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Dublin Journal of Medical and Chemical Science. Nov. 5. (Concluded.)
LUMBAR ABSCESS IN GOUTY DIATHESIS.
313
of the students, and on the best interests ulcerations, had that ingenious contrivance of the community, yet certificates of at- been in existence. tendance on these regular messes of humbug’, " Mr. --, aged 39 years, married, and alone entitle the student to an examination the father of a family, having previously
College of Surgeons, and the Apothe. enjoyed excellent health, with the excepcaries Hall. The incorporators know full tion of a few attacks of hereditary gout, was well, from past experience, that a know- seized about the end of April last with symptoms of cholera, which suhledge of disease cannot be acquired except slight sided under the usual treatment, but were by a constant, an assiduous, attendance at followed by a paroxysm of gout in the feet. the bedside of the sick, and yet they insist The redness and swelling almost entirely on the production of pieces of paper, which at the end of a few days, but were in the back afford only prima facie proof that the succeeded by considerable an unfrequent attendant on bearers of them have derived their know- and loins ; he also complained of pain shooting ledge of disease, through the medium of gout) the right spermatic chord, and through words. A practical knowledge of medicine affecting the testicle. Temporary relief and surgery cannot be acquired except was procured by the use of a suspensorv and an attempt was made to proby means of that most instructive of all bandage, cure a recurrence of the gouty inflammation be the If disease not seen, channels, eye. in the feet by means of a mustard pediluvia. and repeatedly seen too, its characters In consultation with Mr. Colles, it was cannot be recognised in practice, and reagreed to administer small doses of subcarmedial measures cannot be employed unless bonate of soda with extract of gentian, and to procure a free state of the bowels by the empirically. If, then, we call upon students to direct occasional use of the tinct. seminulli coltheir especial attention to the lectures of chici in an aperient draught. On external examination no change of appearance was Baron DUPUYTREN, we do so in the hope observable, except a slight fulness in the that they will, by their complaints or re- right groin occupying the region of the monstrances, urge the teachers here to spermatic chord. From this period (the second week in adopt for their model the conduct of so great little perceptible alteration took place May) a man. In the practice of surgery as in the for a considerable time. He complained of the practice of medicine, the business still of severe but by no means constant wards opens the great road to improvement, pain in the back and loins, which, during and if that business be not conducted assi. the paroxysms, extended to the right hip and knee. He was able to move the lillb, duously by the teacher, he commits a fraud but not to derive assistance from it in walkon the pockets of his pupils, and, what is one part of his chamber to another. ing from still worse, wilfully deprives the student Rest was procurable at night only by the of the means of acquiring a knowledge o assistance of opiates. His appetite, however, that profession, by the exercise of whicl was pretty good, and although he had lost he is designed to render services to hii flesh and become emaciated, there were as fellow-creatures, and establish his owi yet but few decidedly hectic symptoms. The pulse was in general about 90, with fame and fortune. at the
ceased
pain
(not
occasionally
a
rigor
or
perspiration
at re-
aad irregular periods. " About the end of May he requested my attention to a swelling which he said had Dublin Journal of Medical and Chemical appeared in his groin. He conceived that it was likely to suppurate, and from what Science. Nov. 5. (Concluded.) he had heard, ho augured favourably of his from this circumstance. On examinaLUMBAR ABSCESS, UNDER THE DIFFUSED tion 1 found a tumour, not in the situation INFLUENCE OF THE GOUTY DIATHESIS. of the chord, but just below Poupart’s ligaTHE eighth article consists of a case under ment. It was ofan oval or ratlier pyriform the above title by Dr. CHARLES LENDRICK, the long axis being nearly parallel Poupart’s ligament, but directed somephysician to Mercer’s Hospital, Dublin. to The details are highly interesting, and the ! what more downwards and inwards ; tho was between three and four inches, case may certainly he referred to as one in length and the main breadth about one inch. On which Dr. Arnot’s invalid water-bed might desiring him to cough, the fluctuation prehave been employed with advantage to the viously distinct received a perceptible im. mote
case
shape,
314 mentions that the swelling which, however carefully constructed, in. when he felt variably shift theirposition, and act at length on the diseased surface, sparing one part " The fluctuation in the tumour was ob- only to make increased pressure on another. " servable even to the sight on maliing presOne plan, however, we have adopted sure on the abdomen ; and an alternate with great success in Mercer’s Hospital. It in cutting out of a sheet of stickingimpulse was felt by each hand when placed on these parts. On examination in the a portion adopted to the size of the erect posture, the impulse on coughing was injured part ; the surface of the surrounding still easier (if possible) to be detected. plaster having been covered with cotton The right buttock presented a sacculated wadding, a similar piece of plaster spread appearance, and the extension of the fluc- on both sides is placed over it. Thus a tuation here was but too evident. cushion is formed, which on account of the cc I lost no time in representing to his double spreading of one plaster admits of family the formidable nature of the disease. close application to the skin surrounding He was again visited by Mr. Colles; the ulcerated parts, which are thus comMessrs. Crampton and Wilmot were sub- paratively at least saved from the effects of sequently called into consultation, and Dr. pressure. I may add, that the governors of Charles Orpen was in constant attendance the hospital, with their accustomed atwith me during the future progress of the tention to the wants of the afflicted, have ordered two hydrostatic beds to be con. case. " Our patient derived some advantage, structed on the plan recommended by Mr. apparently, as far as his general health was Arnott ; and most sincerely do I hope, that concerned, by a removal a few miles from the contrivance may, as it seems probable, town. His appetite became better, and realize his expectation, and remove this oprest at night was procurable by means of probrium of the healing art. An excellent less doses of opium. He afterwards began, plan of raising the patient from the bed for however, to suffer from perspirations, espe- the purpose of dressing, &c. was adopted cially towards evening, and with increased on the present occasion on the recommendaemaciation his local sufferings became in- tion of Mr. Crampton, but as it is I becreased to an agonizing degree. He could lieve his intention to publish a description bear the limb in the semiflexed position of it, any further observations of mine only, and in this it was retjtined by the would be superfluous. hand of an attendant, as when left to itself Under the painful circumstances in which it became violently and painfully convulsed. we were placed in Mr. -’s case, we had He was now entirely confined to bed, and no alternative but to make an opening in acetate of morphine was exhibited in doses the tumour, and on the 23rd of June Mr. of three grains, before rest, or rather a ces- Colles plunged a lancet into the swelling, sation of the paroxysms, could be procured. and enlarged the opening with a bistoury; Stripping, and subsequently sloughing, this was on a subsequent occasion extended commenced over the sacrum and coccyx, upwards and outwards to within an inch of and this was truly deplorable, as the supine Poupart’s ligament, leaving an orifice in position was the only one that afforded any the superior part of the tumour of about two inches in length. The matter discharged to his other sufferings. respite " His appetite now declined, rest was was not in any respect similar to that of scarcely procurable, and emaciation, with psoas abscess ; it was ichorous and intolera. other hectic symptoms, were progressive. bly fetid, and of a liver colour. From its A change of posture became indispensable, nature there might have been reason to sus. in order to prevent the extension of morti- pect disease of a bone ; but the appearance
pulse.
He
now
had
appeared after sneezing, something give way.
,
consists plaster
fication in the
I mav here W,tS afterwards considerably changed; it of this and became nearly puriform, thick, and yellow, other cases has convinced me of the utter with a slightly greenish tinge, and scarcely inutility of air-cushions, and similar con- any odour. On opening the tumour nearly trivances, for removing pressure from ul- a quart was discharged, and all the sympcerated parts. The medical attendant can- toms were alleviated. It soon, however, not be too careful, by strict attention to became too plain that the relief was only cleanliness, and the application of cam- temporary. It was found impracticable to phorated spirit or tincture of myrrh, with extend the leg, which was agitated by sethe use of powdered starch, and above all, vere convulsions, and all the symptoms that change of posture, if practicable, to prevent had existed previously to the operation rethe occurrence of so great a calamity whilst curred in even an aggravated degree. A the skin is yet unbroken. After this has violent and incessant hiccup at this time once taken place, I really think the plane was a source of much painful anxiety, as hard hospital bed is superior to all the con- all the usual antispasmodic medicines, with ice, lemon-juice, trivances of the various kinds of cushions, musk, ether, &c.,
sloughing parts. experience
observe, that the
315 and the mineral acids, totally once witnessed after the operation of tying failed in producing any influence. It at the iliac artery. The elastic feel was suclast subsided spontaneously, and except in a ceeded by such a distinct fluctuation, that the propriety of making an incision here minor degree, it did not recur. " His frame was now exhausted by the became the subject of consideration, but an combined effects of spasm (which doses of increase of the usual discharge from the even six grains of acetate of morphine were wound was followed by its disappearance. inadequate to check), the usual attendants The more deep-seated tumour was, howon colliquative suppuration, and an exten- ever, still to be felt in the form of a hardensive gangrene of the parts in the neighbour- ed margin surrounding a cup-like cavity. " hood of the sacrum. About the second of the glutæi muscles, the week in August his sufferings underwent perineum, the neighbourhood of the rectum, some alleviation, the spasms became less and the posterior part of the thigh, at varifrequent and severe, the discharge from the ous times presented appearances of fluctuawound was diminished, and he was enabled tion which afterwards subsided. Doubtsome ma.v have originated in the to extend the limb. There could, however, be but little doubt that a metastasis of dis- serous effusion attendant on deep-seated ease to more vital parts had taken place. inflammation, and were independent of puHe was affected with cough, copious ex- rulent deposit. pectoration, and pain in the right side. " The matter was, as I have alreadyWith the exception, however, of the mu- mentioned, after the first discharge, in cous rattle, and a slight dulness of sound general, of a thick consistence, and of a duringpercussion of the side affected there greenish-yellow colour, with but little was no disease appreciable by auscultation, odour ; occasionally, however, it was of respiration being perceptible throughout the former liver colour, and ichorous. On the entire thorax. His faculties remained one occasion it became so dark-coloured perfectly clear ; but from this time he and fetid, that from the circumstance of a rapidly declined, and died on the 18th ofsimilar appearance in the alvine evacuation, August. The bodv was not examined. it was conjectured that the abscess had " This disease was obviously a diffused perforated the intestinal tube ; it is probad abscess, having its origin within the pelvis. ble, however, that this was not the case, as The fatal result was early anticipated ; the the afterwards resumed its usual more certainly because the want of the ad- appearance. hesive process so as to establish a defined neighbourhood of the origins of sac, was a plain proof of the deficiency of considerable nerves to the part so extenthose vital powers from which our very sively affected with suppurative inflammaslender hopes are ever derivable in such tion, sufficiently accounts, in my judgment, cases. It was questionable, however, whe- for the violence of the pain and the spasther the source of the abscess was to be modic agony attendant on the paroxysms. " traced in the course of’ the psoas muscle. But what was the cause of disease in The parts beneath the iliac fascia, or the this case? Was the influence of gout the neighbourhood of that muscle, presented a principal or the accessory? The sympmore probable origin. Deep pressure above toms which ushered in the formation of Poupart’s ligament near the anterior spine matter first occurred immediately on the of the ilium and continued downwards and subsidence of a paroxysm of regular gout inwards, invariably produced a considerable in the foot, to which the patient had for discharge of matter. A probe introduced subject. I am aware that here passed much more superficially than gouty inflammation sometimes terminates the direction of the source of the matter, aE in suppuration in broken constitutions ; of it could be plainly felt through the integu. I witnessed a fatal case in Mercer’s ments of the abdomen, and seemed to lie Hospital; but Mr. was a man of robust even in front of Poupart’s ligament. Pron makeand temperate habits ; he indulged the emaciation of the patient, it was difficull freely in field sports, and before the slight to conjecture what extent of parts inter’ bowel attack, to which I have alluded, was vened anteriorly between the probe and the in the possession of actually rude health. he took considerable foot finzer. , A considerable tumefaction, but of exercise on the 24th of April, at that time various amount, was always discernible by I never saw a man who, to appearance, was deep pressure above the ligament, in the more likely to enjoy continued good health part corresponding to the separation of the and immunity from every disease, except iliac and psoas muscles. Besides this, on which he was habitually subject. one occasion there was another swelling ob.. He did not at any time before the period of viously much more superficial and anterior the gouty paroxysms complain of weariin situation; this was elastic to the feel,, ness, pain in the back, or the usual precurvery much resembling a hernia, which Isors of lumbar abscess."
vinegar,
The region
les .
3
discharge
" The
some yearsbeen
this
-
I remember that
that to
I
313
of the students, and on the best interests ulcerations, had that ingenious contrivance of the community, yet certificates of at- been in existence. tendance on these regular messes of humbug’, " Mr. --, aged 39 years, married, and alone entitle the student to an examination the father of a family, having previously
College of Surgeons, and the Apothe. enjoyed excellent health, with the excepcaries Hall. The incorporators know full tion of a few attacks of hereditary gout, was well, from past experience, that a know- seized about the end of April last with symptoms of cholera, which suhledge of disease cannot be acquired except slight sided under the usual treatment, but were by a constant, an assiduous, attendance at followed by a paroxysm of gout in the feet. the bedside of the sick, and yet they insist The redness and swelling almost entirely on the production of pieces of paper, which at the end of a few days, but were in the back afford only prima facie proof that the succeeded by considerable an unfrequent attendant on bearers of them have derived their know- and loins ; he also complained of pain shooting ledge of disease, through the medium of gout) the right spermatic chord, and through words. A practical knowledge of medicine affecting the testicle. Temporary relief and surgery cannot be acquired except was procured by the use of a suspensorv and an attempt was made to proby means of that most instructive of all bandage, cure a recurrence of the gouty inflammation be the If disease not seen, channels, eye. in the feet by means of a mustard pediluvia. and repeatedly seen too, its characters In consultation with Mr. Colles, it was cannot be recognised in practice, and reagreed to administer small doses of subcarmedial measures cannot be employed unless bonate of soda with extract of gentian, and to procure a free state of the bowels by the empirically. If, then, we call upon students to direct occasional use of the tinct. seminulli coltheir especial attention to the lectures of chici in an aperient draught. On external examination no change of appearance was Baron DUPUYTREN, we do so in the hope observable, except a slight fulness in the that they will, by their complaints or re- right groin occupying the region of the monstrances, urge the teachers here to spermatic chord. From this period (the second week in adopt for their model the conduct of so great little perceptible alteration took place May) a man. In the practice of surgery as in the for a considerable time. He complained of the practice of medicine, the business still of severe but by no means constant wards opens the great road to improvement, pain in the back and loins, which, during and if that business be not conducted assi. the paroxysms, extended to the right hip and knee. He was able to move the lillb, duously by the teacher, he commits a fraud but not to derive assistance from it in walkon the pockets of his pupils, and, what is one part of his chamber to another. ing from still worse, wilfully deprives the student Rest was procurable at night only by the of the means of acquiring a knowledge o assistance of opiates. His appetite, however, that profession, by the exercise of whicl was pretty good, and although he had lost he is designed to render services to hii flesh and become emaciated, there were as fellow-creatures, and establish his owi yet but few decidedly hectic symptoms. The pulse was in general about 90, with fame and fortune. at the
ceased
pain
(not
occasionally
a
rigor
or
perspiration
at re-
aad irregular periods. " About the end of May he requested my attention to a swelling which he said had Dublin Journal of Medical and Chemical appeared in his groin. He conceived that it was likely to suppurate, and from what Science. Nov. 5. (Concluded.) he had heard, ho augured favourably of his from this circumstance. On examinaLUMBAR ABSCESS, UNDER THE DIFFUSED tion 1 found a tumour, not in the situation INFLUENCE OF THE GOUTY DIATHESIS. of the chord, but just below Poupart’s ligaTHE eighth article consists of a case under ment. It was ofan oval or ratlier pyriform the above title by Dr. CHARLES LENDRICK, the long axis being nearly parallel Poupart’s ligament, but directed somephysician to Mercer’s Hospital, Dublin. to The details are highly interesting, and the ! what more downwards and inwards ; tho was between three and four inches, case may certainly he referred to as one in length and the main breadth about one inch. On which Dr. Arnot’s invalid water-bed might desiring him to cough, the fluctuation prehave been employed with advantage to the viously distinct received a perceptible im. mote
case
shape,
314 mentions that the swelling which, however carefully constructed, in. when he felt variably shift theirposition, and act at length on the diseased surface, sparing one part " The fluctuation in the tumour was ob- only to make increased pressure on another. " servable even to the sight on maliing presOne plan, however, we have adopted sure on the abdomen ; and an alternate with great success in Mercer’s Hospital. It in cutting out of a sheet of stickingimpulse was felt by each hand when placed on these parts. On examination in the a portion adopted to the size of the erect posture, the impulse on coughing was injured part ; the surface of the surrounding still easier (if possible) to be detected. plaster having been covered with cotton The right buttock presented a sacculated wadding, a similar piece of plaster spread appearance, and the extension of the fluc- on both sides is placed over it. Thus a tuation here was but too evident. cushion is formed, which on account of the cc I lost no time in representing to his double spreading of one plaster admits of family the formidable nature of the disease. close application to the skin surrounding He was again visited by Mr. Colles; the ulcerated parts, which are thus comMessrs. Crampton and Wilmot were sub- paratively at least saved from the effects of sequently called into consultation, and Dr. pressure. I may add, that the governors of Charles Orpen was in constant attendance the hospital, with their accustomed atwith me during the future progress of the tention to the wants of the afflicted, have ordered two hydrostatic beds to be con. case. " Our patient derived some advantage, structed on the plan recommended by Mr. apparently, as far as his general health was Arnott ; and most sincerely do I hope, that concerned, by a removal a few miles from the contrivance may, as it seems probable, town. His appetite became better, and realize his expectation, and remove this oprest at night was procurable by means of probrium of the healing art. An excellent less doses of opium. He afterwards began, plan of raising the patient from the bed for however, to suffer from perspirations, espe- the purpose of dressing, &c. was adopted cially towards evening, and with increased on the present occasion on the recommendaemaciation his local sufferings became in- tion of Mr. Crampton, but as it is I becreased to an agonizing degree. He could lieve his intention to publish a description bear the limb in the semiflexed position of it, any further observations of mine only, and in this it was retjtined by the would be superfluous. hand of an attendant, as when left to itself Under the painful circumstances in which it became violently and painfully convulsed. we were placed in Mr. -’s case, we had He was now entirely confined to bed, and no alternative but to make an opening in acetate of morphine was exhibited in doses the tumour, and on the 23rd of June Mr. of three grains, before rest, or rather a ces- Colles plunged a lancet into the swelling, sation of the paroxysms, could be procured. and enlarged the opening with a bistoury; Stripping, and subsequently sloughing, this was on a subsequent occasion extended commenced over the sacrum and coccyx, upwards and outwards to within an inch of and this was truly deplorable, as the supine Poupart’s ligament, leaving an orifice in position was the only one that afforded any the superior part of the tumour of about two inches in length. The matter discharged to his other sufferings. respite " His appetite now declined, rest was was not in any respect similar to that of scarcely procurable, and emaciation, with psoas abscess ; it was ichorous and intolera. other hectic symptoms, were progressive. bly fetid, and of a liver colour. From its A change of posture became indispensable, nature there might have been reason to sus. in order to prevent the extension of morti- pect disease of a bone ; but the appearance
pulse.
He
now
had
appeared after sneezing, something give way.
,
consists plaster
fication in the
I mav here W,tS afterwards considerably changed; it of this and became nearly puriform, thick, and yellow, other cases has convinced me of the utter with a slightly greenish tinge, and scarcely inutility of air-cushions, and similar con- any odour. On opening the tumour nearly trivances, for removing pressure from ul- a quart was discharged, and all the sympcerated parts. The medical attendant can- toms were alleviated. It soon, however, not be too careful, by strict attention to became too plain that the relief was only cleanliness, and the application of cam- temporary. It was found impracticable to phorated spirit or tincture of myrrh, with extend the leg, which was agitated by sethe use of powdered starch, and above all, vere convulsions, and all the symptoms that change of posture, if practicable, to prevent had existed previously to the operation rethe occurrence of so great a calamity whilst curred in even an aggravated degree. A the skin is yet unbroken. After this has violent and incessant hiccup at this time once taken place, I really think the plane was a source of much painful anxiety, as hard hospital bed is superior to all the con- all the usual antispasmodic medicines, with ice, lemon-juice, trivances of the various kinds of cushions, musk, ether, &c.,
sloughing parts. experience
observe, that the
315 and the mineral acids, totally once witnessed after the operation of tying failed in producing any influence. It at the iliac artery. The elastic feel was suclast subsided spontaneously, and except in a ceeded by such a distinct fluctuation, that the propriety of making an incision here minor degree, it did not recur. " His frame was now exhausted by the became the subject of consideration, but an combined effects of spasm (which doses of increase of the usual discharge from the even six grains of acetate of morphine were wound was followed by its disappearance. inadequate to check), the usual attendants The more deep-seated tumour was, howon colliquative suppuration, and an exten- ever, still to be felt in the form of a hardensive gangrene of the parts in the neighbour- ed margin surrounding a cup-like cavity. " hood of the sacrum. About the second of the glutæi muscles, the week in August his sufferings underwent perineum, the neighbourhood of the rectum, some alleviation, the spasms became less and the posterior part of the thigh, at varifrequent and severe, the discharge from the ous times presented appearances of fluctuawound was diminished, and he was enabled tion which afterwards subsided. Doubtsome ma.v have originated in the to extend the limb. There could, however, be but little doubt that a metastasis of dis- serous effusion attendant on deep-seated ease to more vital parts had taken place. inflammation, and were independent of puHe was affected with cough, copious ex- rulent deposit. pectoration, and pain in the right side. " The matter was, as I have alreadyWith the exception, however, of the mu- mentioned, after the first discharge, in cous rattle, and a slight dulness of sound general, of a thick consistence, and of a duringpercussion of the side affected there greenish-yellow colour, with but little was no disease appreciable by auscultation, odour ; occasionally, however, it was of respiration being perceptible throughout the former liver colour, and ichorous. On the entire thorax. His faculties remained one occasion it became so dark-coloured perfectly clear ; but from this time he and fetid, that from the circumstance of a rapidly declined, and died on the 18th ofsimilar appearance in the alvine evacuation, August. The bodv was not examined. it was conjectured that the abscess had " This disease was obviously a diffused perforated the intestinal tube ; it is probad abscess, having its origin within the pelvis. ble, however, that this was not the case, as The fatal result was early anticipated ; the the afterwards resumed its usual more certainly because the want of the ad- appearance. hesive process so as to establish a defined neighbourhood of the origins of sac, was a plain proof of the deficiency of considerable nerves to the part so extenthose vital powers from which our very sively affected with suppurative inflammaslender hopes are ever derivable in such tion, sufficiently accounts, in my judgment, cases. It was questionable, however, whe- for the violence of the pain and the spasther the source of the abscess was to be modic agony attendant on the paroxysms. " traced in the course of’ the psoas muscle. But what was the cause of disease in The parts beneath the iliac fascia, or the this case? Was the influence of gout the neighbourhood of that muscle, presented a principal or the accessory? The sympmore probable origin. Deep pressure above toms which ushered in the formation of Poupart’s ligament near the anterior spine matter first occurred immediately on the of the ilium and continued downwards and subsidence of a paroxysm of regular gout inwards, invariably produced a considerable in the foot, to which the patient had for discharge of matter. A probe introduced subject. I am aware that here passed much more superficially than gouty inflammation sometimes terminates the direction of the source of the matter, aE in suppuration in broken constitutions ; of it could be plainly felt through the integu. I witnessed a fatal case in Mercer’s ments of the abdomen, and seemed to lie Hospital; but Mr. was a man of robust even in front of Poupart’s ligament. Pron makeand temperate habits ; he indulged the emaciation of the patient, it was difficull freely in field sports, and before the slight to conjecture what extent of parts inter’ bowel attack, to which I have alluded, was vened anteriorly between the probe and the in the possession of actually rude health. he took considerable foot finzer. , A considerable tumefaction, but of exercise on the 24th of April, at that time various amount, was always discernible by I never saw a man who, to appearance, was deep pressure above the ligament, in the more likely to enjoy continued good health part corresponding to the separation of the and immunity from every disease, except iliac and psoas muscles. Besides this, on which he was habitually subject. one occasion there was another swelling ob.. He did not at any time before the period of viously much more superficial and anterior the gouty paroxysms complain of weariin situation; this was elastic to the feel,, ness, pain in the back, or the usual precurvery much resembling a hernia, which Isors of lumbar abscess."
vinegar,
The region
les .
3
discharge
" The
some yearsbeen
this
-
I remember that
that to
I