of 1 /1
440 of rather florid complexion, and with hair turning grey. Not- withstanding the frequent loss of blood, he declared that he had not grown perceptibly thinner. During the day, he required to pass urine frequently, but the length of the intervals was very variable ; at some times he was able to go two hours, at others being compelled to micturate every five or ten minutes. Movements increased the frequency, and gave rise to some pain, which, however, was never ex- cessive. There was never any retraction of the testes, nor had he ever suffered from sickness or diarrhoea. He was sounded by Mr. Ballamy, but no calculus could be detected, and he was ordered a mixture containing small quantities of tincture of perchloride of iron and tincture of opium. The urine was almost always tinged with blood, but the amount and colour varied greatly ; at times the urine being bright scarlet, and at others the amount of blood being so small as only to be detected by microscopic examination. No calculous matter was passed during his stay in the hospital, but when the quantity of blood in the urine was larger there was usually to be found a large number of whitish flocculent masses at the bottom of the receptacle, which proved, on examination, to be small amounts of de- colorised fibrin. During the absence of Mr. Bellamy the patient came under the care of Mr. Morgan, who on sounding the bladder was unable to detect the presence of any calculus, but the sensation was given of the presence of a soft uneven mass lying at the posterior part of the bladder. Examination per rectum showed the prostate to be slightly enlarged, but did not assist in determining the nature or size of the new growth. Accordingly the patient was placed under the influence of ether and again sounded, when the previous conjecture was still further strengthened. The bladder was then washed out by means of an apparatus which Mr. Morgan has lately devised for the examination of detritus after lithotrity. The result of this was the removal of a large quantity of the decolorised fibrin with a good deal of fresh blood ; but under the miscroscope no characteristic epithelial cells could be detected. On May llth the patient was again placed under ether, and a staff having been passed, and the patient being in the position for lithotomy, Mr. Morgan, having first divided the skin in the middle line a little above the anus, passed a lithotomy knife down to the groove in the staff and made an incision of the urethra of about three-quarters of an inch in length. Through this wound the left forefinger, aided by the pressure of the right hand on the abdomen above the pubis, was able to explore the greater part of the walls of the bladder, as pointed out by Sir Henry Thompson. There was found to be a quantity of soft velvety growth springing from the posterior wall, and generally diffused, but one large mass grew as from a pedicle, and this was easily grasped between the blades of a lithotrite, and removed through the incision. A full-sized catheter was introduced through the wound and secured. Very little bleeding followed the opera- tion, and the patient passed a comfortable night. On the following day the catheter came out of its own accord, and was not replaced. On the second day the patient was slightly feverish, but after the bowels had been well re- lieved this passed off, and he made a rapid recovery; so that he was up and about the ward on the sixth day after the operation, urine being passed by the urethra only every two or three hours, and containing hardly any trace of blood. The growth removed resembled a filbert in size and shape, and in structure consisted of a rather contracted pedicle from which sprang innumerable brancblets, which again were subdivided into small villous prolongations. The villi con- i sisted of a basement containing vessels, and were covered by ’, layers of epithelium of a squamous character. I At his own request, the patient returned home at the end ’, of a fortnight, and Dr. Raper, who has attended him since, reports in a letter dated July 12th, that he " remained very ’, much better for some time after he returned home ; his water was comparatively free from blood, and he only required to pass it once in two or three hours ; sometimes there was a little blood-stained mucus at the bottom of the chamber, and a few gritty particles passed at times, similar to what he had been parsing before he went to the hospital, but less in quantity and in size. Since Friday last he has not been so well, the blood has much increased and he has to pass water more frequently, often two or three times in an hour ; also the water passes less freely, and he has more pain and feels weaker." , DISTRICT HOSPITAL, WEST BROMWICH. RUPTURE OF LIVER ; DEATH IN THIRTY-FOUR HOURS. (Under the care of Mr. SANSOME,) G. R-, aged forty-six, was admitted, Aug. 25th, about 4 P.M. He was a labourer, employed at some chemical works near the hospital. In the afternoon he was standing behind a stationary truck for the purpose of coupling it to others coming up behind and drawn by horse power. For some purpose he stepped out before the hinder trucks had been quite drawn up, the buffer struck him in the back, knocking him forward on to the buffer of the stationary truck with such force that the latter was propelled about two yards. On admission he was suffering from severe shock, his features being pinched and sallow, surface cold, and pulse feeble. The conjunctivas were not discoloured, and there were no marks of violence about the body. The area of hepatic dulness was somewhat extended posteriorly. Hot fomentations were applied, opium administered internally, and milk only ordered. About midnight eight ounces of clear, high-coloured urine were drawn off, but catheterism was subsequently needed. Next morning the same con. ditions obtained, except that the duluess was not 80 exten. sive. He suffered acute pain and nausea; the shovk seemed intensified, and stimulants were ordered, but without avail. About 8 P.M. all pain ceased, and he expressed himself much better. This continued till 11 P.M., when delirium supervened ; he rapidly sank, and died at 12.30 A.M. on the 26th. At the post-mortem, fourteen hours afterwards, the body was found to be well nourished and muscular. On open. ing the abdomen a large quantity of clear bloody fluid escaped, and on the posterior border of the right lobe of the liver was a gaping jagged wound, thiee inches in length and one inch in depth at the centre, which was the deepest part. Three inches anterior to this was another wound two inches long, about one-twelfth of an inch deep, but in which the capsule was not in its entire extent torn through. The gall-bladder and duct were uninjured. There were numerous clots around, and the ascending colon and surrounding structures were much discoloured. The other organs were healthy. It will be observed that the patient lived thirty-four hours after the receipt of the injury. GUEST HOSPITAL, DUDLEY. LATERAL LITHOTOMY ; EXTRACTION OF A LARGE URIC ACID STONE, WEIGHING THREE OUNCES AVOIRDUPOIS. (Under the care of Dr. UNDERHILL.) B. J-, aged twenty.three years, a fender maker, oi average development, but very anaemic, was admitted on June 2nd, 1882. There was no particular family history, and he had had no illness of moment until the present. He stated that when a schoolboy he experienced pain when mic- turating ; that this had continued until the present time; 9 that slime sometimes followed the urine, and that the stream had sometimes stopped suddenly, but that he had not observed any blood in it. For five months before admission he did not work, and remained chiefly in bed, the agony during micturition, which was frequent, being in- tense, and the urine turbid. During that time a sound was twice passed without a stone being detected ; possibly it did not completely enter the bladder, as there was slight hypo- spadias, with much spasm and irritability of the urethra. Under ether a large stone was detected on June 9th. The man being under the influence of ether, left lateral lithotomy was performed in the usual way; the stone was grasped with difficulty, and the forceps slipped twice during the attempt to remove it (as there were none at hand suitable for a very large calculus). The incision. was then ex- tended in a backward direction with a bistoury ; the stone was again grasped, and after long and steady traction, with much force, was extracted. The sphincter ani was slightly lacerated during the last part of the operation. A fair amount of haemorrhage took place, which soon ceased on bringing the thighs together. The mucous membrane of

DISTRICT HOSPITAL, WEST BROMWICH

Embed Size (px)

Citation preview

Page 1: DISTRICT HOSPITAL, WEST BROMWICH

440

of rather florid complexion, and with hair turning grey. Not-withstanding the frequent loss of blood, he declared that hehad not grown perceptibly thinner. During the day, herequired to pass urine frequently, but the length of theintervals was very variable ; at some times he was able togo two hours, at others being compelled to micturate everyfive or ten minutes. Movements increased the frequency,and gave rise to some pain, which, however, was never ex-cessive. There was never any retraction of the testes, norhad he ever suffered from sickness or diarrhoea. Hewas sounded by Mr. Ballamy, but no calculus could bedetected, and he was ordered a mixture containing smallquantities of tincture of perchloride of iron and tincture ofopium. The urine was almost always tinged with blood, butthe amount and colour varied greatly ; at times the urinebeing bright scarlet, and at others the amount of blood beingso small as only to be detected by microscopic examination.No calculous matter was passed during his stay in thehospital, but when the quantity of blood in the urine waslarger there was usually to be found a large number ofwhitish flocculent masses at the bottom of the receptacle,which proved, on examination, to be small amounts of de-colorised fibrin.During the absence of Mr. Bellamy the patient came

under the care of Mr. Morgan, who on sounding the bladderwas unable to detect the presence of any calculus, but thesensation was given of the presence of a soft uneven masslying at the posterior part of the bladder. Examination perrectum showed the prostate to be slightly enlarged, but didnot assist in determining the nature or size of the newgrowth. Accordingly the patient was placed under theinfluence of ether and again sounded, when the previousconjecture was still further strengthened. The bladder wasthen washed out by means of an apparatus which Mr.Morgan has lately devised for the examination of detritusafter lithotrity. The result of this was the removal of alarge quantity of the decolorised fibrin with a good deal offresh blood ; but under the miscroscope no characteristicepithelial cells could be detected.On May llth the patient was again placed under ether,

and a staff having been passed, and the patient being in theposition for lithotomy, Mr. Morgan, having first divided theskin in the middle line a little above the anus, passed alithotomy knife down to the groove in the staff and made anincision of the urethra of about three-quarters of an inch inlength. Through this wound the left forefinger, aided bythe pressure of the right hand on the abdomen above thepubis, was able to explore the greater part of the walls ofthe bladder, as pointed out by Sir Henry Thompson. Therewas found to be a quantity of soft velvety growth springingfrom the posterior wall, and generally diffused, but one largemass grew as from a pedicle, and this was easily graspedbetween the blades of a lithotrite, and removed through the incision. A full-sized catheter was introduced through the wound and secured. Very little bleeding followed the opera-tion, and the patient passed a comfortable night. On thefollowing day the catheter came out of its own accord, andwas not replaced. On the second day the patient wasslightly feverish, but after the bowels had been well re-

lieved this passed off, and he made a rapid recovery; sothat he was up and about the ward on the sixth day afterthe operation, urine being passed by the urethra onlyevery two or three hours, and containing hardly any trace ofblood.The growth removed resembled a filbert in size and shape,

and in structure consisted of a rather contracted pedicle fromwhich sprang innumerable brancblets, which again were subdivided into small villous prolongations. The villi con- isisted of a basement containing vessels, and were covered by ’,layers of epithelium of a squamous character. IAt his own request, the patient returned home at the end ’,

of a fortnight, and Dr. Raper, who has attended him since,reports in a letter dated July 12th, that he " remained very ’,much better for some time after he returned home ; his waterwas comparatively free from blood, and he only required topass it once in two or three hours ; sometimes there was alittle blood-stained mucus at the bottom of the chamber, anda few gritty particles passed at times, similar to what hehad been parsing before he went to the hospital, but less inquantity and in size. Since Friday last he has not been sowell, the blood has much increased and he has to passwater more frequently, often two or three times in an hour ;also the water passes less freely, and he has more pain andfeels weaker." ,

DISTRICT HOSPITAL, WEST BROMWICH.RUPTURE OF LIVER ; DEATH IN THIRTY-FOUR HOURS.

(Under the care of Mr. SANSOME,)G. R-, aged forty-six, was admitted, Aug. 25th, about4 P.M. He was a labourer, employed at some chemicalworks near the hospital. In the afternoon he was standingbehind a stationary truck for the purpose of coupling it toothers coming up behind and drawn by horse power. Forsome purpose he stepped out before the hinder trucks hadbeen quite drawn up, the buffer struck him in the back,knocking him forward on to the buffer of the stationarytruck with such force that the latter was propelled abouttwo yards.On admission he was suffering from severe shock, his

features being pinched and sallow, surface cold, and pulsefeeble. The conjunctivas were not discoloured, and therewere no marks of violence about the body. The area ofhepatic dulness was somewhat extended posteriorly. Hotfomentations were applied, opium administered internally,and milk only ordered. About midnight eight ounces ofclear, high-coloured urine were drawn off, but catheterismwas subsequently needed. Next morning the same con.

ditions obtained, except that the duluess was not 80 exten.sive. He suffered acute pain and nausea; the shovk seemedintensified, and stimulants were ordered, but without avail.About 8 P.M. all pain ceased, and he expressed himselfmuch better. This continued till 11 P.M., when deliriumsupervened ; he rapidly sank, and died at 12.30 A.M. on

the 26th.At the post-mortem, fourteen hours afterwards, the body

was found to be well nourished and muscular. On open.ing the abdomen a large quantity of clear bloody fluidescaped, and on the posterior border of the right lobe of theliver was a gaping jagged wound, thiee inches in lengthand one inch in depth at the centre, which was the deepestpart. Three inches anterior to this was another wound twoinches long, about one-twelfth of an inch deep, but in whichthe capsule was not in its entire extent torn through. Thegall-bladder and duct were uninjured. There were numerousclots around, and the ascending colon and surroundingstructures were much discoloured. The other organs werehealthy.

It will be observed that the patient lived thirty-four hoursafter the receipt of the injury.

GUEST HOSPITAL, DUDLEY.LATERAL LITHOTOMY ; EXTRACTION OF A LARGE URIC

ACID STONE, WEIGHING THREE OUNCESAVOIRDUPOIS.

(Under the care of Dr. UNDERHILL.)B. J-, aged twenty.three years, a fender maker, oi

average development, but very anaemic, was admitted onJune 2nd, 1882. There was no particular family history,and he had had no illness of moment until the present. He

stated that when a schoolboy he experienced pain when mic-turating ; that this had continued until the present time; 9that slime sometimes followed the urine, and that thestream had sometimes stopped suddenly, but that he hadnot observed any blood in it. For five months beforeadmission he did not work, and remained chiefly in bed, theagony during micturition, which was frequent, being in-tense, and the urine turbid. During that time a sound wastwice passed without a stone being detected ; possibly it didnot completely enter the bladder, as there was slight hypo-spadias, with much spasm and irritability of the urethra.Under ether a large stone was detected on June 9th. Theman being under the influence of ether, left lateral lithotomywas performed in the usual way; the stone was graspedwith difficulty, and the forceps slipped twice during theattempt to remove it (as there were none at hand suitablefor a very large calculus). The incision. was then ex-

tended in a backward direction with a bistoury ; thestone was again grasped, and after long and steady traction,with much force, was extracted. The sphincter ani wasslightly lacerated during the last part of the operation. Afair amount of haemorrhage took place, which soon ceasedon bringing the thighs together. The mucous membrane of