Clinical Review.

GUY'S HOSPITAL.

GUY'S HOSPITAL REPORTS. Second Series. No. I. April, 1843. Edited by GEORGE HILARO BARLOW, M.A. and M.D. Fellow of the Royal College of Physicians, and Assistant Physician to Guy's Hospital; EDWARD COCK, Assistant Surgeon to Guy's Hospital; EDMUND L. BIRKETT, M.B. Secretary to the Clinical Society; J. H. BROWN, and A. POLAND. London: S. Highley, Fleet Street.

THIS number opens with an Introduction to the First Volume, which is not undeserving of a notice. The editors start with the observation :

:

"If any opinion of the wants of the profession can be gleaned from the general spirit of its Members, and if any estimation of that spirit can be derived from the titles and subjects of publications, and the general tendency-at present so evident among us to form societies for receiving and imparting the fruits of experience, we are fully justified in considering observation to be the governing principle of advancing medicine; and the Hoc age' of the present period to be, Ut vivas, vigila.' But it must be remembered, that however correct our facts, however trustworthy our modes of determining them, the progress of medicine must also depend on their comparison. The object, therefore, of any medical periodical, whose single aim is scientific improvement, should be twofold-the collection and publication of the results of observation-and the inferences which may thence be justly deduced. On this principle the present work has always been conducted; though the chief energy has been expended on fulfilling the second of these objects; viz. that of giving to the medical world the well-digested inferences of the result of observation in finished treatises. The course the 'Reports' have run, has not been unaccompanied with difficulty; and though perhaps the goal aimed at may not have been reached, still the experience of the seven years which have been now completed-and not, it may be hoped, without a certain amount of usefulness-may be received in evidence of the intentions of the editors, and the success which has been the result.

"We wish now to extend the sphere of this principle; and, in addition to the finished treatises, the works of individuals, with which hitherto our pages have been principally enriched, we propose to illustrate the different classes of disease by the aid of series of Reports, collected within the walls of the Hospital, and furnished by the books of the Clinical Society and likewise, to apportion a part of each Number to the consideration of anomalous cases from the same source; -a plan we consider fraught with great advantage; as nothing has so great a tendency, either to counteract a too great confidence, or to stimulate exertion, as a proper estimate of our difficulties."

This is so obvious that it almost amounts to a truism. Medicine, like every science of observation, must rest upon facts, and those facts must necessarily form two orders-those which have an affinity to one another, and admit of being grouped and reduced into generalizations, and those which are of a more insulated character, and incapable of being so reduced, either from their own nature or the imperfection of our present knowledge, and so Reports must ever consist, as they always consisted, of matters of facts, generalizations, inferences upon the one hand, and of extraordinary, exceptional, anomalous instances upon the other. P

No. LXXVIII.

The Editors proceed to give a sketch of the formation and development of the Clinical Society of Guy's Hospital. But this we may pass over. We cannot, however, do so, without expressing our cordial satisfaction at an institution so creditable to the officers of the hospital, who have fostered it, and to the pupils who are the members of it-an institution eminently calculated to breed a healthy spirit of observation in the young men whose zeal it stimulates, whose energies it directs, and whose prospects in after life it must beneficially influence. The Editors proceed :

"Their objects have been two-fold-the accuracy, and the number of the reports. And these objects they have essayed to accomplish, by facilitating the duties of reporting: 1st, By the division of labour: and 2dly, By the introduction of formulæ for case-taking. The labours of reporting are of course to be diminished by the number of cases under the charge of each reporter. The whole number of patients in the Hospital at one time is generally about 450-the number of Clerks about 30; giving, as a result, about 15 patients as the average complement of each clerk and, calculating that there are weekly from 55 to 65 admissions, the duration of each patient's residence in the hospital would be about seven weeks. Each clerk would therefore have to report rather more than two fresh cases every week-a number, considered as an average, and consisting of mixed cases, both mild and severe, simple and complicated; evidently in the power of any student, at the requisite period of his studies, to do ample justice to, without neglecting his other subjects.

"The subject of formulæ requires a more lengthy notice. The objects to be aimed at, in their formation, are, facility of reporting with uniformity, and increased value of the reports. The first object has certainly been attained, even by the full formulæ now in use by the Society. Indeed many have been induced by them to commence a course of clinical study, the difficulties of which they confessed they should otherwise never have surmounted. So we may pass on to the second item; viz. uniformity and accuracy of the report. In the first place, if cases are to be compared-and such is confessedly one of the main objects of their accumulation-uniformity is almost essential; and in order to uniformity, formulæ are useful, if not positively necessary. These may be full or short, general or special. We believe the fuller they are, the greater is the amount of value accruing both to the reporter and the Society; although, as a point of direct consequence, it must be allowed that the errors would probably be more numerous than in shorter forms, though this only holds good as long as no stride is made beyond the defined limit. The next object contemplated is the fulness of the report, with the accuracy of its details; and for this purpose the formulæ must be full, containing a place for every possible item; and yet so arranged, that the reporter be not left in doubt under what head to note any particular symptom; and that space sufficient be allowed for each head. Special forms, although perhaps of great value in the reduction of matter from a large collected body of reports, imply-so at least it appears to us-a greater advancement in medicine that it has hitherto been our lot to enjoy; for how few diseases can be logically expressed-how widely diseases vary, both as to the number and intensity of the symptoms-and how little hope are we at present justified in entertaining that any law regarding the constancy of symptoms is about to be divulged-though we may perhaps expect some result from the consideration of their variations, and the endeavour to determine their value from their relations."

After remarking that the formulæ first introduced proved inefficient, and were of necessity abandoned, they continue :

"With respect to the construction of formulæ, the rule appears to be concentration of that portion of the report which is usually so indefinite; viz. whatever precedes the admission of the patient, or the first visit of the physician ;—with the expansion of that portion of which the reporter can institute his own investigation; viz. the enumeration of the signs and symptoms, suggesting to the

physician the name of the disease; which may be usefully considered as a condensed arbitrary expression for the sum of the symptoms.

"The formula we at present employ were suggested by the short forms used by Dr. Conolly, at the Lunatic Asylum at Hanwell; and brought therefrom, in the course of the last summer, by the Honorary Secretary. They have of course been much modified; inasmuch as they are intended for diseases in general, whereas the others are specially designed for one class. They may be divided into several portions, as follows :

"1. The relations of the patient with respect to the Hospital.

"2. The previous history of the patient.

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3. The causes of the disease, or the link between the previous history of the patient and the present history of the disease.

"4. The history of the present disease, with the date and the order of the succession of symptoms.

"5. The signs and symptoms of the disease, from the sum of which the diagnosis is to be determined.

"6. The history of the progress of the case with the treatment detailed. "And these again are variously sub-divided, as may be observed by casting the eye over the plan given below.

Hereditary
Moral
Physical

History of Origin, with Date of Present Illness, and Order of

Development
Natural

Succession of Symptoms.

General

Aspect.

Morbid

Position

Lesions of

Motion
Sensation

Special Sensation

We have inserted the whole of the preceding formulæ, because we think the subject an important one. We quite agree with the editors on the value, indeed the indispensable necessity for formulæ, in order to obtain reports on any scale or of extensive value. And we agree with them too, on the propriety of developing the present and tangible features of a case, while its history is placed in a subordinate position. For it requires little experience in case taking to learn how little dependence can be placed upon such history. When the defects of memory, habits of inaccuracy, and positive falsehoods on the part of the patient are added to the imperfect methods of examination, leading questions and possible bias on the part of the Reporter, the results are not such as constitute a sound basis for either practical or theoretical conclusions. And such we believe is found to be really the case.

To the formulæ themselves we have little to object. They are elaborate, and as complete as general formulæ can be. Some may think that they sin upon this side, but it must be recollected that they are for the purpose of systematic reporting, on the part of those who are to make it their business.

The contents of the number before us are as follows:

Case of Suspected Irritant Poisoning, with Remarks on the Poisonous Properties of certain Kinds of Decayed Animal Matter used as Food; by Alfred S. Taylor.-Observations on Pelvic Tumors obstructing Parturition; with Cases; by John C. W. Lever, M.D.-An Inquiry into Certain of the Causes of Death after Injuries and Surgical Operations in London Hospitals, with a view to their Prevention; by Norman Chevers, M.D.-Observations on the Structure, Functions, and Diseases of the Coronary Arteries of the Heart; by Norman Chevers, M.D.-Observations on the Digestive Solution of the Esophagus, and on the Distinct Properties of the Two Ends of the Stomach; by T. Wilkinson King: with a Case, by Mr. John Comley.-A Case of Glanders in the Human Subject; by H. M. Hughes, M.D.-Report of Cases of Hernia, admitted into Guy's Hos

pital from Sept. 1841 to Dec. 1842; by Alfred Poland, (with Plates.)-Account of Observations made under the Superintendance of Dr. Bright, on Patients whose Urine was Albuminous; by George Hilaro Barlow, M.D.; with a Chemical Examination of the Blood and Secretions, by G. O. Rees, M.D. (with Plates.)-Report of Cases of Fever; by J. H. Browne.

1. CASE OF SUSPECTED IRRITANT POISONING, WITH REMARKS ON THE POISONOUS PROPERTIES OF CERTAIN KINDS OF DECAYED ANIMAL MATTER USED AS FOOD. BY ALFRED S. TAYLOR.

It appears that "three members of the family of a shepherd-the wife, son, and daughter, the two latter being young children—were taken ill on Sunday, December 20th. The boy, who was about two years old, died the following day. It was supposed that poison had been administered to the family, and that this was the cause of the boy's death.

"The poison was suspected to have been taken at dinner, about 11 A.M. on Monday, December 21st, when all three dined with the father, on some mutton. No satisfactory history could be obtained of the symptoms suffered by the wife and two children on the Sunday, the day preceding. The only account that could be obtained was, that the body of the deceased was swollen all over. The three were, however, better on the Monday. Having dined at the hour abovementioned, and the father having left for his usual work, they were not seen until about two o'clock, when the mother and daughter were in a state of insensibility, and the boy was dead.

"The following account was obtained :-The father stated, that after he had dined with the family on the Monday at eleven o'clock, he felt, while at work, a sharp burning pain in his inside, for which he could not account. This was between the time of his leaving dinner and two o'clock in the afternoon. The mother, on her recovery, said that she felt great pain after the meal; but no other account of her symptoms could be procured, except that she foamed at the mouth, and was in a state of great nervous excitement. As far as could be ascertained, she had suffered but slightly from vomiting, and there was no purging. The deceased and his sister were, however, affected both with vomiting and purging. The deceased child died in less than three hours after the meal, for he was found quite dead at two o'clock; but no satisfactory account of his symptoms before death could be obtained. It appears, however, that he was very much purged, and that his motions were of a dark-green colour. The matters vomited by him were very copious, and streaked with a yellow-coloured substance: these were, unfortunately, thrown away. The matter vomited by the mother is described as having had a bright glistening appearance like quicksilver on the surface.

"The stomach-pump was applied to the mother about six hours after she was found (eight o'clock P.M.); and the contents of the stomach then drawn off were reserved for a chemical examination.

"The following appearances were met with, on a post-mortem examination of the body of the deceased child (reported by Mr. Cooke) :

"There was no particular appearance externally, except that the cutaneous surface was unusually pallid. The lungs were loaded with blood of a scarlet colour. The heart was natural: the liver of a pink colour, congested with very liquid blood. The stomach contained a small quantity of half-digested food, presenting, on its posterior part, several prominent ruga, which were inflamed, with traces of inflammation on other parts of the lining membrane. The small intestines were inflamed in their upper portion; but the appearance of inflammation was less marked inferiorly. They contained a liquid mixed with blood. The muscular coat of the rectum was very red; but there was nothing in other