Clinical Lecture ON CARIES AND NECROSIS OF THE BONES OF THE SKULL.

FEBRUARY 20, 1864. in which the whole of the skull-cap came bodily away two years after a blow on the head, from a fall in one of the drunken fits of the patient. Tubercular deposits ending in caries or necrosis may occur ON either in the bone itself, or, as is more commonly the ease, beCARIES AND NECROSIS OF THE tween the bone and its investing membranes. The tubercles vary from the size of a millet-seed to that of a walnut. In BONES OF THE SKULL. this portion of a frontal bone belonging to the museum of St. George’s Hospital, two deep excavations of the size of walnuts at St. Delivered George’s Hospital, exist on the inner side of the bone. Nearly symmetrical in size, and situation, these ltrge excavations contained shape, G. BY PRESCOTT F.R.C.S., tubercular masses which evidently had been deposited originSURGEON TO THE HOSPITAL. ally in the bone itself, whence they had made their way on to the dura mater, to which they were firmly attached. The widest in the diploe, present overhanging margins GENTLEMAN,-Tvvo cases of extensive disease of the bones of excavations, formed by the inner plate; new bone has been heaped up both the skull were admitted under my care at my last taking-in. in the bottom of the excavations and around their margins, and this leads me to bring this important subject before your where the skull is decidedly thickened; the bone around is notice to-day. exceedingly vascular, and drilled with minute holes ; but the The bones of the skull are especially liable both to caries and other parts of the inner surface of this frontal are perfectly and so, too, is its outer surface, save in one spot, to necrosis, and numerous are the specimens contained in our healthy, where the bone presents a tubercular excavation of the size of The two diseases very a museums of cranial bones thus affected. large pea. The tubercle had evidently been deposited in the frequently coexist on the same skull-caries in one part, and outer table of the bone; the excavation, very shallow, does not necrosis in another ; or they may lie side by side on the same reach the diploe, and around it is an overhanging lip of bone, bone. More commonly, however, a cranial bone is affected by with a finely radiated margin, and very vascular; but here no Both diseases sometimes follow a new bone has been deposited. The preparation was taken from one of these diseases alone. a young boy who was in the hospital for diseased hip, and low form of inflammation and suppuration, which may have several tubercles were found in other parts of the skull and in arisen in the cranial bone without any apparent cause, or fol- the brain. lowed some injury. But in by far the greater number of cases Another preparation, also belonging to the museum of St. these diseases are connected with scrofula, and much more com- George’s Hospital, shows this disease in a more advanced stage. of the thumb, and one much smaller, monly still with syphilis and the careless administration of Two large holes of the size the skull, exist on the left side of the completely perforating In the two cases admitted the disease of the mercury. just frontal and in the left parietal. Here the tubercular matter bones owes its origin to the syphilitic poison. had, for the most part, evidently taken place between the Following a blow on the head, caries and necrosis are, for periosteum and the bone, the outer parts of the skull in the the most part, strictly confined to the seat of injury. The outer neighbourhood of the disease presenting a bevelled surface with or the inner table only may be affected, or the whole thickrounded margins shelving down to the perforations. But tuberness of the bone may be diseased. There are, however, already cular matter had also been deposited in the structure of the on record several well-marked cases in which widespread disbone. A large excavation, with overhanging margins, and ease of the bones of the skull has followed an apparently slight penetrating deeply into the diploe, exists on the inner surface injury. In some of these cases, the disease has been confined of the bone, immediately in front of the perforation in the to the outer parts of the bones ; in others, the inner table only frontal. And the right parietal, too, presents in one spot of has been affected; and in others, again, the bones have been its outer surface a worm-eaten appearance, tubercular matter stricken in their whole thickness. deposited in the diploe having partially destroyed the outer The outer parts only are affected in this preparation belonging table of the bone. The inner surface of the bones is exceedto the museum of St. George’s Hospital. In this case, a simple ingly vascular, and in some parts there is a thin layer of delicate blow on the head led to extensive caries of the frontal above new bone. the orbits, of both parietals, and of a portion of the occipital. Scrofulous inflammation of the bones, ending in widespread The ulceration has, in many places, dipped deeply into the caries, sometimes, but rarely, shows itself in the skull. Such diploe; but in no part has it involved the inner table of the cases present a striking contrast to the preceding ones: the skull, which, however, is exceedingly vascular throughout. disease, running a more or less rapid course, ends fatally by In Dr. Abercrombie’s case, on the other hand, the inner parts exhaustion, or by exciting intra-cranial inflammation. A skullonly of the bones were affected. The inner table of the frontal cap in the museum of St. George’s Hospital affords a good illusabove the orbits, of the whole of both parietals, of the squamous tration of extensive caries of a scrofulous nature affecting the portions of both temporals, and of rather more than the upper bones of the head. The middle part of the frontal, the whole half of the occipital, was altogether wanting; and there appeared of the right parietal, and the posterior half of the left parietal, the rough, irregular, and cancellous structure of the central part present on their outer surface a worm-eaten appearance, with, of the bone; but the outer surface of the cranium was of a na- here and there, deep pits burrowing under the outer table, and tural appearance, save in a few points where it was perforated penetrating far into the diploe. The corresponding parts on by very small apertures. The patient, aged forty’eight, had, the inner surface of the bones are exceedingly vascular and about a year before her death, fallen down stairs and received porous, with a worm-eaten appearance in some places, espevarious injuries, especially one on the head. cially on the right parietal. In two or three places the skull In Norris’s case caries first attacked, and was for some time has been perforated. The patient died of phthisis. The bones limited to, the outer parts of the bones, thin scales of bone are exceedingly heavy, much more so than usual. came away, and afterwards pieces of the whole thickness of But one of the most extensive cases of scrofulous caries of the bone in many places, and large portions of the skull were the skull, and running an unusually rapid course, has been destroyed. A blow on the forehe2a, in a fall down stairs, thus published by Mr. Caesar Hawkins. The patient, a younn man, led to disease not only of the frontal, but also of both parietals, aged twenty-four, was in St. George’s Hospital, under the care and of the occipital as far as the foramen magnum. The patient of Dr. Nairne, fur phthisis. Three days before his admission died, worn out, at the end of the thirteenth month after the he had been suddenly seized with pain on the right side of the accident. head. There was no apparent cause for this pain, which was In Mr. Drummond’s case the blow was on the back of the soon followed by a swelling, and twelve days after the rirst aphead, and in the course of six years the man (a sailor) lost of pearance of the pain Mr. Caesar Hawkins opened an abscess the right side of the frontal, parietal, and squamous portion of over the lower part of the right parietal. The disease spread the temporal about five square inches; the whole of the occi- most rapidly, and within a month two other abscesses, extenpital to within a short space of the foramen magnum, save a sively laying bare this side of the skull, required opening. The portion of the centre about two inches square, was detached matter, unhealthy and scrofulous, was mixed with flakes of and movable ; in addition to which, a large portion of the left lymph. Shortly afterwards the disease attacked the ear, and side of the frontal, parietal, and temporal bones was in a state passed also over the vertex to the left side; and two months of caries, after the opening of the first abscess the patient sank from exBut the most extensive traumatic disease of the skull with haustion. Neatly the whole of the right side of the skull was which I am acquainted was in the celebrated case of Saviard. involved in the disease. The entire parietal, half of the occiNo.2112.

Clinical Lecture

HEWETT,

206

walls

the squamous and mastoid portions of the temporal, a of the cavity which had lodged the bone, and was then of the great wing of the sphenoid belonging to the zygo. lost. It was reduced to a small size, however, before it reached matic fossa, and a bit of the frontal, were extensively affected this spot, and was impervious. The cause of all this mischief with caries on both surfaces. In many places the whole thick- wis not ascertained ; but it was thought possible that it might ness of the bone had been destroyed, leaving large openings, have arisen from the introduction into the ear of a black pin, around which the skull was considerably thinned; and, where which was found in the cavity left by the removal of the temleast affected, the bone was worm eaten, but in no part had it poral. No pins had been used in the dressings. died. Corresponding to the diseased bones, the pericranium Syphilitic caries and necrosis are, it would appear from the and the dura mater, rough, thickened, and detached, were numerous specimens in our museums, the commonest of all the bathed with quantities of a thin, flaky, purulent fluid. Very diseases of the bones of the skull. Our museums abound in delicate and thin layers of new bone, of a dead-white colour, syphilitic, or so-called syphilitic, skulls. I say so-called syphicovered a small part of the inner surface of the frontal and litic, for as most of these specimens are without any history, it occipital bones. The right lung was consolidated, and pre- would be difficult to say how far the ravages which we see in sented vomicas in its apex. The preparation is in the museum these skulls were dependent upon syphilis, and how far upon mercurial cachexia. Of this, however, there is no doubt, and of St. George’s Hospital. The bones of the skull most commonly affected with scrofu- that is, that diseases of the cranial bones were much more lous disease are those at the base. The body of the sphenoid common formerly than they are now. Formerly, when profuse is the chosen seat of scrofulous caries, which sometimes leads to and long-continued salivations were thought to be of such vital complete destruction of the bone, and perforation into the pha- importance, diseases of the cranial bones were of frequent occurryngeal or nasal cavities. Of this I have met with several ex- rence, and to this period of inordinate mercurialization belong amples, and in the museum of St. George’s Hospital there are most of the diseased skulls in our museums. But in the present two preparations which illustrate this point very well. The day, when mercury is so carefully and so sparingly used, dis. bones of the base of the skull are also not unfrequently affected eases of the bones of the skull are comparatively rarely met with scrofulous disease secondarily : the occipital, from caries with. But, laying aside the question of the effects of mercurial beginning in the upper cervical vertebrae; and more frequently the and mastoid portions of the temporal, from inflam- cachexia upon the osseous system, there is still another difficulty mation beginning in the middle ear. Spreading from the as to these so-called syphilitic skulls. Are there any characmiddle ear, inflammation most frequently leads to caries; but teristic signs by which we can recognize syphilitic disease of it now and then leads also to extensive necrosis, and various the bones of the skull ? Given a diseased skull, are we at pre. sent in a position to say that the disease was of venereal origin? portions of the temporal may thus be cast off. Some time back I had under my care a little girl affected Some of the best of modern pathologists would, I know, answer with scrofulous inflammation of the ears, from whom I removed in the affirmative; but of the correctness of their views, I must large pieces of dead bone, involving nearly the whole of both say that I have all along had very serious doubts. The features mastoid processes. And the greater part of the petrous bone, said to be characteristic of the venereal origin of the disease which had died in consequence of scrofulous disease, has been may be clearly marked in a skull, the history of which tells us removed in many instances. Of this, a preparation in the mu- that the patient had never suffered from syphilis. Of this the It skull, 633, in the College Museum, affords a striking proof. .&bgr;&bgr;um of St. George’s Hospital affords a striking example. includes nearly the whole of the petrous portion of the tem- This skull, classed amongst the syphilitic ulcers of bone, is poral, which I removed from a little boy who had long especially mentioned as typical of the tuberculated variety of been the subject of scrofulous inflammation, beginning in the the disease. There was, it was supposed, no history of the But on looking over the College collection of diseased ,middle ear. The child did perfectly well. case. Dr. Bigger also brought before the Pathological Society of skulls, I at once recognized this skull from the beautiful enDublin two cases of this kind :graving appended by Mr. Norris to his case of " Extensive The first was that of a boy, five years old, in whom there had Disease of the Bones of the Skull from a Blow on the Head." been a fetid discharge from the ear for eighteen months. There And in the details of this case, Norris states that "lest it was no apparent cause for the disease, which had begun with should be supposed by anyone that this disease of the bones pain. A piece of dead bone projecting into the meatus was had its origin in syphilis, it is proper to observe that the patient pulled out. It proved to be the petrous portion of the tem- had not one other even doubtful symptom of that disease; and poral, and included the carotid canal, the inner wall of which that, from the most minute inquiry that he could make, it had been absorbed, as well as the meatus internus. The bone seemed almost certain that she had never been infected by its was porous, but very hard and rough, as if its outer crust had poison." With these accurate details of the case, I think we beenrubbedoff. No bleeding followed the removal of the bone, are bound to giveup the idea of the disease about this skull and, odd to say, no facial paralysis. The child did perfectly being venereal. It may be argued that the disease originated in well. mercurial cachexia, but we have no right to assume that such The second case was also that of a boy, five years old. In was the case, when not one single word is said about the patient this case both petrous bones were removed within a month of ever having been subjected to the influence of mercury. And each other. In both specimens the internal auditory canal was then, supposing even that we could, in this case, thus shift the perfect; and so, too, was the carotid canal, saveits inner wall, disease from the syphilitic to the mercurial poison, one thing at which had been absorbed. The removal of these bones was fol- any rate is very evident-the characteristic features by which lowed neither by haemorrhage nor by facial paralysis. The child we are told that syphilitic disease of the bones of the skull is to be recognized can no longer be relied upon. Norris’s case did perfectly well, his only ailment being deafness. A third case of the same kind was brought before the Patho- proves that the tuberculated, cracked, and starred appearances logical Society of London by Mr. Shaw. The boy was seven supposed to be characteristic of the syphilitic skull maybe due years old, and the piece of bone included the left meatus internus to chronic disease of the bones, independent of venereal or merand labyrinth, the promontory, fenestra ovalis, and rotunda, curial origin. There is, too, in the College Museum another all being easily recognised. The cortical layer only of the bone skull (3141), in which the disease is considered to be syphilitic, but which, after all, may have owed its origin to an injury. In was left, the separation having taken place between it and the diploe. The child did perfectly well; but there was paralysis the description of this skull it is especially noted that the ap,of the facial muscles on this side, and deafness of both ears, the pearances about the bones differ from those of the syphilitic class, and as there is a mark of a healed fracture above the left right one being alao affected with scrofulous inflammation. But, stranger still, the whole of the temporal bone, itself orbit, it may be inferred that the disease originated in this necrosed, has been removed bodily. The case has been re- injury. Singularly enough, the appearances about the occipital lated by Mr. Swan, and a part of he skull from which in this skull are precisely similar to those in the occipital of the bone was removed is in the College museum. A boy, Norris’s case. The skull appears to have been taken from the eleven years old, had purulent discharge from the left ear, dissecting-room ; the carotid canals are filled with injection. which began in the spring of 1824, and ultimately became The frontal and the parietals are the bones of the skull which very offensive. In March, 1825, the integuments around the are said to be most commonly affected with syphilitic disease; ear became swollen and painful, and the whole side of the face but in all the skulls in which the disease is undoubtedly of was enlarged. The bone was denuded in the meatus. In venereal origin, it will, I think, be found that the basilar bone October, 1826, the temporal bone, being quite loose, was ex- and the front part of the foramen magnum are aiso, to some tracted. No haemorrhage followed ; but the boy died four extent at least, affected. And this is just what we might have days afterwards. The auditory and facial nerves terminated anticipated if we recall to mind the frequency with which the in a bulbous mass on the dura mater. The internal carotid soft parts covering these bones are involved in secondary artery, from above and below, could be traced as far as the. syphilis. The diseased appearances to which I refer are a

pital,

part

petrous

°

207 thickened and tuberculated condition, with excessive

vas-

of the under surface of the basilar bone and front part of the foramen magnum; and in some cases I have even found this portion of the foramen magnum contracted by the deposition of minute nodules of bone. I have also, but more rarely, found a carious and worm-eaten appearance about the bones, which may, in such cases, be stricken with necrosis. In the museum of St. George’s Hospital there is a large piece of exfoliated bone, including a portion of the under sutface of the basilar bone, and the front part of the foramen magnum, which was removed by Mr. Keate from a man, the victim of syphilis, who for along time had been suffering from ulceration deeply excavating the back part of the throat. And from the same patient was also removed another piece of bone-the front part of the atlas, including a bit of the articulating surface of the odontoid process. The man ultimately recovered.

cularity

(To

be

continued.)

ON VESICO-UTERINE FISTULA. CASE IN WHICH PREGNANCY OCCURRED AFTER CLOSURE OF THE OS UTERI BY OPERATION.

BY

JAMES

R.

LANE, F.R.C.S.,

MARY’S

AND THE LOCK HOSPITALS, AND TO ST. HOSPITAL FOR DISEASES OF THE RECTUM.

SURGEON TO ST.

MARK’S

IN November, 1862, I read a communication to the Western Medical Society on the subject of Vesico-Uterine Fistula, and related the particulars of a case in which I had cured the incontinence of urine resulting from that condition by closure of the os uteri by a plastic operation. The sequel has been most singular and unexpected, inasmuch as, notwithstanding the complete, or apparently complete, closure of the os uteri, the woman became pregnant four months after the operation. This circumstance renders the further history of the case of sufficient interest to induce me again to bring it before the notice of the

profession. A true vesico-uterine fistula, it may be worth while again to explain, is an abnormal communication (produced usually by sloughing or laceration during labour) between the base of the bladder and the uterine cavity, always, in the few cases hitherto

observed,

at

some

part of the canal of

the cervix

uteri;

the

vagina, and that portion of the cervix seen from the vagina, being in a sound and normal condition. It produces, of course, complete incontinence, the urine flowing through the fistula as fast as formed, and escaping vict the os uteri and vagina.

A vesico-uterine fistula is very rare. It should not be confounded with what has been termed a vesico-utero-vaginal fistula, which differs from it in some important particulars, and requires a different mode of operation. These latter-the vesico-utero-vaginal-are the most common of all the varieties of urinary fistula in the female. They involve the upper end of the vagina and the lower part of the anterior lip of the cervix uteri. They are often of large size, from extensivedestruction of one or both of these parts; under which circumstances they gape widely open, so that it may be almost or quite impossible to bring their edges into contact. They frequently pass by the more common term of vesico-vaginal ; but the distinction is worth making. A vesico-utero-vaginal is more common than a true vesico-vaginal fistula; but of all three, the vesico-uterine is by far the most rare. The following are the particulars of the case which forms the basis of this communication. The details of its earlier history have already been made public; I therefore only recapitulate its leading features so far as to render myself intelligible. C. R-, who stated her age to be forty-five, was first admitted into St. Mary’s Hospital in May, 1862. Five months previously she had been delivered of her second child, at the full period, after a labour of twenty-four hours’ duration. From that time till her admission she had been totally unable to retain her urine. Her clothing was in a continual state of saturation, and her labia and thighs were severely excoriated. I found it by no means easy to discover whence the escape took place, for the vesico-vaginal septum and the urethra were perfectly sound throughout; and, judging from the difficulty attending the investigation of this case, I think it not unlikely that vesico-uterine nstulse may have been sometimes overlooked, and the incontinence attributed to some other cause, such as

neck of the bladder. I found, examination with a speculum, that a small quantity of fluid could be seen to flow from the os uteri into the vagina, and I discovered further, by digital examination, that about half an inch above the os uteri, which was large

paralysis of the sphincter of the however,

on

to admit the up of the finger, there was an opening in the canal of the cervix, leading forwards towards the bladder. The case was rendered perfectly clear when I found that a sound introduced into the bladder by the urethra could, by a little management, be brought into contact with the finger in

enough

the cervix uteri. The question then was how to remedy the evil. I found that two plans of operation had been suggested by M. Jobert. The first was to make free lateral incisions in the cervix uteri and upper end of the vagina, so as to convert the cervix into an anterior and posterior flap, by separating which the fistulous opening could be got at, and sutures applied to it. The second plan was to close up the os uteri, so as to prevent the urine from escaping, but leaving the fistulous opening uninterfered with, and depending upon it to afford an outlet through which the menstrual fluid could escape into the bladder. The first method was, of course, physiologically preferable ; but its danger was, in my opinion, considerable, as evidenced by the history of the only case in which it was practised by Jobert, while its success was exceedingly doubtful. I’therefore the second plan, that of closing the os uteri, and put it in practice on the 14th May, 1862. I will not dwell upon details, but will merely say that I denuded the edges of the os uteri, and brought them together by means of four silver wire sutures. The incontinence of urine was arrested from that moment, the wound healed soundly, and the patient left the hospital quite well in three weeks. She menstruated through the bladder before she left, without inconvenience or pain, and menstruation was continued regularly in the same way for three months, when I lost sight of her for a time. Towards the end of the year, however, she applied to me, telling me that since August or September she had ceased to menstruate, that she had experienced various uncomfortable sensations in the uterine region, and had been increasing in size. On investigation, I found that there was certainly a tumour in the hypo. gastric region, which appeared to be an enlarged uterus ; but on examination per vaginam, the os uteri appeared to be as firmly closed as when she left the hospital in June. These facts seemed to admit of but one conclusion-viz., that the fistulous opening had spontaneously closed, or bad become in some way blocked up ; and that the menstrual fluid, being unable to escape, had accumulated within the uterus, and was the cause of the enlargement. Pregnancy, with the os uteri firmly closed, was a contingency which never presented itself to my imagination, nor I believe to that of any of those who saw the patient. The appropriate treatment, therefore, appeared to be to reopen the os uteri to allow the accumulated matters to escape ; after which, supposing the fistula to be really closed, she would be restored to her original and normal condition. She wasre-admitted into the hospital early in January, 1863. On the 10th of January I attempted to divide the uniting sub. stance with a small knife guided by my finger; but I found it impossible to do this owing to the mobility of the uterus, and the firmness of the uniting medium. I therefore resorted to a trocar and canula, a speculum having been introduced to bring the os uteri into view; but before the trocar would penetrate I found it necessary to hold the os uteri steady with a vulsellum, and to use an unexpected degree of force. Only two or three drops of blood escaped through the canula ; but I satistied myself that I had really opened into the uterus by passing a small bougie, which readily penetrated to the depth of about three inches. The next day I was informed that a considerable quantity of watery fluid had escaped during the afternoon after the puncture had been made, and that she had complained of pain. The discharge of water, however, had soon ceased, and had not been repeated. On the following day I learned, to my extreme surprise, that she had been taken ill during the night, and that a fcetus of about four months’ date had made its appearance. The watery discharge which followed the puncture was, therefore, doubtless the liquor amnii, and was thus clearly accounted for. The patient recovered rapidly from her miscarriage ; but the cicatrix formed by inoperation was, of course, completely broken down by the pas5a:of the fostus, and the os uteri was permanently reopened. The urine escaped through it precisely She left the hospital for a as it did before my first operation. time on the 10th of February, but shortly afterwards applied to me with an urgent request to be re-admitted, in order that the original operation might be repeated. This I did on the

preferred