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The drawings represent the instrument as made by Whickerand Blaise, of St. James’s-street.

Surrey-street, Strand, February, 1858.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.

ADDISON’S DISEASE OF THE SUPRA-RENAL CAPSULES,ASSOCIATED WITH A PSOAS ABSCESS.

(Under the care of Dr. ADDISON.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Procemium.

THERE are three cases of disease of the supra-renal capsules at-the present time in the medical wards, two characterized bywell-marked melasma, the third without any discolorationwhatever. The first of these cases has been for a considerabletime under observation, with variable conditions of improve-.ment ; sometimes the patient, a female, has seemed to improve,and at others to relapse, but on the whole she may be said tobe better, with the melasma of a lighter colour than it hasbeen. The constitutional symptoms are well-marked and un-TnistakaMe, and would of themselves indicate the true nature 01the disease, without any pigmentary discoloration. In fact,the third case, under Dr. Habershon’s care, which we will give.next week, has no melasma whatever, yet the symptoms ledhim and others to believe that they depend upon disease of the-supra-renal capsules. This will become verified by time.The second case is that of a man, under the care ofDr. Wilks, with discoloration for nearly three years. Too

much stress is laid upon the fact by some observers of the ab-sence of melasma indicating the absence of Addison’s disease,whereas it is probable it may not make its appearance until thedisease is in an advanced state ; and, as we heard Dr. Addisonlately say, " In the instances which have fallen under my ownobservation it appears to me quite conclusive that the amountof discoloration in the cases I have met with has been con--nected with the softening process or liquefaction of the con-tents of the organs, the one being in direct ratio with the ex-tent of the other." On the other hand, the discoverer of the edisease has described the discoloration as one of the earliest

symptoms met with in the disease; but (and this is a point ofsome importance) the disease, he believed, might and did’occur without any such discoloration. In the subjoined casethe discoloration was very great, and the constitutional debi-lity severe. It has become of a lighter tint, and her health isimproved.Mary T-, aged fifty-one, admitted Jan. 17th, 1857, a

widow, residing at WhitechapeL She was admitted into Jobward, Oct. lst, 1856. On admission, she was a tall, strongi9mt woman, her skin was darkened in colour, and coveredwtfh dark and white patches; she was in much better condi-ioa than when she was first admitted into the hospital, and

complained of severe pain over the right ilium, and there wasslight swelling in that part, otherwise she was much the same.The thorax was resonant throughout; the heart’s action nor-mal ; pulse 72, feeble and regular ; appetite good; urinehealthy.

Jan. 22nd.-Complains very much of lowness of spirits, andof pain in the back and loins. The brown patches on her skinappear to be of a darker colour, and there is increased depositof pigment on her lips. Her pulse is feeble and appetite indif-ferent.28th.-The pain continues, but is especially concentrated

over the. ight ilium, and she is rather feverish and restless, andmuch depressed. This pain was increased, with swelling overthe right ilium three days after, and the part is very hot andtender. Her depression is very great and she appears feebleand languid. Eats scarcely any food. Leeches were appliedover the seat of pain, and a teaspoonful of cod-liver oil giventwice a day.The pain and swelling remained about the same ; her sleep,

however, became better, and her appetite improved. Herhead became hot, and her brows contracted, and the darknessof her face slightly increased. Some days later fluctuation wasfelt at the seat of pain, which was less by the 10th of February.A week later both pain and swelling were much diminished,and she was constantly sick for some days and vomited muchbiliary matter.March 1st.—Her skin was not so dark, and she was becom-

ing much stronger. The swelling over the ilium had, however,increased, and extended farther downwards towards the thigh,but now without fluctuation. Her appetite was again bad.l5th.-She has continued much in the same condition

as regards her general health since last report. The skin is, ifanything, of a lighter hue. She complains much of pain inher left groin, and the swelling is now more apparent, but thefluctuation is very indistinct. She sleeps well, has a goodappetite, and is much less depressed in spirits. Bowels costive.The compound tincture of iodine to be applied to the rightgroin.

April 18th.-The darkness of her skin still continues, anddoes not apparently diminish in the least, and with the excep-tion of frequent and severe lumbar pains, her general healthappears now perfectly good. The swelling still continues inthe same condition, sometimes appearing increased, at othersdiminished in size. The iodide of potassium ointment to berubbed into the groin night and morning, and to have astrengthening plaster on the loins.May 22nd.-There is no alteration of any consequence in

her symptoms, but she has for the last few days complainedmore of a sense of lassitude, with occasional attacks of vomit-ing. The pain in her loins does not diminish, and the abscessappears somewhat smaller, and shows no tendency to approachthe surface.

July 11.-She still continues in bed, and exhibits a certainf,mount of debility and occasional attacks of depression ofspirits, which are generally followed by an attack of vomiting.She sleeps well at night, her appetite continues good, and thesecretions are healthy. She is taking myrrh mixture, withsesquicarbonate of ammonia, three times a day.l8th.-For the last two days she has been violently sick

after taking food, and appears more feeble and depressed.The vomited fluid is deeply tinged with bile. Her tongue isdry and furred; skin hot and dry; pulse 84, feeble; bowelsopen. Effervescing julep, with dilute hydrocyanic acid, threetimes a day.Aug. 6th.-She has had no return of the sickness, is stronger

and in much better spirits, and her face is decidedly assuminga lighter hue. The pain and swelling in the groin are muchdiminished. She complains somewhat of swimming and painsin her head and ears. The pupils act normally on the stimulusof light.Sept. -has for the last few days been very sick. Sheis otherwise in the same condition.

Oct. 8th.-She is still making a slight but scarcely per-ceptible progress. The skin over the trunk is certainly of amuch lighter hue. She is stronger, and is now able to get upfor a short time each day, and by the aid of crutches walksabout the ward. The sweiling still continues much about thesame size, and causes her considerable pain at times. She hasfrequently had returns of the attack of vomiting, but it hasbeen much leas severe. She takes her food well; suffers lessfrom depression of spirits; bowels somewhat costive, and theswimming in her head is increased.

Nov. llth.-She still continues in much the same state withregard to her skin, but the swelling in the right side is becoming

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much larger, and there is a perceptible enlargement in the leftgroin also, which can be traced downwards on the psoas.There is slight fluctuation on the right, but not on the leftside. She complains very much of pain in the loins, extendingdown her thighs. She is still, however, able to get about theward a little, and there are no apparent inflammatorysymptoms. She passes rather indifferent nights, but her

appetite continues good.Jan. 13tb, 1858.-She has for the last few days been much

distressed with a very troublesome cough, which has tended todepress her a good deal. Her skin is still perhaps a shadeclearer; the dark pigmentary patches are now more particularlyobservable on the forehead, around the eyes, bend of the elbows,lips and gums. She complains much of the swimming painsand sense of giddiness about her head. The pupils are aboutnormal in size, but slightly torpid. There is pain on pressureover the spine in the lumbar region, not confined to any par-ticular spot, but it is perfectly symmetrical. There is slightdulness on percussion at the bases of both lungs, with bronchialand mucous rales; expectoration frothy. Pulse 84, feeble. Ab-domen normal in appearance; evacuations healthy. Tonguefurred, but moist. Urine normal. The swellings in botli

groins are increasing in size, but appear to produce scarcelyany irritation, except from pressure. She sleeps tolerably, ancher appetite continues good. The feeling of lassitude and depression of spirits have now been for some time almost absentand she appears to have gained flesh.

LONDON HOSPITAL.

UNDEVELOPED TESTICLE IN THE GROIN OF AN ADULT.

(Under the care of Mr. CURLLNG.)WE had an opportunity on the 18th inst. of seeing a man,

aged thirty-one years, in this hospital, who was admitted theday before with a tumour in his right groin. On being ex-amined very carefully, it was soon determined that this swell-

ing was his right testicle retained outside of the abdominalring, the gland being in an undeveloped condition, and resem-bling that of a child before attaining the age of puberty. Therewas no hernial protrusion, and only one testicle (the left) wasfound to be in the scrotum. The only ailment complained ofwas an occasional slight abdominal pain when lifting heavyweights. As no surgical interference was necessary in a caseof this kind, he was not retained as an in-patient, but we thinkthe case worthy of record, as such instances are by no meansof every day occurrence.

This case forms the fourth seen here within a few days.Thus, a man was in the hospital without any scrotum,one testicle being situated partly within the abdominal ring,whilst the other was external to it, the patient’s age beingtwenty-one years. A third case was mentioned to us by Mr.Routledge, the house-surgeon, as occurring in a man agedthirty-five, whose scrotum contained but one testicle, the otherlaying in the groin external to the ring, which had been pre-sumed to be hernia, and for which the patient had long worn atruss. And a fourth case is at the present moment in thehospital, in the person of a sailor, in one of the lower wards,who is a patient for a stricture of the urethra, one of histesticles being retained in the groin, similar to the other in-stances.

In the first patient, on firmly squeezing the testicle in thegroin, the same feeling and pain were experienced as occurs inits natural situation.The detention of the testicle in the groin or abdomen

must be regarded, under any circumstances, as an unfortu-nate infirmity, more especially when the gland is attackedwith disease. This will be the better understood when it isremembered that the relation of the gland is still preservedwith the peritoneal cavity, and any marked action within thetesticle itself is most likely to spread to the abdominal organs.Another point of moment in connexion with the testicle inthe groin is its liability to be mistaken for hernia, especiallywhen it can be either wholly or partially pushed back into theinguinal canal. The diagnosis will be assisted by the return ofthe tumour without any impulse on coughing, its size, form,and solidity, the peculiar sensation on pressure, and the absenceof the testicle from the scrotum. There is, of course, a ten-dency to rurture in these cases, and the diagnosis is sometimesmore difficult when there is a combination of the two.

CLINICAL RECORDS.

REMOVAL OF THE PATELLA FROM AN EXCISEDKNEE-JOINT.

ON the 13th of February Mr. Fergusson performed an opera-tion at King’s College Hospital, which was of considerableinterest, in connexion with excision of joints. About fifteenweeks since, he excised the knee-joint of a man for very exten-sive and long-standing disease of the articulation. The manmade excellent progress within a very few weeks, and to allappearance a very serviceable limb was likely to be soon ob-tained. During the last few weeks, however, it would appearthat reparation has ceased, and that Nature had failed to forma bony union between the cut surfaces of the bones. The ex-ternal wound had healed admirably, but latterly considerable

’

annoyance had been caused by the formation of abscesses inthe soft tissues around the patella, which had been allowed to

’ remain at the time of the operation. These abscesses refused! to heal, notwithstanding every method had been used to for-ward their obliteration. The patella was freely movable, and’ it appeared to be floating in a bed of pulpy degenerative tissue,which is so frequently found to exist in diseased conditions of’ the joint. The patient having been placed under chloroform,, an incision was made by the side of the patella., and, finding

on examination with the finger that the under surface of thebone was in a state of ulceration, it was deemed advisable taremove it, with as much of the altered tissue as possible. Thelimb was again placed upon a splint, and the patient is in avery fair way of making a perfect recovery with a useful limb.Mr. Fergusson made some very pertinent remarks upon the

proceeding he had just put in practice. From what he hadlearned of the various steps of the operation of excision of theknee-joint, he was now an advocate for the removal of thepatella, even when healthy, as it was liable to give subsequentannoyance. Mr. Jones, of Jersey, had in a most praiseworthymanner exerted his skill on many occasions to save the cap-bone with its ligament extire, and had frequently succeeded;.but he (Mr. Fergusson) would for the future take away thebone, provided it was not bound to the condyles of the femurby osseous material. He had been the more induced to followthis proceeding of removing the patella, owing to the greatbenefit which resulted from the practice in one case which hadbeen treated by his friend Mr. Price. In this instance thepatella was similarly affected, and since its removal the patienthad been freed from former annoyance. It was sometimesthought that although the ends of the bones remained unitedmerely by soft material for some time, that osseous consolidationwould not ultimately follow. This was a very serious error tofall into; for an admirable illustration of patience and goodmanagement was evinced in the case of a patient now in thehouse, and who had come back to exhibit himself to Mr. Par-tridge, who performed the operation. In this instance themost pleasing result followed ; for the man was now able towalk about without the assistance of stick or crutch, and torenew his ordinary occupations. Mr. Fergusson then alludedto the various notions that were entertained by some surgeonswith regard to the " bringing about of anchylosis." " For hisown part he was ignorant of any plan whereby the surgeoncould forward so desirable a proceeding; and he believed thatthe good result which sometimes followed in old-standing dis-ease of the joints was entirely due to Nature, and that far toofrequently the surgeon had claimed an amount of ingenuity hedid not possess.The result of this operation will be watched with consider.

able interest.

RESULTS OF A GUNSHOT WOUND OF THE LUNGBEFORE SEBASTOPOL.

A YOUNG man, a soldier, was shot through his right lungduring the attack on the Redan at Sebastopol. The shot

passed from the right side of his chest towards the base of theleft, wounding the left kidney, and remaining lodged in thebody. He spat a good deal of blood at the time, and passedblood in his urine, which showed that the kidney was impli-

cated. The ball passed in a direction from above downwards,inwards, and backwards. He has remained tolerably well up

to the last few days, when a not very large but painful abscess. formed in the right loin, for which he entered University Cot-; lege HospitaL Mr. Erichsen thought it was necessary to openthis, as possibly the ball, or any other foreign body, might be