CHOLERA IN THE METROPOLITAN HOSPITALS.

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our previous visits it was painful to pass from bed to bed and find any exception to a hopeless or actually dying condition of its occupant. Deep collapse, with marked duskiness of face and blueness of extremities, was the rule; and where, as in some cases, reaction was taking place, this was either imperfect or attended with local congestions as fatal to the patient as collapse itself. On Sunday, however, there was a notable change. The number ofpatients actually under treatment was greater than ever (theremust havebeen upwards of eighty); but the impression which was produced upon the mind by observation of the cases was much more favourable. Some of the patients were convalescent; others, in very considerable number, were evidently tending towards the same desired result. There were still, however, many whose condition left little or no hope of recovery. The labours of the staff, both of medical ofticers and nurses, continue of course to be of the most laborious kind. Although additions have been made to the staff of nurses, the number is yet below that which is necessary for the care of patients affected with a disorder which demands probably more constant and arduous attention than any diseased condition admitted into hospital. The zeal and energy of the five resident officers continue unabated ; but one cannot help regretting that their labours are not supplemented by the aid of numerous advanced students, who might now be rendering valuable service by carefully observing and recording the progress of the various patients. Cholera is a disease which is so rapid in its course that, to keep pace with its phases, a much more constant supervision is required than is usually necessary even in cases of fever. We cannot help, therefore, feeling somewhat surprised that more of the students receiving their education at the hospital have not thought it either profitable or honourable to delay their vacation for a week or two, and lend a hand in a time of such great need. This feeling has been forced upon us especially in reference to the use of the thermometer. The employment of this instrument in acute diseases is of comparatively recent origin in England. Its use was unknown during the last epidemic in 1854. The thermometer furnishes a guage of the intensity of collapse, which is of the highest importance, inasmuch as it is exact and independent of various modifying conditions of external temperatureand the observer’s impressions. It will become a very great point in the record of cholera cases to note down, not that the " skin was cold," but exactly to what level the mercury falls. In observations of this kind Darticularlv. advanced students. with a verv little instruction, might be made of the greatest assistance.. As it is, the use of the thermometer was commenced in the earlier The dimensions of the tumour at the time the drawings cases by Mr. Fredk. ialackenzie, and continued with praisewere taken were the following : - Length anteriorly, 3 in, ; worthy energy until the large number of cases admitted renbreadth at 4 & f r a c 1 2 ; in.; centre, 2§in.; thickness, dered it simply impossible to continue the records. Mr. Maclength posteriorly, 1-1in. In the engravings the tumour is made to appear thicker kenzie succeeded in applying the instrument at frequent inin proportion to its length than it really is, otherwise it gives tervals in the cases of twenty-four patients. The lowest -a very good representation of it. temperature observed was 90¼° Fahr., in a boy aged fourteen years, whilst in a state of collapse. In other cases the decline Donington, Lincolnshire, July, 1866. of temperature approached this ; but in none of those examined did the mercury fall lower. It was found that in patients who died in collapse, the temperature would rise as death was imminent, and attain the height of from 98° to 100°. The boy whose case we have just referred to recovered from collapse, but died from congestion of the lungs. He was for some OF OF THE PRACTICE time delirious, and when we saw him on the 24th he was occupied in counting aloud incessantly. This phenomenon MEDICINE AND occurred also in a woman who died whilst in the stage of reaction. We were informed by the resident officers, Dr. IN THE James Jackson and Mr. F. Mackenzie (to whom for their HOSPITALS OF LONDON. courtesy in giving us information upon various points we are much indebted), that those who died during reaction generally had the lungs congested. An effort was made to Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morbotmt inject the veins of the boy above mentioned ; but on cutting - et dissectionum historias, turn aliorum, tum proprias collectas habere, et inten down upon one at the bend of the elbow, a small thread se comparare.—MORGAGNI De Sed. et Caus. ltlorb., lib. iv. ProŒmium. only was found, into which it was impossible to insert the syringe. The lad’s arm became afterwards much inflamed, the inflammation (of an erysipelatous character) extending up CHOLERA IN THE METROPOLITAN to the axilla. It has been observed that this tendency to inHOSPITALS. flammation of sore places was very marked among the cholera THE severe outbreak of cholera in the east of London has patients. The sufferings of patients from cramp have been excessive. appeared to die quite suddenly in a continued during the past week to furnish daily a large number state of Many, indeed, cramp. It seems probable that in such cases the of cases to the London Hospital. diaphragm has been affected with cramp. In two cases an eruption resembling psoriasis appeared Up to the present time, as will be seen by the table appended, 336 cases of cholera and diarrhcea have been admitted; of which on the skin. In one, a man, this appeared to be of syphi144 have died and 110 remain under treatment. In a visit which litic character; in the other, a woman, in whom we examined it, there were no signs of specific origin. Certainly we paid to the hospital on the 29th, we were gratified to find a marked change in the aspect of the wards. On the occasion neither of these should be confounded with the specific cholera

scarcely

A Mirror

SURGERY

.

122 eruption

to

which, under the title Roseola Cholerica, we relast impression. In another case, however, which we saw on the 29th, the cholera eruption was very distinctly marked. The patient was a robust sailor, twenty-five years of age, who was the oldest surviving patient in the cholera wards. He was admitted on July 17th, had gone through collapse, reaction had taken place, and the eruption was first ferred in

our

Retit2-it of

cases

admitted into the cholera wards of the London the week ending August 2nd.

Hospital for

observed, we believe, on the 28th. At the time of our visit he was in that state of semi-stupor, with injected conjunctivæ, which is so commonly observable. The rash was developed principally about his throat and chest. It much resembled that of measles in shape, but its colour was much brighterperhaps a scarlet pink would best describe it. The eruption was somewhat raised, and disappeared with rapidity upon pressure-returning, however, very quickly when the finger In St. Bartholomew’s Hospital thirteen cases of cholera have’ was removed. been admitted, of which two have died. Seven patients now Amongst the accidents resulting from imperfect purification remain under treatment. Through the courtesy of Mr. Wood, of the blood during reaction, glandular swellings of the face the resident medical officer, we had an opportunity of seeing and neck have been observed in twocases. We examined one these and learning a few particulars about them. Of patients of these. The patient was a woman who was admitted from the two fatal one was a boy who came from a ship lying Shadwell on July 20th, and who lay in a state of deep collapse at Blackwall. cases, He had been employed on board as a drover, for three days. As reaction ensued, dense swelling took place after the cattle with which it was freighted. The about the parotid and submaxillary gland on the left side of looking we understood, was a nurse, who became affected with her face. The surface was somewhat reddened, the swelling other, cholera when only one patient had been admitted. Another very hard, and pressure caused some pain. We saw also a of the nurses was still a patient at the time of our visit: her child, two or three years of age, who had rallied from long- attack seemed to date from her sleeping at a house in Coldcontinued collapse, and in whom the lower half of each cornea where her mother had died of the disease. The bath-square, was ulcerated and opaque; a condition doubtless due to deother patients whom we noted came from Mitre-court, Johnfective nutrition from the imperfect quality of the blood which Several women, we heard, have died in street ; Curtain-road, Shoreditch; Hackney; Angel-alley, was being circulated. Charles-street, Bethnal-green. Among the a state of pregnancy at various stages. One woman gave birth Bishopsgate-street; cases was one of great interest and importance. A girl aged to a dead child, and died a few hours afterwards. We fifteen was admitted July 27th in a state of collapse, after a a a of who had at saw woman in state miscarried collapse diarrhoea of four or five days’ duration. She improved so, five months the night before. There was comparatively little much that on the 29th it was thought likely she would be able and of a darker colour what there was haemorrhage, appeared to go out very shortly. On that day she ate some pastry which than usual. No milk was present in the breasts. Another a foolish friend managed to smuggle into the ward for her. young woman with a child fourteen months old at the breast Shortly afterwards she was seized with vomiting, and again was admitted on the 26th. that she had her said suckled She sank into deep collapse, in which condition we saw her on the infant on that day. We chanced to see the child. It looked 30th. This is not an uncommon conserecurrence of tolerably well, but the person in charge of it said that its bowels quence of injudicious dietcollapse recovery, and we have seen during were purged, the motions, however, being dark-coloured. death itself caused by it where the patient had been previously The devastation amongst the families of the poor caused b3 convalescent. A man whose wife had died from cholera at this outbreak must be terrible. We were informed of nume. home, and who had taken for some days frequent doses of rous instances illustrating the mode in which the disease swept brandy on account of diarrhoea, was admitted on July 27th suddenly through whole households. There was a German with cholera. On the following evening he was attacked with had of at which thus The mother died cholera suffered. family delirium tremens, got out of bed and ran up-stairs, being, as home, three children were taken into the hospital with thE he told us, under the impression that his children were on fire. disease, where one died, and the others still remained in a The following day he managed again to slip out of bed, and critical condition. The father was in Whitechapel workhouse, smashed the windows of the ward. He was very much betterwhere, we understood, overpowered by his sudden affliction, at the time of our visit, and could talk rationally about what he had tried to destroy himself. In another instance, the had happened. father of a family died in the hospital; the mother now lies who had the advantage of witnessing the twa Mr. there likely to do well. Of their four children, all admitted former Wood, of 1849 and 1854 whilst in the hospital, is with the disorder, one is dead, and the others (of whom one is inclinedepidemics to think the type of the present cases less severe than but six months old) still remain under treatment. They at first appear, he told us, as bad as possible, Upwards of forty autopsies have been made by Dr. Hughlings formerly. but gradually improve instead of becoming worse. In the and Dr. the medical Jackson Sutton, pathologists. As accurate last out of 400 cases admitted in St. Bartholomew’s records as were practicable have been kept of these, and will, 200 died. For our own part we have as yet seen in no hosbe We believe a that doubtless, eventually published. great pital cases marked by the intensity which characterized the of the lungs has been generally obdiminution of the weight admitted during the first week at the London Hospatients served in the patients who died during collapse. In deterThe treatment which is being adopted here consists mining the pathological value of this sign, it will, of course, pital. of calomel and opium, with baths, sinapisms, and beefmainly have to be remembered that in cholera, where the discharges tea There are twenty beds in readiness for cholera injections. have been excessive, the absolute quantity of circulating fluid cases, and, if need be, the whole wing in which these wards are is so far diminished that a lessened gravity of organs, whose situated can be devoted to this class. A staff is orweight is chiefly produced by blood, must naturally be ex- ganized so that no delay would occur in the eventalready of an outheart we The of the has side learn, break. generally, pected. right been observed to be full of black blood. In some cases the Three more cases of cholera have been admitted at Glty’S. intestines have been full of rice-water excretion. The mesenteric glands have not been found to be much altered. For some A young man, serving as fireman on board the Albert Edwarct minutes after death in many cases muscular twitchings have Gravesend Saloon Steamer, came in on Sunday with symptoms, been observed to take place in different parts of the body. In but not of a very severe kind. We found him convalescent on Tuesday. At the time of our visit, a German tailor from a few the arm has moved from its extended position by the side of the corpse, becoming more or less flexed by muscular Horsleydown, and a boy who had arrived only the day before in a ship from Rotterdam, had just been brought in and contraction. under Dr. Barlow’s care. The man had a very feeble placed The only notable point that we remarked in connexion with duskiness of skin, and failing temperature. The boy the treatment pursued was that one of the physicians had dis- pulse, continued the use of drugs in the stage of collapse. Frictions, was pulseless, with dusky face, breath and skin cool (the therhot bottles, and hot baths, if these last were agreeable to the mometer in the axilla gave 94°), and the voice choleraic. The’ whose case was referred to last week had some delirium patient, were continued. So far as our own experience in woman former epidemics has enabled us to judge of the value of drugs during reaction, but is now convalescent. in collapse, we feel rather strongly that this modification of At the Middlesex Hospital two cases have been admitted, both treatment is judicious, and might with advantage be generally males. One died six hours after admission, in a state of collapse. followed. He came from Brewer-street. At the autopsy, eighteen hours-

epidemic,

123 /after death, the rigor mortis was found well-marked. Both lungs much congested. The four cavities of the heart contained a little fluid blood, more in the right cavities than in the left. The intestines were very anæmic, and contained a small quantity of starchy fluid. Liver somewhat fatty. Gall-bladder full. Kidneys granular. This patient had evidently had longstanding disease of the kidneys. The other, a man who lived in Broad-street, is doing well. In the great epidemic about Broad-street in 1854 the house whence this man came contributed two deaths. Mr. Waymouth, resident medical officer, tells us that there is a very large amount of diarrhoea amongst the out-patients. During the last week he has treated them very successfully with sulphuric acid, tincture of opium, decoction of logwood. Two wards, containing upwards of forty been cleared, and are ready for any cases that may beds, present themselves. Two other wards also could be rapidly rendered available. Another case has been admitted into the Westminster Hospital, of which Dr. Maclure, registrar, gives us the following

attacked, the other members of it haveinvariably followed. As regards preparations for cholera, Mr. W. H. Ellis, housesurgeon, informs us that his instructions are to clear the place,

in the parish will be sent to the hosof the workhouse. The drains throughout the establishment have been looked to, and the hospital cleaned and coloured from top to bottom. Carbolic acid, lime, &c., have been provided. If necessary, the resident officer will be aided by a clinical assistant. Twelvebeds on the ground-floor will be left for cholera cases. Nine cases have been admitted onboard the Belleisle hospital ship since our last report, making up to the present time sixteen have terminated the treatment adopted, it fatally. In remembered that the havehitherto varied much as to degree of severity, but that in each and both sets of cases the treatment of which is here described was comprised one or more examples of a severe form of the disease. It was decided at the commencement of the epidemic to adopt particulars : 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. Fivee rhoea since the 26th. She was seized with vomiting, cramps, cases were treated by the hypodermal injection of from three and watery purging early on the 29th. When admitted at and a half to four grains of the sulphate of quinine, and the noon, she was collapsed, with sunken eyes and shrunken fea- rubbing into the skin of from two to three drachms of the tures ; the arms and legs were blue and cold, and the pulse same in the form of a saturated solution. No drug was given There was frequent vomiting and by the mouth, but beef-tea was administered at very frequent was scarcely perceptible. purging, 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 five epidemic of 1854-viz., weak iced gin-and-water freely, and cases so treated, two were fatal, and a third still lies in a the following draught every hour :-Dilute sulphuric acid, five doubtful state, having passed through the stage of collapse minims; tincture of opium, two minims and a half ; pepper- successfully, but now suffering from a severe attack of consemint water, two ounces. The vomiting and purging ceased cutive fever. At the suggestion of Dr. Rooke, this latter stage is during the night, reaction had set in next morning, and the being treated by small bleedings, cold to the head, and afterwards woman appeared to be going on well. Soon afterwards, how- blisters to the scalp. The hypodermal injection and inunction ever, she became comatose, with almost complete suppression by friction of quinine was largely used last year at Constanof 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 ; and has consisted in a weak solution of carbolic acid as Two wards thirty beds)have been got readyin a drink ad libitum, ofgiving into the rectum a somewhat injecting to the time six present King’s College Hospital. Up patients stronger solution of the same with starch, and of subjecting have been admitted under the care of Dr. George Johnson, more the to its influence generally by sprinkling the diluted or less severely affected with cholera. One of these; a man in acidpatients about and around the bed at frequent intervals, and keepa moribund state, died an hour after admission. An infant a it in an earthen vessel close at hand. Six of fifteen months also died. The remaining cases, which do ing quantity of cases are being thus treated, hot air and water baths, with not seem to have been severe, are doing well. simple 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 can on the first appearance of cholera in the neighbourhood, two in nowise be determined, all these cases being now actually large 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, the first few cases shall be placed in the cottage as occurring on and about the Thames, is of a milder character at present in the grounds, which has hitherto only been used than those of 1848 and 1854, in both of which he was actively for cases of ovariotomy ; so that cholera cases will be entirely engaged. This observation verifies many that have been made separated from the other patients. The amount of diarrhcea with reference to the epidemic as it existed last year in Eastern among the out-patients is unprecedented, but Mr. De Tatham, Europe, and in France. The results of the carbolic-acid syshouse-surgeon, informs us that they are generally found to yield tem, with those of any other remedy exhibited, will be anquickly 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 when for 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 countenance, no pulse at the wrist, rice-water purging and vomiting, ofinfectious infectious . LARGE A LARGEhospitalfor ,1 the treatmentof to speak shrivelled hands, suppression of urine, and 98000 have above a whisper; but there was no marked loss of tempera- diseases is about to be erected in Liverpool. ture. Mr. Griffiths, the house-surgeon, in charge of the case, been subscribed, and the town council has made a grant of at once gave him an opiate in brandy, applied mustard poul- :E5000 towards the cost. tices, and ordered the sulphuric-acid mixture every two hours. AND THE REGENERATION OF M. OLLIER (OF He was purged eleven times in the night following, but the BONE.—This eminent occupied the attention of the surgeon vomiting ceased, and the last few stools evidently contained Surgical Society of Paris recently with two communicabile. He was dry-cupped over the loins. He passed a little to the removal of polypi occupying the tions-one relating seemed to be and The secreurine, progressing favourably. sal fossæ and pharynx, the other describing excision of tion of urine, however, did not continue; and, when we last The preservation of ligaments, tendons, &c. heard, he was comatose. operation advocated for polypi is nothing less than bringing At 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. The amongst the out-patients. Two wards in the south wing of nose, when raised again towards the forehead, unites in a satisthe building have been cleared, and are ready for any cases factory manner. In his excisions, M. Ollier preserves all the which may be sent. fibrous tissues, the ligaments, the capsule, and the tendinous In 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 type At the Great Northern Hospital, as yet, there have been no as the joint which has been taken away. One can easily understand such an operation upon the healthy articulation of an cases of cholera, but amongst the out-patients a great deal of diarrhoea has been treated. Some cases have been exceedingly animal; but the pathological changes in joint diseases are The diarrhoea has been increasing sometimes of such a nature that the author’s operation would, severe, with cramps &c. dailv for the last week. Where one in a family has been at first sight, appear extremely difficult, if not impossible. as

any

cases

pital instead

anda total of

have

should be

occurring

entries; of these, five

giving a synopsis of

cases

(containing

becompleted,

hospital

inability

LYONS)

joints, with