ST. BARTHOLOMEW'S HOSPITAL

Paget
1867 The Lancet  
of ascending or descending inflection. This is a subject on which I do not for the present wish to dilate, though it has never occurred to me to see, either in treatises or in practice, any use made of the singing voice as a modification of vocal resonance. The nearest approach I am aware of is " whispering pectoriloquy," a phenomenon of kindred nature, and of great interest, though, like the preceding, difficult at times to substantiate, from the fact that many persons are unable to whisper,
more » ... the true sense of the word, but when requested to do so only speak in a very low voice. Real whispering is formed entirely in the mouth, the stream of air which forms the consonants being unaccompanied by any vibration of the vocal cords whatever. This, then, is exactly the condition of the excited musical sound above described, with the additional advantage that the vibrating column of air is inhaled, and that the weight of the metal pitch-pipe held between the yielding lips prevents vibrations sensible to the touch from being transmitted to the ear of the auscultator. Even if the experiment be carried no farther, we have obviously a means of testing morbid states of lung in cases where, from laryngeal disease, or aphonia of any other sort, the natural larynx is incompetent to the function. These cases are not very rare in practice ; already it has become evident from the use of the laryngoscope that many cases of aphonia associated with pulmonary disease are dependent on the damaged state of the bellows, rather than on organic lesion of the larynx such as was formerly believed in. I have had occasion to examine many patients at the Brompton Hospital in my own practice, in that of my colleagues there, and in conjunction with my friend Dr. Morell Mackenzie, where this valuable instrument relieved the patient from risk of irrelevant and misdirected local treatment. The use of a musical sound formed in what may be termed an artificial larynx, appears to offer the positive and complementary evidence demanded of the auscultator after the negative revelations of the laryngoscope. Dr. Grabham has adopted a different method for exciting musical vibrations in the thorax, which consists in fixing an ordinary tuning-fork upright on a pleximeter. The pleximeter being then rested steadily on one side of the chest, and the tuning-fork made to vibrate, the auscultator listens to the transmitted sound on the opposite side, or at varying distances around. I have no doubt that valuable information may be obtained by this process, though it has the disadvantage of involving the thoracic walls themselves in the vibration. Their resonance and elasticity prove, even in the ordinary practice of percussion, a common drawback from the accuracy of the signs obtained, especially in the case of children, where those qualities are most obvious and characteristic. Dr. Grabham and I hope, however, by comparison of the two methods, and by observations now in progress, to carry the subject a step farther, and to show that the musical sound at times behaves differently from that of the voice, and occasionally affords special and trustworthy information. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, tum proprias collectas habere, et inter ge comparare.-MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium. UNUSUAL difficulties surrounded the operation for removal of a calculus in the following case. So formidable were these that Mr. Paget remarked, before commencing to operate, that he felt by no means certain of achieving his object. By pa-tience and skilful manipulation, however, the obstacles were successfully encountered, and the stone removed from the bladder. Mr. J. A. Bloxam, late house-surgeon, has been kind enough to give us the following history of the patient's case. George D--, aged fifty-one, was admitted on April 12th,. 1866. For twenty-eight years he had suffered from stricture of the urethra, complicated during eighteen years with perineal fistulæ. He attributed his stricture to gonorrhcea. He had had several attacks of retention, the last occurring seventeen I years ago, which was the last occasion upon which an instrument had been passed into his bladder. The patient was kept quiet in bed for a few days, and then Mr. Paget, on passing a catheter, discovered a stone in his bladder, of the presence of which the man had no suspicion. He was exceedingly corpulent, and bore a most unhealthy look. Operation.-On the 28th of April the man was placed under the influence of chloroform upon the operating table, and Mr. Paget proceeded to introduce a small staff, provided with a median groove. The size of this instrument was necessarily less than that usually employed, on account of the stricture existing in the urethra. By patient manipulation the staff, after a little delay, entered the bladder, and was held in position by Mr. T. Smith. The man was then placed in the usual posture and bound. A number of fistulous openings were then visible in the perineum. Mr. Paget chose the median operation on account of these sinuses. He thought that were lateral lithotomy employed the diseased condition of the tissues would result in much hæmorrhage ; and he preferred, therefore, to cut into a part the state of which was healthier. With a strong bistoury he then divided the integuments in the median line, and carried the knife onwards towards the staff. But here a difficulty presented itself, as it was found that the staff, which had certainly been introduced into the bladder, had slipped from its proper position. The patient was then released from his bonds, placed in a recumbent position, and the staff reintroduced. It was now discovered that the staff had entered one of the false passages, of which there were several. It was withdrawn, and again passed into the bladder. The lithotomy position having been resumed, there was now no difficulty in striking the groove. The knife was then pushed steadily onwards for a few lines, so as just to incise the apex of the prostate, and was then withdrawn. Mr. Paget then, after dilating the opening into the bladder with his finger, introduced a blunt gorget. The staff was taken out of the bladder, and the forceps, having been passed along the gorget, seized the stone, part of which it removed, the remainder being extracted by the scoop. The stone was soft, at least externally, and broke down under the least pressure. For the first three days after the operation the man appeared to be doing moderately well, having had less shock than is usual with one of his age. He was, however, somewhat distressed by the chloroform. The urine came freely away from the wound, and he took a fair quantity of food. On May 2nd he had some febrile disturbance, and passed less urine through the wound. His pulse became more frequent, and the number of his respirations increased. From that time he gradually became worse ; his pulse was quick, small, and irregular; his tongue brown and dry, skin hot, and general aspect bad. The abdomen became somewhat distended, and there was a tendency to diarrhoea, but at no time was there any tenderness. The wound presented a sloughing appearance. Delirium ensued, and he died on May 6th. His treatment consisted of stimulants, with barley-water and lemonade, to increase, if possible, the amount of secretion by the kidneys. Opium was given, but in small quantities only, for disease of the kidneys was suspected. On post-mortem examination, suppuration in the pelvic fascia was discovered, but no signs of general peritonitis. The kidneys were extensively diseased. The bladder was much thickened, and its mucous coat ulcerated.
doi:10.1016/s0140-6736(02)67176-4 fatcat:nmxvdcq2ivhwbfqnww6sc4x3ja