185

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.

____

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.