- Email: [email protected]
CHOLERA AT WEST HAM.
Let our middling classes, too, from whose ranks our pros titutes are mostly recruited, learn to bring up their daughter: to some service in which they may be controlled and watched the
encouraging such notions as that "they are above bein girls; they had better turn needlewomen, when they will be more their own mistresses," has brought many a girl; servant
made and redeemed for better things, who has chosen to enlis1 in these over-stocked, and, therefore, frightfully ill-paid ranks, to penury and prostitution; while we are ready to give comfortable homes, and any reasonable amount of wages, for respectable domestic servants, so difficult are they to get. So far the remedy lies in our own hands; but there are otheI causes at work-causes in which nothing but legislative authority can interfere. Amongst the most prominent of these are1. The immoralities and indecencies of our lodging-houses. 2. The unchecked uses of drugs and ardent spirits in our gin palaces, (connived at by the publicans.) 3. The halo of excitement and pleasure with which such a life is outwardly surrounded, from harlots’ balls and the display of dress amongst these women as they flaunt down our streets, so alluring to others. 4. The influence and violence used to keep down a girl who has once found her way to a house of ill-fame. 5. The plots and intrigues of procuresses, not half punished when detected. 6. The very great difficulty of a girl being able to earn her livelihood again honestly who has once been known as a prostitute. 7. The immunity with which libertine seducers of innocent girls escape. Now our police, aided by such a Board of Morality as you propose, could do much to keep under proper control many of these causes; they could entirely put down others. Let the street-walking and harlots’ balls at once be abolished. Let brothels (not prostitutes) be regularly licensed; let Government commissioners, or a local board, or both, be appointed, having the right to enter them at any time, see that no girls are brought, or kept there, against their will; that no drugs are used; and let there be in every room of every brothel a clearlyprinted notice, that any girl desirous of quittingsuch a life, and of earning. a livelihood respectably, may At once leave, and that she will be received and trained at any Qf the refuges or homes for fallen women, of which houses, .or of some of the nearest of them, a list should be added.Let seducers be punished by imprisonment as well as fines. Thus will prevention and cure work hand in hand together. Is’ it too much to hope that something may be proposed in the fFouse of Commons during the present session ? I am, Sir, your obedient servant, R. R. HUTTON, Chaplain of Colney Hatch Asylum
NECROSIS OF THE SYMPHYSIS OF THE LOWER JAW. To the Editor of THE, LANCET. SIR,—Having observed in your report of the proceedings of the Pathological Society, of Nov. 1’i’th, that Mr. Bryant exhibited a specimen of Necrosis of the Symphysis of the Lower Jaw, removed, froma man who had previously been in King’s College Hospital, perhaps you will allow me to make a few remarks on the case, whilst it was under my observation, which may tend to render it still more interesring to your readers. It appears that the patient in question was employed in some gas-works, where he was exposed to great alternations of temperature. Fourteen years ago he received a severe blow on the left cheek; and five years ago, having in the meanwhile contracted syphilis and been profusely salivated, he first felt painsin the left cheek, which he described as being very severe and preventing him from sleeping at night. A few weeks afterwards lie perceived that the cheek was swollen. ’On going into ths couatry these symptoms slightly abated; but about six weeks ago they again returned, and the right cheek also became affected. On admission, all the teeth of the lower jaw, with the exception of the last two molars on the right side, A probe were loose, and matter oozed up from their sockets. could be passed on either side of the teeth, in each case impinging on bare bone. There was a great deal of swelling beneath the gum, and the tissues over the bone were much consolidated. On the left side the skin was red, and matter evidently existed near the surface. The whole of the skin and mucous membrane on the left side was benumbed, but pressure
588
pain and a sensation of ° pins and needles."
These sympside. Mr. Bowman, under whose care the man was, made an incision below the chin, which gave exit to some pus; and he also ordered the loose teeth to be removed. After this, the swelling about the parts diminished, and the discharge became less abundant. In a few days the necrosed portion of bone protruded through the gum at several points, and was found to be movable with a probe; but, what is somewhat important to remark, the subsidence of inflammation about the parts was attended with the return of perfect sensation. It was Mr. Bowman’s intention not to have forcibly removed the whole piece of bone at once, but to cut down on the dental foramina, chipped away the bone bit by bit, and, if possible, saved the nerve; but unfortunately the man, having behaved himself in an insubordinate manner, was discharged from the hospital two days previously to that on which Mr. Bowman had intended to perform the operation. The fact that the chin had never entirely lost its sensation, although the functions of the nerve were, perhaps for a time, interfered with by the great inflammation of the surrounding textures, is, one would think, sufficient proof that the nerve did exist, and the chance of saving it might have been worth the trial. It would be interesting to know the present condition of the parts since the removal of the bone, and whether complete or partial paralysis exists. gave
toms did not exist
on
the
right
have
T
a.m.
Sir
your
nhp.fHftif; servant.
WILLIAM PAUL SWAIN, House-Surgeon.
King’s College Hospital, Dec.
1, 1857.
CHOLERA
AT
WEST
HAM.
To the Editor of THE LANCET. SIR,—In an article inserted in your number of the 31st. ult., is a brief history of the visitation of cholera at West Ham, in which I have stated that all the cases, except that on the 10th, were without premonitory symptoms. This remark, I may explain, was intended to refer only to the fatal cases, seven in number, although inadvertently that limitation was not expressed. That statement has called fcrth two letters, in
which the writer endeavours to prove that that assertion is cases there had existed a premonitory diarrhoea for a few hours, or for a few days, or for a few weeks, and that this is invariably the case; and that the fourteenth case was not one of cholera. As he appears to have been misled by inaccurate information, it seems incumbent on me to give the correct statement more in detail. The Doctor says he called on me, and that I gave him all the information I possessed relative to these cases. That is not exactly the real state of the case. ’ I offered to give him that information, and to read to him my notes of the cases; but, to my great surprise, he declined to hear them. Thinking I had misunderstood him, I repeated the offer, which he still declined to accept. He wanted only the names and addresses of the cases. As my notes were taken from the gentlemen who had attended the cases, and as I have since referred to them to verify their statements, and have taken pains to get such corroboration as was practicable from the surviving parties, I have implicit confidence in their correctness. If the Doctor had condescended to hear these notes read, so that he might, at the least, have compared them with information derived from less reliable sources; and if he had not had a foregone conclusion to support, this unseemly discrepancy in the histories of the cases might have been avoided. The phrase, premonitory diarrhœa, is incorrect, and it would be better to drop it than to cavil about it. The really practical and useful question is, whether invariably diarrhœa is the earliest symptom of cholera, and, in every case, exists for some hours, or days, or weeks p-ior to the stage of collapse. In former epidemics of cholera, diarrhoea has usually constituted the first stage of the disease, and that symptom has continued for a period of uncertain duration before the occurrence of collapse. In a majority of cases, it has existed for a considerable period previous to that stage; and sometimes the duration of these symptoms has been very short. Sometimes cholera, in the stage of collapse, has made its attack without any preceding diarrhoea, collapse having taken place rapidly; sometimes diarrhoea has occurred, not before, but after collapse has existed some time, and just before death. On the other hand, it is not doubtful that diarrhoea, very frequently exists without the supervention of cholera at all. It is difficult, in our present state of ignorance, to distinguish the cases of diarrhoea that, if left to their natural course, would not be succeeded by collapse or death, from those cases that would so terminate; but there can be no doubt that there is a diarahœa
incorrect, and that in each of the thirteen
distinct disease, and a diarrhoea as a symptom, or an early had diarrhoea, from teething a month previous to havingcholera, stage of cholera. It is, therefore, illogical, in either case, to which lasted three weeks; she had no diarrhoea for a week becall diarrhoea a premonitory symptom; it cannot be said to be fore the attack; the bowels were not acted upon from the day premonitory of that which is not about to follow; and cannot before. On October 10th, she was seized with cramps, became be said to be premonitory of a disease of which it constitutes a cold, sickness, followed by diarrhoea, came on, then consecutive symptom. The cold stage is not said to be premonitory of ague. fever set in, she rallied, was then seized with measles on Taking the fatal cases in the order in which, in these letters, Oct. 26th, and died on Nov. 7th. as a
In all these cases, where it could be ascertained whether they are stated :CASE 1. - Mrs. Creswell, aged forty-six, was remarkably well sickness or diarrhoea occurred first, the entry has been made I remain, Sir, yours, &c., and free from bowel complaint when she went to bed. At six accordingly. At twelve, A.M. she was seized with sickness and diarrhœa. W. ELLIOT, M.D., Medical Superintendent to the Local Board of she was in a state of collapse, with cramps, loss of voice, supHealth of West Ham.
pression of urine for some hours, rice-water vomiting and purging. She died at half-past two the following morning. CASE 2.-Andrew Redpath, aged twenty-eight, had diarrhoea
for two days previously. At seven P.M. he walked to the surgery for some medicine, and back,-a distance of about a mile and a half. At half-past nine he was seized with vomiting, and he died at five o’clock the following cramps, collapse, &c.;
morning.
The previous CASE 3.-Ann Miller, aged twenty-three. evening she had a supper of bread and cheese and porter, and went to bed quite well and free from diarrhoea. At four A.M. she was seized with sickness, purging, cramps in the legs and bowels. At six A. M. the sickness and purging ceased, collapse continuing and increasing. She died at half-past three P.M. CASE 4.-George Norris, aged twenty-four. The previous day, in the morning, he had a costive motion. At half-past eight A.M. he was seized with sickness, and had an evacuation that was formed, not loose, of a yellow colour; at ten A.M. collapse took place, and at seven P.M. he died, having had purging of rice-water just before. CASE 5.-Mrs. Pigram, aged sixty. She had a purgative pill at bed-time, on account of costiveness. At four A.M she had diarrhoea; at half-past seven A.M. she had rice-water sickness and purging, collapse, and no urine had passed for several hours; at twelve she was pulseless and sinking. The following morning, at a quarter past seven, she died. CASE 6.-Joseph W. Mansfield, aged three years and a half. He was out playing, when, at three P.M., he ran into the house, suffering from cramps; sickness came on immediately, as he was being carried to the watercloset, where he was purged. He was then taken to bed; collapse came on immediately; and he died in four hours, at seven P.M. CASE 7.-Keziah Palmer, aged sixty-six. Had been bedridden for six years; was as well as usual till a quarter to eleven A.M., when she was seized with violent cramps, followed immediately by sickness, and diarrhoea which was so severe that the rice-water evacuation soaked through bed and bedding and a lot of clothes that had been thrown under the bed, and formed a stream that ran across the floor. During the attack she foamed slightly at the mouth, but was sensible until her death, which took place in about six hours. These were the fatal cases. After the narration of these cases by your correspondent, which differs in important points from the foregoing, he goes on to say: " We have here six deaths from cholera; the seventh is not one of cholera. Five of these cases had a premonitory diarrhcea for a shorter or longer period previous to the attack of vomiting, spasms, &c....... And therefore, in conclusion, I have no doubt that these six cases of cholera were preceded by a premonitory diarrhoea, for a longer or shorter period." The profession have before them this brief statement from gentlemen who attended the cases, and who had no foregone conclusion to confirm; they will form their own judgment. Of the other cases, it may be well to give a short notice. CASE 1.-Edward Dixon, aged four years and a half; had looseness of bowels two days previously to the attack, which ceased immediately; he went to school as usual; he was taken ill suddenly with cramps and sickness, followed by diarrhoea and collapse; he did not pass urine for four days. CASE 2.-Mrs. Dixon, aged thirty-two; had diarrhoea nearly a week before cramps, sickness, &c., came on. CASE 3.-Alfred Dixon, aged three; was seized suddenly With cramp, followed by sickness, afterwards by diarrhoea. CASE 4.-M. A. Sampson, aged four; had measles for nine days previously, diarrhoea, then cholera slightly. CASE 5.-Ebenezer Champness, aged sixteen; had diarrhoea for some days previously; had cholera with secondary fever, and recovered. CASE 6.-Susan Mansfield, aged twenty-nine; had ordinary diarrhoea for two days previously; she had cholera, collapse, and consecutive fever, and recovered. CASE 7.-Mary A. Mansfield, aged fourtEen months; she
HOSPITAL REFORM. To the Editor of THE LANCET.
SIR,—In your journal of last week is a letter on " Hospital Reform," in which the writer urges the appointment of a
" senior resident surgeonto our metropolitan hospitals. Having had some considerable experience in the practical working of hospitals, and having served the office of house-surgeon to one of them, I beg to protest against any such appointment, as being absolutely injurious, not only to the hospital as part of a medical school, but to the charity itself as such. And first, as regards the charity:there can be no doubt that new brooms sweep clean, and that a succession of young men who regard the office as a great privilege have advanced to it through the grades of out- and in-patient dresser, and have very possibly paid a considerable sum for it, will be much more on
the
alert, and pay greater attention
to the cases, than
paid for the duties performed, and looks upon them as so much drudgery to be gone through in order to get a livelihood. As regards the individual holding the appointment, there can be no question as to the value of the office to him in giving him practice, but still not entirely without control, and laying upon him also responan
older, perhaps disappointed
man, who is
can always obtain relief from his seniors if necessary. Would your correspondent say in which of our hospitals it is the custom to send for the surgeon immediately on the admission of a compound fracture? I never knew such a thing being done, unless the house-surgeon judged immediate amputation to be necessary. With regard to a severed femoral artery, (a very rare accident,) I can speak from personal experience. While I was house-surgeon, in a case of aneurism treated by ligature of the femoral artery, a day or two after the separation of the ligature the artery gave way at the wound, and violent hæmorrhage occurred. I don’t think a man " above thirty years of age" would have run upstairs as quickly as I did, and he certainly could not have done more-viz., arrest the haemorrhage with the hand until tourniquets were applied, and then send for the surgeon to tie higher up. In another case of haemorrhage after amputation of the thigh, I followed what I believe to be the correct practice-viz., opened up the stump, and took up the artery again without waiting for the surgeon, the patient being in a very critical state, and every drop of blood of importance. That housesurgeons are frequently fettered and harassed by the senior surgeons is too often the case I believe, but not from personal experience, and surely that is their misfortune, and not their fault. What can be more despicable than for an old, greyheaded surgeon, an examiner, perhaps, at the College, to insist upon opening every abscess and removing every little bit of necrosed phalanx, and abuse his house-surgeon in no measured terms if he has ventured to do anything himself? But that which most requires rectifying is the position occupied by the house-surgeon at operations in the operatingtheatre. I appeal to those of your readers who are in the habit of visiting the different operating-theatres of this metropolis whether operations are not conducted in a more quiet and orderly manner, with the best results to operator, patient, and spectators in that theatre (there is but one) where the housesurgeon and dressers are the regular assistants to the surgeon, the other full and assistant surgeons never so much as touching a sponge, unless their assistance is requested by the operating surgeon ? I need say nothing as to the value of this arrangement to the young men themselves, for that is sufficiently obvious, and the sooner the practice is imitated by other institutions the better. With the latter paragraph of your correspondent’s letter I cordially agree. By all means, let us have the right men in the right place.-I am, Sir, your obedient servant, JUVENIS. November, 1857.
sibilities, from which, however, he
589
encouraging such notions as that "they are above bein girls; they had better turn needlewomen, when they will be more their own mistresses," has brought many a girl; servant
made and redeemed for better things, who has chosen to enlis1 in these over-stocked, and, therefore, frightfully ill-paid ranks, to penury and prostitution; while we are ready to give comfortable homes, and any reasonable amount of wages, for respectable domestic servants, so difficult are they to get. So far the remedy lies in our own hands; but there are otheI causes at work-causes in which nothing but legislative authority can interfere. Amongst the most prominent of these are1. The immoralities and indecencies of our lodging-houses. 2. The unchecked uses of drugs and ardent spirits in our gin palaces, (connived at by the publicans.) 3. The halo of excitement and pleasure with which such a life is outwardly surrounded, from harlots’ balls and the display of dress amongst these women as they flaunt down our streets, so alluring to others. 4. The influence and violence used to keep down a girl who has once found her way to a house of ill-fame. 5. The plots and intrigues of procuresses, not half punished when detected. 6. The very great difficulty of a girl being able to earn her livelihood again honestly who has once been known as a prostitute. 7. The immunity with which libertine seducers of innocent girls escape. Now our police, aided by such a Board of Morality as you propose, could do much to keep under proper control many of these causes; they could entirely put down others. Let the street-walking and harlots’ balls at once be abolished. Let brothels (not prostitutes) be regularly licensed; let Government commissioners, or a local board, or both, be appointed, having the right to enter them at any time, see that no girls are brought, or kept there, against their will; that no drugs are used; and let there be in every room of every brothel a clearlyprinted notice, that any girl desirous of quittingsuch a life, and of earning. a livelihood respectably, may At once leave, and that she will be received and trained at any Qf the refuges or homes for fallen women, of which houses, .or of some of the nearest of them, a list should be added.Let seducers be punished by imprisonment as well as fines. Thus will prevention and cure work hand in hand together. Is’ it too much to hope that something may be proposed in the fFouse of Commons during the present session ? I am, Sir, your obedient servant, R. R. HUTTON, Chaplain of Colney Hatch Asylum
NECROSIS OF THE SYMPHYSIS OF THE LOWER JAW. To the Editor of THE, LANCET. SIR,—Having observed in your report of the proceedings of the Pathological Society, of Nov. 1’i’th, that Mr. Bryant exhibited a specimen of Necrosis of the Symphysis of the Lower Jaw, removed, froma man who had previously been in King’s College Hospital, perhaps you will allow me to make a few remarks on the case, whilst it was under my observation, which may tend to render it still more interesring to your readers. It appears that the patient in question was employed in some gas-works, where he was exposed to great alternations of temperature. Fourteen years ago he received a severe blow on the left cheek; and five years ago, having in the meanwhile contracted syphilis and been profusely salivated, he first felt painsin the left cheek, which he described as being very severe and preventing him from sleeping at night. A few weeks afterwards lie perceived that the cheek was swollen. ’On going into ths couatry these symptoms slightly abated; but about six weeks ago they again returned, and the right cheek also became affected. On admission, all the teeth of the lower jaw, with the exception of the last two molars on the right side, A probe were loose, and matter oozed up from their sockets. could be passed on either side of the teeth, in each case impinging on bare bone. There was a great deal of swelling beneath the gum, and the tissues over the bone were much consolidated. On the left side the skin was red, and matter evidently existed near the surface. The whole of the skin and mucous membrane on the left side was benumbed, but pressure
588
pain and a sensation of ° pins and needles."
These sympside. Mr. Bowman, under whose care the man was, made an incision below the chin, which gave exit to some pus; and he also ordered the loose teeth to be removed. After this, the swelling about the parts diminished, and the discharge became less abundant. In a few days the necrosed portion of bone protruded through the gum at several points, and was found to be movable with a probe; but, what is somewhat important to remark, the subsidence of inflammation about the parts was attended with the return of perfect sensation. It was Mr. Bowman’s intention not to have forcibly removed the whole piece of bone at once, but to cut down on the dental foramina, chipped away the bone bit by bit, and, if possible, saved the nerve; but unfortunately the man, having behaved himself in an insubordinate manner, was discharged from the hospital two days previously to that on which Mr. Bowman had intended to perform the operation. The fact that the chin had never entirely lost its sensation, although the functions of the nerve were, perhaps for a time, interfered with by the great inflammation of the surrounding textures, is, one would think, sufficient proof that the nerve did exist, and the chance of saving it might have been worth the trial. It would be interesting to know the present condition of the parts since the removal of the bone, and whether complete or partial paralysis exists. gave
toms did not exist
on
the
right
have
T
a.m.
Sir
your
nhp.fHftif; servant.
WILLIAM PAUL SWAIN, House-Surgeon.
King’s College Hospital, Dec.
1, 1857.
CHOLERA
AT
WEST
HAM.
To the Editor of THE LANCET. SIR,—In an article inserted in your number of the 31st. ult., is a brief history of the visitation of cholera at West Ham, in which I have stated that all the cases, except that on the 10th, were without premonitory symptoms. This remark, I may explain, was intended to refer only to the fatal cases, seven in number, although inadvertently that limitation was not expressed. That statement has called fcrth two letters, in
which the writer endeavours to prove that that assertion is cases there had existed a premonitory diarrhoea for a few hours, or for a few days, or for a few weeks, and that this is invariably the case; and that the fourteenth case was not one of cholera. As he appears to have been misled by inaccurate information, it seems incumbent on me to give the correct statement more in detail. The Doctor says he called on me, and that I gave him all the information I possessed relative to these cases. That is not exactly the real state of the case. ’ I offered to give him that information, and to read to him my notes of the cases; but, to my great surprise, he declined to hear them. Thinking I had misunderstood him, I repeated the offer, which he still declined to accept. He wanted only the names and addresses of the cases. As my notes were taken from the gentlemen who had attended the cases, and as I have since referred to them to verify their statements, and have taken pains to get such corroboration as was practicable from the surviving parties, I have implicit confidence in their correctness. If the Doctor had condescended to hear these notes read, so that he might, at the least, have compared them with information derived from less reliable sources; and if he had not had a foregone conclusion to support, this unseemly discrepancy in the histories of the cases might have been avoided. The phrase, premonitory diarrhœa, is incorrect, and it would be better to drop it than to cavil about it. The really practical and useful question is, whether invariably diarrhœa is the earliest symptom of cholera, and, in every case, exists for some hours, or days, or weeks p-ior to the stage of collapse. In former epidemics of cholera, diarrhoea has usually constituted the first stage of the disease, and that symptom has continued for a period of uncertain duration before the occurrence of collapse. In a majority of cases, it has existed for a considerable period previous to that stage; and sometimes the duration of these symptoms has been very short. Sometimes cholera, in the stage of collapse, has made its attack without any preceding diarrhoea, collapse having taken place rapidly; sometimes diarrhoea has occurred, not before, but after collapse has existed some time, and just before death. On the other hand, it is not doubtful that diarrhoea, very frequently exists without the supervention of cholera at all. It is difficult, in our present state of ignorance, to distinguish the cases of diarrhoea that, if left to their natural course, would not be succeeded by collapse or death, from those cases that would so terminate; but there can be no doubt that there is a diarahœa
incorrect, and that in each of the thirteen
distinct disease, and a diarrhoea as a symptom, or an early had diarrhoea, from teething a month previous to havingcholera, stage of cholera. It is, therefore, illogical, in either case, to which lasted three weeks; she had no diarrhoea for a week becall diarrhoea a premonitory symptom; it cannot be said to be fore the attack; the bowels were not acted upon from the day premonitory of that which is not about to follow; and cannot before. On October 10th, she was seized with cramps, became be said to be premonitory of a disease of which it constitutes a cold, sickness, followed by diarrhoea, came on, then consecutive symptom. The cold stage is not said to be premonitory of ague. fever set in, she rallied, was then seized with measles on Taking the fatal cases in the order in which, in these letters, Oct. 26th, and died on Nov. 7th. as a
In all these cases, where it could be ascertained whether they are stated :CASE 1. - Mrs. Creswell, aged forty-six, was remarkably well sickness or diarrhoea occurred first, the entry has been made I remain, Sir, yours, &c., and free from bowel complaint when she went to bed. At six accordingly. At twelve, A.M. she was seized with sickness and diarrhœa. W. ELLIOT, M.D., Medical Superintendent to the Local Board of she was in a state of collapse, with cramps, loss of voice, supHealth of West Ham.
pression of urine for some hours, rice-water vomiting and purging. She died at half-past two the following morning. CASE 2.-Andrew Redpath, aged twenty-eight, had diarrhoea
for two days previously. At seven P.M. he walked to the surgery for some medicine, and back,-a distance of about a mile and a half. At half-past nine he was seized with vomiting, and he died at five o’clock the following cramps, collapse, &c.;
morning.
The previous CASE 3.-Ann Miller, aged twenty-three. evening she had a supper of bread and cheese and porter, and went to bed quite well and free from diarrhoea. At four A.M. she was seized with sickness, purging, cramps in the legs and bowels. At six A. M. the sickness and purging ceased, collapse continuing and increasing. She died at half-past three P.M. CASE 4.-George Norris, aged twenty-four. The previous day, in the morning, he had a costive motion. At half-past eight A.M. he was seized with sickness, and had an evacuation that was formed, not loose, of a yellow colour; at ten A.M. collapse took place, and at seven P.M. he died, having had purging of rice-water just before. CASE 5.-Mrs. Pigram, aged sixty. She had a purgative pill at bed-time, on account of costiveness. At four A.M she had diarrhoea; at half-past seven A.M. she had rice-water sickness and purging, collapse, and no urine had passed for several hours; at twelve she was pulseless and sinking. The following morning, at a quarter past seven, she died. CASE 6.-Joseph W. Mansfield, aged three years and a half. He was out playing, when, at three P.M., he ran into the house, suffering from cramps; sickness came on immediately, as he was being carried to the watercloset, where he was purged. He was then taken to bed; collapse came on immediately; and he died in four hours, at seven P.M. CASE 7.-Keziah Palmer, aged sixty-six. Had been bedridden for six years; was as well as usual till a quarter to eleven A.M., when she was seized with violent cramps, followed immediately by sickness, and diarrhoea which was so severe that the rice-water evacuation soaked through bed and bedding and a lot of clothes that had been thrown under the bed, and formed a stream that ran across the floor. During the attack she foamed slightly at the mouth, but was sensible until her death, which took place in about six hours. These were the fatal cases. After the narration of these cases by your correspondent, which differs in important points from the foregoing, he goes on to say: " We have here six deaths from cholera; the seventh is not one of cholera. Five of these cases had a premonitory diarrhcea for a shorter or longer period previous to the attack of vomiting, spasms, &c....... And therefore, in conclusion, I have no doubt that these six cases of cholera were preceded by a premonitory diarrhoea, for a longer or shorter period." The profession have before them this brief statement from gentlemen who attended the cases, and who had no foregone conclusion to confirm; they will form their own judgment. Of the other cases, it may be well to give a short notice. CASE 1.-Edward Dixon, aged four years and a half; had looseness of bowels two days previously to the attack, which ceased immediately; he went to school as usual; he was taken ill suddenly with cramps and sickness, followed by diarrhoea and collapse; he did not pass urine for four days. CASE 2.-Mrs. Dixon, aged thirty-two; had diarrhoea nearly a week before cramps, sickness, &c., came on. CASE 3.-Alfred Dixon, aged three; was seized suddenly With cramp, followed by sickness, afterwards by diarrhoea. CASE 4.-M. A. Sampson, aged four; had measles for nine days previously, diarrhoea, then cholera slightly. CASE 5.-Ebenezer Champness, aged sixteen; had diarrhoea for some days previously; had cholera with secondary fever, and recovered. CASE 6.-Susan Mansfield, aged twenty-nine; had ordinary diarrhoea for two days previously; she had cholera, collapse, and consecutive fever, and recovered. CASE 7.-Mary A. Mansfield, aged fourtEen months; she
HOSPITAL REFORM. To the Editor of THE LANCET.
SIR,—In your journal of last week is a letter on " Hospital Reform," in which the writer urges the appointment of a
" senior resident surgeonto our metropolitan hospitals. Having had some considerable experience in the practical working of hospitals, and having served the office of house-surgeon to one of them, I beg to protest against any such appointment, as being absolutely injurious, not only to the hospital as part of a medical school, but to the charity itself as such. And first, as regards the charity:there can be no doubt that new brooms sweep clean, and that a succession of young men who regard the office as a great privilege have advanced to it through the grades of out- and in-patient dresser, and have very possibly paid a considerable sum for it, will be much more on
the
alert, and pay greater attention
to the cases, than
paid for the duties performed, and looks upon them as so much drudgery to be gone through in order to get a livelihood. As regards the individual holding the appointment, there can be no question as to the value of the office to him in giving him practice, but still not entirely without control, and laying upon him also responan
older, perhaps disappointed
man, who is
can always obtain relief from his seniors if necessary. Would your correspondent say in which of our hospitals it is the custom to send for the surgeon immediately on the admission of a compound fracture? I never knew such a thing being done, unless the house-surgeon judged immediate amputation to be necessary. With regard to a severed femoral artery, (a very rare accident,) I can speak from personal experience. While I was house-surgeon, in a case of aneurism treated by ligature of the femoral artery, a day or two after the separation of the ligature the artery gave way at the wound, and violent hæmorrhage occurred. I don’t think a man " above thirty years of age" would have run upstairs as quickly as I did, and he certainly could not have done more-viz., arrest the haemorrhage with the hand until tourniquets were applied, and then send for the surgeon to tie higher up. In another case of haemorrhage after amputation of the thigh, I followed what I believe to be the correct practice-viz., opened up the stump, and took up the artery again without waiting for the surgeon, the patient being in a very critical state, and every drop of blood of importance. That housesurgeons are frequently fettered and harassed by the senior surgeons is too often the case I believe, but not from personal experience, and surely that is their misfortune, and not their fault. What can be more despicable than for an old, greyheaded surgeon, an examiner, perhaps, at the College, to insist upon opening every abscess and removing every little bit of necrosed phalanx, and abuse his house-surgeon in no measured terms if he has ventured to do anything himself? But that which most requires rectifying is the position occupied by the house-surgeon at operations in the operatingtheatre. I appeal to those of your readers who are in the habit of visiting the different operating-theatres of this metropolis whether operations are not conducted in a more quiet and orderly manner, with the best results to operator, patient, and spectators in that theatre (there is but one) where the housesurgeon and dressers are the regular assistants to the surgeon, the other full and assistant surgeons never so much as touching a sponge, unless their assistance is requested by the operating surgeon ? I need say nothing as to the value of this arrangement to the young men themselves, for that is sufficiently obvious, and the sooner the practice is imitated by other institutions the better. With the latter paragraph of your correspondent’s letter I cordially agree. By all means, let us have the right men in the right place.-I am, Sir, your obedient servant, JUVENIS. November, 1857.
sibilities, from which, however, he
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