129

careful and cautious investigation as any novelty, howeverenticing; and I am aware that such investigation is beingcarried out both in the metropolitan hospitals and in privatepractice, several as yet unpublished successful cases havingalready occurred. The two cases to which I have alludedhave been already noticed in different medical periodicals,and have been detailed in THE LANCET, in the 11 Mirror" ofthat journal, (July 26,1851, and October 9,1852.) Many soundand valuable remarks, drawn from a careful analysis of, andreasoning on, successful and unsuccessful cases, accompany thedetail. One of the two cases above alluded to was under thecare of my colleague, Mr. Critchett, at the London Hospital;the other under my own superintendence. In both, a plan oftreatment very analogous to that recommended by Dr. Bel-lingham and other Dublin surgeons was had recourse to. Aftera preliminary preparation of the patients by the recumbentposition for several days, and attention to the state of theconstitution generally; the principle of the compression treat- Iment, the nature of the disease, and the action of the com-pression instruments, were explained to the patients in asclear a manner as possible; and, after they had been shownthe method of carrying it out, these instruments were placedalmost entirely under their own control, so that the amountof pressure was at no time likely to be injurious, the patient’sown sensations being the best criterion as to the amount ofpressure that could be well tolerated at one part of the limbbefore having recourse to it at another. In order that themanipulation of the instruments should be effected with asmuch facility as possible, and unimpeded by any uneasiness ofposition of the patients, the comfort of the latter, while in therecumbent position, was carefully attended to. Thus themattrass, sheets, pillows for the head, and the pad on whichthe affected limb rested, were all firmly fixed together; alarge pillow was also bound down to the foot-piece at the endof the bed, so as, by serving as a point d’app1lÌ for the foot ofthe unaffected limb, to prevent any gliding of the body fromits original position. A cradle large enough to cover thetrunk and extremities was made fast to the sides of the bed-frame, and thus the patient’s hands, unimpeded in the slightestby the bed-clothes, were as free as possible, and could adjustthe instruments to a nicety. The mattrass and its appendages,in consequence of their being thus firmly fixed together,hardly required re-arranging during the entire treatment, andthe patients, in consequence of lying on a smooth and evensurface, were entirely devoid of that restlessness so frequentlythe result of a shifting of the bed-clothes, and which couldhardly have occurred without great personal annoyance andconsequent interference with the proper action of the instru-ments, both of which conditions were obviated by the aboveprecautions having been taken. The hair was shaved from offthe pubis and the part of the thigh at which the other pointaf pressure was made, and the skin dusted over with Frenchchalk. The advantage of this proceeding was well marked inMr. Critchett’s case: for, at the commencement of thetreatment, compression was made at the pubis without itsadoption; the pain that ensued was of a most intense burningcharacter, the skin having become much inflamed, and allbut threatening gangrene. I

In the one instance, the aneurism became consolidated onthe eighteenth; in the other, on the eighth day. The lattercase appeared primâ facie to be anything but favourable forthe compression treatment. The tumour was of the size of a.shaddock at the lower and inner part of the thigh, and therewas one particular point on its surface at which the sacappeared very thin, the integument over it being of a bluishcolour, as though from subcutaneous ecchymosis, and severalgentlemen who examined it gave a very unfavourable prognosis,and I firmly believe that the result would have been anythingbut satisfactory if the above details of treatment had notbeen carefully attended to. These details, though unim-portant possibly, individually, constitute, in the aggregate, inmy opinion, a most necessary accompaniment to the compres-sion treatment, and without which the latter, however skil-fully conducted, may occasionally fail. Objections have beenmade to the surrender of the treatment almost entirely to thepatient’s own control, mainly grounded on the statement thatsome individuals are so deficient in common sense, that itwould be impossible to render the nature of the disease, andthe principle on which the cure is effected, intelligible tothem. It is possible that this may occasionally occur; but inmany instances may not the difficulty depend rather on theinstruction being conveyed in an unintentionally technicalstyle, and not in a clear and simple manner, adapted to an un-professional capacity ? Lastly, I think that the instrumentsmade use of in the compression treatment, if the patient be

allowed to conduct it himself, should be as simple as possiblecompatible with the object in view. In one of the casesabove mentioned, a common meat-weight, and small pad tothe pubis, and a clamp to the groin, without an elastic appa-ratus, were used; in the other, also a meat-weight and pad atthe groin, and an elastic compressor at the thigh, and they

were found to act without any difficulty.

I Broad-street-buildings, Jan. 1853.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

MIDDLESEX HOSPITAL.

Purpura Hœmorrhagica; Death; Autopsy.(Under the care of DR. STEWART.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, turn aliorum proprias, collectas habere et inter secomparare.-MORGAGNL. De Sed. et Caus. l1’I01’b., lib.14. Prooemium.

CASES of purpura are so seldom seen in the wards of theLondon hospitals, that we hasten to put the present one uponrecord; and in doing so can hardly refrain from inquiringwhy so few cases of this kind should present themselves. In

considering this question, we find that systematic writers arequite agreed as to the cause of the disease-viz., that it originatesfrom debility, or from too exclusive an adherence to one sortof food; but we are much inclined to believe that as regardsland-scurvy, both circumstances are probably at the root of theevil. This is, indeed, very likely to be the fact, for the causesof debility are so multiplied in this metropolis, that if aweakened constitution could alone generate the disease, weshould witness a great many more cases than are actually ob-served. It is true that sea-scurvy sometimes makes dreadfulhavoc among crews composed of very robust people; but thecontinued use of one kind of food, or rather the continuedabsence of fresh vegetables, acts with sufficient powerto undermine the fine constitutions of our sailors. The useof lemon-juice has fortunately put a stop to the fearful ravagesof sea-scurvy, and the disease may almost be looked upon as

conquered.We purposely place purpura bsemorrhagica and sea-scurvy

in juxtaposition, being of opinion that these diseases are essen-: tially the same; the only shade of difference is, that on land.

very poor diet and the absence of fresh vegetables and. fruit act on previomly debilitated frames. Thus may, in

l some degree, be explained the infrequency of the disease on

. shore.Some time ago, we had occasion to report a case of this

kind, treated at St. Thomas’s Hospital, by Dr. Risdon Bennett,(THE LANCET, vol. ii. p. 529, 1850.) Chronicity was one ofthe characters in this case, and very good results wereobtained by a vegetable diet and tonics; but the patient towhich we are this day alluding suffered from an acute attackof the disease, so acute, indeed, and with so many symptomsof typhus, that it required no less than the boornorrhagictendency, the vibices, &c., to give the affection its truecharacter. In fact it may be said that the more severe theattacks of scurvy are on land, the closer they resemble theaffection as it was formerly known to reign on board our ships,destroying the crew in about as short a time as sufficed tobring on a fatal issue in the present case.

It would appear that lemon-juice acts much more as aprophylactic than a curative agent; for in severe cases it doesnot seem to have much control over the disease, althoughcombined with tonics and a generous diet. We are thusdriven to look upon land-scurvy, in its aggravated forms, as adisease closely allied to typhus, and in which the physician

cannot do more than keep up his patient’s strength as muchI as he may, so as to lessen the tendency to death byexhaus- tion. The facts of the present case, as obtained from theI notes of Mr. Edward Vernon, the clinical clerk, are asfollow:-

130

Samuel J-, aged thirteen years and a half, was admitted only a quarter of an inch to the right side of sternum; bron-into Cambridge ward, under the care of Dr. Stewart, August chitic respiration clear and distinct in the intra-scapular region13,1852. of both sides. Urine very copious and clear,but there is a depositNo particular history was obtainable of the patient’s past life, of very deep-coloured lithates as the fluid cools. Bowels

or of the state of his health previous to unequivocal symptoms three times opened since last night. Wine and lemon-juiceof his disease exhibiting themselves in a marked manner. ad libitum.He is of slight make; his countenance is pale and waxy; and Sixth day.-Sleep much disturbed during the night; pulsehe states that he has been an errand-boy, that he has worked now 152, of the same strength as on the fifth day, but pre-hard, and did not live very well. For the last two years the senting a more hurried thrill; complexion much more yellow;patient has been very subject to obstinate attacks of epistaxis. expression of face anxious and pinched, almost cadaverous;He was an out-patient of the hospital for nine days before tongue very dry and brown; teeth covered with black sordes;admission, during which period he had several times long-con- slight subsultus of arms and hands; some haemorrhage fromtinued and profuse haemorrhage from the nose. Dr. Stewart, the upper gums; vibices and purpura spots still lighter inwho saw him in the out-patient’s room, enjoined rest and colour; urine darker but copious, acid, and depositing anquietude, and prescribed steel and sulphuric acid. abundance of lithates on cooling. Dr. Stewart ordered theOn the day of his admission, the boy came with many wine and lemon-juice to be continued, and prescribed ammonia

vibices and purpura spots on the neck, trunk, and extremities; and steel in a bitter infusion every fourth hour.he was, in consequence, received as an in-patient of the Seventh day.--Countenance still very sallow, but somewhathospital. There had been no attack of epistaxis for several more animated; pulse 144, small and thready; tongue verydays, nor bleeding from the gums; but, on the day of his pale and glazed, beneath its dorsum brown and white; thecoming into the house he had thrown out several mouthfuls of vibices and spots are pale and fading, some are almost gone;blood. The tongue and gums were pale and bloodless, and the the intercostal spaces are well defined and drawn inwards; thepulse small but regular. Dr. Stewart ordered the mixture of left side of thorax measures one-eighth of an inch less thanacid and steel to be continued, and lint dipped in a solution the right; respiration noisy; oegophony on the left side absentof alum to be carried up the anterior nares, in order to relieve to the lower border of the sixth rib, where the apex of thea peculiar feeling of discomfort complained of in that heart is now felt beating in its proper place. The cardiacregion. sounds are loud all over the chest, with a smart, distinctSecond day.-Sleep much disturbed by frightful dreams, systole; percussion on right side yields a clear sound to the

from which the patient awoke looking pale and terrified. He mesial line; urine not so copious, and depositing fewer lithates.ate his breakfast with good appetite; but, soon after this meal, The medicines were continued, but about noon the boy’sthe epistaxis returned with great severity, the blood issuing countenance became pinched and cadaverous; the pupilsfrom the right nostril. This attack was unlike the usual epis- were much dilated, but the intellect remained clear andtaxis of children, being a constant oozing of a sanguinolent watchful. Breathing much louder, and at times rattling.fluid, bright scarlet, very watery, and not forming clots when Beef-tea and wine were given at short intervals; but theat rest. When seen the boy was quite blanched; there was pulse continued small, rapid, and scarcely perceptible, and theslight jactitation of the upper extremities; pulse 136, very patient expired at five o’clock in the afternoon.soft, and slightly jerking; gums pallid; tongue also pale, with Post-mortem (xamÚzation, twenty hours after death warma brown fur on its dorsum; no headache or cough. The and damp Zveat3er.--Body slightly emaciated; general colouranterior and posterior nares were plugged, but the aqueous very pale; scarcely anv cadaveric rigidity; many smallblood oozed through the anterior plug like water. petechial spots all over the surface. On opening the chest,In the evening it was found that there had not been any the muscles were found of normal colour; in the left pleura

return of bleeding; on examining the chest, complete dulness there were about two pints of sanguineous fluid of the specificon the left side was observed, except beneath the clavicle, and gravity of 1’065. On standing, this blood deposited a sediment,on the anterior half of the third and fourth ribs; respiration. consisting of red and white blood-corpuscles, with some largeeverywhere distant and obscure; oegophony well-marked on granular cells; it soon decomposed, and became very foetid.the upper parts of the breast and neck, both on the right and The right pleural sac was bound down by many adhesions; itleft sides. The heart’s dulness was found continuous through- contained no fluid, but in the pericardium about five ouncesout the prsecordial region, and the left side of the chest was of red serum were found, similar to that observed in the leftfuller than the right-the former measuring three quarters of pleura. Thymus gland very large; to its left and beneath itan inch more than the latter. The whole trunk and extremi- is a solid tumour, the size of a hen’s egg, composed mainly ofties were thickly studded with vibices and purpura spots. The e a number of enlarged bronchial glands, covered and boundboy was now ordered four ounces of wine, and to take four together by condensed tissue. A section of one of these glandsgrains of alum in an acid mint mixture every three hours. presented a tough, dry, and yellowish surface, and its substanceLemon juice ad libitum. broke down when some force was applied. A section was

Third day.-There was much haemorrhage from the nostril also made through the large central tumour: it consisted of alast night, the anterior plug having slipped from its place; the much condensed tissue, the middle portion similar to thepatient is in a state of great prostration and pallor, but is gland just described, but browner in colour, and almost as toughperfectly collected; he has had three hours’ sound sleep. Re- as leather; its investing tissue was very firm, of a rosy fawn-Spiration thirty-seven to the minute; pulse 144, soft, and rather colour, with many petechial spots exhibited on the section.fuller than the previous evening; loss of appetite, no action Some other bronchial glands were enlarged and contained aof the bowels, manner irritable, countenance watchful and soft light-yellow deposit.-Lungs: The left crepitated freelyanxious. The same medicines were continued. everywhere except at the lower part, which was of the colour

Fourth day.-Pulse very feeble and difficult to count, ranging and consistence of liver; it sunk in water. The right lungfrom 140 to 180. Appetite little or none; tongue hard and was found healthy in structure, with some slight congestionrough, covered with a brown fur. There is much dryness in the lower lobe. There were a few petechial spots on bothof fauces, and distressing thirst. The vibices and purpura layers of the pleura; trachea and bronchi healthy.-Heart:spots are still as numerous, if not more so than before, but The visceral layer of the pericardium exhibited a number ofthey are of a fainter colour. Since the previous evening the boy haemorrhagic spots beneath it; these were chiefly visible overhad passed between three or four pints of turbid urine; the the right auricle and ventricle, but the largest were on thelatter was acid, and not affected by heat or nitric acid, specific auricular appendage. These differed in size from a point togravity 1’010. Bowels open once yesterday. Measurement one-eighth of an inch in diameter; when first exposed to theof the thorax, from the spine to the sternum, right side, thir- air they were of a vivid scarlet-colour, but rapidly faded. Theteen inches, left, thirteen inches and three-quarters. CEg-ophony heart was found of average size; in the right ventricle ais continuing all over the left side, and percussion yields dul- moderately firm coloured coagulum was situated; the walls ofness one inch beyond the sternum on the right side; a purring the heart were pale, and its valves healthy; in the aorta therethrill observed beneath the right half of sternum; well-marked was a small coagulum, its lining membrane being much stained.pulsation in the epigastric region. The patient was desired Liver rather large and pale, but healthy; stomach large, con-to go on with the same medicines. taining undigested food, a number of haemorrhagic spots were

Fifth day.-Seems better to-day ; pulse, late last night, 142, seen on its inner coat. Kidneys of natural size; several smallstrong and well-marked; it is now 152, but the patient has been petecliiae had formed beneath the capsules; left kidney some-exciting himself; face exsanguineous and yellow; vibices and what congested, the right remarkably anasmic; structure ofpnrpura spots all fading. Tongue moist and clean round the both quite healthy. Spleen large, but healthy; nothingsides, but brown in the centre. Measurement of thorax: right abnormal about the bladder or intestines.-Head: On removingside twelve inches and tliree-quarters, left thirteen inches and the calvarium, the bone was found large, thi’n, and transparent;one-eighth; much less bulging of the intercostal spaces; dulness the cavity of the arachnoid was rather dry, but several

131

petechial spotswere seen beneath that membrane; Pacchionianbodies moderately numerous. On slicing the brain-substance,it was found firm and pale, with rather fewer punctae on theright than on the left side. Lower down were seen a numberof small spots of effused blood, chiefly grouped together inpatches about the size of a shilling; these were all in the lefthemisphere, also some similar spots at the base of the brain.The ventricles were rather dry, the membrane healthy, andnot the seat of haemorrhage. The choroid plexus was foundquite sound, and the whole brain tissue normal in consistenceand colour.The exudation of blood, resulting either from its abnormal

fluidity or the want of tone in the vessels, was here wellmarked; and a case of this kind is well calculated to convinceof their error those who maintain that such exudation nevertakes place, but that the rupture of some vessel is indis-pensable for the escape of blood. The general manner inwhich the petechise were scattered all over the frame wasvery remarkable; in fact, spots and vibices were found onthe pleura, pericardium, on the investing membrane of a massof bronchial glands, on the lining membrane of the aorta,beneath the capsules of the kidneys, under the arachnoidmembrane, and even in the substance of the left hemisphereof the brain; besides the large spots which were extensivelydisseminated on the skin. The intercurrent pleuro-pneumonia,which contributed in giving the case a very serious character,was likewise influenced in its pathological manifestations bythe haemorrhagic nature of the case, as the fluid effused inthe left pleura was strongly tinged with blood. This state ofthe circulating fluid presents a very striking contrast withthe pitchy appearance of the blood in another destructiveaffection-viz., cholera.

CASES OF STONE IN THE BLADDER.

ST. BART11OL03IEw’s HOSPITAL ......

GUY’S HOSPITAL ...............

KING’S COLLEGE HOSPITAL .........

UNIVERSITY COLLEGE HOSPITAL ......

Mr. 1,AWRENCE.Mr. B. CoopER.Mr. FERGUSSON.Mr. ERICHSEN.

ST. BARTHOLOMEW’S HOSPITAL.Calculus of unusually large dimensions; Lithotomy; Death;

Autopsy.(Under the care of Mr. LAWRENCE.)

THE difficulties encountered by the lithotomist are nume-rous, and of various kinds: a very deep perinseum, an im-pacted calculus, a very irritable and small bladder, anenlarged prostate gland, a very friable stone, a very small ora very large one, will throw obstacles in the way of theoperation, and endanger the issue of the case. We frequentlysee the surgeons of our metropolitan hospitals grapple withdifficulties of this nature; and the manner in which the latterare generally overcome is certainly very interesting and in-structive to behold.Mr. Lawrence lately operated upon a patient, whose case

presented the difficulty of a very large stone-indeed, solarge, that but very few such have been removed. Additionalincisions, and more than ordinary force, management, andtime, were of course required for the extraction of thiscalculus, which extraction was at length effected. It is nota little surprising that the patient continued many years witha stone in his bladder, which for a long period must almosthave filled up that viscus; but we are by this case taught towhat extent certain organs will accommodate themselves tounfavourable circumstances; and, moreover, that the growthof calculi is almost unlimited, when they form upon patientswho will for a long period bear the suffering and inconveniencecaused by the presence of the foreign body. We are indebtedfor the following particulars to Mr. Archer, Mr. Lawrence’shouse-surgeon :-

Levi B aged thirty-seven years, a labourer, of a pale,sallow countenance, and much emaciated, was admittedDec. 27,- 1852, into Henry’s ward, under the care of Mr.Lawrence, suffering greatly from the ordinary symptoms ofstone, the existence of which was at once discovered on theintroduction of a sound.The poor fellow was in such a state of distress and exhaus-

tion as to be wholly unable to afford other than most con-tradictory statements respecting the origin and progress ofhis complaint; indeed, nothing definite could be elicited fromhim of the history of his disorder. But his wife subsequentlystated, that the patient had suffered from childhood with fre-quent micturition, followed by pain, sanguineous urine, &c.

that he had been married eight years; and that she had threechildren. Her husband had been under medical treatment

for several years, and had discontinued work for the lasttwelvemonth.On examination, however, by the rectum, a very large stone

was discovered, the boundaries of which could be but imper-fectly traced by the finger.Mr. Lawrence ordered wine, beef-tea, arrow-root, barley-

water, &c., and opiates, to allay pain and procure sleep. Thepatient still continued to suffer greatly, and on Jan. 3, 1853,he was placed under the influence of chloroform, and Mr.Lawrence proceeded to perform lithotomy.The operation was commenced in the ordinary manner, but

owing to the very large size of the stone, it was found neces-sary to divide the right side of the prostate gland also, andto enlarge the external incision. After a protracted and ex-tremely difficult operation-in the course of which the patientlost a considerable quantity of blood-the stone was at lengthremoved. We here give a rough sketch of the stone, of thesize of nature.

The calculus, size of nature; it weighed twelve ounces and a quarter.Crust of lithate of ammonia, with probably a uric-acid nucleus.

As the pulse was very feeble and frequent after the opera-tion, and there was slight vomiting and constant nausea, diffu.sible stimulants were given, followed, as night came on, by afull dose of opium.The patient slept several hours, expressinghimself very greatly

relieved next morning, and stating that he had not passed socomfortable a night for years. The urine was discharged freelyby the wound; there was no haemorrhage; no tenderness of theabdomen; the vomiting and nausea had subsided; and the man’scondition was altogether satisfactory, except that the pulseremained extremely feeble and frequent, and that he com-plained greatly of thirst.No material change in his condition occurred; and,notwith-

standing the frequent exhibition of brandy, no reaction fol-lowed ; the man gradually sank, and died at nine- o’clock illthe morning of the second day after the operation, retaininghis consciousness to shortly before death.

Exa??tinatio2z of the body.-The whole urinary apparatusexhibited in a striking manner the ordinary consequences oflong-continued stone:-The bladder was as contracted as theenormously thickened condition of its walls would seem topermit. The mucous membrane was raised into numerouselevations, more or less rounded, but varying in size and out-