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was doubtful whether he should have undertaken it but for the very successful case which had been recorded by Mr. Syme.
Mr. Fergusson then showed the patient from whom, in June last, he had removed the scapula, leaving the arm otherwise entire (see " Mirror,” Aug. 26th, 1865). The man appeared in perfectly good health, and had gained much flesh since we last saw him. The wound had healed long since, and a scar, shaped something like the letter H, occupied the position of the scapula. The advantage gained by leaving the acromion process was very patent. There was remarkably litle deformity, and, owing to the preservation of the attachmeut of the trapezius muscle, the mobility of the limb was excellent. The man could move his arm freely in any direction, lifting it even laterally with the greatest ease and evident power.
PURPURA HÆMORRHAGICA, COMMENCING AT FOUR YEARS OF AGE. AND ENDING FATALLY BY HEMORRHAGE FROM THE UTERUS ON THE OCCASION OF FIRST MENSTRUATION.
By JOHN P. QUINLAN, Surgeon, Borrisoleigh.
Margaret R, the daughter of a well-to-do widow in the farming line, was placed under my care in the year 1854 or 1855 for the above disease. From the history of the case, I learned that about a year previous small red spots appeared over the body, which continued increasing steadily, becoming larger and of a darker colour, until now, when they presented the appearance of irregular patches, as if produced by bruises, as well as my memory serves me. At this stage there were no symptoms indicative of any great derangement of health. Having taken no notes of the case I am now unable to say what treatment I then adopted; but I recollect that after three or four months under my care the little patient got better, when I lost sight of the case.
On the morning of the third of April last, I was expressed for to see my former patient (not then known to me as such). On my arrival I learned from her mother that for the past week the girl (now 16 years of age) had her first menstrual change on; that she continued to work at agricultural business during the time (weeding potatoes); she had lost a good deal of blood, and had fainted two or three times during the day and night before. On inquiry as to the state of her health since my former attendance, I learned that she grew up stout and strong, the spots had disappeared, but there was still a tendency to the ecchymosis from any slight bruise, and for the three years previous she bled from the gums very often, so much so as to stain her pillow at night. There was no other hæmorrhage.
On examination I saw at a glance that hæmorrhage to an alarming extent had prevailed, the girl was pale and faint, sighing and restless, the surface cold; in fact, in a state of well-marked acute anæmia, involving life in great danger, and, to my great disappointment, I found myself entirely unarmed with a drug of any use in the case; stimulants I could get none immediately, not even a drop of whisky, we being in the midst of the mountains, a considerable distance from any town or village. I had the head lowered, warm jars put to the feet, directed perfect quietness, and dry-cupped the loins, and requested a messenger to follow me at once for medicine; but before my medicine reached, at all events before there was time for its administration, or for the stimulants ordered, death ensued.
CLINICAL SURGICAL CASES.
By GEORGE BUCHANAN, A.M., M.D., Surgeon to the Glasgow Royal Infirmary.
The following case shows the obscure symptoms which sometimes follow fracture of a vertebra when the displacement is so small as to cause no deformity. They were so obscure that I was only able to point out to the students, during the lifetime of the patient, the probability of some injury to the medulla. It was evidently of little extent, for sensation and voluntary motion of the lower extremities were unimpaired. Careful examination of the back detected no fracture, and I was led to suppose he had sustained some unimportant injury to the cord which would pass off and leave him restored. The post-mortem examination disclosed a lesion, which of course, rendered the symptoms more grave every day.
Instead of epitomizing, I give the case in the words of Mr. A. H. Miller, my assistant.
James L, aged forty-four, engineer, admitted Aug. Sth. This patient was brought in by policemen, who reported that he had fallen from a ladder at a height of three stories, and that he fell with his feet foremost. On admission the skin was found to be cold: surface pallid and moist. Pulse rather slow and weak. Patient perfectly sensible, but scarcely able to answer questions addresssed to him.
On examination of the body no fracture could be detected. There was a slight prominence over the sacrum; on its left side this was found to be quite soft, as if formed of effused blood. There was no other injury apparent, with the exception that the cartilage of the seventh rib had been separated from its attachment to the sternum. The patient had no difficulty in moving any of his limbs, and sensation was perfect.
Complained of great pain in the hypogastric region, which seemed to be caused to some extent by an accumulation of urine. When the urine was drawn off he experienced considerable relief.
Aug. 16th.-For the last eight days the patient has had bilious vomitting, accompanied with great sickness and loss of appetite. He can only take food that is very easily digested-e. g., arrowroot milk, &c. The skin is still rather cold, pale, and moist. Pulse 80, weak and soft. As yet he has not recovered any power over his bladder or his bowels. His urine is retained, but the stools are passed unvoluntarily. Although this is the case, there is no tendency to looseness, but rather to costiveness so much so that he has had castor-oil and five grains of calomel at separate intervals.
18th. Bowels to-day rather loose; stools passed involuntarily; appetite much approved.
21st.-To-day the feet are observed to be oedematous. Bandages were ordered to be applied from the toes upwards. The patient was subject to frequent and profuse perspirations, and is evidently losing flesh rapidly. He is so weak that he is scarcely able to rise in bed. Ordered one-sixteenth of a grain of strychnia twice a day. He complains now of a pain in the right groin. From his own statement it appears to be very severe. Fomentations were ordered for this, and frequent doses of solution of morphia.
25th.-Patient now complains of a pain in the epigastric and hypochondriac regions, and extending to the spine behind. It is thought to be dependent to some extent on displacement of the cartilage before reported. A bandage was ordered for the chest, and continuation of narcotics. Conjunction noticed to be slightly icteritic in colour. Bowels at this time rather irritable; pulse 100, weak.
Sep. 7th.-For the last two days the patient has been troubled with a cough so severe as to require medical treatment. He is recommended to assume the lateral position, each side alternately, in order to facilitate the expectoration of the bronchial secretion accumulated during all the time that the decubitus has been dorsal. This coughing comes on at intervals of seven or eight hours, and often continues from four to five minutes at a time. Expectoration frequently very profuse, principally frothy muscus. Pulse 110, weak.
14th. Continues in a very weak and helpless state. Although he takes a large supply of nourishment, he daily loses flesh; his cheeks have become hollow, and his eyes much sunk. He again passes his stools involuntarily, but retains control over his bladder. Cough continues to be very troublesome; exacerbations more frequent and severe; perspiration
very profuse. To-day patient called attention to a pain in his left groin, so severe that he could not bear the slighest pressure upon the part, Pulse 120, rather soft and weak.
20th. As the patient in health was accustomed to take large quantities of stimulants, he has been allowed for three weeks on an average from five to six ounces of spirits daily, and during the last few days of his life. although he could take a moderate quantity of food, he showed a great craving for alcoholic stimulants. Sensation in lower extremities perfectly normal, and voluntary motion was only lost by the general weakness, which was the cause of his death to-day.
Post mortem examination.-On opening the chest there were found firm adhesions of both pleura. The lower lobe of the left lung was collapsed, and firmly bound down by strong adhesions. The lower lobe of the right lung was much consolidated, hard, and containing some chronic abscesses of pneumonic origin. No tubercular deposit. The liver, from
its anterior surface to a considerable depth into its structure, presented the appearance of recent inflammatory action. Both kidneys and spleen were much congested and bound to neighbouring parts by effused lymph. semi-organized. On the removal of the abdominal viscera an abscess was detected on each side of the vertebral column, opposite the eleventh and twelfth dorsal vertebræ. The twelfth dorsal vertebra was found to be fractured transversely throughout the entire thickness of its body, and the fragments very slightly, if at all displaced. The fracture only implicated the body of the vertebra. The abscess extended round the spinal column, and on dissecting the vertebral muscles to expose the injured bone, it was found that the abscess extended vertically for about six inches on each side of the column posteriorly. The membranes of the spinal cord opposite, and extending an inch above and below the seat of fracture, were found matted together by effused lymph. There was also some effusion on the surface of the cord, but the nerve-substance did not appear to have suffered from inflammatory action.
LARGE AND MOVABLE ABDOMINAL TUMOUR OF THE LEFT SIDE, SUPPOSED TO BE OF NINE YEARS DURATION, AND TO BE OVARIAN; DIAGNOSIS, LARGE CYST OF THE KIDNEY.
(Under the care of Mr. HOLMES COOTE.)-M. K, aged 19, domestic servant, a well conducted and most respectable girl, was admitted Feb. 16th, 1865. She had been once employed as artificial flower maker, but subsequently became a nursemaid, which place she was forced to resign, not on account of any inconvenience which the tumour occasioned,
but simply because the duties were too heavy for her strength. She says that she has had a large abdomen for the last eight or nine years, but was not aware of the existence of a tumour until two years ago, when she was temporarily in another hospital. She has attempted to resume her work, but has always found it " too hard."
There is a well-defined tumour on the left side, under the abdominal parietes, movable, and extending from the illiac to the lumbar region. The measurement from the pubes to the upper end of the tumour is nine inches. When she lies in bed both sides of the abdomen seem equal, but when she stands up the left side is fuller than the right. The urine is thick, and contains lithates and a variable quantity of mucus. Vaginal examination yields nothing abnormal.
A careful examination of the relations of this tumour, its apparent want of connection with the uterus and its appendages, its prominence in the lumbar region, combined with the condition of the urine, induced Mr. Coote to come to the conclusion, in which he was supported by his colleagues, that the disease was a cyst in the kidney. The possibility of such an occurrence should be borne in mind in the examination of abdominal tumours. In the museum of the hospital (series 26, No. 38) there is the following specimen: "A large sac caused by dilatation of the pel vis of a kidney, in consequence of the impaction of a calculus in the ureter." It formed a movable abdominal tumour, the nature of which was doubtful during life. The late Dr. Bright observed: "I have known the enlarged kidney to be mistaken for disease of the spleen-of the uterus of the ovary-and for a tumour developed in the concave part of the liver; nor is it possible, perhaps, by the greatest care and the most precise knowledge, altogether to avoid such errors."
As in most tubular gland structures, the kidney may present either a single large cyst near its ejaculatory tube, or a great number of smaller cysts pervading its entire substance. Such a case is recorded by the late Dr. Bright p. 208, on Abdominal Tumours. Mr. Coote remarked that many years ago he had removed from the body of a patient who died in Bethlehem Hospital two kidneys, both enlarged to three or four times their natural dimensions. During life no symptoms indicated their presence; the urine was to all appearance normal; there was no trace of albumen. The cysts seemed to have separated and pressed aside the component parts of the kidney; but the vascular and secreting structure readily admitted the passage of fine injection. The abdominal enlargement was very marked as the subject lay undressed on the dissecting
Mr. Coote's patient remained but a short time in hospital, and then