53

movements of the eyeballs and upper extremities; tendernessin the throat, epigastrium, and abdomen ; weak respiration, 15in the minute; pulse languid, 60; the mind, secretion and dis-charge of urine, undisturbed; vomited and purged incessantlyfor thirty minutes before I arrived.I administered new milk and magnesia freely, applied a

large mustard poultice to the epigastrium and abdomen, bottleswith hot water to’the feet, &c. Symptoms of recovery speedilyappeared.The case being reported to Dr. Young, the police surgeon

for the Calton district, that gentleman promptly attended, andapproved of my treatment on the occasion. The man labouredunder diarrhoea for three days afterwards, which yielded to th<usual expedients.

July, 1855. _________________

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.

CALCULUS IN THE FEMALE; REMOVAL BY LITHOTRITY.

(Under the care of Mr. FERGUSSON.)

Nulla est alia pro certo noscendl via, nisi quam plurimas et morboruni&eacute;t dissectionum historias, tam aliorum proprias, collectas habere et interse eompa.ra.re.&mdash;M&E6A&NI. De Sed. et OauB. M01’b.lib. 14. Procemimn.

LITHOTRITY in the female is a very rare operation in hos-pitals, yet why it is so does not very clearly appear. Duringtwenty-three years, at St. Thomas’s Hospital, in 144 cases ofoperation for stone, Mr. South only saw two cases of calculousdisease in the female, and these were removed by anothermode of operating. Lithotrity in the child, more especially inthe female, is still more rare, if not entirely unknown. Wewere accordingly very much interested in a case of this kindwhich occurred amongst Dr. Johnson’s out-patients last monthat King’s College Hospital. It was thought necessary on the5th instant to have the opinion of Mr. Fergusson on the case,who, on sounding the bladder, discovered the stone, and pro-posed to remove it, as he did on the following Saturday, bylithotrity.On both occasions Mr. Fergusson directed the attention of

his class to the fact of the comparative rarity of stone in thebladder in the female-a circumstance due to the extreme short-ness, largeness, and dilatability of the canal of the urethra infemales as compared to males. The nuclei of stone, and some-times stones of considerable size are spontaneously voided,calculi weighing some ounces, according to trustworthy authors,have been from time to time taken out by patients themselves.This remarkable dilatability of the urethra, Mr. Fergusson be-lieves, has led surgeons to trust too much to simple dilatationfor the extraction of calculi from the female bladder-a processoften followed by very distressing incontinence of urine. Mr.Fergusson, from these and various other considerations, nowadopts the plan of removing the calculus in the female bylithotrity. He has had accordingly a small instrument andscoop specially made for such cases in children, as he has hadopportunities of operating more frequently in private than inhospital practice.

A. B-, aged about twelve, otherwise in good health,was brought to Dr. Johnson one day last month with symptomsof stone in the bladder. She was ordered some very simplealterative medicine, and placed under Mr. Fergusson’s care,’who on sounding, as already stated, immediately discovereda large stone lying across the neck of the bladder, almost inthe urethra. Though the patient was under chloroform eachtime, the jerk with which the urine, both at the operation andat the sounding, was ejected from the bladder was very re-markable, and helped to explain in what manner and with whatforce small calculi may be passed from this organ. The pre-sent case is interesting in connexion with a somewhat similarone mentioned in the "Mirror," (THE LANCET, vol. ii. 1852,p. 518,) in which the nucleus proved to be a hair-pin, intro-duced into the bladder of an adult female. Another instance

is also there recited, occurring under the care of Mr. Hilton atGuy’s Hospital, in which an ivory " netting-needle" had itLsome incomprehensible manner found its way into the bladder.In all these instances, as well as in the operation on the 7thinstant, the urine was ammoniacal, and the stone very soft-an additional reason, Mr. Fergusson believes, to avoid allcutting and dilating processes in the female, and if possibleto have recourse to lithotrity, as we thus removed the stoneeffectually, though more slowly, and obviated the deplorable

L results too often following the plan by dilatation-results evenL more formidable, according ’to some surgeons, than those fol-

lowing extensive incisions. A very obvious objection to litho-, trity in children has been urged&mdash;that the lithotrite cannot be

made strong enough, and may break; but the comparativesoftness of the stone to a certain extent obviates this objection.It is said also that lithotomy succeeds so well in children, thatwe have no necessity to resort to crushing the stone. Surgeonsin actual practice, however, are not so sure on this point, andmany seem agreed as to the superiority of lithotrity.We observed, on Saturday, (the 7th inst.,) that as soon as

the little girl was brought into the operating-theatre, she wasplaced under the influence of chloroform by Dr. Snow, thoughlithotrity in the adult is one of the few operations in whichCiviale, Brodie, Skey, and others believe it to be contra-indi-cated, as the pain of the manipulation furnishes an index wherethe lithotrite is doing mischief. We have observed this test tobe very useful, during the past month, in a case twice operatedon by Mr. Curling at the London Hospital, and in one operatedon by Mr. Coulson several times at St. Mary’s. Mr. Fergussonseemed, however, to believe, that in the female, as in the.present instance, the -stone was so nearly in view, or withinthe grasp of the lith’otrite, that the latter could do no harm,while the chloroform restrained, though it did not entirelyprevent, the restlessness and plunging of the patient. Chloro-form may also, in some cases, enable the female viscus to retainthe fluid injected, which all surgeons seem now to believeshould be small in quantity, not exceedina three or four ouncesfor an adult. It was stated at King’s College Hospital, on theday above mentioned, that in some parts of England lithotomyin the female is more frequent than in London. It may be re-membered, though Mr. South gives us one case of calculus inthe female, to seventy-two in the male, Dupuytren, in Paris,found only one case in eight. We have all varieties, infact, between these extremes. Mr. Fergusson believes onecase in about twenty is a fair average: this, we find, isthe mean proportion of 5000 cases reported in THE LANCETand elsewhere. Something is due to locality, for calculusis a much more frequent disease in some places than inothers. At one side of the river Rhine, stone, as a disease, isalmost unknown, from the use, it is said, of white wines, richin alkalis; while on the opposite, or Strasburg side, the acidred wines produce calculous diseases, almost like an endemic,both amongst males and females. Under these different aspects,the operation of lithotrity in the female, though it may havefallen into disuse, is one, in Mr. Fergusson’s opinion, very de-serving of more general attention and study.

UNIVERSITY COLLEGE HOSPITAL.CALCULUS IN THE FEMALE; REMOVAL BY DILATATION.

(Under the care of Mr. ERICHSEN.)

Amongst our notes, we find, also, a case under the care ofMr. Erichsen, which offers one or two points of interest; first,as to the uncertainty, even when the patient is on the operating-table, of detecting the stone before the first incision or dilata-tion process ; next, as to the unadvisability of using cuttinginstruments in such a small space as the female urethra.

In March of the present year, a little girl, three years and a,half old, was sent to Mr. Erichsen, from Barnet, with symptoms-of stone in the bladder. The child was carefully sounded, anda stone apparently detected. She was accordingly admitted,with the view to have it extracted. A few days subsequentlyshe was brought into the theatre, but after the most carefulexploration the calculus could not be felt. The child was ac-cordingly sent back to the ward and treated constitutionally-A case almost similar occurred not long since at St. Thomas’s,Hospital, where the class, waiting for an operation, were morethan once disappointed, a stone which was easily detected oneday, being totally lost when exploration was tried in thetheatre on the next. The stone was probably small, and liableto be hidden or washed out in the operation as soon as thebladder was reached.On May 9th, the child was again brought into the theatre,

the symptoms of stone continuing in a marked degree. Mr.

54

Erichsen, avoiding all cutting operations, contented himselfwith simple dilatation, by a two-bladed screw dilator, and thepreviou;3 use of a sponge tent. Seizing the calculus ultimatelyin a well-made pair of curved forceps, Mr. Erichsen abstractedit entire, when it proved of the size of a garden bean, and con-sisted of lithic acid.

____

GUY’S HOSPITAL.VARICOSE ULCERS, AND THEIR TREATMENT BY POSITION

OF THE LIMB.

(Under the care of Mr. HILTON.)

AMONGST the excellent every-day practical cases at preseniin this hospital are some varieties of old and troublesomevaricose ulcers of the legs, which, having. gone through theusual routine of the ordinary plans of treatment by rollers,tying veins, &c., without any amendment, had yielded quicklyto a mode of treatment suggested and tried for some time pastby Mr. Hilton. This plan consists of placing the limb perma-nently in a higher position than the body of the patient, andthus preventing the column of venous blood from pressing onthe congested capillaries. The plan seems simple enough,indeed, perhaps too simple for the present exacting age ofpathological novelties; but in three cases recently of very indo-lent ulcer, at this hospital, the steady application of simpledressings, and keeping the limb above the level of the patient’sbody in bed, by ordinary sand-bags, more than realized Mr.Hilton’s expectations, and in a few days effected a perfect cure.Bandages and lace stockings, in these cases, require theutmost nicety, Mr. Hilton observed, as to their application,for if they press unduly on the granulations, as was veryobvious in one of the present cases, they do more harm thangood, constrict the veins and vessels, and thus throw thepatient back for several weeks. If the roller be applied at all,it requires much careful attention, so as not to act as a con-stricting agent at any point-more attention, indeed, thanstudents can conveniently pay to such cases, the roller notalways passing over the ulcer as it ought to do.

WESTMINSTER HOSPITAL.

TREATMENT OF CHRONIC LUMBAR ABSCESS.

(Under the care of Mr. HOLT.)LARGE lumbar abscesses, connected as they generally are

with scrofulous caries of the vertebrae, present little varietyand possess but a small amount of novelty or interest for surgeons habituated to our larger hospitals. Such cases are

particularly adapted to the expectant mode of treatment&mdash;toleaving, in fact, a great deal to the surgery of Nature. ThesEabscesses, observed Mr. Holt to his class one day last week, mayform swellings at or above Poupart’s ligament, or take the courseof the spermatic cord, thus simulating hernia; or, again, theymake their way down to the sacro-ischiatic opening, and puzzlethe uninitiated very much. In the case of a boy, who hasbeen some time in the hospital, the appearance of hernia wasrather marked; but by pressing alternately in the region ojthe head of the psoas and other lumbar muscles, and pressingcautiously on the abscess in the groin, which gave an indistinctimpulse on coughing, the tumour could be made to bulge outor disappear according to the nature of the pressure used.Mr. Holt impressed on his class the absolute necessity of notopening such abscesses. He had never known a large psoasabscess opened by the surgeon either with the seton or valve-like opening recommended by Abernethy, in which the patientdid not sink from fatal attacks of irritative fever. The old

explanation used to be that the pyogenic membrane lining theabscess became inflamed all over its surface; but we believe our

modern pathologists have taught that there was no such thingas a pyogenic membrane secreting pus. Surgeons in generalwere quite familiar with large psoas abscesses, even abscessescontaining quarts of matter, with flakes of curdy substance,like that seen in other abscesses usually denominated scrofu-lous. Tubercle in bone was now known to be sometimes metwith, and more frequently in the spongy bones, like those ofthe bodies of the vertebra, which Sir B. Brodie always findsdiseased in psoas abscess. This tubercle, generally of theopaque yellow variety, becoming deposited in the cancelli, in-duces a gradual absorption of the bony septa, leading to theformation of scrofulous abscesses, composed of a mixture of theproducts of iuflammation, imperfect pus, and additional tuber-culous matter. Indeed, so much are the parts destroyed, thatMr. Stanley doubts if ever a process of reparation is set up atall, no more than in a phthisical cavity in a luncr. The ab-

scesses next spread into the surrounding cellular and musculartissues, as in this case, into the psoas and lumbar muscles, theformation of pus going on gradually from month to month.

Mr. Holt also directed the attention of his class to a some-what singular case which lately came under his observation,and presenting rather a difficult point of practice-viz.,whether the abscess should be opened or not. It was the caseof a married lady, lately pregnant, who had ’a psoas abscess ofabout twenty months’ formation, and of an enormous size,at the upper part of the thigh. If the abscess had burst, orhad been opened, there seemed little hope but she would havesunk under the combined effects of the drain on the system,the irritative fever, and the subsequent excitement and shockof labour at the full period. The proper mode of proceedingwould seem rather to be that which he had adopted. She waswell supported, and delivered prematurely of a living child atseven months, and the abscess was treated on the ordinaryplan, according to the indications as they arose, the mere factof the abscess being two years growing still presenting someuncertain hopes of her recovery.

Reviews and Notices of Books.On Local Treatment of the Mucous Membrane of the Throat

for Cough and Bronclaitis. By J. E. RIADORE, M.D.,F. R. C. S., late Lecturer on Surgery to the Hunterian Schoolof Medicine, &c. &c. London, 1855. pp. 99.

WE have received several hints of practical value from theperusal of Dr. Riadore’s little treatise, and would advise anacquaintance with its pages to those who have to deal with

any obstinate cases of throat affection. The value of alum, ofthe nitrate of silver, and of the nitro-muriatic acid, in suchforms of disease, will be found here well illustrated. We can-not say, however, that we should hold up Dr. Riadore’s styleas worthy of imitation. It is one scarcely in keeping withwhat is expected now-a-days in scientific productions. The

following critique on homceopathy is the result of the personalexperience of Dr. Riadore, and for its truth is worthy of ex-tract :-

"I attended for a short time the practice at one of thehom&oelig;opathic hospitals, and also the lectures there delivered.I found that for all complaints the number of the numerously-named globules, containing or not containing infinitesimalquantities of the drugs after which they were named, were notmore than from ten to nteen at the utmost. The homoeopathicpractitioners have always in their consulting-rooms very largeboxes full of bottles, labelled with the names of every drugmentioned in their very trashy books, which they exhibit asremedies to their deluded dupes, and so impose upon them themagnitude of their varied means of cure. When, however,they leave home to visit their simple patients, a small box inthe waistcoat pocket suffices for cit2-ative purposes; this eon-tains about a dozen of little labelled bottles, the contents andproperties of which are just as well understood, perhaps, bymany learned and skilled young ladies in their teens, whoamuse themselves with the homoeopathic delusion, as by thehoary and medically-educated practitioner who takes up thisvery strange mode of earning a livelihood after having failedto do so in the honourable course of practice." -p. 38.

A System of Instruction in Qualitative Chemical Analysis. ByDr. G. REMIGIUS FRESENIUS. Fourth Edition. Edited byT. LLOYD BuLL&CjK:, F. C. S. pp. 310. London : Churchill.

THE appearance of this new edition, corresponding with theeighth German edition, is the strongest proof that could begiven of its popularity, and practical utility. To the presentvolume some important additions have been made. The

admirable and simple directions, now first given, for the

analysis of mineral and spring waters, and the detection ofpoisons for forensic purposes, will be found to add greatly tothe value of the work. The translation, on the whole, is ex-cellent. There are not nearly so many Germanisms as are tobe detected in most versions of the kind. With regard to thenomenclature, it may, perhaps, be suggested that 8ulphide andphosphide are anything but an improvement on the 8ulphuret