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CLINICAL NOTES.
564 than to the operative proceeding. Inflammation of the cellular tissue, and other parts about the neck of the bladder, is the main danger to be apprehended; all, or nearly all, surgeons are now agreed upon this point, while the general mortality of the operation unfortunately testifies to its frequency. A free incision of the prostate exposes the patient to the danger of infiltration of urine into the cellular tissue of the pelvis. This accident is quickly followed by inflammation of the worst kind; the urine makes its way beneath the peritonaeum, the serous becomes implicated, and if the patient happen to surmembrane vive the first shock, he rarely if ever does the effects of peritonitis. In fifteen cases of death after the lateral operation which M. Blandin had occasion to examine, peritonitis was found nine times. Contusion and laceration of the neck of the bladder during the extraction of a large calculus, and the efforts made to extract the foreign body from an irritable, contracted, or diseased bladder, not only produce great suffering, but give rise to secondary inflammation of the tissues surrounding the neck of the bladder, which is nearly as dangerous as that arising from infiltration of urine. I shall not now recur to the difficulties that attend the extraction of large calculi, nor to the difficulty of always proportioning our internal incision to the size of the foreign body which is to be removed. These points have been sufficiently discussed already, but I cannot avoid adding, that the secondary inflammation spoken of cannot always be connected with the extraction of large calculi, because they are, as statistics show, comparatively frequent ; while calculi exceeding a few ounces in weight are
or
preference
cases
to
lithotomy.
Chronic catarrh of the bladder does not contra-indicate lithotrity, other circumstances being favourable; but anything approaching acute inflammation shonld prevent us from having recourse to a method so likely to aggravate the complication. An hypertrophied, irritable, and contracted state of the bladder contra-indicates lithotrity, and the same may be said of great sensibility of the neck of the bladder, unless the stone be small and rather soft, affording the hope that it may be crushed in a small number of sittings. Atony, or partial paralysis of the bladder, is a circumstance unfavourable for litbotrity, though it does not absolutely contraindicate it; but on this point I must refer you to what I have said at the concluding part of my eighth lecture. Finally, for reasons which I also fully explained in the same lecture, I would transfer to the lithotomist all cases of stone occurring in persons under twenty-one years of age. I have now, gentlemen, said all that is necessary for forming a judgment on the relative merits and demerits of the two methods. It has been said that lithotomy is applicable to all cases of urinary calculus, whereas lithotrity is applicable to a limited number of cases only; and M. Velpeau, M. Sanson, and other French surgeons, who took part in the celebrated dircussion at the Academy of Medicine in 1835, insisted much on the great advantage which lithotomy presents. It is true that the latter operation may be applied to nearly all cases of stone, without distinction, but this is not the proper way of putting the question. The real question is - should lithotomy be so applied? and I have little hesitation in answering, No; for this simple reason, that in all cases of small calculi, unattended by any serious disease of the urinary organs, and when the patient’s general health is good, the safety and advantages of lithotrity are so superior to those of lithotomy, that the latter operation should not, though it may, be undertaken to the exclusion of the former. I would, therefore, in general terms, conclude that all under the age of twenty-one, should be cut; and that all adults, except those unfit for the operation, should be submitted to lithotrity. The statistical results,* which I have arranged in a tabular form, for your examination, will bear out this general conclusion. I have now, gentlemen, brought this course to its termination. It has exceeded the limits which I originally contemplated, but I have endeavoured to make these lectures as perfect as I could; hence the cause of their length. Notwithstanding this endeavour, I am fully aware of their imperfections; but I am confident that you will regard them with indulgence, and I shall ever remember with what attention you have so often listened to me.
comparatively rare. The repeated shocks of lithotrity, or the more sudden and violent one of lithotomy, may develop latent disease of the kidneys, and thus prove fatal. As the secondary effect is equally dangerous in both cases, we have merely to consider its relative frequency. Upon this point I do not find sufficient data to enable me to form a decided opinion. M. Civiale and a few other writers affirm that lithotrity is much less liable to cause or aggravate renal affections than.lithotomy; while other surgeons hold a contrary opinion. We have now, gentlemen, to compare the two methods with regard to the cases to which they are respectively applicable. This is a very important part of the subject. To form a correct notion of the value of lithotrity, it must be judged from the results it affords in cases to which experience shows the method may be properly applied. In nearly all such cases it is a safe and efficacious mode of treatment; in proportion as we recede from these cases, it becomes difficult of execution, and more or less dangerous in its application; and if we are imprudent enough to employ it in
other tumours about the neck of the bladder, the bar-like these circumstances would cause us to give a
ridge, &c.,-all
beyond its domain, it becomes even more dangerous than itself. The object, then, of the present comparison
lithotomy
to restrict the two methods within their proper limits. From the considerable space which I devoted to indications and contra-indications, this part of the subject may be disposed of in a cursory manner. In determining the propriety of appl5ing lithotrity to any case, two main points are to be considered-viz. the nature of the calculus, and the condition of the urinary organs. It is also necessary to reflect how far these two elements may influence the results of the operation, and enable the surgeon to complete it without exciting any dangerous irritation of the genito-urinary organs, or producing any unfavourable influence on the general health of the patient. The presence of a great number of calculi in the bladder is unfavourable for lithotrity-less so for lithotomy. When the stone is very hard, and at the same time large, lithotrity is not applicable to the case. Still much will here depend on the condition of the bladder. If this organ be capacious, and not very irritable, the modern instruments will safely crush calculi of almost any density, provided they can be embraced between the blades of the lithotrite. Very large calculi do not admit of being so seized, and lithotrity is therefore not suited for their removal; but the lateral operation is almost inapplicable to cases of this kind, for hardly one patient in ten escapes the dangers attendant on the extraction of a very large stone through the neck of the bladder. The position of the calculus has great influence on the facility with which it can be seized and crushed, and must therefore be taken into account. When it lies in an artificial cyst, lithotrity is out of the question, and lithotomy-at least the lateral operation-does not hold out much greater prospect of success. The balance, however, is in favour of lithotomy. If the stone be embraced in a deep excavation behind the prostate, forming what I have termed hour-glass contraction of the bladder, both
will be
,
operations are contra-indicated. Any serious organic disease of the bladder renders lithotrity inapplicable, and thus limits the sphere of its utility. Any great
’
obstacle at the neck of the bladder will have the same effect. Hence considerable enlargement of the prostate, fungoidl
CLINICAL
NOTES.
BY MARSHALL HALL,
M.D., F.R.S., &c.
NOTE IX.-ON THE INFLUENCE OF POSTURE IN THE TREATMENT OF EPILEPSY. WEhave only to raise one hand and arm high above the head, and allow the other to hangdown, for a minute or two, and then bring the hands together and compare the syncopal condition of the former with the apoplectic condition of the latter, to form an idea of the influence of posture in the treatment of diseases consisting of affections of the circulation, especially that of the head. I believe ordinary syncope may pass into fatal sinking if the raised posture be continued. I believe that simple apoplexy may become deeper and deeper, simply from the opposite course of retaining the patient in the recumbent position. Sleep, which is a sub-apoplexy, may pass into epilepsy or apoplexy, solely from the fact of a recumbent position. As a preventive of epilepsy and apoplexy during sleep, it is of the utmost moment that the patient should habitually repose with the head and shoulders much raised. For this purpose both bed and mattress should be raised by means of a bed-chair, or triangular cushion, and the patient be prevented from gliding down in the bed by means of a firm bolster, four inches in diameter, placed under the sheet, under the front of the ischia. The trunk should be raised to an angle of 450 or 60°. In this manner the will be less oppressed with blood, the sleep will be lighter, the disposition to epilepsy or apoplexy will be diminished. This should be the patient’s habit during the rest of life. -
encephalon
These will be
published in
an
early number.
565 There are two other circumstances in which attention to organ appeared healthy. I ordered him ten grains of Dover’s powder, in two pills, at bed-time, and the following draught posture is most important. Thefrst is the condition of the patient after certain fits of every four hours:-Gallic acid fifteen grains, diluted sulphuric epilepsy, the respiration being impeded by rattles in the throat. acid fifteen minims, decoction of bark one ounce and a half. The posture should be much raised; but besides this, it should I also directed him to use a good diet, and to assuage his thirst not be such that the saliva may fall into the fauces. The allowed him cold spring water, with the addition of small stupor and insensibility prevent the patient from swallowing. quantities of alum and port-wine. After some hours he felt The saliva, therefore, if a just position be not adopted, accu- better; had slept, and was in good spirits. The same plan was mulates and falls into the fauces, and a throat-rattle and continued, but the benefit was only temporary; and after trying dyspnosa, painful to witness, and dangerous to life, are the matico, &c., I found him much worse on the 21st. Pulse 100, consequence. The posture of the patient should be such as to very feeble, and less jerking; a sense of rapid sinking; slow, allow the saliva to flow out of the corner of the mouth. In sighing respiration, cold skin, &c.; and death by asthenia and one case such a change of posture relieved the patient immesyncope occurred at four A.M., on the 22nd. Post-morten2 Examination at two P.JBI., in the presence of Drs. diately. The second case requiring extreme attention to the posture Gull and Wilks.-After turning aside the intestines, and reof the patient is that of Syncopal Epilepsy, or that form of epi moving an enormous quantity of fat, I dissected out and relepsy in which there is ghastly pallor of the countenance and moved the kidneys, ureters, and bladder entire. The kidneys other signs of syncopal affection. The patient should be placed were large and very pale, but otherwise healthy, and weighed with the head low. If this be not done, the syncope may be about seven ounces each. The right ureter was sufficiently speedily fatal, an event which actually occurred in an inter- dilated to admit the little finger; it led backwards to a dilated renal pelvis, and forwards to an opening in the bladder, so esting case a few days only ago. The patient was no other than Ann Ross, on whom Mr. small as not to admit the point of a small blow-pipe. At this Anderson had performed the operation of tracheotomy. Her part of the bladder, on its internal surface, was a peculiar fits had changed from those of the epilepsia la1.yngea to the tufted growth, about the diameter of a sixpence, and oneabortive form. The reader may remember that the patient’s eighth of an inch in depth or thickness, and in its vicinity age was thirty-six; that her case was hereditary, her father were two or three much smaller and more vascular-looking having been epileptic; and inveterate, her fits having recurred tufts, but possessing the same general characters as the larger during twenty-four years; and that she herself was thin and one. The bladder contained about three ounces of black pallid. She was seized with syncopal epilepsy; was laid on coagula; its capacity was normal; its coats healthy; the musthe bed and expected to recover as formerly; was left; and cular striae, of course, very distinct; and the entire organ unA low position and usually pale. All the other organs were remarkably healthy, was at length found to have expired ! and not a trace of the disease found in the bladder could be proper attention might have saved the poor creature’s life. I need scarcely observe, that what I have said of epilepsy found elsewhere. The heart contained a few dark coagula applies to many other diseases. It is the principle of position adhering to its auriculo-ventricular openings, and I need which I wish to enforce; a principle the importance of which scarcely say that the whole body and its contents were almost I believe to be still greater and still more extensive in appli- bloodless. It was very evident that the disease was strictly cation than is generally imagined. local, and limited to these growths in the bladder; that these had effectually drained the body of all its blood, and so killed It is, an unusually powerful and otherwise healthy man. of the highest importance to ascertain their origin, therefore, FATAL HÆMATURIA FROM PECULIAR nature, and treatment. Now, what should give rise to them
I
GROWTHS IN THE BLADDER. in such a man, I leave others to guess. Their structure is peculiar. When shaken in cold water, they spread out into a BY DANIEL HOOPER, B.A., M.B. LOND., M.R.C.P., &c. dense arborescent form, so that one could not say what bulk THE following very interesting and instructive case of they might have occupied, when distended with blood, during hsematuria has lately occurred in my practice :life. Under the microscope, they appear to consist of most James E-, aged thirty-four, a railway porter, a re- beautiful arborescent tufts, which, on close examination, seem markably robust and well-made man, of sanguine tempera- to be made up of immense numbers of capillaries, covered ment, steady habits, and good general health, and who never with columnar, narrowly-elliptical, epithelial cells, with large was the subject of any serious disease or accident, became a nuclei. Lastly, as treatment and cure are the ends of all our patient of the Surrey Dispensary under my care, on the 17th knowledge, it would be a great and a good thing to be able to of November, 1852-four days before his death. recognise this disease during life, and so to treat it that we -ascertained that four months ago, without any premonitory might enable the patient to live, even if we could not get rid illness or symptoms, he first observed blood in his urine. This of the structure; and this much I believe we can do, (prevenbeing unattended with any pain or other symptoms, he con- tion with our present ignorance of the cause is of course imtinued his work for one month, the hsematuria going on, and possible.) Connecting, then, this case with two others which then feeling feeble and unwell, he applied for advice; and for occurred to Dr. Gull, of Guy’s Hospital, I am of opinion that the last three months has been under medical treatment. when we find continued hsematuria in a person in all other He told me, that during this period he had taken steel, lead, respects healthy and well, without any history or symptom of and turpentine without any eifect; the hsematuria having any kind to unravel the case, we may pronounce it to be one never once been checked from the first moment it was disof this peculiar disease of the bladder, and treat it as such; covered. Once, about the end of September, he applied at; and I would merely suggest, that in addition to some such the surgery of Guy’s Hospital for relief from retention oftreatment as that adopted in this case, the bladder should be urine; when a catheter was passed, which gave him intense injected with some powerful astringent, and the patient so pain, and relieved his bladder of an enormous quantity of kept alive. I trust these remarks may lead myself and others to be on bloody urine and coagula. After this, he said, the hmmaturia and failure of strength progressed rapidly. On November 17,, the look-out for the disease, and enable us to discover a cure, at six P.M., I found him excessively bleached, complaining ofor at least some better treatment. headache, watchfulness, thirst, rapid prostration of strength,, I hope, on some future occasion, to be prepared to describe and tendency to syncope on any motion of the body. His! more minutely the characteristics of these growths, which, as tongue, and mucous membrane of the mouth, were almost; far as I know, have not yet received a name. white. Pulse 120, feeble, but jerking; skin dry, white, and Wellington-street, London-bridge, Nov. 1852. feverish. He was passing from three to four pints of urine daily, of a very dark brown colour, with large, black, semimembranous, cystiform clots at the bottom of the vessel. One or two of these clots accompanied each emission of urine, and, A THERMOMETER FOR THE HUMAN BODY. in their transit through the urethra, occasioned great pain and By J. SPURGIN, M.D. Cantab., &c. sense of obstruction; although he always (except in the one instance mentioned) eventually got rid of them without instruIT is well known that there are variations of temperature mental aid. Their appearance was so unlike that of mere in different parts of the body, and that these variations are blood, that until Mr. Birkett had examined them microsco. frequently an important help to diagnosis in disease; but this pically, I was not convinced that they were such. His bowels knowledge is derived more from our sensations than by means acted daily, his appetite was not much amiss, and he was nol of any suitable application of the thermometer. It is evident, conscious of any wasting of the body, which, to me, appearec however, that our sensations are quite inadequate to furnish fut and well-nourished. He had no pain anywhere, and ever an accurate test of temperature. To supply a want therefore ,
-.
or
preference
cases
to
lithotomy.
Chronic catarrh of the bladder does not contra-indicate lithotrity, other circumstances being favourable; but anything approaching acute inflammation shonld prevent us from having recourse to a method so likely to aggravate the complication. An hypertrophied, irritable, and contracted state of the bladder contra-indicates lithotrity, and the same may be said of great sensibility of the neck of the bladder, unless the stone be small and rather soft, affording the hope that it may be crushed in a small number of sittings. Atony, or partial paralysis of the bladder, is a circumstance unfavourable for litbotrity, though it does not absolutely contraindicate it; but on this point I must refer you to what I have said at the concluding part of my eighth lecture. Finally, for reasons which I also fully explained in the same lecture, I would transfer to the lithotomist all cases of stone occurring in persons under twenty-one years of age. I have now, gentlemen, said all that is necessary for forming a judgment on the relative merits and demerits of the two methods. It has been said that lithotomy is applicable to all cases of urinary calculus, whereas lithotrity is applicable to a limited number of cases only; and M. Velpeau, M. Sanson, and other French surgeons, who took part in the celebrated dircussion at the Academy of Medicine in 1835, insisted much on the great advantage which lithotomy presents. It is true that the latter operation may be applied to nearly all cases of stone, without distinction, but this is not the proper way of putting the question. The real question is - should lithotomy be so applied? and I have little hesitation in answering, No; for this simple reason, that in all cases of small calculi, unattended by any serious disease of the urinary organs, and when the patient’s general health is good, the safety and advantages of lithotrity are so superior to those of lithotomy, that the latter operation should not, though it may, be undertaken to the exclusion of the former. I would, therefore, in general terms, conclude that all under the age of twenty-one, should be cut; and that all adults, except those unfit for the operation, should be submitted to lithotrity. The statistical results,* which I have arranged in a tabular form, for your examination, will bear out this general conclusion. I have now, gentlemen, brought this course to its termination. It has exceeded the limits which I originally contemplated, but I have endeavoured to make these lectures as perfect as I could; hence the cause of their length. Notwithstanding this endeavour, I am fully aware of their imperfections; but I am confident that you will regard them with indulgence, and I shall ever remember with what attention you have so often listened to me.
comparatively rare. The repeated shocks of lithotrity, or the more sudden and violent one of lithotomy, may develop latent disease of the kidneys, and thus prove fatal. As the secondary effect is equally dangerous in both cases, we have merely to consider its relative frequency. Upon this point I do not find sufficient data to enable me to form a decided opinion. M. Civiale and a few other writers affirm that lithotrity is much less liable to cause or aggravate renal affections than.lithotomy; while other surgeons hold a contrary opinion. We have now, gentlemen, to compare the two methods with regard to the cases to which they are respectively applicable. This is a very important part of the subject. To form a correct notion of the value of lithotrity, it must be judged from the results it affords in cases to which experience shows the method may be properly applied. In nearly all such cases it is a safe and efficacious mode of treatment; in proportion as we recede from these cases, it becomes difficult of execution, and more or less dangerous in its application; and if we are imprudent enough to employ it in
other tumours about the neck of the bladder, the bar-like these circumstances would cause us to give a
ridge, &c.,-all
beyond its domain, it becomes even more dangerous than itself. The object, then, of the present comparison
lithotomy
to restrict the two methods within their proper limits. From the considerable space which I devoted to indications and contra-indications, this part of the subject may be disposed of in a cursory manner. In determining the propriety of appl5ing lithotrity to any case, two main points are to be considered-viz. the nature of the calculus, and the condition of the urinary organs. It is also necessary to reflect how far these two elements may influence the results of the operation, and enable the surgeon to complete it without exciting any dangerous irritation of the genito-urinary organs, or producing any unfavourable influence on the general health of the patient. The presence of a great number of calculi in the bladder is unfavourable for lithotrity-less so for lithotomy. When the stone is very hard, and at the same time large, lithotrity is not applicable to the case. Still much will here depend on the condition of the bladder. If this organ be capacious, and not very irritable, the modern instruments will safely crush calculi of almost any density, provided they can be embraced between the blades of the lithotrite. Very large calculi do not admit of being so seized, and lithotrity is therefore not suited for their removal; but the lateral operation is almost inapplicable to cases of this kind, for hardly one patient in ten escapes the dangers attendant on the extraction of a very large stone through the neck of the bladder. The position of the calculus has great influence on the facility with which it can be seized and crushed, and must therefore be taken into account. When it lies in an artificial cyst, lithotrity is out of the question, and lithotomy-at least the lateral operation-does not hold out much greater prospect of success. The balance, however, is in favour of lithotomy. If the stone be embraced in a deep excavation behind the prostate, forming what I have termed hour-glass contraction of the bladder, both
will be
,
operations are contra-indicated. Any serious organic disease of the bladder renders lithotrity inapplicable, and thus limits the sphere of its utility. Any great
’
obstacle at the neck of the bladder will have the same effect. Hence considerable enlargement of the prostate, fungoidl
CLINICAL
NOTES.
BY MARSHALL HALL,
M.D., F.R.S., &c.
NOTE IX.-ON THE INFLUENCE OF POSTURE IN THE TREATMENT OF EPILEPSY. WEhave only to raise one hand and arm high above the head, and allow the other to hangdown, for a minute or two, and then bring the hands together and compare the syncopal condition of the former with the apoplectic condition of the latter, to form an idea of the influence of posture in the treatment of diseases consisting of affections of the circulation, especially that of the head. I believe ordinary syncope may pass into fatal sinking if the raised posture be continued. I believe that simple apoplexy may become deeper and deeper, simply from the opposite course of retaining the patient in the recumbent position. Sleep, which is a sub-apoplexy, may pass into epilepsy or apoplexy, solely from the fact of a recumbent position. As a preventive of epilepsy and apoplexy during sleep, it is of the utmost moment that the patient should habitually repose with the head and shoulders much raised. For this purpose both bed and mattress should be raised by means of a bed-chair, or triangular cushion, and the patient be prevented from gliding down in the bed by means of a firm bolster, four inches in diameter, placed under the sheet, under the front of the ischia. The trunk should be raised to an angle of 450 or 60°. In this manner the will be less oppressed with blood, the sleep will be lighter, the disposition to epilepsy or apoplexy will be diminished. This should be the patient’s habit during the rest of life. -
encephalon
These will be
published in
an
early number.
565 There are two other circumstances in which attention to organ appeared healthy. I ordered him ten grains of Dover’s powder, in two pills, at bed-time, and the following draught posture is most important. Thefrst is the condition of the patient after certain fits of every four hours:-Gallic acid fifteen grains, diluted sulphuric epilepsy, the respiration being impeded by rattles in the throat. acid fifteen minims, decoction of bark one ounce and a half. The posture should be much raised; but besides this, it should I also directed him to use a good diet, and to assuage his thirst not be such that the saliva may fall into the fauces. The allowed him cold spring water, with the addition of small stupor and insensibility prevent the patient from swallowing. quantities of alum and port-wine. After some hours he felt The saliva, therefore, if a just position be not adopted, accu- better; had slept, and was in good spirits. The same plan was mulates and falls into the fauces, and a throat-rattle and continued, but the benefit was only temporary; and after trying dyspnosa, painful to witness, and dangerous to life, are the matico, &c., I found him much worse on the 21st. Pulse 100, consequence. The posture of the patient should be such as to very feeble, and less jerking; a sense of rapid sinking; slow, allow the saliva to flow out of the corner of the mouth. In sighing respiration, cold skin, &c.; and death by asthenia and one case such a change of posture relieved the patient immesyncope occurred at four A.M., on the 22nd. Post-morten2 Examination at two P.JBI., in the presence of Drs. diately. The second case requiring extreme attention to the posture Gull and Wilks.-After turning aside the intestines, and reof the patient is that of Syncopal Epilepsy, or that form of epi moving an enormous quantity of fat, I dissected out and relepsy in which there is ghastly pallor of the countenance and moved the kidneys, ureters, and bladder entire. The kidneys other signs of syncopal affection. The patient should be placed were large and very pale, but otherwise healthy, and weighed with the head low. If this be not done, the syncope may be about seven ounces each. The right ureter was sufficiently speedily fatal, an event which actually occurred in an inter- dilated to admit the little finger; it led backwards to a dilated renal pelvis, and forwards to an opening in the bladder, so esting case a few days only ago. The patient was no other than Ann Ross, on whom Mr. small as not to admit the point of a small blow-pipe. At this Anderson had performed the operation of tracheotomy. Her part of the bladder, on its internal surface, was a peculiar fits had changed from those of the epilepsia la1.yngea to the tufted growth, about the diameter of a sixpence, and oneabortive form. The reader may remember that the patient’s eighth of an inch in depth or thickness, and in its vicinity age was thirty-six; that her case was hereditary, her father were two or three much smaller and more vascular-looking having been epileptic; and inveterate, her fits having recurred tufts, but possessing the same general characters as the larger during twenty-four years; and that she herself was thin and one. The bladder contained about three ounces of black pallid. She was seized with syncopal epilepsy; was laid on coagula; its capacity was normal; its coats healthy; the musthe bed and expected to recover as formerly; was left; and cular striae, of course, very distinct; and the entire organ unA low position and usually pale. All the other organs were remarkably healthy, was at length found to have expired ! and not a trace of the disease found in the bladder could be proper attention might have saved the poor creature’s life. I need scarcely observe, that what I have said of epilepsy found elsewhere. The heart contained a few dark coagula applies to many other diseases. It is the principle of position adhering to its auriculo-ventricular openings, and I need which I wish to enforce; a principle the importance of which scarcely say that the whole body and its contents were almost I believe to be still greater and still more extensive in appli- bloodless. It was very evident that the disease was strictly cation than is generally imagined. local, and limited to these growths in the bladder; that these had effectually drained the body of all its blood, and so killed It is, an unusually powerful and otherwise healthy man. of the highest importance to ascertain their origin, therefore, FATAL HÆMATURIA FROM PECULIAR nature, and treatment. Now, what should give rise to them
I
GROWTHS IN THE BLADDER. in such a man, I leave others to guess. Their structure is peculiar. When shaken in cold water, they spread out into a BY DANIEL HOOPER, B.A., M.B. LOND., M.R.C.P., &c. dense arborescent form, so that one could not say what bulk THE following very interesting and instructive case of they might have occupied, when distended with blood, during hsematuria has lately occurred in my practice :life. Under the microscope, they appear to consist of most James E-, aged thirty-four, a railway porter, a re- beautiful arborescent tufts, which, on close examination, seem markably robust and well-made man, of sanguine tempera- to be made up of immense numbers of capillaries, covered ment, steady habits, and good general health, and who never with columnar, narrowly-elliptical, epithelial cells, with large was the subject of any serious disease or accident, became a nuclei. Lastly, as treatment and cure are the ends of all our patient of the Surrey Dispensary under my care, on the 17th knowledge, it would be a great and a good thing to be able to of November, 1852-four days before his death. recognise this disease during life, and so to treat it that we -ascertained that four months ago, without any premonitory might enable the patient to live, even if we could not get rid illness or symptoms, he first observed blood in his urine. This of the structure; and this much I believe we can do, (prevenbeing unattended with any pain or other symptoms, he con- tion with our present ignorance of the cause is of course imtinued his work for one month, the hsematuria going on, and possible.) Connecting, then, this case with two others which then feeling feeble and unwell, he applied for advice; and for occurred to Dr. Gull, of Guy’s Hospital, I am of opinion that the last three months has been under medical treatment. when we find continued hsematuria in a person in all other He told me, that during this period he had taken steel, lead, respects healthy and well, without any history or symptom of and turpentine without any eifect; the hsematuria having any kind to unravel the case, we may pronounce it to be one never once been checked from the first moment it was disof this peculiar disease of the bladder, and treat it as such; covered. Once, about the end of September, he applied at; and I would merely suggest, that in addition to some such the surgery of Guy’s Hospital for relief from retention oftreatment as that adopted in this case, the bladder should be urine; when a catheter was passed, which gave him intense injected with some powerful astringent, and the patient so pain, and relieved his bladder of an enormous quantity of kept alive. I trust these remarks may lead myself and others to be on bloody urine and coagula. After this, he said, the hmmaturia and failure of strength progressed rapidly. On November 17,, the look-out for the disease, and enable us to discover a cure, at six P.M., I found him excessively bleached, complaining ofor at least some better treatment. headache, watchfulness, thirst, rapid prostration of strength,, I hope, on some future occasion, to be prepared to describe and tendency to syncope on any motion of the body. His! more minutely the characteristics of these growths, which, as tongue, and mucous membrane of the mouth, were almost; far as I know, have not yet received a name. white. Pulse 120, feeble, but jerking; skin dry, white, and Wellington-street, London-bridge, Nov. 1852. feverish. He was passing from three to four pints of urine daily, of a very dark brown colour, with large, black, semimembranous, cystiform clots at the bottom of the vessel. One or two of these clots accompanied each emission of urine, and, A THERMOMETER FOR THE HUMAN BODY. in their transit through the urethra, occasioned great pain and By J. SPURGIN, M.D. Cantab., &c. sense of obstruction; although he always (except in the one instance mentioned) eventually got rid of them without instruIT is well known that there are variations of temperature mental aid. Their appearance was so unlike that of mere in different parts of the body, and that these variations are blood, that until Mr. Birkett had examined them microsco. frequently an important help to diagnosis in disease; but this pically, I was not convinced that they were such. His bowels knowledge is derived more from our sensations than by means acted daily, his appetite was not much amiss, and he was nol of any suitable application of the thermometer. It is evident, conscious of any wasting of the body, which, to me, appearec however, that our sensations are quite inadequate to furnish fut and well-nourished. He had no pain anywhere, and ever an accurate test of temperature. To supply a want therefore ,
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