- Email: [email protected]
INSTANCES OF LONDON AGUE.
The pain he described as dull and aching, descending the left thigh as low down as the knee, the thigh being at the same time slightly swollen, and also ascending obliquely backwards towards the small of his back. Twelve months ago he was an inmate of St. George’s Hospital, under the care of Mr. Hawkins, who treated him with iodide of potassium and codliver oil internally, and tincture of iodine locally. He was presented by Mr. Hawkins, at the expiration of eight months, slightly relieved. He resumed his original occupation, and followed it for a short time, until he became so weak that he was compelled to give it up. The patient is a man of middle stature, light complexion, grey eyes, and light hair; presenting all the appearances of having lost an abundance of blood-suffice it to say, however, that he has not lost any; skin of his body generally extremely white, hot, and pungent; conjunctive watery. Chest well formed, mobile during respiration, and resonant on percussion; equally resonant posteriorly. Lungs healthy. On listening to the sounds of the heart, there could be heard indistinctly a systolic bruit in the course of the aorta, ("anaemic bruit diagnosed.") He never had rheumatism or pain in his limbs. His voice is strong and clear; tongue moist and clean; has evidently an enlarged spleen bulging out of the left hypochondriac region; it can be distinctly felt through the abdominal walls; has enlarged glands in the left groin, about the size of a gOOS6’S egg; no other glands perceptibly enlarged; has general anasarca; skin pits on pressure in every part of the body and extremities; urine healthy, specific gravity 1017 ; bowels open; motions of a clay colour, "pale." Mr. Stocker, the apothecary, saw the patient on the 8th out : age twenty-two.’’ The of the lymphatic glands, which thus seems of June, and ordered the following medicine : two grains of the peculiar feature of this malady, is remarkable for the iodide of potassium, in an ounce of julep of ammonia, three lingering form of fatal eachexia which it produces. The ex- times a day. June 9th.-He had a good night. His blood was examined treme pallor of the paf,ient-as we have witnessed at this hosmicroscopically this morning, and was found to contain an expital-at once attracts the attention of the observer. In relation to the six cases we have briefly noticed, Dr. Wilks cess of white corpuscles, " comparatively speaking;" but, in observes, in regard to the symptoms during life and the appear- reality, there seemed to be a deficiency of the red corpuscles, rather than an excess of the white. ances after death-‘‘ Their uniformity is too considerable to constitute merely a coincidence of disease between the glands llth.-Dr. Pavy prescribed five grains of the citrate of iron, and the spleen, and therefore there is, without doubt, a pecu- with quinine, thrice a day. liar form of affection involving these organs, accompanied by 13th.-Has a severe headache this morning, and a troubleI say a peculiar some cough is coming on, without any expectoration. To have an anamic cachexia, prostration, and death. affection; for although allied to the tubercular, I believe it to five grains of extract of conium night and morning; also, five be one not yet recognised under the ordinary forms of disease." ounces of wine daily. This affection has been mistaken for scrofula, especially 16th.-Feels better since he has had the wine; cough much where the glands in the necks of weakly children havecom- about the same. Ordered, lactate of iron, five grains; iodide menced to enlarge. It occurs to persons of all ages. It may of potassium, two grains; syrup of poppies, half a drachm; gradually extend over a period of two or more years, when the water, an ounce: three times a day. thoracic and abdominal glands become involved, and slow pros18th.-Expresses himself as being better; lower extremities still very œdematous; coughs a good deal at night. tration precedes death. The intimate structure of the enlarged glands is a fibro- I July 4th.-Thirst excessive; appetite lost; expectoration -nucleated tissue, and this is not to be distinguished from more abundant, of a bluish grey, slightly frothy character, and ordinary fibro-plastic growths. Dr. Hodgkin described a case strongly adherent to the bottom of the utensil. of this kincl in the seventeenth volume of the " Medico-Chirur8th. -The patient evidently seems much worse; lies prosgical Transactions," in which he refers to its connexion with a trate in bed; is not able to sit up for five minutes together; peculiar affection of the spleen; but he affixed no name to it. mouth and tongue very dry, the latter being brown in the Dr. Wilks correctly styles it anœemia lymphatica, which is a centre, and white along the margins. 9th.-Had a very restless night; respiration became hurried; very distinctive appellation, the anaemia being the most important result, and tending to the fatal issne. Moreover, it is pulse quick and feeble; eyes turned upwards; mouth wide a simple and good name for it, as he thinks it indicates the open, and dry. Ordered, eight ounces of wine; ammonia and most important condition of the malady, and the one often only serpentaria. 10th.—Unconscious; lies on his back, with his head thrown recognizable when the enlargement of the glands is entirely within. There is no excess of white corpuscles in this disease; backwards ; pulse rapid, and extremely feeble. similar to that observed in the leucocythœmia splenica of Ben11th.—Expired at six A. M. Died quietly. Post-mortem examination thirty-three hours afterwards.—On nett, but rather a deficiency of the red, as was observed in the! following case, for the notes of which we are indebted to Mr. opening the thoracic cavity, it was found to contain a larger Hugh Bennett, clinical clerk to the hospital. In this instance, quantity of fluid than is usually met with in health, and an exthe duration of the disease was three years and a half, and the cess of fluid was also found in the pericardium. Lungs free extreme whiteness of the skin resembled the anæmia of females from adhesions; patches of softening were here and there found who have lost much blood. The anaemic bruit was also present. on cutting into them. Liver, kidneys, and heart healthy; William B -, aged twenty-seven years, was admitted, on the latter contained no clot, except a very small one in the June 8th last, into Job ward. He was a single man, by occu- lefc ventricle; blood being remarkably thin, like port wine pation a gunmaker, and residing in Fleet-street; states thatt and water mixed. Spleen enlarged; weighed twenty-four his health has been good up to three years and a half ago, ex- ounces and a half ; full of white tubercles. Lumbar glands cepting having had an attack of iiiflainmation of the bowels greatly enlarged; inguinal glands also enlarged. fifteen years since, and thre attacks of gonorrhoea, four years ago; he had a chancre on penis, no sore throat, no bubo, nor eruption; six months afterwards had enlarged glands in the CLINICAL RECORDS. left groin, which have increased in size ever since; he was never of dissipated habits, and always kept good honrs. INSTANCES OF LONDON AGUE. His parents and brothers are healthy ; no history of scrofula in 1. he H. the family. Three years and a half ago, noticed a small W-, aged thirty-one, farrier; resident in Paddingout of London for years; came from Essex; no ague not in the left a with It was ton ; pain. slight groin, accompanied lump he lived. Was admitted into St. Mary’s Hospital, under the pain, and not the lump, which chiefly attracted his atten-
All of them proved fatal, as well as those which have since under our notice. The peculiarities noticeable in these cases were as follows:CASE 40.-Enlargement of the lumbar and posterior mediastinal lymphatic glands, forming a chain of tumours along the whole length of the spine upon each side of the aorta; spleen enlarged, opaque white deposits through it: age twenty-four. CAPE 41.-Lumbar glands much enlarged, and accompanying the aorta along the spine to the pelvis; mesenteric and bronchial glands enlarged; spleen large, with a number of ovoid white bodies: age nine years. CASE 42.-Cervical, mediastinal, bronchial, and lumbar glands enlarged; spleen four times larger than natural, three-fourths of it resembling opaque white tallow: age ten years. CASE 43.-Lymphatic glands of neck, and around the great vessels in the chest and abdomen, enlarged; spleen had a few white tubercles : age sixteen years. CASE 44.-Great enlargement of the absorbent glands of the neck, axilla, and groin; spleen enlarged, with an infinite number of small, white, opaque age fifty. CASE 45.-(Dr. Markham, 4th vol. "Transactions of the Pathological Society.")—Enlargement of anterior and posterior mediastinal glands, each cling the arch of the aorta; spleen enlarged, with small yellow masses throughout : age thirty. Some other instances might be added to these ; but it will be sufficient to append the following, shown to the Pathological Society in the course of its last session :"Enlargement of thecervical, mediastinal, and lumbar glands; the spleen much enlarged, with white deposits through-
tion.
come
groin,
deposits :
enlargement
,
-
-
____________________
I
I where
214
Dr. Handfield Jones’s care, on the 9th September, 1858. He Took was convalescent from tertian ague, but pale and weak. citrate of iron and quinine with liquor of the arsenite of potass, with much benefit. 2. S. P-, aged twenty, female; resident at Notting-hill ROYAL MEDICAL & CHIRURGICAL SOCIETY. now, before that was in Paddington, to which place she came from Warwickshire, her native county. Ill six weeks with MR. F. C. SKEY, PRESIDENT, IN THE CHAIR. tertian ague. 3. S. W-, male, aged forty-eight; resident in London six ON TRACHEOTOMY IN CROSJ?’. Had ague three years ago, which subsided ’i or seven years. BY CONWAY EVANS, M.D., was then in London. Has been living during i spontaneously; ASSISTANT-PITYSICIAN TO gING’S COLLEGE HOSPITAL, AKD PHYSICIAN TO the last six months at Shepherd’s-bush. Ill a month; had THE PUBLIC DISPENSARY, LINCOLN’S-INN, ETC. quotidian ague all last week, which he got, he thinks, while THE author commenced by remarking upon the frequency working at a house, laying floors. 4. M. K-, female, aged fifty-one; has resided for eighteen and fatality of croup as a disease of early life, in illustration of years near Portland-market, in Marylebone; never went into which he observed that out of every thousand deaths of ehilKent. Got tertian ague in the beginning of May, but never i dren between the ages of one and ten years which occurred in had it before. Has just been discharged from Middlesex Hos- England and Wales during the year 1856, sixty were due to pital, where she was under Dr. Stewart’s care, who kindly sent ’, this malady. He then proceeded to examine into the rate of her to Dr. Jones. mortality from croup, and pointed out the very slight measure 5. J. T. S-, aged sixteen, male; resident in Paddington of success which has hitherto attended the methods of treatthree months; at Wisbeach in Cambridgeshire before, where ment usually employed in this disease. The following casesague is prevalent, but never had it till he came to London. Ill four of croup, and two of diphtheria ( ? )-in. which tracheotomy was performed, were then narrated in detail :now one week with tertian ague. CASE 1.—A boy, aged nine years. Attacked with croup of 6. M. A. G-, aged twenty-six, female; servant in Gloucester-place, Paddington. Ill six weeks with ague, at first slow accession; temporary amendment in the symptoms, foltertian, last fortnight quotidian. Never had it before. Came lowed by threatening suffocation; tracheotomy; death four from Southolt, in Suffolk, where there is no ague endemic hours after the operation; existence of croupous exudation as far as she knows. She resided there three years, and in down to the second and third subdivisions of the bronchi. CASE 2.—A girl, aged three years. Croup, treated by leeches, London for three years previously. Before this she lived at Yarmouth, in Norfolk, where she visited a friend for about five counter-irritation, tartar emetic, and calomel ; tracheotomy on weeks last Christmas; in the vicinity of Yarmouth ague is the fifth day, asphyxia being so complete as to render artificial very prevalent, but no one had it in the house or immediate respiration necessary; ejection of false membrane from trachea, and likewise two casts of small bronchial tubes; after-treatvicinity where she was staying. The first four of these cases seem certainly to have originated ment of a freely-supporting character, recovery perfect. CASE 3.-A boy, aged two years. Croup, between two and either in London or in its outskirts. The predisposition in the fifth case was in all probability acquired at Wisbeach, but three days, treated with emetics; tracheotomy on the third London influences developed the disease, which otherwise day, suffocation being nearly complete; death during the opemight haveremained in abeyance for an indefinite time. In ration ; the croupous exudation fouud after death to extend the sixth case Dr. Jones thinks the disorder must have origi- down to the first subdivision of the bronclai. CASE 4.-A boy, aged two years and a half. Croup, treated nated in London, as the patient had resided previously at Yarmouth without suffering from it, and her visit having been by tartar emetic; suffocation imminent on the fourth day, from in the winter time makes it unlikely that any ague miasm was the accession of the croupous breathing; tracheotomy; death from exhaustion sixty-five hours after the operation; false then active. The practical interest of these observations lies in the view membrane found after death to extend down to the fourth (which Dr. Jones is much inclined to believe is correct) that subdivisions of the bronchi. CASE 5.-A boy, aged five years. Diphtheria (?), coming on ague, when occurring in localities which one might expect would be free, and which usually are so, serves as an exponent slowly and insidiously; breathing croupous on the seventhof the dominant type of disease. It is itself eminently a neu- day ; treated by emetics, counter-irritation, calomel, and comrosis, and when it prevails such disorders will surely be in the pound antimonial powder; suffocation imminent on the eighth ascendant. That such is the case now is matter of general day; tracheotomy, followed by supporting treatment; ejection of a piece of false membrane; sudden accession of severe diarexperience. rhœa, about thirty-six hours after the operation, and death from exhaustion. No post-mortem examination. DIVISION OF THE TENDON OF THE RECTUS CASE 6.-A boy, aged ten years. Diphtheria, coming on FEMORIS. very insidiously during nearly a month; treated by salines, THE faulty position of the limb in the following case, arising and the application of a solution of nitrate of silver to the from an old fracture of the femur, rendered it completely use- throat; supervention of croupous symptoms, treated by counterless for the ordinary means of progression. There was apparent irritation, leeches, antimony, calomel, and chlorate of potash; anchylosis depending upon contraction of the quadriceps ex- asphyxia impending; tracheotomy, and stimulating aftertensor muscle. This was successfully remedied by the import- treatment; death, apparently from syncope, about twenty-six ant operation of subcutaneous division of the tendon of the hours after the operation. After death, a thick false memrectus femoris by Mr. Brodhurst. It is not often that this brane, separable from the subjacent mucous membrane only special tendon has been divided, and the case is one of much with considerable force, was found to line the larynx and interest from its rarity. trachea, and to extend to the bifurcation of the latter; it proW. C-, aged thirty-eight, a powerful sailor, in July, bably, indeed, passed down into the lungs, but an examination 1857, fell from the rigging of a man-of-war on to the deck, a of these organs was not permitted. of twenty feet, fracturing the femur in the upper third. Observing that, as in a large proportion of the fatal cases of height Union took place, but with considerable irregularity, so much croup the disease destroys life by asphyxia,, the author proceeds to inquire into the reasons why tracheotomy is so rarely so that the bone might be seen projecting very considerably on the outer side of the limb. He was admitted a patient at the resorted to for the relief of this malady in Great Britain, and Orthopaedic Hospital in May, 1859, under Mr. Brodhurst, with traces this mainly to the influence oi’ the strong opinions against apparently partial anchylosis of the knee-joint. There existed the operation which have from time to time been pronounced very slight motion at the knee, which was stopped suddenly, by many great authorities,, both British mol American, whose and as though by a projection of bone. Chloroform was ad- views in reference to this point are cited. These opinions the ministered, and it then became evident that the contracted author believes have no valid foundation, and are unworthy of condition of the quadriceps extensor was the cause of immo- the confidence generally placed in them; and to this conclusion bility. It was therefore determined t6 divide the tendon of he is led by four classes of considerations, which are examined the rectus femoris. The division was effected from an inch and in detail. These are—1st, the high rate of mortality from a half to two inches above the patella, so as to avoid the bursa. croup, both with and without treatment; 2nd, the immediate Gradual extension was employed after the external wound had cause of death in a large majority of the fatal cases of the-dishealed, and indeed it is still being carried on. At present the ease-namely, asphyxia; 3rd. the recorded cases of croup in leg is flexed beyond a right angle, and the motion of the knee- which tracheotomy has been resorted to in this country when joint is so far free. There is no doubt that the motion of the the patient has been all but suffocated, and in which complete recoverv has followed the operation : and 4th. the great sucjoint will be perfectly restored.
Medical Societies.
215
All of them proved fatal, as well as those which have since under our notice. The peculiarities noticeable in these cases were as follows:CASE 40.-Enlargement of the lumbar and posterior mediastinal lymphatic glands, forming a chain of tumours along the whole length of the spine upon each side of the aorta; spleen enlarged, opaque white deposits through it: age twenty-four. CAPE 41.-Lumbar glands much enlarged, and accompanying the aorta along the spine to the pelvis; mesenteric and bronchial glands enlarged; spleen large, with a number of ovoid white bodies: age nine years. CASE 42.-Cervical, mediastinal, bronchial, and lumbar glands enlarged; spleen four times larger than natural, three-fourths of it resembling opaque white tallow: age ten years. CASE 43.-Lymphatic glands of neck, and around the great vessels in the chest and abdomen, enlarged; spleen had a few white tubercles : age sixteen years. CASE 44.-Great enlargement of the absorbent glands of the neck, axilla, and groin; spleen enlarged, with an infinite number of small, white, opaque age fifty. CASE 45.-(Dr. Markham, 4th vol. "Transactions of the Pathological Society.")—Enlargement of anterior and posterior mediastinal glands, each cling the arch of the aorta; spleen enlarged, with small yellow masses throughout : age thirty. Some other instances might be added to these ; but it will be sufficient to append the following, shown to the Pathological Society in the course of its last session :"Enlargement of thecervical, mediastinal, and lumbar glands; the spleen much enlarged, with white deposits through-
tion.
come
groin,
deposits :
enlargement
,
-
-
____________________
I
I where
214
Dr. Handfield Jones’s care, on the 9th September, 1858. He Took was convalescent from tertian ague, but pale and weak. citrate of iron and quinine with liquor of the arsenite of potass, with much benefit. 2. S. P-, aged twenty, female; resident at Notting-hill ROYAL MEDICAL & CHIRURGICAL SOCIETY. now, before that was in Paddington, to which place she came from Warwickshire, her native county. Ill six weeks with MR. F. C. SKEY, PRESIDENT, IN THE CHAIR. tertian ague. 3. S. W-, male, aged forty-eight; resident in London six ON TRACHEOTOMY IN CROSJ?’. Had ague three years ago, which subsided ’i or seven years. BY CONWAY EVANS, M.D., was then in London. Has been living during i spontaneously; ASSISTANT-PITYSICIAN TO gING’S COLLEGE HOSPITAL, AKD PHYSICIAN TO the last six months at Shepherd’s-bush. Ill a month; had THE PUBLIC DISPENSARY, LINCOLN’S-INN, ETC. quotidian ague all last week, which he got, he thinks, while THE author commenced by remarking upon the frequency working at a house, laying floors. 4. M. K-, female, aged fifty-one; has resided for eighteen and fatality of croup as a disease of early life, in illustration of years near Portland-market, in Marylebone; never went into which he observed that out of every thousand deaths of ehilKent. Got tertian ague in the beginning of May, but never i dren between the ages of one and ten years which occurred in had it before. Has just been discharged from Middlesex Hos- England and Wales during the year 1856, sixty were due to pital, where she was under Dr. Stewart’s care, who kindly sent ’, this malady. He then proceeded to examine into the rate of her to Dr. Jones. mortality from croup, and pointed out the very slight measure 5. J. T. S-, aged sixteen, male; resident in Paddington of success which has hitherto attended the methods of treatthree months; at Wisbeach in Cambridgeshire before, where ment usually employed in this disease. The following casesague is prevalent, but never had it till he came to London. Ill four of croup, and two of diphtheria ( ? )-in. which tracheotomy was performed, were then narrated in detail :now one week with tertian ague. CASE 1.—A boy, aged nine years. Attacked with croup of 6. M. A. G-, aged twenty-six, female; servant in Gloucester-place, Paddington. Ill six weeks with ague, at first slow accession; temporary amendment in the symptoms, foltertian, last fortnight quotidian. Never had it before. Came lowed by threatening suffocation; tracheotomy; death four from Southolt, in Suffolk, where there is no ague endemic hours after the operation; existence of croupous exudation as far as she knows. She resided there three years, and in down to the second and third subdivisions of the bronchi. CASE 2.—A girl, aged three years. Croup, treated by leeches, London for three years previously. Before this she lived at Yarmouth, in Norfolk, where she visited a friend for about five counter-irritation, tartar emetic, and calomel ; tracheotomy on weeks last Christmas; in the vicinity of Yarmouth ague is the fifth day, asphyxia being so complete as to render artificial very prevalent, but no one had it in the house or immediate respiration necessary; ejection of false membrane from trachea, and likewise two casts of small bronchial tubes; after-treatvicinity where she was staying. The first four of these cases seem certainly to have originated ment of a freely-supporting character, recovery perfect. CASE 3.-A boy, aged two years. Croup, between two and either in London or in its outskirts. The predisposition in the fifth case was in all probability acquired at Wisbeach, but three days, treated with emetics; tracheotomy on the third London influences developed the disease, which otherwise day, suffocation being nearly complete; death during the opemight haveremained in abeyance for an indefinite time. In ration ; the croupous exudation fouud after death to extend the sixth case Dr. Jones thinks the disorder must have origi- down to the first subdivision of the bronclai. CASE 4.-A boy, aged two years and a half. Croup, treated nated in London, as the patient had resided previously at Yarmouth without suffering from it, and her visit having been by tartar emetic; suffocation imminent on the fourth day, from in the winter time makes it unlikely that any ague miasm was the accession of the croupous breathing; tracheotomy; death from exhaustion sixty-five hours after the operation; false then active. The practical interest of these observations lies in the view membrane found after death to extend down to the fourth (which Dr. Jones is much inclined to believe is correct) that subdivisions of the bronchi. CASE 5.-A boy, aged five years. Diphtheria (?), coming on ague, when occurring in localities which one might expect would be free, and which usually are so, serves as an exponent slowly and insidiously; breathing croupous on the seventhof the dominant type of disease. It is itself eminently a neu- day ; treated by emetics, counter-irritation, calomel, and comrosis, and when it prevails such disorders will surely be in the pound antimonial powder; suffocation imminent on the eighth ascendant. That such is the case now is matter of general day; tracheotomy, followed by supporting treatment; ejection of a piece of false membrane; sudden accession of severe diarexperience. rhœa, about thirty-six hours after the operation, and death from exhaustion. No post-mortem examination. DIVISION OF THE TENDON OF THE RECTUS CASE 6.-A boy, aged ten years. Diphtheria, coming on FEMORIS. very insidiously during nearly a month; treated by salines, THE faulty position of the limb in the following case, arising and the application of a solution of nitrate of silver to the from an old fracture of the femur, rendered it completely use- throat; supervention of croupous symptoms, treated by counterless for the ordinary means of progression. There was apparent irritation, leeches, antimony, calomel, and chlorate of potash; anchylosis depending upon contraction of the quadriceps ex- asphyxia impending; tracheotomy, and stimulating aftertensor muscle. This was successfully remedied by the import- treatment; death, apparently from syncope, about twenty-six ant operation of subcutaneous division of the tendon of the hours after the operation. After death, a thick false memrectus femoris by Mr. Brodhurst. It is not often that this brane, separable from the subjacent mucous membrane only special tendon has been divided, and the case is one of much with considerable force, was found to line the larynx and interest from its rarity. trachea, and to extend to the bifurcation of the latter; it proW. C-, aged thirty-eight, a powerful sailor, in July, bably, indeed, passed down into the lungs, but an examination 1857, fell from the rigging of a man-of-war on to the deck, a of these organs was not permitted. of twenty feet, fracturing the femur in the upper third. Observing that, as in a large proportion of the fatal cases of height Union took place, but with considerable irregularity, so much croup the disease destroys life by asphyxia,, the author proceeds to inquire into the reasons why tracheotomy is so rarely so that the bone might be seen projecting very considerably on the outer side of the limb. He was admitted a patient at the resorted to for the relief of this malady in Great Britain, and Orthopaedic Hospital in May, 1859, under Mr. Brodhurst, with traces this mainly to the influence oi’ the strong opinions against apparently partial anchylosis of the knee-joint. There existed the operation which have from time to time been pronounced very slight motion at the knee, which was stopped suddenly, by many great authorities,, both British mol American, whose and as though by a projection of bone. Chloroform was ad- views in reference to this point are cited. These opinions the ministered, and it then became evident that the contracted author believes have no valid foundation, and are unworthy of condition of the quadriceps extensor was the cause of immo- the confidence generally placed in them; and to this conclusion bility. It was therefore determined t6 divide the tendon of he is led by four classes of considerations, which are examined the rectus femoris. The division was effected from an inch and in detail. These are—1st, the high rate of mortality from a half to two inches above the patella, so as to avoid the bursa. croup, both with and without treatment; 2nd, the immediate Gradual extension was employed after the external wound had cause of death in a large majority of the fatal cases of the-dishealed, and indeed it is still being carried on. At present the ease-namely, asphyxia; 3rd. the recorded cases of croup in leg is flexed beyond a right angle, and the motion of the knee- which tracheotomy has been resorted to in this country when joint is so far free. There is no doubt that the motion of the the patient has been all but suffocated, and in which complete recoverv has followed the operation : and 4th. the great sucjoint will be perfectly restored.
Medical Societies.
215