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ROYAL MEDICAL & CHIRURGICAL SOCIETY. TUESDAY, NOVEMBER 13TH, 1860.
affection, and, closely simulating other more serious diseases of ! dilute hydrocyanic acid, three minims; compound tincture of the same part, has many times been mistaken for tumour of the cardamoms, half a drachm; effervescing mixture, one ounce:
breast. A good illustrative case is now under the care of three times a day, which speedily afforded relief. Half a grain Mr. Coulson in St. Mary’s Hospital :of morphia pill every night. S. T--, aged twenty, single, a female servant, the history 9th.-The limb is gradually being straightened by means of of whose affection dates back two years and a half. As is a bandage over the knee-joint. 25th.-- Purging came on to-day. usually the case with chronic abscess at this site, its origin was Tongue red and dry. unconnected with any acute lacteal inflammation, but arose Rather flushed and feverish in appearance. The upper part of without any distinct cause; it was attributed by the patient the wound has nearly healed ; but the discharge from the lower to cold. The first attack was aborted by prompt treatment. portion is very profuse. Ordered, bicarbonate of soda, fifteen The nipple has remained retracted, and the breast subject spirit of ammonia, fifteen minims; infusion to occasional attacks of painful swelling. A month ago, it of rhubarb and cinnamon water, half an ounce of each : three had been unusually inflamed and painful, and presented typical a day. features of the disorder. removed to-day in consequence of a small cirThe classical authority in surgery says that "the cure of cular appearing on the knee-cap from the pressure exthese encysted abscesses of the breast may be most conveniently erted in straightening the leg. The limb was now placed on a effected hy making a puncture into them, and then passing a fracture-cushion, and was supported by sand-bags to prevent seton across them in a perpendicular direction; the inflamma- rotation inwards. tion thus excited in the tumour will speedily lead to its being July 9th. -Somewhat better; purging has abated. A small softened down, and eventually disappearing." The treatment abscess on the left of the second or third lumbar vertebra was which Mr Coulson adopted in this case, and which he comquantity of pus let out. The discharge from the monly employs with success, was of a milder character. Scott’s hip very profuse, and rather offensive. To take citrate of iron ointment was applied to the breast on lint; strips of plaster, and quinine, four grains, three times a day. of an inch and a half in breadth, were then placed tightly 14th.-Some return of the purging and sickness this mornaround this dressing, and the whole carefully bandaged. Four ing. Ordered, compound tincture of cardamoms, tincture of days snhsequently, Mr. Coulson caused the dressing to be re- ginger, and spirit of sulphuric ether, of each half a drachm; moved aud renewed. The improvement in the case was very water, one ounce. 17th.—Much weaker; pulse small and feeble; tongue red marked, and the disease is fast progressing to a cure. and dry; lips parched ; skin hot; complains of thirst. To have barley-water. His allowance of wine increased to fourteen ounces, it having been hitherto twelve ounces daily. 26th.-There is a swelling in the groin, which is very painful, and looks as if an abscess were torming, but no fluctuation is perceptible; coughs a good deal, and expectorates a mucopurulent fluid. NORTH STAFFORDSHIRE INFIRMARY. Aug. 2nd.-This morning a grooved needle was passed into EXCISION OF THE HIP-JOINT. the swelling in the groin, and a small quantity of pus exuded. 6th.-Is evidently sinking; appetite failing; the wounds (Reported by Mr. CHARLES PARSONS, House-Surgeon.) profusely; cough and expectoration continue. To discharge EDWARD B-, aged thirty, compositor, single, was ad- take bicarbonate of potass, fifteen grains; spirit of nitric ether, mitted into this infirmary, under the care of Mr. Folkar, on and tincture of squills, of each twenty minims; water, one the 24th of May last, with disease of the hip-joint. He states ounce : three times a day. that on Easter Monday, 1858, whilst jumping in the gardens bth.-It having been intimated to him that there was little at the Crystal Palace, he felt something like a blow in the left chance of his recovery, he was to-day removed to his home at hip-joint. Constant twitching pains in the muscles of the thigh his own request; and on the 23rd he died. and leg soon followed, and sometimes their violence was so During the whole period of treatment his diet was liberal great as to almost throw him down as he walked along the and nutritious, with a free allowance of port wine. street. These symptoms continued to increase and grow worse till August, 1858, when he went into King’s College Hospital, under the care of Mr. Partridge. He remained under treatment till about Nov. 9th, when he was advised to go into the country. He returned to his nativeplace, Hanford, in Staffordshire. About January, 1859, the pain in the hip increased, but he continued to move about on crutches. For some months ROYAL MEDICAL & CHIRURGICAL SOCIETY. no material change ensued, except that the hip grew in size, and the pain was more intense, till August, 18.9, when an TUESDAY, NOVEMBER 13TH, 1860. abscess, just above the situation of the acetabulum, discharged MR. SPENCER SMITH, VICE-PRESIDENT, IN THE CHAIR. three or four pints of watery, curdy pus. About three months ago, another abscess, about two or three inches below the ON A CASE OF EXTRA-UTERINE GESTATION. former, broke and discharged slightly. They have both remained open ever since. On the advice of his friends, he BY J. ADAMS, ESQ., F.R.C.S., came into the North Staffordshire Infirmary to have the joint SURGEON TO THE LONDON ROSPITAL. excised. Present condition.—Thin, pale, and rather emaciated. The THIS case has been frequently alluded to in the pages of THE left leg is much contracted at the knee, and the toes are pointed LANCET. The woman’s age was twenty-eight, and she was in over the dorsum of the left foot, the heel being retracted. The other respects a healthy woman. She became pregnant in entire limb is about three inches shorter than the other, and January, or the beginning of February, 1859, and passed the leg is somewhat flexed towards the thigh, and the thigh through the usual stages of her condition with no suspicion that towards the trunk. There are two open sores, one above, and anything extraordinary had occurred until the latter end of the other below, the situation of the acetabulum, and both October, when she expected to be confined. She never had any distinct morning sickness, although she suffered from nausea discharge pretty freely. On May 26th, chloroform having been administered, an in- and other signs of indisposition. Mr. Williams, of Plaistow, cision, about five inches long, exposed the great trochanter. Essex, was engaged to attend her, but when her full period The capsule was opened, and the head of the femur was found had passed, nothing but a discharge of blood took place from partially anchylosed to the superior posterior margin of the her vagina, and pieces of flesh-like substance were expelled in acetabulum. Having dislocated the head, a portion of the gushes; there were no distinct uterine pains. Milk was femur was removed, just below the great trochanter. The dis- secreted in her breasts, and in February, 1860, menstruation eased portion of the acetabulum was then gouged. No vessel recommenced, and this has continued ever since uninterruptedly. required a ligature. A long thigh splint, interrupted by an In March the milk disappeared from her breasts. At this time arch of iron over the diseased joint, was next applied; but in she was seen by Dr. Ramsbotham and Mr. Adams, who both consequence of the leg having been so long flexed on the thigh, agreed that an extra-uterine foetus existed, and she was advised to wait until six months had elapsed from the termination of it was impossible to fully extend it. June 1st.—The wound looks healthy, and suppurates freely. her full term, so that the cyst might be further consolidated The patient vomited slightly this morning, and was ordered with the peritoneum. The tumour was irregularly ovoid in
grains; aromatic times 30th.-Splint
slough
opened, anda
°
Provincial
Hospital Reports.
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511
its long axis vertical, and it was situated towards the side of the umbilical and iliac regions of the abdomen; the abdominal walls could be moved to a slight extent over the surface of the tumour. It was not possible to distinguish the individual parts of a foetus. Gastrotomy was’performed on the 31st of May, and she left the hospital with a small fistulous opening at the lower part of the wound, whence a slight quantity of foetid discharge continued : this has since disappeared. In this case no attempts were made to extract the placenta,, as, The on traction by the funis, it appeared firmly adherent. child was delivered by the breech. The patient went on uninterruptedly well. The author entered rather fully into the question of the propriety of performing gastrotomy in cases of extra-uterine gestation ; and after giving due weight to the arguments which may be fairly advanced against an early operation, and prior to the commencement of any distinct indication of nature, as evinced by ulceration or suppuration, came to the conclusion that such an operation is quite justifiable. He advocated delay for some time after the end of the full term, to favour the opportunity for the consolidation of the cyst to the peritoneum, so as to avoid the additional risk of peritonitis. In this case the peritoneum was opened without any inconvenient consequences. He (Mr. Adams) had seen the patient that day. The wound had entirely closed. There was no evidence of any escape of the placenta beyond that which he had already stated in the paper. Mr. SPtrtcEx WELLS asked for some further informittion than he had gathered from the paper as to the possibility of removing. the cyst with the attached placenta in the case just related. So far as he (Mr. Wells) understood the description, the cyst was in the peritoneal cavity, free and unattached on its left side,, while on the right side it was adherent to the abdominal parietes. It was so free, that when the child was removed, it contracted or collapsed. This being the-case, it would depend upon the extent and firmness of the adhesions on’the right side, and upon the nature of the connexion with the Fallopian tube and uterus, whether a surgeon would be justified in attempting. ,to remove the cyst with its contained ,placenta rather than! leave both to the slow process Mr. Adams’ patient had gone through. Supposing the adhesions not to be very extensive, and the connexion with the uterus to be only by means of the Fallopian tube, it would seem, at first sight, te be better sur-, gery to remove both cyst and plaoenta than to leave them. It: was one thing to attempt to separate the placenta from the cyst, another to remove both together. He (Mr. Wells) congratulated Mr. Adams most warmly on ’the very successful result of the interesting ease he had recorded; bat, as a guide to some rule of practice in future cases, he asked for a more detailed account of the amount of adhesions, and of the nature of the connexion between the cyst, the Fallopian tube, and the uterus. Mr. ADAMS said it was true there were considerable adhesions on the right side of the tumour, whilst the left was comparatively free. He had refrained from further interference in the case from a desire not to add to its gravity. The circumstances were peculiar, and altogether different from those which appertained to an ovarian cyst. It was impossible to determine in his case the exact amount of adhesion, and how far these adhesions implicated important parts; besides, we are ignorant at present to what extent the placental vessels were connected with the circulation of the mother. Under all the circumstances, he thought the best practice was to do no more than In another case referred to in his paper, rude was necessary. attempts were made to remove the placenta, and the surgeon cut away a portion of the cyst; the patient died. There was no analogy between ovariotomy and this operation, but ovariotomy might, in some cases, looking at the amount of adhesions to be up, the division of the pedicle, &c., be a In this case, a.pormore dangerous proceeding than this one. - tion of the omentum had protruded, and was cut away. No ill effects followed, but as no advantage could result from the proceeding, he should, if such a case occurred to him again, simply replace the protruding part, and avoid the hæmorrhage consequent upon its excision. He thought the mode of dressing employed in this case advisable, and considered that the of the ligature through the skin and adjacent .simple cellular tissue less dangerous than when .it was passed through the muscles and peritoneum, the .plan adopted by some operators in cises of ovariotomy. In his case the simple bandage and cotton pad were kept in close approximation to the wound, which was left undisturbed until all risk of peritonitis had
shape,
right
application
passed.
Mr. POLLOCK inquired if any record outside the
was on
case
Fallopian 512
At the concluding read :-
meeting of last session the following paper
was
CASES OF TREPHINING IN SYPHILITIC DISEASE OF BONES OF THE SKULL; WITH OBSERVATIONS. BY HENRY SURGEON TO
INXWS
LEE, ESQ.,
COLLEGE HOSPITAL, AND SENIOR SURGEON TO THE LOCK HOSPITAL.
The author gives the particulars of three cases, in all of which the bones of the skull were very extensively diseased. In the first, the outer and middle table of the frontal bone, principally on the left side, and part of the left parietal bone, had become necrosed, but the internal table retained its vitality when the trephine was applied. The inner surface of the portion of bone which was removed, presented a very uneven surface., from whence numerous small, irregular spicula of bone projected. The dura mater which had been in contact with these, was altered in structure, and did not bleed, as the dura mater usually does when a portion of bone is removed by the trephine. There was here general debility, loss of sensation on the right side of the face, and deafness in both ears. There had been also extensive and long-continued ulceration on the left side of the neck. The removal of the portion of bone was followed by general restoration of the health, recovery of the sensation of the face, (with the exception of a small portion of the right side of the upper lip, which still remains numb,) and perfect hearing. This patient had no other treatment except a pint of the decoction of sarsaparilia daily. In the second case there was extensive disease of the outer and middle tables of the .skull. The patient became, in consequence, subject to a peculiar kind of fit. This commenced with flushing of the face, followed by twitching of the muscles of that part. The fit would then sometimes terminate; at others, however, it would be followed by rigidity of the muscles of mastication and of the other muscles of the body. Some of these fits lasted as much as six hours, during which the patient retained his consciousness. This patient was affected with an ulceration, which lasted over a period of between eight and nine years, and which had extended over the ,skin of the whole righ.t.arm, from the shoulder to the wrist. The application of the trephine in this case was made over the right temporal bone-; the portion of the internal table -removed was slightly roughened, but not nearly so much :as in the preceding case. The fits recurred a few hours after the application of the trephine, but ultimately ceased. The ulceration of the right arm, which had existed between eight and vine years, healed, and the patient was restored to a comparative state of health. In the third case the bones of the skull had been extensively destroyed, but in one part the inner table had perished where the outer and middle table still maintained their vitality. Opposite ’this point, effusion of plastic matter had taken place, and the disease had spread by continuity of action to the brain, and produced red softening of that organ. There was no disease either in the brain or its membranes ill these situations where the entire thickness .of the skull had beem removed. In this instance, again, there had been long continued and most troublesome ulcerations, principally of the right leg, and destruction, by ulceration, of the’eye and nostril on one side. The trephine was here applied to the right parietal bone, in the immediate neighbourhood of the portion of the internal table which had perished. The exact spot was not hit.npon; but as softening of the brain had already taken place, and the patient was .comatose, any operation -in this particular instance was too late. The.author dwelt particularly upon the absence of disease in - those :parts where the entire thickness of the skull had been removed, and concluded from thence that the early removal of the diseased internal table afforded the best chance of success in such cases. It was evident in the last case, that the continued contact of the diseased bone had produced the effusion— first, between the bone and dura mater; then between the membranes of the brain; and that the brain itself had ultimately become diseased by continuity of action. Had this diseased bone been earlier removed, the results would.not have occurred. The object of trephining in these cases was, thenof extra-uterine foetatior 1st. To remove the cause of irritation from the surface of tube ? This question, hE the dura mater. -
broken
bore on the operation of removal. In ovariotomy the disease was formed by the organ itself, but in Fallopian pregnancy the tube might be said only to contain the diseased mass. M. GROUX afterwards demonstrated the sounds and motions of the heart upon his own person.
thought,
2nd. To allow the discharge of any matter there secreted. 3rd. To establish a healthy suppuration from one part of that membrane, whereby the irritation caused by the prolonged contact of diseased bone would be relieved. The author directed particular attention to the prolonged, persistent, and recurring ulcerations of the skin, which formed In one of the most troublesome symptoms in all the cases. illustration of the cause of these ulcerations, he referred to Dr. Brown-Séquard’s experiments, in which it was shown, that by cutting off the sympathetic nervous influence from a part, the vessels of that part became dilated; and also to M. Magendie’s experiments upon the fifth nerve, by which it was shown that ulceration might follow the abstraction of nervous influence. In the third case, destruction of the eye had actually followed, as in Magendie’s experiment, and as had also been observed by the author in a case of fracture of the base of the skull, in which the fifth nerve had been completely paralysed. Dr. Brown-S6quard had also shown that, by irritating certain portions of the nervous system, an animal might be rendered liable to epileptic fits. In Case 2 the author attributed the occurrence of the fits to the irritation produced in the membranes of the brain by the continued contact of the diseased bone, and concluded that the removal of even a comparatively small portion of that bone, so diseased, was calculated to relieve the irritation, as it certainly appeared to have done in the cases recorded.
the invasion of that country by the victorious army of Charles VIII. of France. The malady is generally allowed to have earliest broken out in a marked degree at Naples about the time that Charles took possession of that city in the spring of 1495, or nearly two years after Columbus’s return from his first voyage to Hispaniola. Charles set out again for France in May, 1495, and the malady seems to have been both diffused by his infected troops along the line of their northward march, and afterwards carried to their respective houses by his own as well as by his various Swiss, German, and Flemish auxiliaries. The new malady was not long in reaching Scotland, as attested by edicts issuedin 1497 by the Town Council of Aberdeen with reference to the appearance of the disease there, and by the Privy Council in Scotland in relation to its prevalence in Edinburgh. By the Aberdeen edict it was " statut and ordanit, that all licht wemen be chargit and ordanit to decist fra thar vices and syne of venerie;" and a few years later, "that diligent inquisition be taken of all infect personis with this strange sickness,
during
Frenchsoldiers,
,
of Nappelis."
The Edinburgh edict was six months later in date than the first of those issued by the Aberdeen authorities. It was, as already stated, drawn up by the King’s Privy Council, and proceeds thus:—" It is our Soverane Lordis will and the command of the Lordis of the Counsall, sent to the prowest and baillies within this burgh, that this proclamation follow and be put into execution for the eschewing of the greit apperand danger of the infection of his lieges fra a contagious sickness callit the Grandgore, &c. EPIDEMIOLOGICAL SOCIETY. " That is to say,we charge straitlie and command that all ma,ner MONDAY, Nov. 5TH, 1860. of personis, being within the fredome of this burgh, quhilk are infectit, or has been infectit and incurit, of this said contagious DR. BABINGTON, PRESIDENT, IN THE CHAIR. plage callit the Grandgore, devoyd, red, and pass furth of this town, and compair upoun the sandis of Leith, at ten houris A PAPER by Professor SIMPSON, of Edinburgh, entitled, before none, and thair sail have and synd bocis reddie in the NOTICES OF THE APPEARANCE OF SYPHILIS IN SCOTLAND IN haven ordainit to thame, be the officary of this burgh reddilie furneist with victuales, to have thaim to the Inch,’ and thare THE LAST YEARS OF THE FIFTEENTH CENTURY, to remain quhile God provide for their health." was read by Dr. M’WiLLiAM. The edict further ordains that those who take upon them The paper commenced by stating that medical men are for the cure of the disease are also to pass with the "infectit" to and disobedience of the edict on the part of the the most part agreed upon two points in relation to the history of syphilis—viz., that it is a species of disease which was un- doctor or hispatient rendered both alike amenable to the known to the Greek, Roman, and Arabian physicians, and that penalty of being " brynt on the cheik with the ’marking irne,’ it first began to prevail in Europe in the latter years of the that they may be kennit in time to cam." At the time of the first appearance of syphilis in the northern fifteenth century. The non-existence of syphilis in ancient times, and the cir- realm the throne of Scotland was occupied by James IV., a cumstance of its original appearance in Europe about the date prince who was a great patron ofthe arts and sciences of his alluded to, are opinions strongly borne out by two sets of facts. time. At different times we find him experimenting in cheFor first, no definite account of this marked and extraor- mistry, in physiology, and in medicine. His daily expense dinary species of disease is to be found in the writings of any books contain many entries of purchases for instruments and. one of the ancient Greek or Roman physicians, historians, or materials to make the unmakable " quinta essentia," or philo-, poets; and secondly, of the numerous authors whose works sopher’s stone ; and he had laboratories for these investigations exist in the learned collections of Luisinus, Astruc, and Gir- both at Edinburgh and Stirling. King James practised the tanner, and who saw and described the malady in the latter art of leech-craft, as well as experimented in alchemy and He was, says Lindsay of Pitscottie, " weill years of the fifteenth or commencement of the sixteenth cen- physiology. tury, almost all comment upon it as (to use their own general learned in the airt of medicine, and was ane singular guià It chirurgiane; and thair was none of that profession, if they hadexpressions) "morbus novus," " morbus ignotus," &c. &c. would not, however, said Dr. Simpson, affect our present any dangerous cure in hand, hot would have craved his adobject were we to consider the disease, as it appeared about the wyse." The Treasurer’s account shows that the king had a period in question, not to have been a new malady previously totally unknown, but merely, as some have thought, an aggra- right way, in one important respect, with his patients, vated form of a disease formerly existing in so mild a form as by might have secured a large consulting and private not to haveattracted general observation. Dr. Simpson con- practice, even in these modern days of high rivalry and comsidered it unnecessary to his case to investigate the question of petition ; for he paid his patients, instead of being paid by the probable source of the disease, and the exact date at which them. Thus, in his daily expense book, under the date of syphilis first burst forth in Europe. In relation to the object April 14th, 1491, is the following entry :he had in view, it mattered not whether it sprang up sponta" Item, to Dominico, to gif ye King leve to lat him blnd," 18s. neously and .endemically in Spain, Italy, or France at the era Scotch; and, a short time afterwards, "Item, to Kynnard, in question; or was imported from Africa, as Gruner, Infessura, ye barbour, for twa teith draun furtht of his hed be ye King, and others allege; or from Hispaniola, as Astruc, Girtanner, xviii.shillings." also to have tried his hand at ocular surgery; but Wetherhead, and a host of authorities have stoutly, and not unsuccessfully, maintained. Nor was it necessary to discuss the entry ominously hints that he was not a successful whether it first showed itself in 1493, as Sanchez and Hensler operator for cataract :-" Item, giffin to ye blind wif yat had consider that they have proved; or in 1492, as Fulgosi asserts; her ein schorne, xviii. shillings." or as early even as the month of October, 1483, as Peter Pinctor A prince, imbued with such medical and surgical propen. in 1500 proved astrologically to his own complete satisfaction sities, would naturally feel deeply interested in the first apthat it ought at least to have done, inasmuch as that was, as pearance within his realm of such a malady as syphilis; and, he has sagaciously shown, the precise and exact date of the in his treasurer’s accounts there are several entries indicating conjunction of Venus with Jupiter, Mars, and Mercury; and that the king had bestowed moneys upon various persons the conjunction of these or other stars in the heavens above affected with this disease. Thus there are several entries be. to was, as he and many of the astrological physicians of his time tween September, 1497, and April, 1498, for sums awarded believed, the origin of this new scourge on the earth below. persons of both sexes affiicted with the grantgore." There are various sarcastic allusions to the disease by the Dr. Simpson started from the general proposition, that the disScottish poets of these early days, amply testifying to the fact ease was in 1494 and 1495 first distinctly recognised in Italy
the "Inch;"
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-
High royal
that it he
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breast. A good illustrative case is now under the care of three times a day, which speedily afforded relief. Half a grain Mr. Coulson in St. Mary’s Hospital :of morphia pill every night. S. T--, aged twenty, single, a female servant, the history 9th.-The limb is gradually being straightened by means of of whose affection dates back two years and a half. As is a bandage over the knee-joint. 25th.-- Purging came on to-day. usually the case with chronic abscess at this site, its origin was Tongue red and dry. unconnected with any acute lacteal inflammation, but arose Rather flushed and feverish in appearance. The upper part of without any distinct cause; it was attributed by the patient the wound has nearly healed ; but the discharge from the lower to cold. The first attack was aborted by prompt treatment. portion is very profuse. Ordered, bicarbonate of soda, fifteen The nipple has remained retracted, and the breast subject spirit of ammonia, fifteen minims; infusion to occasional attacks of painful swelling. A month ago, it of rhubarb and cinnamon water, half an ounce of each : three had been unusually inflamed and painful, and presented typical a day. features of the disorder. removed to-day in consequence of a small cirThe classical authority in surgery says that "the cure of cular appearing on the knee-cap from the pressure exthese encysted abscesses of the breast may be most conveniently erted in straightening the leg. The limb was now placed on a effected hy making a puncture into them, and then passing a fracture-cushion, and was supported by sand-bags to prevent seton across them in a perpendicular direction; the inflamma- rotation inwards. tion thus excited in the tumour will speedily lead to its being July 9th. -Somewhat better; purging has abated. A small softened down, and eventually disappearing." The treatment abscess on the left of the second or third lumbar vertebra was which Mr Coulson adopted in this case, and which he comquantity of pus let out. The discharge from the monly employs with success, was of a milder character. Scott’s hip very profuse, and rather offensive. To take citrate of iron ointment was applied to the breast on lint; strips of plaster, and quinine, four grains, three times a day. of an inch and a half in breadth, were then placed tightly 14th.-Some return of the purging and sickness this mornaround this dressing, and the whole carefully bandaged. Four ing. Ordered, compound tincture of cardamoms, tincture of days snhsequently, Mr. Coulson caused the dressing to be re- ginger, and spirit of sulphuric ether, of each half a drachm; moved aud renewed. The improvement in the case was very water, one ounce. 17th.—Much weaker; pulse small and feeble; tongue red marked, and the disease is fast progressing to a cure. and dry; lips parched ; skin hot; complains of thirst. To have barley-water. His allowance of wine increased to fourteen ounces, it having been hitherto twelve ounces daily. 26th.-There is a swelling in the groin, which is very painful, and looks as if an abscess were torming, but no fluctuation is perceptible; coughs a good deal, and expectorates a mucopurulent fluid. NORTH STAFFORDSHIRE INFIRMARY. Aug. 2nd.-This morning a grooved needle was passed into EXCISION OF THE HIP-JOINT. the swelling in the groin, and a small quantity of pus exuded. 6th.-Is evidently sinking; appetite failing; the wounds (Reported by Mr. CHARLES PARSONS, House-Surgeon.) profusely; cough and expectoration continue. To discharge EDWARD B-, aged thirty, compositor, single, was ad- take bicarbonate of potass, fifteen grains; spirit of nitric ether, mitted into this infirmary, under the care of Mr. Folkar, on and tincture of squills, of each twenty minims; water, one the 24th of May last, with disease of the hip-joint. He states ounce : three times a day. that on Easter Monday, 1858, whilst jumping in the gardens bth.-It having been intimated to him that there was little at the Crystal Palace, he felt something like a blow in the left chance of his recovery, he was to-day removed to his home at hip-joint. Constant twitching pains in the muscles of the thigh his own request; and on the 23rd he died. and leg soon followed, and sometimes their violence was so During the whole period of treatment his diet was liberal great as to almost throw him down as he walked along the and nutritious, with a free allowance of port wine. street. These symptoms continued to increase and grow worse till August, 1858, when he went into King’s College Hospital, under the care of Mr. Partridge. He remained under treatment till about Nov. 9th, when he was advised to go into the country. He returned to his nativeplace, Hanford, in Staffordshire. About January, 1859, the pain in the hip increased, but he continued to move about on crutches. For some months ROYAL MEDICAL & CHIRURGICAL SOCIETY. no material change ensued, except that the hip grew in size, and the pain was more intense, till August, 18.9, when an TUESDAY, NOVEMBER 13TH, 1860. abscess, just above the situation of the acetabulum, discharged MR. SPENCER SMITH, VICE-PRESIDENT, IN THE CHAIR. three or four pints of watery, curdy pus. About three months ago, another abscess, about two or three inches below the ON A CASE OF EXTRA-UTERINE GESTATION. former, broke and discharged slightly. They have both remained open ever since. On the advice of his friends, he BY J. ADAMS, ESQ., F.R.C.S., came into the North Staffordshire Infirmary to have the joint SURGEON TO THE LONDON ROSPITAL. excised. Present condition.—Thin, pale, and rather emaciated. The THIS case has been frequently alluded to in the pages of THE left leg is much contracted at the knee, and the toes are pointed LANCET. The woman’s age was twenty-eight, and she was in over the dorsum of the left foot, the heel being retracted. The other respects a healthy woman. She became pregnant in entire limb is about three inches shorter than the other, and January, or the beginning of February, 1859, and passed the leg is somewhat flexed towards the thigh, and the thigh through the usual stages of her condition with no suspicion that towards the trunk. There are two open sores, one above, and anything extraordinary had occurred until the latter end of the other below, the situation of the acetabulum, and both October, when she expected to be confined. She never had any distinct morning sickness, although she suffered from nausea discharge pretty freely. On May 26th, chloroform having been administered, an in- and other signs of indisposition. Mr. Williams, of Plaistow, cision, about five inches long, exposed the great trochanter. Essex, was engaged to attend her, but when her full period The capsule was opened, and the head of the femur was found had passed, nothing but a discharge of blood took place from partially anchylosed to the superior posterior margin of the her vagina, and pieces of flesh-like substance were expelled in acetabulum. Having dislocated the head, a portion of the gushes; there were no distinct uterine pains. Milk was femur was removed, just below the great trochanter. The dis- secreted in her breasts, and in February, 1860, menstruation eased portion of the acetabulum was then gouged. No vessel recommenced, and this has continued ever since uninterruptedly. required a ligature. A long thigh splint, interrupted by an In March the milk disappeared from her breasts. At this time arch of iron over the diseased joint, was next applied; but in she was seen by Dr. Ramsbotham and Mr. Adams, who both consequence of the leg having been so long flexed on the thigh, agreed that an extra-uterine foetus existed, and she was advised to wait until six months had elapsed from the termination of it was impossible to fully extend it. June 1st.—The wound looks healthy, and suppurates freely. her full term, so that the cyst might be further consolidated The patient vomited slightly this morning, and was ordered with the peritoneum. The tumour was irregularly ovoid in
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its long axis vertical, and it was situated towards the side of the umbilical and iliac regions of the abdomen; the abdominal walls could be moved to a slight extent over the surface of the tumour. It was not possible to distinguish the individual parts of a foetus. Gastrotomy was’performed on the 31st of May, and she left the hospital with a small fistulous opening at the lower part of the wound, whence a slight quantity of foetid discharge continued : this has since disappeared. In this case no attempts were made to extract the placenta,, as, The on traction by the funis, it appeared firmly adherent. child was delivered by the breech. The patient went on uninterruptedly well. The author entered rather fully into the question of the propriety of performing gastrotomy in cases of extra-uterine gestation ; and after giving due weight to the arguments which may be fairly advanced against an early operation, and prior to the commencement of any distinct indication of nature, as evinced by ulceration or suppuration, came to the conclusion that such an operation is quite justifiable. He advocated delay for some time after the end of the full term, to favour the opportunity for the consolidation of the cyst to the peritoneum, so as to avoid the additional risk of peritonitis. In this case the peritoneum was opened without any inconvenient consequences. He (Mr. Adams) had seen the patient that day. The wound had entirely closed. There was no evidence of any escape of the placenta beyond that which he had already stated in the paper. Mr. SPtrtcEx WELLS asked for some further informittion than he had gathered from the paper as to the possibility of removing. the cyst with the attached placenta in the case just related. So far as he (Mr. Wells) understood the description, the cyst was in the peritoneal cavity, free and unattached on its left side,, while on the right side it was adherent to the abdominal parietes. It was so free, that when the child was removed, it contracted or collapsed. This being the-case, it would depend upon the extent and firmness of the adhesions on’the right side, and upon the nature of the connexion with the Fallopian tube and uterus, whether a surgeon would be justified in attempting. ,to remove the cyst with its contained ,placenta rather than! leave both to the slow process Mr. Adams’ patient had gone through. Supposing the adhesions not to be very extensive, and the connexion with the uterus to be only by means of the Fallopian tube, it would seem, at first sight, te be better sur-, gery to remove both cyst and plaoenta than to leave them. It: was one thing to attempt to separate the placenta from the cyst, another to remove both together. He (Mr. Wells) congratulated Mr. Adams most warmly on ’the very successful result of the interesting ease he had recorded; bat, as a guide to some rule of practice in future cases, he asked for a more detailed account of the amount of adhesions, and of the nature of the connexion between the cyst, the Fallopian tube, and the uterus. Mr. ADAMS said it was true there were considerable adhesions on the right side of the tumour, whilst the left was comparatively free. He had refrained from further interference in the case from a desire not to add to its gravity. The circumstances were peculiar, and altogether different from those which appertained to an ovarian cyst. It was impossible to determine in his case the exact amount of adhesion, and how far these adhesions implicated important parts; besides, we are ignorant at present to what extent the placental vessels were connected with the circulation of the mother. Under all the circumstances, he thought the best practice was to do no more than In another case referred to in his paper, rude was necessary. attempts were made to remove the placenta, and the surgeon cut away a portion of the cyst; the patient died. There was no analogy between ovariotomy and this operation, but ovariotomy might, in some cases, looking at the amount of adhesions to be up, the division of the pedicle, &c., be a In this case, a.pormore dangerous proceeding than this one. - tion of the omentum had protruded, and was cut away. No ill effects followed, but as no advantage could result from the proceeding, he should, if such a case occurred to him again, simply replace the protruding part, and avoid the hæmorrhage consequent upon its excision. He thought the mode of dressing employed in this case advisable, and considered that the of the ligature through the skin and adjacent .simple cellular tissue less dangerous than when .it was passed through the muscles and peritoneum, the .plan adopted by some operators in cises of ovariotomy. In his case the simple bandage and cotton pad were kept in close approximation to the wound, which was left undisturbed until all risk of peritonitis had
shape,
right
application
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Mr. POLLOCK inquired if any record outside the
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Fallopian 512
At the concluding read :-
meeting of last session the following paper
was
CASES OF TREPHINING IN SYPHILITIC DISEASE OF BONES OF THE SKULL; WITH OBSERVATIONS. BY HENRY SURGEON TO
INXWS
LEE, ESQ.,
COLLEGE HOSPITAL, AND SENIOR SURGEON TO THE LOCK HOSPITAL.
The author gives the particulars of three cases, in all of which the bones of the skull were very extensively diseased. In the first, the outer and middle table of the frontal bone, principally on the left side, and part of the left parietal bone, had become necrosed, but the internal table retained its vitality when the trephine was applied. The inner surface of the portion of bone which was removed, presented a very uneven surface., from whence numerous small, irregular spicula of bone projected. The dura mater which had been in contact with these, was altered in structure, and did not bleed, as the dura mater usually does when a portion of bone is removed by the trephine. There was here general debility, loss of sensation on the right side of the face, and deafness in both ears. There had been also extensive and long-continued ulceration on the left side of the neck. The removal of the portion of bone was followed by general restoration of the health, recovery of the sensation of the face, (with the exception of a small portion of the right side of the upper lip, which still remains numb,) and perfect hearing. This patient had no other treatment except a pint of the decoction of sarsaparilia daily. In the second case there was extensive disease of the outer and middle tables of the .skull. The patient became, in consequence, subject to a peculiar kind of fit. This commenced with flushing of the face, followed by twitching of the muscles of that part. The fit would then sometimes terminate; at others, however, it would be followed by rigidity of the muscles of mastication and of the other muscles of the body. Some of these fits lasted as much as six hours, during which the patient retained his consciousness. This patient was affected with an ulceration, which lasted over a period of between eight and nine years, and which had extended over the ,skin of the whole righ.t.arm, from the shoulder to the wrist. The application of the trephine in this case was made over the right temporal bone-; the portion of the internal table -removed was slightly roughened, but not nearly so much :as in the preceding case. The fits recurred a few hours after the application of the trephine, but ultimately ceased. The ulceration of the right arm, which had existed between eight and vine years, healed, and the patient was restored to a comparative state of health. In the third case the bones of the skull had been extensively destroyed, but in one part the inner table had perished where the outer and middle table still maintained their vitality. Opposite ’this point, effusion of plastic matter had taken place, and the disease had spread by continuity of action to the brain, and produced red softening of that organ. There was no disease either in the brain or its membranes ill these situations where the entire thickness .of the skull had beem removed. In this instance, again, there had been long continued and most troublesome ulcerations, principally of the right leg, and destruction, by ulceration, of the’eye and nostril on one side. The trephine was here applied to the right parietal bone, in the immediate neighbourhood of the portion of the internal table which had perished. The exact spot was not hit.npon; but as softening of the brain had already taken place, and the patient was .comatose, any operation -in this particular instance was too late. The.author dwelt particularly upon the absence of disease in - those :parts where the entire thickness of the skull had been removed, and concluded from thence that the early removal of the diseased internal table afforded the best chance of success in such cases. It was evident in the last case, that the continued contact of the diseased bone had produced the effusion— first, between the bone and dura mater; then between the membranes of the brain; and that the brain itself had ultimately become diseased by continuity of action. Had this diseased bone been earlier removed, the results would.not have occurred. The object of trephining in these cases was, thenof extra-uterine foetatior 1st. To remove the cause of irritation from the surface of tube ? This question, hE the dura mater. -
broken
bore on the operation of removal. In ovariotomy the disease was formed by the organ itself, but in Fallopian pregnancy the tube might be said only to contain the diseased mass. M. GROUX afterwards demonstrated the sounds and motions of the heart upon his own person.
thought,
2nd. To allow the discharge of any matter there secreted. 3rd. To establish a healthy suppuration from one part of that membrane, whereby the irritation caused by the prolonged contact of diseased bone would be relieved. The author directed particular attention to the prolonged, persistent, and recurring ulcerations of the skin, which formed In one of the most troublesome symptoms in all the cases. illustration of the cause of these ulcerations, he referred to Dr. Brown-Séquard’s experiments, in which it was shown, that by cutting off the sympathetic nervous influence from a part, the vessels of that part became dilated; and also to M. Magendie’s experiments upon the fifth nerve, by which it was shown that ulceration might follow the abstraction of nervous influence. In the third case, destruction of the eye had actually followed, as in Magendie’s experiment, and as had also been observed by the author in a case of fracture of the base of the skull, in which the fifth nerve had been completely paralysed. Dr. Brown-S6quard had also shown that, by irritating certain portions of the nervous system, an animal might be rendered liable to epileptic fits. In Case 2 the author attributed the occurrence of the fits to the irritation produced in the membranes of the brain by the continued contact of the diseased bone, and concluded that the removal of even a comparatively small portion of that bone, so diseased, was calculated to relieve the irritation, as it certainly appeared to have done in the cases recorded.
the invasion of that country by the victorious army of Charles VIII. of France. The malady is generally allowed to have earliest broken out in a marked degree at Naples about the time that Charles took possession of that city in the spring of 1495, or nearly two years after Columbus’s return from his first voyage to Hispaniola. Charles set out again for France in May, 1495, and the malady seems to have been both diffused by his infected troops along the line of their northward march, and afterwards carried to their respective houses by his own as well as by his various Swiss, German, and Flemish auxiliaries. The new malady was not long in reaching Scotland, as attested by edicts issuedin 1497 by the Town Council of Aberdeen with reference to the appearance of the disease there, and by the Privy Council in Scotland in relation to its prevalence in Edinburgh. By the Aberdeen edict it was " statut and ordanit, that all licht wemen be chargit and ordanit to decist fra thar vices and syne of venerie;" and a few years later, "that diligent inquisition be taken of all infect personis with this strange sickness,
during
Frenchsoldiers,
,
of Nappelis."
The Edinburgh edict was six months later in date than the first of those issued by the Aberdeen authorities. It was, as already stated, drawn up by the King’s Privy Council, and proceeds thus:—" It is our Soverane Lordis will and the command of the Lordis of the Counsall, sent to the prowest and baillies within this burgh, that this proclamation follow and be put into execution for the eschewing of the greit apperand danger of the infection of his lieges fra a contagious sickness callit the Grandgore, &c. EPIDEMIOLOGICAL SOCIETY. " That is to say,we charge straitlie and command that all ma,ner MONDAY, Nov. 5TH, 1860. of personis, being within the fredome of this burgh, quhilk are infectit, or has been infectit and incurit, of this said contagious DR. BABINGTON, PRESIDENT, IN THE CHAIR. plage callit the Grandgore, devoyd, red, and pass furth of this town, and compair upoun the sandis of Leith, at ten houris A PAPER by Professor SIMPSON, of Edinburgh, entitled, before none, and thair sail have and synd bocis reddie in the NOTICES OF THE APPEARANCE OF SYPHILIS IN SCOTLAND IN haven ordainit to thame, be the officary of this burgh reddilie furneist with victuales, to have thaim to the Inch,’ and thare THE LAST YEARS OF THE FIFTEENTH CENTURY, to remain quhile God provide for their health." was read by Dr. M’WiLLiAM. The edict further ordains that those who take upon them The paper commenced by stating that medical men are for the cure of the disease are also to pass with the "infectit" to and disobedience of the edict on the part of the the most part agreed upon two points in relation to the history of syphilis—viz., that it is a species of disease which was un- doctor or hispatient rendered both alike amenable to the known to the Greek, Roman, and Arabian physicians, and that penalty of being " brynt on the cheik with the ’marking irne,’ it first began to prevail in Europe in the latter years of the that they may be kennit in time to cam." At the time of the first appearance of syphilis in the northern fifteenth century. The non-existence of syphilis in ancient times, and the cir- realm the throne of Scotland was occupied by James IV., a cumstance of its original appearance in Europe about the date prince who was a great patron ofthe arts and sciences of his alluded to, are opinions strongly borne out by two sets of facts. time. At different times we find him experimenting in cheFor first, no definite account of this marked and extraor- mistry, in physiology, and in medicine. His daily expense dinary species of disease is to be found in the writings of any books contain many entries of purchases for instruments and. one of the ancient Greek or Roman physicians, historians, or materials to make the unmakable " quinta essentia," or philo-, poets; and secondly, of the numerous authors whose works sopher’s stone ; and he had laboratories for these investigations exist in the learned collections of Luisinus, Astruc, and Gir- both at Edinburgh and Stirling. King James practised the tanner, and who saw and described the malady in the latter art of leech-craft, as well as experimented in alchemy and He was, says Lindsay of Pitscottie, " weill years of the fifteenth or commencement of the sixteenth cen- physiology. tury, almost all comment upon it as (to use their own general learned in the airt of medicine, and was ane singular guià It chirurgiane; and thair was none of that profession, if they hadexpressions) "morbus novus," " morbus ignotus," &c. &c. would not, however, said Dr. Simpson, affect our present any dangerous cure in hand, hot would have craved his adobject were we to consider the disease, as it appeared about the wyse." The Treasurer’s account shows that the king had a period in question, not to have been a new malady previously totally unknown, but merely, as some have thought, an aggra- right way, in one important respect, with his patients, vated form of a disease formerly existing in so mild a form as by might have secured a large consulting and private not to haveattracted general observation. Dr. Simpson con- practice, even in these modern days of high rivalry and comsidered it unnecessary to his case to investigate the question of petition ; for he paid his patients, instead of being paid by the probable source of the disease, and the exact date at which them. Thus, in his daily expense book, under the date of syphilis first burst forth in Europe. In relation to the object April 14th, 1491, is the following entry :he had in view, it mattered not whether it sprang up sponta" Item, to Dominico, to gif ye King leve to lat him blnd," 18s. neously and .endemically in Spain, Italy, or France at the era Scotch; and, a short time afterwards, "Item, to Kynnard, in question; or was imported from Africa, as Gruner, Infessura, ye barbour, for twa teith draun furtht of his hed be ye King, and others allege; or from Hispaniola, as Astruc, Girtanner, xviii.shillings." also to have tried his hand at ocular surgery; but Wetherhead, and a host of authorities have stoutly, and not unsuccessfully, maintained. Nor was it necessary to discuss the entry ominously hints that he was not a successful whether it first showed itself in 1493, as Sanchez and Hensler operator for cataract :-" Item, giffin to ye blind wif yat had consider that they have proved; or in 1492, as Fulgosi asserts; her ein schorne, xviii. shillings." or as early even as the month of October, 1483, as Peter Pinctor A prince, imbued with such medical and surgical propen. in 1500 proved astrologically to his own complete satisfaction sities, would naturally feel deeply interested in the first apthat it ought at least to have done, inasmuch as that was, as pearance within his realm of such a malady as syphilis; and, he has sagaciously shown, the precise and exact date of the in his treasurer’s accounts there are several entries indicating conjunction of Venus with Jupiter, Mars, and Mercury; and that the king had bestowed moneys upon various persons the conjunction of these or other stars in the heavens above affected with this disease. Thus there are several entries be. to was, as he and many of the astrological physicians of his time tween September, 1497, and April, 1498, for sums awarded believed, the origin of this new scourge on the earth below. persons of both sexes affiicted with the grantgore." There are various sarcastic allusions to the disease by the Dr. Simpson started from the general proposition, that the disScottish poets of these early days, amply testifying to the fact ease was in 1494 and 1495 first distinctly recognised in Italy
the "Inch;"
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