No. 1567.

SEPTEMBER 10, 1853.

A MIRROROF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. THOMAS’S HOSPITAL.Mercurial Tremor.

(Under the care of Dr. GOOLDEN.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tam aliorum proprias, collectas habere et inter secolnparare.-MORGAGNt. DeSed.etCaus.Morb.,Iib.i4. Frooemium.

WE had a little time ago (THE LANCET, vol. ii. 1853, p. 97)occasion to refer to the evil effects of lead upon the system,and shall soon have to recur to the subject, as there are atpresent in the wards of this hospital several journeymenpainters and colour-grinders who present symptoms not gene-rally described in books. But lead is unfortunately not theonly metal the handling of which is destructive to health, andmercury has also its victims. Indeed, it is not easy to deter-mine which forms the most pitiable object: the painterwrithing under colic, with his powerless hands lying by hisside; or the tottering, trembling, shaking, and stuttering water-gilder, or looking-glass silverer.As to the latter trade, we understand from Dr. Goolden’s

patient, that the workmen who are actively engaged in

silvering, cannot continue the same avocation more than fiveyears, and that the masters generally put them after thatperiod to other kinds of labour, for fear they should becomewhat is in the trade called " shake." In spite, however, ofsuch precautions, there are among the silverers men whoseconstitution is completely broken down; whose mouth is dis-organized by ulceration of the soft parts and caries of bone,and with whom the muscular system is permanently debili-tated. These have generally suffered repeated attacks oftremor, from which they had partially recovered, and were soimprudent as to expose themselves again to the noxiousmercurial vapours. No doubt but the nervous centres sufferat last in these inveterate cases, the morbid effects seemingto travel from the peripheral nervous expansions to the centralorgans.On considering these melancholy results of a branch of

industry, the question naturally arises, whether they could notbe avoided 1 Could ventilation, the wearing of veils, &c., pre-vent mercurial tremor ? It seems not; for we are bound tobelieve that every means has been tried to prevent the sadeffects of the metallic vapours upon the health of the work-man. One way, however, still remains open-viz., to intermitthe labour connected with the quicksilver, and manage insuch a manner that the same journeyman should be exposedfor only one week every month. This regular and periodicwithdrawal would, perhaps, have the effect of dispelling theincipient influence of the metal, and give time to the system

’to withstand, as it were, a renewed attack.Besides this hygienic question there is another of a purelychemical kind-viz., how the quicksilver acts: as metallic dust,or as an oxide. There must of course be a difference whetherheat be used or not, for it is easy to understand, where mer-cury is vapourized by the aid of caloric, that a partial oxidationtakes place. But how is it, since water-gilders undoubtedly

breathe an atmosphere charged at least with some oxide ofthe metal, that they are seldom salivated, though pretty oftenattacked with tremor ? 1As to looking-glass silverers, it is probable, as the mercury

is merely subjected to great pressure, that the oxidation isnot greater than that which has been found to result from themaking of mercurial ointment. Here again salivation is of arare occurrence. As to other means of oxidation, it might,perhaps, be suspected that the molecules of mercury, whichbecome attached to the skin, undergo a certain amount ofoxidation by the action of the acids (as the lactic) with whichthey come in contact on the tegumentary surface, the actionbeing favoured by the natural heat of the body.No. 1567.

But many of our readers must certainly have been struckwith the great analogy which exists between paralysis agitans,chorea, and mercurial tremor: now where lies the primarycause of the two former affections ? l Certainly in the nervouscentres; and why should it not be so with the third malady îWhy should we not believe that the blood becomes impreg-nated with the oxide of the metal, or at least changed by itsinfluence, the nervous centres becoming in consequence soderanged as to give rise to convulsive symptoms ? Analogywould certainly support such a position, the more so as wesee people suffering either from ramollissement of the brain,or who have recovered from an attack of apoplexy, totter asthey walk, and hesitate and stammer when they attempt tospeak. Nor does the usual result of the tonic treatment,generally used in mercurial tremor, militate against the viewjust emitted, for steel and general tonics are certainly con-ducive to favourable changes, through the instrumentality ofthe circulating fluid, in the cerebro-spinal axis.On this head we may mention a water-gilder, who has been

under the care of Dr. Barlow, at Guy’s Hospital, for the lastfew weeks, and is on the eve of being discharged. The im-provement was here principally due to ammonia and steel,aided of course by good diet, and the withdrawal of the patientfrom the atmosphere loaded with mercurial vapours. Thispatient was suffering for the third time, and was on admissionin a very distressing state. He evidently belongs to thecategory to which we above alluded-viz., men who returnagain and again to the same work after each fit of illness,until the nervous system is permanently injured. We shouldnot omit to state that the noxious effects of the mercury arecertainly aggravated with individuals who drink intemperatelyof spirituous liquors. Let us turn to the case now under thecare of Dr. Goolden.

’ John B-, aged thirty-eight years, married, and having afamily of children, was admitted August 9th, 1853, into Jacobward. It appears that the patient, who is of a fair complexion,I pale and anxious aspect, carries on the trade of looking-glasssilverer, and that he enjoyed good health up to the time hebecame actually engaged in the silvering room, although hishabits were very intemperate.On inquiry into the details of the process, it is found that

the man’s occupation principally consists in applying tin-foiland quicksilver to the glass, and he mentions that the dust ofthe mercury, during the pressure of the plate upon the metal,is supposed to act in a pernicious manner upon the system.Before he took to the silvering, he was engaged with themanagement of the glass, and enjoyed very good health forthe space of nine years; but for the last six, during which hehas been exposed to the metallic influence, he has sufferedthree severe attacks of tremor, with loss of power in the lowerlimbs, and imperfect articulation.On the first seizure he was taken with tremor, convulsive

movements, difficulty of speech, tottering gait, &c.; he re-

mained two months under treatment at his own house, andso far recovered as to be able to walk, but at the time hereturned to his work some tremor and stammering still per-

sisted. The patient now confined himself to examining theglass and superintending the silvering; but he was at timespretty long in the room where the process was being carriedon, and in about two years’ time experienced another attack,which proved as severe as the first.He now became an out-patient to a hospital, remained about

six weeks under treatment, and so far recovered as to be sentto Carshalton for the benefit of the air. He could at thattime walk pretty well, but there was still much tremor whenhe carried a glass or cup to his mouth. On returning fromthe country, the patient resumed his work, and now onlysuperintended the silvering, taking care to go frequentlyout of the room where the mercury was used. The force ofhabit, however, prevailed, and the man confesses that he againmade too free (as he expresses it) with the silvering, and thethird attack (none having, however, been accompanied bysalivation) brought him to this hospital.

Before his admission he was treated at home, but theconvulsive movements and imperfect walking were suddenlymade much worse by a fright he had upon the house next tohis taking fire; and it was in this aggravated state that thepoor man was brought to this institution.On examination, he was found pale, weak, and anxious-

looking, with a slow but regular pulse; the tongue was furred,the teeth mostly greenish-black and carious, and the skingenerally dry and cold. He could not walk at all, hardlyspeak, and when he attempted to move, or was asked a ques-

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tion, his whole frame was thrown into the most immoderateconvulsive actions. He was ordered to keep his bed, to beexposed to no disturbing causes, to have good diet and wine,and to take small doses of iodide of potassium.

This plan of treatment was soon followed by very satis-factory results; the man recovered the power of walking withan uncertain gait, the tremor became less violent, the appetiteimproved, and about a month after admission the principaland most distressing symptoms had disappeared.The patient will probably be discharged with a certain

amount of tremor remaining upon him, and if he shouldagain expose himself to the noxious influence which hasalready done him so much harm, it is likely that his healthwill gradually become deteriorated. It is, however, but fairto add that it is not easy for a man, who has to support himselfand family, to change his trade and calling. This points tothe necessity of preventive measures.

ST. GEORGE’S HOSPITAL.

Pleuritic Effusion; Death; Autopsy.(Under the care of Dr. WILSON.)

THERE is a remark in the letter of one of the correspondentsof this journal, inserted last week, (p. 227,) which has struckus as being extremely just, and founded upon facts of a verymelancholy nature. The writer alludes to the rapidity andincompleteness which must necessarily characterise the exa-minations made in the out-patients’ rooms of our hospitals,and cites as an example that a young woman may presentherself with incipient pleurisy, (which affection, we hardlyneed say, can in that state be detected only by very closeand deliberate physical examination,) and being but cur-

sorily looked at, may be told to take some cough mixtureand return in a few days. But cough mixtures neither checkthe inflammation of the pleura, nor the consequent hyper-secretion, and in the space of a few days almost irreparablemischief has been done.Now, this very pertinent remark applies fully to cases

treated in private practice with an insufficient physical ex-amination, or to such patients as completely neglect to seekfor medical advice. In cases like these, the disease makesrapid and unsuspected progress, the pleura becomes enormouslydistended with fluid, the lung is compressed, double work isthrown on the corresponding organ, the latter is attackedwith pneumonia, and the patient dies. Such was very pro-bably the succession of symptoms in Dr. Wilson’s patient, andfrom the physical signs on admission, as well as from thepost-mortem examination, it is clear that the poor man wasperhaps past recovery when admitted into hospital.We feel the more interested in this case, as there are now

under our observation two others of the same kind-the firstat St. Thomas’s Hospital, under the care of Dr. Bennett; thesecond at St. George’s, under the care of Dr. Bence Jones.-In both of these did we see paracentesis thoracis performed.With Dr. Bennett’s patient the fluid was of a serous nature;but the pleura, in the case at St. George’s, was filled withhorridly foetid pus. We are watching these patients withmuch solicitude, as the question of tapping of the chest is one

. of vital importance, and not as yet quite settled.In Paris, M. Trousseau, formerly physician to the Children’s

Hospital, and now attached in the same capacity to the HotelDieu, has taken a prominent part in advocating early tapping,and careful exclusion of air; and there is no doubt that whenpractitioners shall study the writings of that physician andthe cases which he cites, they will be induced to follow asimilar line of treatment. One stumbling-block has, however,not been removed as yet-viz., the liability of confoundingserous effusion with empyema. As to the latter event, wemust say that of all the cases which we have seen at Guy’s,St. George’s, and other hospitals, none of the patients whomwe were enabled to watch recovered after the operation ofparacentesis; whilst we recollect some cases of serous effusion(especially one treated by Dr. Wilson, at St. George’s Hos-pital, about two years ago) the issue of which was favourableafter tapping of the chest.

If we mistake not, however, there is a rule generallyadhered to in our hospitals, which is, to give a fair chance to

diuretic medicines before considering the subject of operativec evacuation. And here we would repeat what we said a shorttime ago, touching the benefit which might be derived fromthe vapour-bath, which certainly is a simple and effectual

- mode of abstracting a large. quantity of fluid from the system,and exciting the absorption of a superabundant pleural secre-

tion. But the great point will ever be, for every practitioner(since all agree that prevention is better than cure) to prevent,as far as lies in his power, the occurrence of effusion by earlyand vigorous antiphlogistic measures, when the principalsymptoms of pleurisy are complained of. And even supposingthat our diagnosis were not quite correct, and that pleurisywere supposed to exist where mere pleurodynia had takenplace, is it not better that the patient should, even unneces-sarily, lose a few ounces of blood, than that lie should runthe risk of pleuritic effusion, and its fearful and distressingconsequence 1 Having said thus much, we now turn to Dr.Wilson’s case, the details of which, as noted down by Dr.Barclay, the medical registrar, are as follows :-Edward C-, aged forty years, was admitted June 15th,

1853. The patient had been suffering from cough for sixweeks before admission. He was emaciated; his skin feltsoft and thin; the pulse was quick and feeble; the voicerather hoarse, and the bowels costive. He stated that hewas subject to a winter cough, but had never spat blood; hewas low and depressed, the appetite bad, &c. A mixture ofammonia and emollients was ordered, as well as morphia atnight, and a gentle aperient.On examining the chest, dulness was found very general

over the right side, with great deficiency of breathing; thevoice-sounds were nowhere exaggerated, except under theclavicle, where prolonged expiration was also heard. Thepatient complained much of the examination, which wastherefore very incomplete; it was on that account not re-peated, as the general symptoms appeared to point to tuber-cular infiltration.For some days after this, the man complained of pain under

the clavicle, stating that he had been hurt there some yearspreviously; he was in a low, desponding state, and unable toeat his ordinary diet. A few alterations were made in themedicines, but he became gradually weaker, and on July 9th,(twenty-four days after admission,) the cough, with muco-purulent expectoration, was still very severe.At that time the patient lay constantly on his right side,

and slept a good deal; blood soon appeared in the sputa, thepulse became quicker and feebler, the face dusky, and thebreathing oppressed. He had been lately taking wine andporter, and the haemoptysis had been checked by lead andopium. The patient died on the 29th, forty-four days afteradmission.

Post-mortem examination, (by Dr. Ogle, one of the curatorsof the museum.)-The body was rather emaciated, and therewere petechiae or maculae on various parts of the skin. In-teguments of the face and neck very livid. Chest: Pleuraladhesions existed to a great extent on both sides; somelight-yellow fluid was found in the left pleural sac, and alarge quantity on the right side, which also contained muchthick, recent fibrin in various parts. The left lung, pos-teriorly, and low down, was very congested and heavy, andcontained a great deal of red-brick-coloured fluid, but did notsink in water. The right lung was almost entirely compressedby the surrounding fluid, and was of a tough, leathery consist-ence ; the lining membrane of the bronchi was very vascular,and the bronchial glands contained much black carbonaceousmatter. The visceral pericardium was in places ratheropaque, and the flaps of the mitral valve, as well as theroot of the aorta, were slightly occupied by opaque yellowpatches. Abdomen: The omentum was adherent to theparietal walls, and there was also omental hernia on the leftside, the epiploon being firmly adherent to the neck of the sac.Nothing worthy of note was found in the rest of the viscera.

CHARING-CROSS HOSPITAL.

Purpura Hœmorrhagica in a debilitated subject; ExtensiveSloughing of the lower Lip and of the Integuments of theleft Forearm and Hand; Closure of the Mouth; Operation;Recovery.

(Under the care of Mr. HANCOCK.)WE noticed a short time ago, at this hospital, a young girl,

whose mouth was contracted to a very small size, the partsaround being considerably puckered, drawn up, and somewhatthickened. On examining the patient, we found that the leftforearm and hand were covered by thick, bluish, tough, andunsightly seams, evidently resulting from extensive loss ofintegument and subcutaneous areolar tissue, and subsequentformation of a hard, longitudinal, raised cicatrix. Scars ofthe same description were also noticed on one of the legs, andwe were led to infer from these marks that from some cause