GUY'S HOSPITAL

509

to overrule apprehensions raised by the existence of greatnervousness and irritability.The patient in question was about forty years of age, and

had been suffering for the last two years from the usual syiilp-toms of stone in the bladder. The pain he was undergoingwas of a severe nature, and his distress very great ; Mr.Lawrence therefore determined to remove the calculus,which had been distinctly felt by the sound, and gave thepreference to the lateral operation.On the 2nd of March, the patient was brought into the

theatre, placed in the usual position for the operation of litho-tomy, and rendered insensible by the inhalation of chloroform.Mr. Lawrence, instead of taking his seat exactly opposite thepatient’s perinseum, sat down with his right side turnedtowards the pupils, and gave them, by this position, a fullview of the parts to be operated upon. The staff being heldby an assistant, Mr. Lawrence made the usual incision fromthe raphe to the left ischium with a common-sized scalpel,and when the muscles and fasciae had been successivelydivided, a double-edged gorget was introduced. When itspoint reached the groove of the staff, Mr. Lawrence broughtthe handle of the latter downwards towards the patient’sperincGum with his left hand, and allowed the gorget to cutits way into the bladder, by laterally dividing the neck of thatviscus. A gush of urine immediately testified that the instru-ment had penetrated the bladder; the gorget was withdrawn,the left forefinger passed into the wound, the forceps carefullyintroduced, and a stone about the size of a small plum ex-tracted.As this foreign body was found to be of a friable nature,

Mr. Lawrence proceeded to inject the bladder, through thewound, with lukewarm water, so as to wash away any particleswhich might have crumbled at the moment the stone wasseized. The patient, upon whom the chloroform had at firstacted in a suffocating manner, but who eventually was

thoroughly brought under its influence, was then untied, andremoved, without having experienced more than the usualamount of hcemorrhage.A slight amount of bleeding took place, however, when the

patient had been in bed for a little while; this was easilystopped by plugging, but it was found very difficult to controlthe nervous and irritable state into which the patient hadbeen thrown. Various means were used to counteract theseunfavourable symptoms, but they proved unavailing, thepatient became gradually weaker, and died three days afterthe operation. -

On a post-mortem examination, the bladder was foundtolerably healthy, no artery of any importance had beendivided, and no traces of peritonitis could be discovered. Urn-der such circumstances it seems that the fatal result mustbe attributed either to the extreme irritability and nervous-ness of the poor man, or to the effects of the chloroform. Itshould be mentioned, however, that hydatids were found inthe liver.

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GUY’S HOSPITAL.

Disease of the Heart.(Under the care of Dr. HUGHES.)

Post-mortem appearances are allowed to be of great valuein cases where the diagnosis has necessarily been obscure, andthe symptoms unusually severe; we therefore hope that thefollowing case, recently under the care of Dr. Hughes, will beread with interest, and prove of practical utility. It is, un-fortunately, but too true, that in the majority of cardiac affec-tions, be they either primary or secondary, we can but palliateand keep off the evil hour: this temporary benefit is, however,in many instances, of sufficient importance to call for theexercise of our best energies to ward off the tendency to im-moderate action, or to flaccidity and debility in the centralorgan of circulation.On the 27th of March, a man, about thirty, was admitted

under the care of Dr. Hughes, with intense dyspnoea; his dis-tress in this respect was very great; he could not lie down,and his breathing was so hurried and noisy that it was quiteimpossible to judge accurately either of the pulmonary orcardiac sounds. The pulse could not be counted, but it was be-lieved, from examination of the heart, that its pulsations wereno less than 240 in a minute, or even more; the countenancewas suffused and bluish; the cough comparatively trifling;but the patient was tormented by frequent vomiting. Theonly history which could be obtained from him was, that hehad always enjoyed good health, and followed the occupationof a fisherman, until three weeks ago, when, in hauling nets,

he was suddenly seized with great pain in the chest, anddyspnoea, which latter had since been constant, and indeedcontinually increasing up to his admission.The patient lived in much pain and anxious panting for

three days, and was found dead only a very few minutes afterthe physician had seen him, subsequently to one of the severeparoxysms of vomiting, after which it is supposed he fell backexhausted.The autopsy, which excited a great deal of interest, from the

violent symptoms, and uncertain diagnosis of the case, wasconducted by Dr. Lloyd. The venous system of the thoracicand abdominal cavities was found very highly congested; theheart was hypertrophied in every respect, the walls of bothventricles being remarkably thickened, and the capacity ofthe ventricles materially increased. As far as could bejudged by the eye, the organ was almost double the ordinarysize. In following the walls, from the base to the apex in theleft ventricle, their thickness was observed to diminish sud-denly very near the apex, which was bifid; the thinning ex-tended in that region over a space the size of a crown piece,the walls being of about the thinness of the sterno-hyoidmuscle. A fibrinous concretion, which had softened down inthe centre, occupied the thinned apex, and being partially if’.-terlaced with the musculi pectinati, caused it to bulge, thusincreasing, if not producing, its bifid extremity. There was sno trace of ulceration, nor actual perforation, nor, of course,haemorrhage into the pericardium. Dr. Lloyd carefully re-moved part of the fibrinous mass, and followed the course ofthe carnece columnse, in order to discover whether actual rup-ture had taken place in any of them, but none of these fleshybands was found torn across.The lungs presented a very unusual form of tubercular de-

posit. This abnormal substance was so firmly and evenlyspread upon the pleura that at first sight it looked like anordinary fibrinous deposit, and accurately resembled some ofthe vegetable lichens; but on cutting through the substanceof the lung, thick arborescent clusters of tubercular depositwere found pervading the whole thickness of both organs,many parts of which were completely solidified, both by thecongestion resulting from the cardiac affection, and the pre-sence of tubercular matter arranged in remarkably minutepoints.

It was supposed by some that the constant vomiting, withwhich the patient was troubled, was caused by the pressure ofthe heart and lungs upon the pneumogastric nerve; the mucousmembrane of the stomach was, however, very much congested,presenting here and there patches of a deep colour. The liverwas in the condition known by the name of cirrhosis, and theremaining organs tolerably healthy, though greatly congested,as mentioned above.From the autopsy a certain amount of light is thrown upon

the phenomena exhibited in this case. Without indulgingtoo much in suppositions, it might be maintained, that thetubercular affection, which had fixed upon the lungs, wasthe primary disease, which may have taken many years toarriye at the development found after death. This is again aninstance of disorganization and spoiling of the lung going onfor a long period, without exciting much cough, or any hæmo-ptysis, or creating (if the patient’s statements can be entirelyrelied upon) any great degree of inconvenience. Still theman’s occupation was one of frequent and violent exertion,and the circulation through the lungs being necessarily imperfect, the hydraulic machine receiving and driving away theblood, had evidently to contend against obstacles which itovercame by more powerful contractions, which led to hyper-trophy. Now, it may be inquired, what pathological con-

dition gave rise to the sudden seizure which the man

experienced ? Was the aneurismal thinning of a small spaceof the left ventricle caused by rupture of some of the carneæcolumnse, a certain amount of haemorrhage, and consequentabsorption ? or was the fibrinous mass found in the apex andattached thereto, a result of inflammation which led to theattenuation of the walls, and to less energetical contrac-tions ?

It is very likely that cases of this description may be greatlybenefited, when seen in time, by the observance of greatquiet of mind and body, and small bleedings. Great good canbe done, for a time, as mentioned by Dr. Watson, by wardingoff all cause of agitation and hurry. When, however, a

laborious occupation, and perhaps intemperate habits, (asmight be inferred from the cirrhosed liver,) step in the placeof caution and perfect tranquillity, it is hardly possible thatsuch a state of organs should end otherwise than in a fit ofdyspnoea, more or less sudden, according to the amount ofexertion used at the time. ’