CLINICAL REMARKS, BY DR. BRINTON, AT THE ROYAL FREE HOSPITAL.

position, by strongly contracting the flexor muscles of the limits which the bladder and constitution are capable of enfingers of the right hand, the male branch is driven forwards during. As a general rule, therefore, I advise that chloroform with a kind of jerk on the stone, which, if not too hard, is should not be administered, and the chief exceptions which I soon crushed by a few movements of this kind. During this would make are in nervous patients-females, for instance, and manipulation, the right elbow should be firmly kept against children. the side. Should the calculus not yield to the action of the (To be continued,) hand, nothing is easier than to bring the screw of M. Civiale’s instrument into action. The catch-box is turned from right to left; this allows the screw to play, the action of which is de- CLINICAL REMARKS, BY DR. BRINTON, veloped by turning the fly-wheel attached to the extremity of the instrument. AT THE ROYAL FREE HOSPITAL. Even this manipulation will not always succeed, for any considerable enlargement of the middle lobe of the prostate has IT has repeatedly been suggested to me by professional the effect of creating a depression in the floor of the bladder conversant with the number and importance of the friends, immediately behind the enlargement, in which depression the cases constantly under my care at the Royal Free Hospital, calculus often lies concealed, and escapes the instrument. In cases of this kind, as I mentioned in the former paper, the that, in the absence of any such reports of them as might be lithotrite should be two or three inches longer than those in given by Clinical Lectures, a few brief remarks on some of their ordinary use; its beak must be reversed, and carried down- more characteristic features would often have sufficient interest wards till it reaches the stone. to deservepublication in THE LANCET. For many years, howAgain, when the calculus is large and dense, the bladder con- ever, I have not complied with these suggestions; in the hope is the tracted, and the instrument employed long beakedi lithotrite with narrow blades, we cannot adopt the manipula- of being able to incorporate such experiences, either with vari. tion applicable to simple cases. The various movements pre- ous monographs, on the one hand, or with clinical instruction viously described are unnecessary, and cannot safely be executed in a recognised Hospital, on the other. in the contracted and probably sensitive bladder. In cases of The circumstances which induce me now to modify this resothis kind there is little difficulty in finding the stone, because I need not detail; save to point out, that the contrast lution it is usually large; but, for the same reason, there may be considerable difficulty in seizing it. The instrument, slightly between the amount of an Hospital Physician’s practical duties, opened, is laid sideways on the stone, and the two branches and of his literary leisure, soon forbids anyone who rightly apare gradually separated until the edges of the foreign body are preciates the responsibilities of authorship from attempting to touched, when the attempt is made to fix it. write on many diseases, even in the sense of contributing mer When, in simple cases, the stone has been broken by the Essays on certain of their aspects. And since, for some time pressure of the hand or the screw, the surgeon may proceed to crush some of the larger fragments, provided the whole opera- past, I have rarely gone round the wards unaccompanied by tion has not occupied more than five or six minutes. As a rule, some student or practitioner, to whom explanation or illustra. however, little more should be done at the first operation than tion has often been a matter of common professional courtesy, to break the stone once.. Before withdrawing the instrument I have gradually found myself talking what, rather to my owa from the bladder, it is absolutely necessary to ascertain that auditors have sometimes challenged as being, for the branches are perfectly closed, and that no fragments of the surprise, my all practical purposes, clinical instruction. stone or detritus are retained between them. I believe that is not, however, in this light that I would offer the clinical It to of the the neck the injury bladder, chiefly produced by débl’is between the blades of the lithotrite, and in other cases remarks of which the following form the first illustration. Inby the shortness of the instruments employed, is a frequent struction in an art like that of Medicine should, doubtless, be cause of mischief after lithotrity. If any fragments or detritus actual demonstration rather than by verbal description. remain, they must be got rid of, either by renewing the pressure by And as examination at the bedside now seems likely to be until the female branch is completely emptied, or by giving a few turns backwards and forwards to the screw. adopted as a means of finally testing the student’s fitness for The completion of these manipulations implies that a certain practice, it may be hoped that, by-and-bye, the Examining portion of the stone has been sufficiently reduced to pass off by Bodies will dispense with the clumsy expedient of merely rethe urethra without difficulty. The last step of the operation, the number of beds in an Hospital; and will accept therefore, consists in immediately freeing the bladder from the cognising the student who can detect and treat disease, without asking detritus. If the operation has proceeded in a favourable manwhether he has learnt to do so by working sedulously in a ner, the patient is placed in the erect posture, and a full-sized metallic catheter, with a slit on the upper surface near its ex- small Hospital or a large one. But however limited is now the tremity, is then introduced. The fluid which is in the bladder range of the private clinical instruction I have to give, and being withdrawn, some tepid water is repeatedly injected until whatever the difficulties and discouragements which balance the patient complains of fatigue or no detritus comes away. I its usefulness, I cannot but think that brief casual remarkshave often been surprised, however, to find that the quantity of d6bris which comes away with this injection is small com- "here a little, and there a little,"-such as form the staple of pared with what exists in the bladder, and comes away two or this bedside demonstration of disease, might sometimes convey, three days afterwards by the natural efforts of micturition. even to those of us who are more advanced in the study of our In some complicated cases, where considerable enlargement of profession, a livelier idea of any ordinary case than systematic the prostate exists, it will be much easier to introduce the detail days and hours, and continuous sympcatheter while the patient is in the recumbent posture, and in reports, which toms, with wearisome iteration. this position wash out the bladder. And here let me incidentally mention a plan by which I In ordinary cases, four or five operations will suffice for the removal of the stone. The interval between the first and have long wished to see clinical instruction imparted in our second should be longer than that between the other opera- recognised Hospitals. I dare not trust myself to point ott the tions. After the first crushing, even when performed with the defects of our existing system, or to contrast the average of utmost caution, febrile symptoms often supervene, together instruction of this kind given in London with the more careful with local irritation, which it may require one or more weeks and conscientious efforts which seem to be made by our brethren to subdue before the crushing is repeated. Between the subse- in Dublin and Edinburgh. But if our present system of teachquent operations an interval of only a few days may be neces- ing is to be maintained, I think it should be made to aim less at the training of a few clinical clerks or dressers (often of sary. Whether chloroform should be employed in lithotrity, is: superior diligence and capacity) to great excellence, than at a question which the surgeon will have to determine. Twoaffording every pupil possessed of average ability and industry high authorities, Sir B. Brodie and M. Civiale, have pronounced the opportunity of acquiring a fair practical skill. And just against the use of chloroform, and in two cases only during theas it is by the number of pupils so taught how to benefit the last four years have I resorted to its use. Lithotrity is not; public that I should estimate the usefulness of the clinical necessarily a painful operation, and the feelings of the patient; teaching at any given hospital, so I am sure it would be easy must be looked to as our guide in two important particulars. to devise a plan by which every student in the course of his They serve to indicate whether any serious injury is inflictedl career should fall under the close personal supervision and on the soft parts by our manipulations, and they assist us inL teaching of a clinical Demonstrator; to be either passed on to determining whether the operation is carried on within thosethe above valuable appointments as really qualified to hold 82 ‘

.

and to even

or telegraphed to the Hospital authorities, or NOTES ON Examining Bodies, as having, perhaps from some most aside this important ATROPHY AND DEGENERATION OF THE reason, voluntarily put practical improvement, when pressed on his acceptARTERIES, ETC.

use

them,

to the

sufficient means of

ance. I am aware

of the difficulties which oppose such a plan, and BY EDWIN CANTON, ESQ., F.R.C.S., the obstacles it would assuredly meet with. But as I have the SURGEON TO THE CHARING-CROSS HOSPITAL, AND LECTURER ON SURGICAL ANATOMY. very best means of knowing how much practical demonstration can really do in clinical medicine-how much, namely, it has done in the case of pupils of my own-I venture to think that PART III. this suggestion, of systematically carrying out what has casually been long proposed and adopted by the most eminent teachers JAMES P-, aged fifty-three, a cabman of well-hnown inin Great Britain, is not unworthy of mention. In any case, what between the wide publication which this suggestion now temperate habits, was admitted into the Charing-cross Hosreceives in THE L--NCET, and the repeated attempts I have pital, under my care, on the 8th of May, 1858, with a commade to secure for some such plan as the preceding a trial in pound fracture of the lower third of the tibia and fibula. The one or two of our larger Hospitals, I may at least claim to have external wound was not an inch in length. The bones were uttered the conviction which fourteen years of teaching and readily adjusted, and the edges of the opening over them easily lecturing have impressed upon me. Liberavi animam rneam. In concluding this brief introduction, I have but to warn brought together. A small quantity of blood only had been the reader not to expect in the following "remarks" any- lost. No other injury had been received, and the recovery thing more than such a term strictly implies. But I hope from shock was apparently speedy. It was soon to be perthat their fragmentary character will not seriously diminish ceived, however, that the reparative powers were in abeyance; their usefulness. I believe that it need not prevent me from man’s spirits were always depressed; his countenance, at the occasionally making them the vehicle of some novel details first plump, soon became jaded, and the listless expression of of practice, suggested to me by many years of arduous hospital work. They will be illustrated neither more nor less the eyes spoke of gloomy forebodings ; there was no rallying copiously than it is my custom to make sketches or diagrams smile betokening force. In twenty days from his admission he help verbal descriptions in the wards. And lastly, while I i died from pyaemia, without having displayed a single hopeful can only promise their careful revision, I can at least guarantee I that, whether as remarks or Lectures, they will faithfully report symptom. At the autopsy, the body was seen to be moderately well the particulars to which they refer. stored with fat, and though the age was but fifty-three, there IRREGULAR AGUE. existed in each cornea a broad circle of fatty degeneration. In this bed is an Italian, suffering from an ague, extra- Thorax well formed. Cartilages of the ribs to a great extent and presented under the microscope fatty degeneration ordinary only in the length (five days) its intermissions have ossified, for some time offered. His spleen is enlarged (here its outlines where calcification had not yet taken place. There was a large quantity of pus in the right pleural cavity. Lungs healthy. were marked out), though so moderately, that unless Mr. me at the to tap out- The trunk of the left coronary artery of the heart presented, (a student present) will kindly permit side of his coat, as a sort of exea°inzentum c1’ucis, I can hardly here and there, calcareous scales, and its branches were speckled between their coats. The heart itself was hope you will fully realize this fact. Measured thus accurately, by fatty deposits firm in substance/but its fibres were, in many parts, by anyone thoroughly versed in auscultation, scarcely one spleen tolerably in a hundred fails to show some abnormal enlargement during in an advanced stage of fatty degeneration. All the valves (often long after) an ague. Our patient, whose next paroxysm were normal.* Abdomen : Liver large, pale, and fatty, confalls due to-morrow, will probably never have another fit, and taining abscesses of various sizes. Spleen quite pulpy, and in some parts almost diffluent. Kidneys pale, and the middle may go out well in a fortnight. (He has since done so.) His case recalls a very good illustration of the Protean portion of each showed fatty degeneration.! The aorta, in its presented atheromatous patches and calcareous aspects of ague, in a countryman of his, who, a few weeks ago, entire length, This condition pervaded also the iliac and femoral of or plates. the same A bed. Piedmontese, forty-five fifty - occupied years old, came in with great general anasarca. The heart was arteries. The larynx was almost completely ossified, --inclusive weak, but otherwise healthy; the urine, though scanty and of nearly the whole of the arytenoid cartilages; those portions concentrated, was also otherwise healthy, both chemically and which were as yet unaffected by bony change were involved fibrous and fatty degeneration. microscopically. His face, and a peculiar booming first sound byP—— was a well-built man, of only fifty-three YCW’S of age, of the heart, thin almost to a blowing character, suggested much older; in "living on his forces" coiistitittionally But know the though if the toil, aguish poisoning. privations, you and the filthy crowded dwellings of some of these poor he had lived too fast, and undermined their integrity. He was foreigners in London, you will see that his pallor and debility in constant exposure to all states of weather, and the habitual excitement of dram-drinking and cab-driving. Gradually inmight well have been due to other than malarious causes. Of course I eagerly searched his history. But he spoke creasing impairment of nutrition resulted, eventuating in nothing save a Piedmontese pcäoÍ’5, not easy for me to compre- atrophy and degeneration. The great extent to which the * hend. However, our dialogue soon made me quite sure that " In the course of some investigations made in the year 1649, I was led to he had never had anything akin to ordinary ague. His brain, observe, that fatty disease of the heart and disease ot the valves were not found together. This was at first an impression; but as these may however, was enfeebled. His story, poor fellow, always took usually sometimes be erroneous, I set about collecting data on which to found solid me b:1c1;: to his wife’s death in Italy, from typhoid fever, some conclusions, and in a short time had collected some 53 eases. Of these, I three years ago, and the suffering he endured in watching and found the valves were healthy in 43, which left only 10 of an opposite character. Here, then, was a fact of some consequence, and which I have taken every nursing, to finally lose her. of testing since, and with no other result thsn still further con" The spleen was a trifle larger, but scarcely duller to per- opportunity firming the point. I have noted 152 additional cases, so that the entire, now, have been. should than it Remember the difference amount to 205. These numbers, I thin]:, speak for themselves, and appear to cussion, between these two points. A thin, flat, solid cake, over a cavity myself to prove that valvular diseaseand fatty heart are rarely eo-existent."— M.D.: "Edinbmgh Medical Journal," No. xlix., p. 15, July, 1S59. like the cardiac end of the stomach, gives you quite a tympanitic H.tKennedy, The following interesting case is extracted from Dr. Todd’s " Clinical sound. It is the tone sype2-acided to thifs which, at the thin Lectures on certain Diseases of the Uiinary Organs and Drupies" (p. 83, A copper-plate printer, and by the nature of his avocation edge of the spleen, marks its widened outline; a fact which I London,to1857):-" great vicissitudes of temperature. His age is hfty-flve years. He just now demonstrated, though I cannot well describe it in subject denies being an intemperate man, but admits that his habit h1s been to drink words. Dullness to percussion means thickening. about two quarts of porter and a quartern of gin daily. He never had rheucomplaints. "Here, then, I was left to make a diagnosis. A spleen, matism or gout, nor have any of his family suffered either of these On examining the eyes, each cornea exhibits a well-marked arcus senilis. which might mean little; a face and heart, which might mean " This patient was under treatment for many months, suj’er;:ig’ from renal many things. A dropsy, utterly disproportionate to every- dropsy, of which he eventually died. "A post-mortem examination was made of the abdomen only, when the thing else, and very rare as the chief or sole symptom, even in kidneys were found to be larger than natural, and presented exceedingly good regular ague. And a history which suggested nothing at all. Itrusted to that professional instinct which had mentally specimens of fatty degeneration of these oigans, exhibiting under the microthe usual characters of this form of renal disease." Hashed into an opinion the moment I saw the patient’s face, scope Dr. Christison, in speaking of intemperance, in its different degrees, as a and before I even reached his bed-side. Under quinine and cause of granular degeneration of the kidneys, observes : "Iam not prepared state the exact proportion of cases referable to one variety or another of iniron, and a generous diet, he recovered from his dropsy in little to but I certainly am within the mark in stating it at three-fourths, ’more th&.n a fortnight; and went out of hospital comparatively temperance, or even four-fifths, of the whole:’-" Oa Granular Declaration of the Kidnevs." n. 110. Edin1mr2’1->. 1R39. ruddy, fat, and strong, in little more than a month." -

’’

’

c

83