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The dimensions of the tumour at the time the drawingswere taken were the following : - Length anteriorly, 3 in, ;length posteriorly, 4½ in.; breadth at centre, 2§ in.; thickness,1-1 in. In the engravings the tumour is made to appear thickerin proportion to its length than it really is, otherwise it gives-a very good representation of it.

Donington, Lincolnshire, July, 1866.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

CHOLERA IN THE METROPOLITANHOSPITALS.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morbotmt- et dissectionum historias, turn aliorum, tum proprias collectas habere, et intense comparare.—MORGAGNI De Sed. et Caus. ltlorb., lib. iv. ProŒmium.

THE severe outbreak of cholera in the east of London hascontinued during the past week to furnish daily a large numberof cases to the London Hospital.Up to the present time, as will be seen by the table appended,

. 336 cases of cholera and diarrhcea have been admitted; of which144 have died and 110 remain under treatment. In a visit whichwe paid to the hospital on the 29th, we were gratified to finda marked change in the aspect of the wards. On the occasion

of our previous visits it was painful to pass from bed to bedand find scarcely any exception to a hopeless or actually dyingcondition of its occupant. Deep collapse, with marked duski-ness of face and blueness of extremities, was the rule; andwhere, as in some cases, reaction was taking place, this waseither imperfect or attended with local congestions as fatal tothe patient as collapse itself. On Sunday, however, there wasa notable change. The number of patients actually undertreatment was greater than ever (there must have been up-wards of eighty); but the impression which was producedupon the mind by observation of the cases was much morefavourable. Some of the patients were convalescent; others,in very considerable number, were evidently tending towardsthe same desired result. There were still, however, manywhose condition left little or no hope of recovery. The laboursof the staff, both of medical ofticers and nurses, continue ofcourse to be of the most laborious kind. Although additionshave been made to the staff of nurses, the number is yet belowthat which is necessary for the care of patients affected witha disorder which demands probably more constant and arduousattention than any diseased condition admitted into hospital.The zeal and energy of the five resident officers continue un-abated ; but one cannot help regretting that their labours arenot supplemented by the aid of numerous advanced students,who might now be rendering valuable service by carefullyobserving and recording the progress of the various patients.Cholera is a disease which is so rapid in its course that, tokeep pace with its phases, a much more constant supervisionis required than is usually necessary even in cases of fever.We cannot help, therefore, feeling somewhat surprised thatmore of the students receiving their education at the hospitalhave not thought it either profitable or honourable to delaytheir vacation for a week or two, and lend a hand in a time ofsuch great need. This feeling has been forced upon us espe-cially in reference to the use of the thermometer. The employ-ment of this instrument in acute diseases is of comparativelyrecent origin in England. Its use was unknown during thelast epidemic in 1854. The thermometer furnishes a guage ofthe intensity of collapse, which is of the highest importance,inasmuch as it is exact and independent of various modifyingconditions of external temperature and the observer’s impres-sions. It will become a very great point in the record ofcholera cases to note down, not that the " skin was cold," butexactly to what level the mercury falls. In observations ofthis kind Darticularlv. advanced students. with a verv littleinstruction, might be made of the greatest assistance.. As itis, the use of the thermometer was commenced in the earliercases by Mr. Fredk. ialackenzie, and continued with praise-worthy energy until the large number of cases admitted ren-dered it simply impossible to continue the records. Mr. Mac-kenzie succeeded in applying the instrument at frequent in-tervals in the cases of twenty-four patients. The lowesttemperature observed was 90¼° Fahr., in a boy aged fourteenyears, whilst in a state of collapse. In other cases the declineof temperature approached this ; but in none of those examineddid the mercury fall lower. It was found that in patients whodied in collapse, the temperature would rise as death wasimminent, and attain the height of from 98° to 100°. The boywhose case we have just referred to recovered from collapse,but died from congestion of the lungs. He was for sometime delirious, and when we saw him on the 24th he wasoccupied in counting aloud incessantly. This phenomenonoccurred also in a woman who died whilst in the stage ofreaction. We were informed by the resident officers, Dr.James Jackson and Mr. F. Mackenzie (to whom for theircourtesy in giving us information upon various points weare much indebted), that those who died during reactiongenerally had the lungs congested. An effort was made toinject the veins of the boy above mentioned ; but on cuttingdown upon one at the bend of the elbow, a small thread

only was found, into which it was impossible to insert thesyringe. The lad’s arm became afterwards much inflamed,the inflammation (of an erysipelatous character) extending upto the axilla. It has been observed that this tendency to in-flammation of sore places was very marked among the cholerapatients. The sufferings of patients from cramp have been ex-cessive. Many, indeed, appeared to die quite suddenly in astate of cramp. It seems probable that in such cases thediaphragm has been affected with cramp.

In two cases an eruption resembling psoriasis appearedon the skin. In one, a man, this appeared to be of syphi-litic character; in the other, a woman, in whom we exa-mined it, there were no signs of specific origin. Certainlyneither of these should be confounded with the specific cholera

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eruption to which, under the title Roseola Cholerica, we re-ferred in our last impression. In another case, however, whichwe saw on the 29th, the cholera eruption was very distinctlymarked. The patient was a robust sailor, twenty-five yearsof age, who was the oldest surviving patient in the cholerawards. He was admitted on July 17th, had gone throughcollapse, reaction had taken place, and the eruption was firstobserved, we believe, on the 28th. At the time of our visithe was in that state of semi-stupor, with injected conjunctivæ,which is so commonly observable. The rash was developedprincipally about his throat and chest. It much resembledthat of measles in shape, but its colour was much brighter-perhaps a scarlet pink would best describe it. The eruptionwas somewhat raised, and disappeared with rapidity uponpressure-returning, however, very quickly when the fingerwas removed.Amongst the accidents resulting from imperfect purification

of the blood during reaction, glandular swellings of the faceand neck have been observed in two cases. We examined oneof these. The patient was a woman who was admitted fromShadwell on July 20th, and who lay in a state of deep collapsefor three days. As reaction ensued, dense swelling took placeabout the parotid and submaxillary gland on the left side ofher face. The surface was somewhat reddened, the swellingvery hard, and pressure caused some pain. We saw also achild, two or three years of age, who had rallied from long-continued collapse, and in whom the lower half of each corneawas ulcerated and opaque; a condition doubtless due to de-fective nutrition from the imperfect quality of the blood whichwas being circulated. Several women, we heard, have died ina state of pregnancy at various stages. One woman gave birthto a dead child, and died a few hours afterwards. Wesaw a woman in a state of collapse who had miscarried atfive months the night before. There was comparatively littlehaemorrhage, and what there was appeared of a darker colourthan usual. No milk was present in the breasts. Another

young woman with a child fourteen months old at the breastwas admitted on the 26th. She said that she had suckled herinfant on that day. We chanced to see the child. It lookedtolerably well, but the person in charge of it said that its bowelswere purged, the motions, however, being dark-coloured.The devastation amongst the families of the poor caused b3

this outbreak must be terrible. We were informed of nume.rous instances illustrating the mode in which the disease sweptsuddenly through whole households. There was a Germanfamily which had thus suffered. The mother died of cholera athome, three children were taken into the hospital with thEdisease, where one died, and the others still remained in a

critical condition. The father was in Whitechapel workhouse,where, we understood, overpowered by his sudden affliction,he had tried to destroy himself. In another instance, thefather of a family died in the hospital; the mother now liesthere likely to do well. Of their four children, all admittedwith the disorder, one is dead, and the others (of whom one isbut six months old) still remain under treatment.Upwards of forty autopsies have been made by Dr. Hughlings

Jackson and Dr. Sutton, the medical pathologists. As accuraterecords as were practicable have been kept of these, and will,doubtless, eventually be published. We believe that a greatdiminution of the weight of the lungs has been generally ob-served in the patients who died during collapse. In deter-

mining the pathological value of this sign, it will, of course,have to be remembered that in cholera, where the dischargeshave been excessive, the absolute quantity of circulating fluidis so far diminished that a lessened gravity of organs, whoseweight is chiefly produced by blood, must naturally be ex-pected. The right side of the heart has generally, we learn,been observed to be full of black blood. In some cases theintestines have been full of rice-water excretion. The mesen-teric glands have not been found to be much altered. For someminutes after death in many cases muscular twitchings havebeen observed to take place in different parts of the body. Ina few the arm has moved from its extended position by theside of the corpse, becoming more or less flexed by muscularcontraction.The only notable point that we remarked in connexion with

the treatment pursued was that one of the physicians had dis-continued the use of drugs in the stage of collapse. Frictions,hot bottles, and hot baths, if these last were agreeable to thepatient, were continued. So far as our own experience informer epidemics has enabled us to judge of the value of drugsin collapse, we feel rather strongly that this modification oftreatment is judicious, and might with advantage be generallyfollowed.

Retit2-it of cases admitted into the cholera wards of the LondonHospital for the week ending August 2nd.

In St. Bartholomew’s Hospital thirteen cases of cholera have’been admitted, of which two have died. Seven patients nowremain under treatment. Through the courtesy of Mr. Wood,the resident medical officer, we had an opportunity of seeingthese patients and learning a few particulars about them. Ofthe two fatal cases, one was a boy who came from a ship lyingat Blackwall. He had been employed on board as a drover,looking after the cattle with which it was freighted. Theother, we understood, was a nurse, who became affected withcholera when only one patient had been admitted. Anotherof the nurses was still a patient at the time of our visit: herattack seemed to date from her sleeping at a house in Cold-bath-square, where her mother had died of the disease. Theother patients whom we noted came from Mitre-court, John-street ; Curtain-road, Shoreditch; Hackney; Angel-alley,Bishopsgate-street; Charles-street, Bethnal-green. Among thecases was one of great interest and importance. A girl agedfifteen was admitted July 27th in a state of collapse, after adiarrhoea of four or five days’ duration. She improved so,much that on the 29th it was thought likely she would be ableto go out very shortly. On that day she ate some pastry whicha foolish friend managed to smuggle into the ward for her.Shortly afterwards she was seized with vomiting, and againsank into deep collapse, in which condition we saw her on the30th. This recurrence of collapse is not an uncommon conse-quence of injudicious diet during recovery, and we have seendeath itself caused by it where the patient had been previouslyconvalescent. A man whose wife had died from cholera athome, and who had taken for some days frequent doses ofbrandy on account of diarrhoea, was admitted on July 27thwith cholera. On the following evening he was attacked withdelirium tremens, got out of bed and ran up-stairs, being, ashe told us, under the impression that his children were on fire.The following day he managed again to slip out of bed, andsmashed the windows of the ward. He was very much better-at the time of our visit, and could talk rationally about whathad happened.Mr. Wood, who had the advantage of witnessing the twa

former epidemics of 1849 and 1854 whilst in the hospital, isinclined to think the type of the present cases less severe thanformerly. They at first appear, he told us, as bad as possible,but gradually improve instead of becoming worse. In thelast epidemic, out of 400 cases admitted in St. Bartholomew’s200 died. For our own part we have as yet seen in no hos-pital cases marked by the intensity which characterized thepatients admitted during the first week at the London Hos-pital. The treatment which is being adopted here consistsmainly of calomel and opium, with baths, sinapisms, and beef-tea injections. There are twenty beds in readiness for choleracases, and, if need be, the whole wing in which these wards aresituated can be devoted to this class. A staff is already or-ganized so that no delay would occur in the event of an out-break.Three more cases of cholera have been admitted at Glty’S.

A young man, serving as fireman on board the Albert EdwarctGravesend Saloon Steamer, came in on Sunday with symptoms,but not of a very severe kind. We found him convalescent onTuesday. At the time of our visit, a German tailor fromHorsleydown, and a boy who had arrived only the day be-fore in a ship from Rotterdam, had just been brought in andplaced under Dr. Barlow’s care. The man had a very feeble

pulse, duskiness of skin, and failing temperature. The boywas pulseless, with dusky face, breath and skin cool (the ther-mometer in the axilla gave 94°), and the voice choleraic. The’woman whose case was referred to last week had some deliriumduring reaction, but is now convalescent.At the Middlesex Hospital two cases have been admitted, both

males. One died six hours after admission, in a state of collapse.He came from Brewer-street. At the autopsy, eighteen hours-

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/after death, the rigor mortis was found well-marked. Both lungs attacked, the other members of it have invariably followed.much congested. The four cavities of the heart contained a As regards preparations for cholera, Mr. W. H. Ellis, house-little fluid blood, more in the right cavities than in the left. surgeon, informs us that his instructions are to clear the place,The intestines were very anæmic, and contained a small quan- as any cases occurring in the parish will be sent to the hos-tity of starchy fluid. Liver somewhat fatty. Gall-bladder pital instead of the workhouse. The drains throughout thefull. Kidneys granular. This patient had evidently had long- establishment have been looked to, and the hospital cleanedstanding disease of the kidneys. The other, a man who lived and coloured from top to bottom. Carbolic acid, lime, &c.,in Broad-street, is doing well. In the great epidemic about have been provided. If necessary, the resident officer will beBroad-street in 1854 the house whence this man came con- aided by a clinical assistant. Twelve beds on the ground-floortributed two deaths. Mr. Waymouth, resident medical officer, will be left for cholera cases.tells us that there is a very large amount of diarrhoea amongst Nine cases have been admitted on board the Belleisle hos-the out-patients. During the last week he has treated them pital ship since our last report, making up to the present timevery successfully with sulphuric acid, tincture of opium, and a total of sixteen entries; of these, five have terminateddecoction of logwood. Two wards, containing upwards of forty fatally. In giving a synopsis of the treatment adopted, itbeds, have been cleared, and are ready for any cases that may should be remembered that the cases have hitherto variedpresent themselves. Two other wards also could be rapidly much as to degree of severity, but that in each and both setsrendered available. of cases the treatment of which is here described was com-

Another case has been admitted into the Westminster Hos- prised one or more examples of a severe form of the disease.pital, of which Dr. Maclure, registrar, gives us the following It was decided at the commencement of the epidemic to adoptparticulars : E. H-, a stout, strong woman, aged twenty- a definite plan of treatment with sets of about six cases

eight, was admitted on July 29th, having had painless diar- seriatim, and the quinine plan was first put into action. Five erhoea since the 26th. She was seized with vomiting, cramps, cases were treated by the hypodermal injection of from threeand watery purging early on the 29th. When admitted at and a half to four grains of the sulphate of quinine, and thenoon, she was collapsed, with sunken eyes and shrunken fea- rubbing into the skin of from two to three drachms of thetures ; the arms and legs were blue and cold, and the pulse same in the form of a saturated solution. No drug was givenwas scarcely perceptible. There was frequent vomiting and by the mouth, but beef-tea was administered at very frequentpurging, with rice-water discharges. She was treated on a intervals, the surface of the body kept as warm as possible,plan which Dr. Basham found eminently useful during the and a moderate quantity of cold water allowed. Of the fiveepidemic of 1854-viz., weak iced gin-and-water freely, and cases so treated, two were fatal, and a third still lies in athe following draught every hour :-Dilute sulphuric acid, five doubtful state, having passed through the stage of collapseminims; tincture of opium, two minims and a half ; pepper- successfully, but now suffering from a severe attack of conse-mint water, two ounces. The vomiting and purging ceased cutive fever. At the suggestion of Dr. Rooke, this latter stage isduring the night, reaction had set in next morning, and the being treated by small bleedings, cold to the head, and afterwardswoman appeared to be going on well. Soon afterwards, how- blisters to the scalp. The hypodermal injection and inunctionever, she became comatose, with almost complete suppression by friction of quinine was largely used last year at Constan-of urine; the coma increased, the breathing became stertorous tinople, and, as physicians there affirm, with marked success.towards night, and she died at three A.M. on the lst of August. A system of treatment by carbolic acid was next commenced ;Two wards (containing thirty beds) have been got ready in

and has consisted in giving a weak solution of carbolic acid as

King’s College Hospital. Up to the present time six patients a drink ad libitum, of injecting into the rectum a somewhat

have been admitted under the care of Dr. George Johnson, more stronger solution of the same with starch, and of subjectingor less severely affected with cholera. One of these; a man in

the patients to its influence generally by sprinkling the diluteda moribund state, died an hour after admission. An infant

acid about and around the bed at frequent intervals, and keep-of fifteen months also died. The remaining cases, which do ing a quantity of it in an earthen vessel close at hand. Six

not seem to have been severe, are doing well. cases are being thus treated, hot air and water baths, withsimple friction, being also used ; and beef-tea, with iced drinks,

The St. Mary’s Hospital Weekly Board have decided that, given to any amount. At present the success of this plan canon the first appearance of cholera in the neighbourhood, two in nowise be determined, all these cases being now actuallylarge temporary structures shall be at once erected in the under treatment, and so in a state of transition. Dr. Rooke,grounds at the back of the hospital, and that until they can surgeon to the Dreadnought, states that the present epidemic,be completed, the first few cases shall be placed in the cottage as occurring on and about the Thames, is of a milder characterat present in the grounds, which has hitherto only been used than those of 1848 and 1854, in both of which he was activelyfor cases of ovariotomy ; so that cholera cases will be entirely engaged. This observation verifies many that have been madeseparated from the other patients. The amount of diarrhcea with reference to the epidemic as it existed last year in Easternamong the out-patients is unprecedented, but Mr. De Tatham, Europe, and in France. The results of the carbolic-acid sys-house-surgeon, informs us that they are generally found to yield tem, with those of any other remedy exhibited, will be an-quickly to the sulphuric-acid mixture of the hospital pharmaco- nounced in our next number. It should be mentioned that

poeia. A man of middle age, who had been working and lodging Dr. Domett Stone was acting resident medical officer whenfor the last week in the east of London, was admitted here on the first cases of cholera were received on board the Belleisle.Sunday morning in a state of great prostration, with dusky coun-tenance, no pulse at the wrist, rice-water purging and vomiting, . LARGE hospital ,1 treatment of infectiousshrivelled hands, suppression of urine, and inability to speak A LARGE hospital for the treatment of infectiousabove a whisper; but there was no marked loss of tempera- diseases is about to be erected in Liverpool. 98000 have

ture. Mr. Griffiths, the house-surgeon, in charge of the case, been subscribed, and the town council has made a grant ofat once gave him an opiate in brandy, applied mustard poul- :E5000 towards the cost.

tices, and ordered the sulphuric-acid mixture every two hours. M. OLLIER (OF LYONS) AND THE REGENERATION OFHe was purged eleven times in the night following, but the BONE.—This eminent surgeon occupied the attention of thevomiting ceased, and the last few stools evidently contained Surgical Society of Paris recently with two communica-bile. He was dry-cupped over the loins. He passed a little tions-one relating to the removal of polypi occupying theurine, and seemed to be progressing favourably. The secre- sal fossæ and pharynx, the other describing excision oftion of urine, however, did not continue; and, when we last joints, with preservation of ligaments, tendons, &c. Theheard, he was comatose. operation advocated for polypi is nothing less than bringingAt University College Hospital no cases of cholera have been down the nose from above like the lid of a box, and thus

received. Diarrhoea, Dr. Rickards tells us, is exceedingly rife getting easy access to the fossae and base of the skull. Theamongst the out-patients. Two wards in the south wing of nose, when raised again towards the forehead, unites in a satis-the building have been cleared, and are ready for any cases factory manner. In his excisions, M. Ollier preserves all thewhich may be sent. fibrous tissues, the ligaments, the capsule, and the tendinousIn St. George’s Hospital also two wards have been prepared. insertions; none but the osseous or cartilaginous textures are

removed, and he thus obtains an articulation of the same typeAt the Great Northern Hospital, as yet, there have been no as the joint which has been taken away. One can easily un-

cases of cholera, but amongst the out-patients a great deal of derstand such an operation upon the healthy articulation of andiarrhoea has been treated. Some cases have been exceedingly animal; but the pathological changes in joint diseases are

severe, with cramps &c. The diarrhoea has been increasing sometimes of such a nature that the author’s operation would,dailv for the last week. Where one in a family has been at first sight, appear extremely difficult, if not impossible.