803

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS of LONDON.

GUY’S HOSPITAL.CLINICAL REMARKS ON MISCELLANEOUS CASES.

(By Dr. WILKS.)

Nullaautem est alia pro certo noscendi via, nisi quamplurimasetmorboruniet dissectionum historias, tum aliorum, tum proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Prooemium.

On the Diagnosis of Diseases of the Stomach and (Esophagus.- An emaciated man, fifty-three years of age, was admittedon May llth, with supposed disease of the stomach. The

following were the chief points in the history of the case:for eight months past severe pains over the stomach, andalmost immediate return of swallowed food, particularly ofmeat and dry solid matter; profuse haematemesis on twooccasions; loss of flesh. Dr. Wilks stated that in cases ofthis kind it was necessary for the medical attendant to findout for himself whether there was immediate regurgitationof the food after deglutition, or vomiting occurring sooneror later after this act, but still not until the passage of thefood into the stomach. The former symptom would indicatesome contraction of the cesophagus; the latter, disease ofthe stomach-probably cancer or gastric ulcer. Haemorrhagefrom the stomach varied very much in amount, accordingto the nature of the case: in cases of gastric ulcer it mightbe slight or severe ; but when due to liver disease it wasalways excessive, since the bleeding must necessarily beassociated with extreme engorgement of the portal system.Pain in the epigastrium was invariably present in cases ofvomiting, even with sea-sickness. Severe fixed pain wasnot a constant symptom of ulcer of the stomach; occasion-ally it was very slight and not a source of complaint, whilstin other instances it was very acute. In the latter class ofcases the peritoneal coat of the stomach was generally in-volved in the ulceration, and had probably become adherentto some neighbouring part. In one case, related by Dr.Habershon, twigs of the pneumogastric nerve were foundinvolved in the margin of the ulcer. Dr. Wilks was inclinedto look upon the present case as one of disease of the

oesophagus, since the food was either regurgitated imme-diately after deglutition, or, when retained for a short timebefore its return, was distinctly felt by the patient himselfin a fixed position at the lower end of the gullet. Small

fragments of toast or dry bread could be passed into thestomach with difficulty, but the bolus when mixed with teaor some other fluid was immediately returned. Dr. Wilksdid not look with any favour on the plan of passing bougiesfor the treatment of disease of the oesophagus from morbiddeposit. The contraction of this tube from this cause isnot of inflammatory origin, nor analogous in any way to astricture of the urethra, and cannot be treated with successby a process of stretching.

Lumbago.—There is at present in the hospital a case ofthis troublesome affection in a strong, muscular man, per-fectly healthy, with the exception of severe pain in thelumbar region whilst walking or moving his back. Dr.Wilks stated that this patient had been treated as an out-patient for this affection during nine months, chiefly by in-ternal remedies, but without gaining any relief. It wasthen decided to admit the man into the hospital, and totreat him by repeated subcutaneous injections of morphia,and afterwards, in case of this method failing, by the ap-plication of galvanism. Cases of acute or recent lumbagowere generally amenable to warm stimulating applications,as hot air, steam, fomentations, hot water; and tincture ofcapsicum ; but when the affection had become chronic, itwas frequently most intractable. Dr. Wilks has seen goodresults from the subcutaneous injection of morphia in caseswhere a prolonged medicinal treatment had been of no avail.

Galvanism, also, was stated to be equally beneficial in ob-stinate cases.

Bichloride of Mercury in the Treatment of Nervous Affec-tions. -A man, forty years of age, received, two months’before his admission into the hospital, a severe blowupon the back of the head. This injury was followed bypersistent and severe frontal cephalalgia, occasional tem-porary attacks of loss of consciousness, and, on one occa-sion, loss of power in the right arm. On admission, therewas great nervous excitement and restlessness, and impair-ment of consciousness. These symptoms soon subsided onthe administration of small doses of bichloride of mercury.The general nervous affection passed off, and left the patientin a good state of health, with the exception of the pain inthe head, which still persisted. Dr. Wilks speaks favour-ably of the good results of preparations of mercury in casesof obscure nervous affections with much irritability andmental disturbance. A case of this kind was also alludedto, in which the failure of many other remedies was speedilyfollowed by the successful administration of five-grain dosesof grey powder.

Bright’s Disease.—In some remarks on a case of renaldropsy and bronchitis, Dr. Wilks pointed out the rigid stateof the radial artery; and stated that the early researchesof Dr. Bright on the morbid appearances of the renalarteries, and the recent investigations of Dr. Johnson onthe general condition of the small arteries of the body indisease of the kidney, taken together with several patho-logical facts, among which he mentioned that of the exist-ence of Bright’s disease in a great majority of patients whohave died from apoplexy, all went to justify the classifyingof this affection with the general, instead of with the strictlylocal, diseases of the body. In this special case, Dr. Wilksstated, incidentally, that there was a slight but persistentfriction-sound on the left side of the chest. This he be-lieved to be a dry pleuritic rub, caused by some rougheningof the pleura without adhesion. Although it was easy tocomprehend how this condition might really happen andremain persistent, opportunities for hearing a dry sound ofthis nature very rarely occurred.

ROYAL FREE HOSPITAL.NEW INSTRUMENT FOR THE OPERATION IN FISTULA

IN ANO.

IN a recent case of operation for fistula in ano, instead ofthe usual plan of introducing the bistoury through thefistula, and bringing it down through the sphincter, Mr.Weeden Cooke used a scissors constructed for him byMessrs. Weiss. The finger having been introduced into therectum as a guide, Mr. Cooke passed one blade of the scissorsinto the fistula up to its extreme point, and then the otherblade into the rectum. The two blades were then connectedby a small screw, and by one rapid scissors action thesphincter was divided.As the position required for this operation renders it un-

advisable to give chloroform, and as the patient, unless verycarefully held by assistants, often shrinks so as greatly toembarrass the surgeon, any plan which ensures rapidity isadvantageous, and it is with this view that the mode ofoperation described has been suggested. It was thoughtthat it caused less pain than the bistoury.CASE OF ACUTE NECROSIS OF THE TIBIA; AMPUTATION

OF THE THIGH.

(Under the care of Mr. J. D. HILL.)Mr. Hill lately performed amputation of the thigh for acute

necrosis of the tibia and disorganisation of the contiguousknee-joint. The case, a somewhat rare one, was that of oneof the porters of the Royal Orthopaedic Hospital, a youngman of rheumatic diathesis, who had enjoyed pretty goodhealth until about a month previously, when he was at-tacked with febrile symptoms, erratic pains about the largejoints, followed by acute pain on the inner aspect of thetibia. This was succeeded by a circumscribed swelling atthe seat of pain, and effusion into the contiguous knee-joint ; subsequently, diffuse cellular inflammation affectedthe whole extremity, and double pneumonia and pericarditissupervened. The excessive discharges of pus from abscessesconnected with the joint and the necrosed tibia, and the