortnight the parts were much less sensitive. On then

passing a sound, the bladder was found to be rough and muchcontracted, but no stone could be felt.The same treatment was then pursued, ten drops of laudanum

being added to the draught; but the symptoms referable to.the bladder were not materially alleviated, excepb that theboy was enabled for a time to retain his urine for about halfan hour.

Early in the following month a fluctuating swelling wasnoticed in the right iliac fossa, the formation of which did notseem to be attended with any marked symptoms. It graduallycame forward, and presented a little way above Poupart’sligament, near the anterior superior spine of the ileum. The

poor boy became gradually weaker and much emaciated, onwhich account wine and good diet were ordered for him. Theabscess was not interfered with, and burst in about ten days;after this the patient sank rapidly, and died on the 26th ofDecember, seven weeks after admission.

Post-mortem examination. - Body greatly emaciated; a

rounded ulcer opened, just under Poupart’s ligament on theright side, into a large sac. The abdominal cavity con-tained much purulent fluid, with recent yellow fibrine, andthe intestines were in places adherent to each other and to thebladder. On passing a probe, and examining the opening inthe integuments before spoken of, the instrument passed intoa large abscess, occupying a considerable portion of the rightpsoas and iliacus muscles, but no diseased bone could anywherebe found, neither was it satisfactorily made out whence the,abscess had taken its origin. The fat and areolar tissue aroundthe base of the bladder were very indurated, and the bladderitself curiously divided by a horizontal septum into two cavitiescommunicating by a small opening. The lining membrane wasalmost entirely gone, and the muscular parietes left bare andgreatly fasciculated; in the posterior part of the upper cavitywas a rounded opening formed by ulceration, which entirelypierced the walls of the organ, and had doubtless been occludedby intestine. The kidneys were much diseased; one of themwas literally occupied through its whole area by scrofulousmatter, except certain fibrous partitions dividing it into

cavities. In the other kidney, ’which contained pus andcalcareous matter in its pelvis, were one or two small collectionsof scrofulous deposit also. The ureters were not examined.The other organs presented nothing unusual.

Epilepsy ; Death ; A utopsy.(Under the care of Dr. B. JONES.)

Epilepsy is well known to have affected individuals withoutany material lesion of any point of the cerebro-spinal axis-afact which has been frequently verified by post-mortem exa-minations ; but it is not rare, on the other hand, to findtumours, bony protrusions, softening, &c., as tangible causesof the epileptic attacks. Often is epilepsy seen in the surgicalwards of hospitals, as the result of some lesion of the brain orspinal marrow, from a traumatic cause. The cases, however,in which the pathological changes which caused the fits can beclearly traced are not common, (for a very interesting one, seeTHE LANCET, vol. ii. 1853, p. 520;) we therefore beg to placethe following one upon record, as noted by Dr. Barclay, themedical registrar of the hospital.

Elizabeth S—, aged thirty-four years, was admitted,Dec. 21, 1853, under the care of Dr. Bence Jones. The

patient is of diminutive size, anæmic-looking, ill-fed, andstates that she has been suffering five or six months from fitsof some sort, in which she was entirely unconscious. Therewas no evidence of her ever having bitten her tongue or injuredherself; she could not tell whether she was convulsed, but hadbeen told that she always tore her clothes when in a fit.Menstruation had been irregular for a long period, and entirelysuppressed for twelve months. There was also leucorrhcea,combined with pruritus vulvæ, and the bowels were habituallyconfined. Some compound decoction of aloes was ordered;afterwards shower-baths twice a week, and steel wine. Onthe evening of the sixth day after admission, she was suddenlyseized with fits of an epileptic character, which lastedthroughcut the night, recurring at short intervals. She thensank into coma, and died.Post-mortem examination, (conducted by Dr. Ogle, curator

of the museum to the hospital. )-The body was emaciated, andthe hands livid. -Cranium: The bones of the skull werenatural, as also the dura mater. The vessels of the arachnoidwere very full, and the membrane itself, in places, opaque andthickened, containing several small, yellow deposits, of thesize of millet-seeds. On the posterior part of the righthemisphere were three or four small masses of calcareoussubstance, intimately connected with the arachnoid. At a

corresponding point on the left side-viz., at the lateral andposterior part—was a thickened mass of the same membrane,which at first sight had the appearance of a cyst. Onexamination, the following condition was observed:-Amongthe meshes of this thickened membrane a rather con-

siderable amount of flllid existed, and continuous with theformer was another membrane, lining a cavity composed of thesurface of the cerebral convolutions, which at this place hadapparently been subjected to considerable pressure. One ofthe convolutions was so diminished in size as to be reduced toa narrow band, as it were, which, like one or two of the sur-rounding convolutions which formed the floor of the cavity,was somewhat softened. The membrane lining the cyst wastolerably thick, and from its colour at nrst sight looked likebrain matter; it could be entirely raised by the forceps, andon examination by the microscope was found to consist of a

great number of vessels, with much granular matter, and somefibrillated structure mixed therewitli. The softened braintexture consisted of granular matter, with great numbers ofoval, irregular nuclear cells, some wasted nerve tubes, andhere and there accumulations of star-shaped and caudate bodies,with dark margins, and having a calcareous appearance. On

section, the brain proved to be rather vascular, but of naturalconsistence generally; the ventricles were rather large, andcontained two or three drachms of clear fluid, but were notdistended. The arteries of the base of the brain were natural,and the other organs of the body did not offer any strikingabnormal condition.

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KING’S COLLEGE HOSPITAL.

Cases of Epilepsy.(Under the care of Dr. TODD.)

BEING on the subject of epilepsy, we shall just refer, in afew words, to some curious cases which were treated by Dr.Todd some time ago, and which presented features of some in-terest.

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CASE 1.—Ellen T-, aged sixteen years, was admittedOctober 15, 1851. The patient has generally enjoyed goodhealth until within the last three years. Her present affectioncommenced at that period, when she complained of constantpain in the right side just below the ribs, and now and thenwould tumble down suddenly, perhaps about once a week,with loss of speech, of consciousness, and power of motion.The attack seemed to commence at one side of the body, as if-with pain, and she would fall quite doubled up. The girloccasionally complains of pain in the head, but more generallyin the side, and the fits have gone on increasing in severity,frequency, and duration. During a fit she is completely un-conscious, the legs and arms becoming powerfully contracted;the attack soon passes off, but the head seems to suffer forsome time, and her expression remains dull. Her father hasnot observed that one side is especially affected. She is verysmall for her age, has a low forehead, and rather dull aspect.While in the out-patient room she was taken with a fit, whichlasted about a minute. She strode across the room, raisingher legs very high, and then fell forwards. There were noother signs of disturbance, and a few seconds after the fall sherose and seemed as well as ever.On the day after admission the patient fell from her

bed, whilst at breakfast, but almost instantly recovered. Dr.Todd ordered a warm bath, and a powder of mercury andrhubarb.Second day.-Had a short fit this morning; struggled and

drew herself up. Left side chiefly affected; bit her tongue,has several times pointed to the right side of her head, whereshe states that she has a pain this morning. Eight drops oftincture of muriate of iron three times a day.

° Third day. -Had four fits to-day of the same description andslight character as the last.

This patient went on having fits, with screaming and foam-ing ; a fortnight after admission she had eleven iits in the night,each lasting about a quarter of an hour.On the eighth day she had had no fits for three days, and

looked extremely well ; but on the twenty-first day tlcelcr’ fitsof a very severe character occurred in the night. The patientwas discharged unrelieved Nov. 29th, 1851, six weeks afteradmission.UASE 2.-Willi-am B-, aged fourteen years, always a

delicate child, was admitted October 15, 1851. He worksat a hot-presser’s, in a close room containing a boiler anda steam-engine, and continues for thirteen hours a day. Hisbrothers and sisters are healthy, and not subject to fits.About seven years ago the patient had intermittent feverwith delirium, and his sister died of the same diseaseat that time. He remained under treatment a few weeks, andperfectly recovered ; ever since then he has been quite well, butdelicate.Two days before admission the boy came home poorly,

seemed to get worse, and fell into convulsions, during whichhe cried out loudly. These abated considerably, but lastedthroughout the night and also during the following day, andincreased up to the morning when the patient was receivedinto the hospital. During the fits he raved loudly, yelled,made violent efforts to injure those about him, and succeeded inbiting his mother’s fingers. The peculiar grimaces and noisesinduced his friends and the neighbours to believe that he wasaffected with hydrophobia.When brought into the hospital lie was shrieking and yelling,

making desperate efforts to bite; the muscles of the face wereviolently convulsed, and the contortions af the face most

grotesque. He would open his mouth as wide as possible, andthen close it, and foaming at the corners. This state lastedfter his admission about an hour. Dr. Todd ordered thehead to be shaved; a stimnlatixy enema was injected, andmustard plasters applied to the legs. As soon as the

symptoms began to abate, the boy complained of themustard causing him pain and burning at the hottom of hisfeet, but after this he remained quiet and insensible for about anhour. The enema brought away hardened faeces, but ncworms. At ten o’clock P.M. he took calomel, whereupon thebowels were well opened. No cause can be assigned for thetits, except that the patient had partaken of blackberry-pie the day before he was seized, and &/te meat at sup-per. His mother is accustomed to fits when she takes anextra quantity of gin, and yesterday was seized with one ojthe same description as that above described.

Oct. 17th.-Perfectly calm to-day; says he feels quite com-fortable; did not sleep well; pupils dilated, acting normally.Discharged in a satisfactory condition, five days after admission.

Convulsive Hysteria.Ann B-, aged forty-five, married, was admitted Oct. 16,

1851. She has had nine children, and was always regular andwell, except an occasional epileptic fit, following an excessiveindulgence in gin-drinking, to which habit she is at timesaddicted. These iits have not occurred more than once ortwice a year. The first fit of which her husband has know-ledge occurred fourteen years ago, and the last, six monthssince. When seized, the woman falls suddenly down withoutany premonitory symptoms whatever, generally on the sameday, or the day after the excess. During the tit, which lastsabout half an hour, she clenched her fists, struggles, and grindsher teeth. Both sides are equally affected, but she does notbite her tongue or foam at the mouth.On the day of admission, she was seized with a fit similar to

that from which her son had been suffering. She had been

drinking that day; and when her husband came home, aboutmid-day, he states that lie found her lying on the ground. He

placed her on the bed, and soon afterwards she became violent,shrieked loudly and continuously, and made constant efforts tobite. She excited in the minds of her friends fears that she,like her son, was suffering from hydrophobia. In this stateshe was brought to the hospital. Large quantities of coldwater were poured over her head ; the shock seemed to checkconsiderably the violence of the iit, and the grimaces stopped,after having lasted about an hour. After coming to herself,she complained of pain at the crown of the head. A mustard

poultice was applied to the nape of the neck, and a castor oiland turpentine injection given. The patient was then orderedsaline medicine, went on improving, and was discharged quitewell Oct. 18, two days after admission.The first of the three preceding cases comes very probably

under the head of those connected with some cerebro-spinallesion ; and the two following atford very interesting examples,1st, of epileptic seizures following upon indigestion in a deli-cate and predisposed subject, and 2nd, of hysterical epilepsybrought on by occasional intemperance.

Land-Scurvy and Purpura.(Under the care of Dr. BUDD.)

There are, perhaps, few diseases the etiology of which is sowell known as that of scurvy, and we are glad to add that thetherapeutics of the affection are also very firmly established.Vdant and the absence of vegetable food are almost certain tobring on the scurvy, and its ally, purpura; and these disorderswill mostly take the definite course which is described byauthors. We need hardly say that this affection is veryseldom seen in the wards of our hospitals; not that, unfor-tunately, there he a happy absence of want among the popu-lation, but because our hadly fed, ill clothed, and worsehoused poor snatch here and there a suificiency of vegetablenutriment to keep off the phenomena of scurvy. It is nodoubt in the recollection of many that scurvy reigned for sometime whilst the indigent were suffering from the failure of thepotato crop; nor should it lae forgotten that Dr. Garrod hasshown that a deficiency of potash in the food may be the causeof scorbutic manifestations. It would in the meanwhile ap-pear, from the cases which have been recorded, and from thosewe have seen, that a previously debilitated state of healthfavours the breaking-cut of the disease, so that we can hardlywonder that Dr. Budd’s patient, as will lie seen presently,experienced an attack of scurvy, since he brought 6own hisstrength to the lowest level hy intemperance, this unhappymistake being followed by want of the necessaries of life, andthe absence of vegetables and milk in his scanty fare. The

following notes were taken by Mr. Woodward, one of Dr.; Budd’s clinical clerks :-

James C-, aged fifty-three years, a widower, father to; eight children, and formerly a newspaper reporter, was ad-. mitted Jan. 31, 1854, under the care of Dr. Budd. The; patient is now a very temperate man, has generally enjoyed. good health, and lived in a becoming manner, until he was

thirty years of age, when he became addicted to excessive; drinking and smoking, taking spirits and heer continually,

and to such a degree that he was not sober for long togetherfor the period of ten years from the commencement of the

. practice. When about forty-five years old, he lost his employ-L ment, and with it all means of support, being thus exposed toF much privation. He was thus compelled to abandon drinking

entirely, and has since lived principally on dry bread and- cheese, and that not in sufficient quantity, taking scarcely any. meat or vegetables of any description, and but very little milk,- sugar, or pastry,-neither apples nor any other fresh fruit.He does not think that he lias taken more than half a pound

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of potatoes or any other vegetables for twelve month?,nor has he had a pint of milk within the last fortnight.The patient had several attacks of gout, especiallyabout the great toe, shortly before his admission; and whilehis ankles were swollen from that cause, he noticed, after

walking about, that his legs were covered with purple spotsfrom the ankles to the knees, and presented the appearance ofbruises; the same has several times recurred, and he felt atthe same time languid and weak, being obliged to keep his bedfor several weeks together. Three months before admission,his gums became painful, red, and swollen; and as manyweeks before the present examination, they bled for a wholeday, but this is the only time the oozing continued so long.He has had no hæmorrhage from the nose or any other region.

State on admission.—The face is of a copper or rather dark-

yellow colour, and the entire surface of the body discolouredin the same way, but in a less degree. The conjunctivæ arequite white. There are purpura spots on both legs, which arealso covered with patches of purple-and-yellow colour, verymuch resembling recent bruises. The right ankle is painfuland a little œdematous, but the arms are not affected. The

gums are soft, swollen, and spongy, and seem in many placesquite black. The teeth are covered with dark sloughs, whichalso reach to the tongue and to many parts of the interior ofthe mouth. The breath is very offensive; appetite good; greatthirst; mouth always very dry; urine high-coloured; specificgravity 1020; slightly acid; containing no albumen; underthe microscope, crystals of lithic acid are discovered in thefluid; pulse 84; when in the erect posture, he feels very weak,and often faints.A lead gargle, and five grains of sesquicarbonate of ammonia,

were at first prescribed. Soon afterwards, however, Dr. Buddordered the patient to have milk diet, with two eggs and threeoranges daily. Also a chloride of lime gargarism.The next day the man felt much better, which change he

attributed to the oranges. On the night of the second day,hin nose bled a good deal; but he felt on the fourth day verymuch stronger and better, not being faint until some timeafter he sat up in bed. Gums less spongy, and not so muchcovered with sloughs; fœtor of breath diminished. To takehalf a pound of potatoes daily. All the symptoms were onthe sixth day giving way under the use of the oranges,potatoes, eggs, and milk; and there is every likelihood thatthe man will not make a long stay in the hospital.

This case shows very forcibly that total abstinence fromvegetable food is very likely to give rise to scurvy, and mayserve as a warning, should the cholera unfortunately visit usagain, to those who, from fear of the epidemic, carefully avoidfruits and vegetables. Exclusiveness is not the proper systemto follow; moderate use of animal and vegetable food, pureair, healthful labour and exercise, and the avoidance of anykind of excesses, will be trustworthy prophylactics of bothcomplaints.

Oil of illctle Fern in Tceraics Solitcrra.

(Under the care of Dr. BUDD.)Most of our readers are aware that the price of the kousso is

now considerably lower than it was a few years ago, and thatit may thus be employed in hospital practice on a larger scalethan formerly. This is certainly a very favourable circum-stance, for no one can doubt the efficacy of the kousso in ex-pelling the tænia solium; but we are bound to remind ourreaders that, judging from the cases which we have seen andreported, the kousso does not always produce the evacuation ofthe head of the parasite, and that several cases of relapse have eoccurred after the use of that medicine. The latter remains,nevertheless, extremely useful; but it cannot be too universallyknown, especially in remote country places, that the oil ofmale fern is almost as efficacious as the kousso ; the oil doesnot invariably free the patient from the head of the worm, butthe same reproach might be addressed to the kousso. Weshall just allude to the following case as an example of themode of administration :-John M-, aged forty years, was admitted into Fisk ward,

July 2, 1853. Two years before admission he began to passjoints of tape-worm, and has continued to do so at times eversince. He obtained medicine from chemists on several occa-sions, but has never parted with more than two yards of the-worm at a time.On admission the patient’s tongue was furred, but his appe-

tite very good; he said he was accustomed to have slight painacross the stomach just before passing joints.

Dr. Budd ordered three grains of calomel and four of scam-mony, to be taken both at night and in the morning.

Second day,. -A large portion of the taenia came away in thenight, but not any approach to the head, all the joints beingvery wide.The patient was now ordered to fast nearly all day, and at

four o’clock next morning to take an ounce of castor oil, to befollowed in two hours by two drachms of the oil of male fernin a sufficient quantity of mucilage.

Third day.—Almost all the worm came away about nineo’clock in the morning, but not the head, although the jointstapered to a fine thread. The medicine made him feel giddyand weak.Such a result is sufficiently encouraging to induce practi-

tioners to persevere with the oil ; perhaps by repeated doses,or by larger ones, could the entire parasite be driven from theintestinal tract.

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ST. MARY’S HOSPITAL.

Fever, and Hœmorrhage from the Bowels; Recovery.(Under the care of DR. CHAMBERS.)

HÆMORRHAGE from the bowels is certainly a symptom of aserious nature in fever, and is well calculated to darken the

prognosis, as it is considered that the loss of blood is very oftendependent on ulceration of certain points of the intestinal mu-cous membrane. This complication may, however, be the resultof mere exudation from the overloaded vessels, as has beenshown bv certain post-mortem examinations, and it is of somepractical importance to remark that although intestinal hæmor-rhage is a vory alarming complication, it is not invariably accom-panied by a fatal issue. The following case illustrates thisremark in a very striking manner.

William P-, aged twenty-five years, was admittedJuly 28, 1853. He cannot remember how long he has beenill, but thinks about five weeks. Originally the patient hadbeen exposed to wet, and has since had the general symptomsof fever. On admission there was no diarrhcea, but muchthirst; the tongue was red at the edges, and brown in thecentre; the lips congested, and the face somewhat dusky; theskin dry; and no pain in the abdomen was complained of. Dr.Chambers ordered a mercurial purgative, an alkaline mixture,and also simple broth diet. Sibilant râles were heard on bothsides posteriorly, and also anteriorly on the right side.On the next day, a little wandering took place, and Dr.

Chambers ordered bark and ammonia, as well as beef-tea.On the third day, it was found necessary to give two ounces

of wine.On the fifth day, there was a little diarrhcea, but no pain in

- the abdomen.Tenth day.-Gaining strength; delirium gone; bowels

relaxed. The patient was now ordered to have a chop, andchalk mixture with opium.

Thirteenth day.—Has passed a large quantity of liquidblood by the bowels, and a number of clots, about five pintsand a half in all, from two P.M. till ten A.M. No foecal matterwas to be seen. A draught of gallic acid and opium was ordered.

Fourteenth day.-Bowels open twice in the night; themotions contained much blood, and the patient is very paleand weak. He now took three grains of acetate of lead, and aquarter of a grain of opium, three times a day. No pain onpressure in the abdomen.

Fifteenth day.—Bowels not open; the patient looks better;he had a little wandering, but slept well, and the skin wascool. Two drachms of castor oil were administered. Fromthis time the symptoms went on improving for the nexttwenty days, when the patient was discharged completelyconvalescent.Now, by the side of this case, we may mention one lately

under the care of Dr. Burrows, at St. Bartholomew’s Hospital,in which hæmorrhage from the bowels also took place, but noulceration of intestines was observed after death. The patientMary D-, was admitted on the same day (July 28, 1853) asthe man mentioned in the above case, and lived only six days.She had the usual symptoms of typhus, and also sanguineousevacuations. The treatment, consisting of ammonia, wine,&c., failed to rouse the patient, and on a post-mortem examina-tion no ulceration of the bowels was discovered.

Eczema treated by Nitrate of Silver.(Under the care of Mr. URE.)

Eczema is a cutaneous affection which very often taxes theskill of the practitioner to the utmost, as the various remedies

which have been proposed prove in certain cases quite power-less, although they may have rendered some service in others.