- Email: [email protected]
"SYNCOPE AFTER INFLUENZA."
63
"SYNCOPE AFTER INFLUENZA."
disproof of the point which I stated as clearly as I could in my letter to you of Oct. 7th-namely, that it is irrational to write papers urging "The Complete Abandonment of the Cutting Operation for removing Calculi entire from the Bladder." The proof of the correctness of my statement is that calculi
with which cannot be seized the urethra, and that sometimes cannot even be detected until the finger has been passed into the bladder through a vesical incision. These are calculi lying in one or other of the vesical pouches described by me in THE LANCET of April 8th, 1891. The question of the "Tolerance of the Indian Bladder " is a side issue altogether, but I am easily beguiled from the straight and narrow way into an alluring by-path. In reading the papers which have led to this correspondence I find : 1. A native, aged sixty years, had his urethra opened by perineal incision. A phosphatic calculus weighing two ounces was crushed, and the bladder evacuated of d6bris by instruments, some as large He went as No. 20, passed through the perineal wound. home cured on the third day. 2. A youth aged eighteen years, afflicted with a huge vesical calculus, was so ill that after several consultations with colleagues it was thought that operation must be followed by death. The urethra was opened from the perineum, a lithotrite was passed through the wound into the bladder, the stone seized and broken up by the repeated blows of a hammer. Three ounces of debris were removed, and after two hours’ work the patient was put back to bed. Four days afterwards the remaining four ounces of stone were similarly attacked and removed in one hour and In three days the patient left the hospital, passing a half. all his urine by penis and free from pain. 3. I also read that in a thousand cases of lithotrity there has been only one case of recurrence of stone. Am I not justified, being accustomed to the British urinary bladder, in marvelling at the vesica tolerance of the natives of India ? Underlying, however, th{ whole subject which has led to this correspondence is realll the question of the proper treatment of large vesical calculi With your permission I hope to discuss this matter in a pape: in your columns very shortly. I am, Sirs, yours truly, G. BUCKSTON BROWNE. Wimpole-atreet, W., Dec 30b, 1893. are
not
infrequently met
by instruments introduced through
tinuation into the femoral and external iliac veins, to become plugged three weeks after convalescence from influenza, and after the patient was sufficiently recovered to leave the house. Without discussing the probable causes of this tendency, which are still but obscurely known, such cases preach the necessity for careful supervision of a patient until the debility so characteristic of many of these cases has passed off. The weak pulse means the weak heart as a rule, and the latter may on slight provocation give up the struggle, to contract and suddenly assume the fatal diastole characteristic of syncope from such causes. I
am.
Sirs.
yours
trnlv_
ALEXANDER MORISON, Upper Berkeley- street, W., Dec. 30th, 1893.
M.D., M.R.C.P.
"THE DIFFICULTIES OF DIAGNOSING SMALL-POX." To the Editors
of THE
LANCET.
SIRS, -The fact of the submission of a question of medical
to the arbitrament of a police magistrate affords ’ood for reflection, and suggests the need of some further onsideration of the point involved. The difficulty is a real )ne, which has occurred to many others beside Mr. J. D. Hirst Smyth, and which, in spite of what Mr. Curtis Bennett may say, cannot be got over by mending or marring an Act of Parliament. May I give one instance to illustrate how this difficulty may occur in practice ? On Dec. 25th, 1892, a ship arrived in the Thames having on board a man who had been ill for four days. He was seen by two experienced and responsible medical officers, one of whom diagnosed the case as small-pox, the other as chicken-pox, and so it figured in their respective returns under different names. On Jan. 4th two cases were removed from the ship, and on the 9th a third, all undoubtedly suffering from small-pox. The remainder of the crew were then put on a hulk, from which, on Jan. 23rd, a case had to be removed, which was described as being clinically chicken-pox throughout, but it has been treated as small-pox on account of the history. This is the record of experienced men free from bias. The difficulty admitted, can anything be done to remove it ? Or must the statement of Dr. Ricketts "SYNCOPE AFTER INFLUENZA." remain an established fact that in some instances variola and To the Editors of THE LANCET. varicella so closely resemble each other that none but th& SIRS,-Mr. Percy Reynolds well remarks in his interesting most skilled observer is competent to distinguish the two. narrative of syncope after mild influenza, which you publish diseases. Following the description of Dr. Gee, the eruption in THE LANCET of Dec. 30th, that the case affords " much of varicella, which does not last more than a week, consists, food for thought." The influence of influenza (to use a , first, of some rose spots simply hypersemic, not shotty, which somewhat tautological expression which reveals how little in a few hours become raised into blebs the size of split peas there is in that nosological term) is recognised in the or larger, without areola, giving the patient the appearance of Registrar-General’s returns as an aggravating factor in the having been subjected to a shower of scalding water, the Fresh death-rate from diseases of the chest generally. It would vesicles being unicellular and not umbilicated. appear that of the 53,085 deaths due to disease of the crops appear for several successive days, then the circulatory system in England during 1891, 1355 were ascribed vesicles dry up or are destroyed and the thing is over. to syncope. Most of those who have had much experience of Now if this is a fair description of the disease-and certainly the debilitating epidemic now prevalent must recall instances cases are constantly seen answering to it-it is hard to underof a similar sudden fatality. I have myself met with a case stand how it can be mistaken for small-pox ; in fact, it in which a delicate woman convalescent from influenza seems to me not quite easy to see in what ways the two suddenly died of syncope on the night-stool which was diseases resemble each other. The difficulty is not really beside her bed, and which she had sought immediately after here at all ; it is to be found in another set of cases, equally recumbency. Mr. Reynolds does not comment upon his case, well known to all who have to do with children, cases such but appears to assume from the sequence of events mentioned as this. A child is seen with some papules scattered over in the title of his communication that cardiac thrombosis had the body which have rather a shotty feel. The patient preceded the fatal syncope. His reason, I imagine, for so appears quite well, except perhap. for a rise of temperature doing was the presence of what he terms ante-mortem clot of a degree or so, lasting only a few hours. Next day, in the chambers of the heart. If he rests his assumption looking carefully, some of the papules will be seen to be merely upon decolourisation of the blood-clot and not upon surmounted with minute vesicles, and on this or the following stratification or consecutive accretion, I think it is permissible day one or two of them, remaining quite small, become more to question whether the coagulation preceded the syncope or less umbilicated. At this point the progress stops,. or followed it. It has been proved th:1t blood in the chambers a few tiny scabs from, perhaps, the umbilicated vesicles of the dead heart takes considerably longer to coagulate than leave a slight mark. Now, what is this disease ? I after extravasation into a vessel, and in this slow process asuppose it would receive the name of chicken-pox of very considerable subsidence of the corpuscles is possiblethat variety which gives rise to difficulty in diagnosis. before the usual interval has elapsed when a necropsy takes Now, if the first described ailment is true chicken-pox, by place. In this case the examination was made next day. what right can the second malady claim the same appellaIf I may be permitted respectfully to express an opinion, IL tion ? Can it, for instance, be clearly shown that either form should say that in the present ini-tance the syncope was thebreeds the other? Do the two forms resemble each other initial event, and the decolourisation of blood-clot a post- closely enough to be considered as derivatives from a common mortem occurrence. It is not to be denied, however, that stock? On the other hand, have we any other instance of there seems to be some tendency to the formation of intra- a specific disease assuming such different characters ? Again, vascular coagula in these cases. I have knovn the wholes if this second form differs so markedly from typical varicella, internal saphenous vein, and with great probability its con- does it not present a strong family likeness to variola-greatly
liagnosis
-
.
-
"SYNCOPE AFTER INFLUENZA."
disproof of the point which I stated as clearly as I could in my letter to you of Oct. 7th-namely, that it is irrational to write papers urging "The Complete Abandonment of the Cutting Operation for removing Calculi entire from the Bladder." The proof of the correctness of my statement is that calculi
with which cannot be seized the urethra, and that sometimes cannot even be detected until the finger has been passed into the bladder through a vesical incision. These are calculi lying in one or other of the vesical pouches described by me in THE LANCET of April 8th, 1891. The question of the "Tolerance of the Indian Bladder " is a side issue altogether, but I am easily beguiled from the straight and narrow way into an alluring by-path. In reading the papers which have led to this correspondence I find : 1. A native, aged sixty years, had his urethra opened by perineal incision. A phosphatic calculus weighing two ounces was crushed, and the bladder evacuated of d6bris by instruments, some as large He went as No. 20, passed through the perineal wound. home cured on the third day. 2. A youth aged eighteen years, afflicted with a huge vesical calculus, was so ill that after several consultations with colleagues it was thought that operation must be followed by death. The urethra was opened from the perineum, a lithotrite was passed through the wound into the bladder, the stone seized and broken up by the repeated blows of a hammer. Three ounces of debris were removed, and after two hours’ work the patient was put back to bed. Four days afterwards the remaining four ounces of stone were similarly attacked and removed in one hour and In three days the patient left the hospital, passing a half. all his urine by penis and free from pain. 3. I also read that in a thousand cases of lithotrity there has been only one case of recurrence of stone. Am I not justified, being accustomed to the British urinary bladder, in marvelling at the vesica tolerance of the natives of India ? Underlying, however, th{ whole subject which has led to this correspondence is realll the question of the proper treatment of large vesical calculi With your permission I hope to discuss this matter in a pape: in your columns very shortly. I am, Sirs, yours truly, G. BUCKSTON BROWNE. Wimpole-atreet, W., Dec 30b, 1893. are
not
infrequently met
by instruments introduced through
tinuation into the femoral and external iliac veins, to become plugged three weeks after convalescence from influenza, and after the patient was sufficiently recovered to leave the house. Without discussing the probable causes of this tendency, which are still but obscurely known, such cases preach the necessity for careful supervision of a patient until the debility so characteristic of many of these cases has passed off. The weak pulse means the weak heart as a rule, and the latter may on slight provocation give up the struggle, to contract and suddenly assume the fatal diastole characteristic of syncope from such causes. I
am.
Sirs.
yours
trnlv_
ALEXANDER MORISON, Upper Berkeley- street, W., Dec. 30th, 1893.
M.D., M.R.C.P.
"THE DIFFICULTIES OF DIAGNOSING SMALL-POX." To the Editors
of THE
LANCET.
SIRS, -The fact of the submission of a question of medical
to the arbitrament of a police magistrate affords ’ood for reflection, and suggests the need of some further onsideration of the point involved. The difficulty is a real )ne, which has occurred to many others beside Mr. J. D. Hirst Smyth, and which, in spite of what Mr. Curtis Bennett may say, cannot be got over by mending or marring an Act of Parliament. May I give one instance to illustrate how this difficulty may occur in practice ? On Dec. 25th, 1892, a ship arrived in the Thames having on board a man who had been ill for four days. He was seen by two experienced and responsible medical officers, one of whom diagnosed the case as small-pox, the other as chicken-pox, and so it figured in their respective returns under different names. On Jan. 4th two cases were removed from the ship, and on the 9th a third, all undoubtedly suffering from small-pox. The remainder of the crew were then put on a hulk, from which, on Jan. 23rd, a case had to be removed, which was described as being clinically chicken-pox throughout, but it has been treated as small-pox on account of the history. This is the record of experienced men free from bias. The difficulty admitted, can anything be done to remove it ? Or must the statement of Dr. Ricketts "SYNCOPE AFTER INFLUENZA." remain an established fact that in some instances variola and To the Editors of THE LANCET. varicella so closely resemble each other that none but th& SIRS,-Mr. Percy Reynolds well remarks in his interesting most skilled observer is competent to distinguish the two. narrative of syncope after mild influenza, which you publish diseases. Following the description of Dr. Gee, the eruption in THE LANCET of Dec. 30th, that the case affords " much of varicella, which does not last more than a week, consists, food for thought." The influence of influenza (to use a , first, of some rose spots simply hypersemic, not shotty, which somewhat tautological expression which reveals how little in a few hours become raised into blebs the size of split peas there is in that nosological term) is recognised in the or larger, without areola, giving the patient the appearance of Registrar-General’s returns as an aggravating factor in the having been subjected to a shower of scalding water, the Fresh death-rate from diseases of the chest generally. It would vesicles being unicellular and not umbilicated. appear that of the 53,085 deaths due to disease of the crops appear for several successive days, then the circulatory system in England during 1891, 1355 were ascribed vesicles dry up or are destroyed and the thing is over. to syncope. Most of those who have had much experience of Now if this is a fair description of the disease-and certainly the debilitating epidemic now prevalent must recall instances cases are constantly seen answering to it-it is hard to underof a similar sudden fatality. I have myself met with a case stand how it can be mistaken for small-pox ; in fact, it in which a delicate woman convalescent from influenza seems to me not quite easy to see in what ways the two suddenly died of syncope on the night-stool which was diseases resemble each other. The difficulty is not really beside her bed, and which she had sought immediately after here at all ; it is to be found in another set of cases, equally recumbency. Mr. Reynolds does not comment upon his case, well known to all who have to do with children, cases such but appears to assume from the sequence of events mentioned as this. A child is seen with some papules scattered over in the title of his communication that cardiac thrombosis had the body which have rather a shotty feel. The patient preceded the fatal syncope. His reason, I imagine, for so appears quite well, except perhap. for a rise of temperature doing was the presence of what he terms ante-mortem clot of a degree or so, lasting only a few hours. Next day, in the chambers of the heart. If he rests his assumption looking carefully, some of the papules will be seen to be merely upon decolourisation of the blood-clot and not upon surmounted with minute vesicles, and on this or the following stratification or consecutive accretion, I think it is permissible day one or two of them, remaining quite small, become more to question whether the coagulation preceded the syncope or less umbilicated. At this point the progress stops,. or followed it. It has been proved th:1t blood in the chambers a few tiny scabs from, perhaps, the umbilicated vesicles of the dead heart takes considerably longer to coagulate than leave a slight mark. Now, what is this disease ? I after extravasation into a vessel, and in this slow process asuppose it would receive the name of chicken-pox of very considerable subsidence of the corpuscles is possiblethat variety which gives rise to difficulty in diagnosis. before the usual interval has elapsed when a necropsy takes Now, if the first described ailment is true chicken-pox, by place. In this case the examination was made next day. what right can the second malady claim the same appellaIf I may be permitted respectfully to express an opinion, IL tion ? Can it, for instance, be clearly shown that either form should say that in the present ini-tance the syncope was thebreeds the other? Do the two forms resemble each other initial event, and the decolourisation of blood-clot a post- closely enough to be considered as derivatives from a common mortem occurrence. It is not to be denied, however, that stock? On the other hand, have we any other instance of there seems to be some tendency to the formation of intra- a specific disease assuming such different characters ? Again, vascular coagula in these cases. I have knovn the wholes if this second form differs so markedly from typical varicella, internal saphenous vein, and with great probability its con- does it not present a strong family likeness to variola-greatly
liagnosis
-
.
-