PROVINCIAL MEDICAL & SURGICAL JOURNAL. CASES ILLUSTRATIVE OF THE BENEFICIAL holding his head backwards, and having his should- TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL. SIR, I have pleasure in forwarding, for insertion in your valuable Journal, details of the following cases of spinal disease. The first is a case of caries of the dorsal vertebræ, to such an extent, that the patient when first seen, with difficuity dragged himself upon his crutches, his chin resting upon the sternum, which had become much hollowed by the constant pressure; the occiput also rested upon the projecting spine, and each side of his head upon his shoulders: the second, an instance of the most extreme spinal curvature and general deformity from rickets, which has occurred to me in the course of my practice. An outline of the former of these cases, for the first eight months that it was under treatment, is inserted in the second edition of my work, on Diseases of the Spine; but the conclusion of the case being so exceedingly satisfactory, I have thought it desirexceedingly satisfactory, I have thought it desirable to give it publicity in the pages of your Journal. W. F., was born in December, 1832. When an infant, although he was not stout, he was yet a fine child, and his flesh was firm; he had the hooping cough while at the breast, and was subsequently exceedingly ill from enlargement and hardness of the abdomen. In June, 1834, his nurse slipped and let him fall, in consequence of which he suffered so much that it was not thought he could recover; he did, however, so far improve, that it was hoped no further ill effects would follow. In the month of September, 1835, he had the measles; in the spring of the following year, a projection of some of the dorsal vertebræ, with an altered form of his chest, was observed, in consequence of the child walking in a singular manner, No. 15, July 10, 1814, ers much raised. Medical assistance was immediately procured, but the disease progressed rapidly, the spine and sternum becoming more and more prominent, which they have continued to do to the present time. In the course of the summer, he lost the use of his lower extremities, and, for ten months, had not any sensation in them, even modic contractions in them during the nights were when they were pinched, intentionally; the spasmost severe, his limbs being forcibly drawn up to his body. which was at first thrown backwards, fell upon his As the disease advanced, his head, chest, as he was not able to support the weight of it without some assistance; his strength entirely lett him, and bis emaciation was, and has been since, extreme. His whole trunk was now exceedingly deformed, being much diminished in length; his chest was greatly contracted, his cough very troublesome, and his breathing most distressing, especially when asleep. He had the greatest diffi culty in turning himself in bed; if he did so, he would be ten minutes or more, before he wouldrecover from the effects of the exertion; his com plexion, at these times, was quite livid. From this period, 1837, he was confined altogether to his bed or a chair, until 1842, when he somewhat recovered the use of his limbs, so as to be able to walk a few yards with the assistance of crutches, but his debility was such, that it was. painful to see him drag his limbs after him, and his difficulty in breathing was so great as to prevent him walking more than a few paces; but no symptom caused him so much suffering as his difficulty in micturition, being often twenty minutes or more in excruciating pain, without being able to relieve himself in that respect; the secretion from the kidneys was dark in colour, and exceedingly strong in odour. June 27, 1843. At present the patient is sai fering extremely; his cough is very troublesome, but he has no expectoration; his breathing is extremely difficult, being short, frequent, and altogether diaphragmatic, at times producing great lividity of the face; he is troubled with headach; his sleep is short, much disturbed, and apparently accompanied with increased difficulty of respiration; his complexion is sallow and unhealthy, his skin hot and dry; he complains of general and Q great lassitude and debility, rendering him unwilling, if he had the power, to exert himself, while he is so feeble, that he is not able to lift even a trifling weight. His emaciation is extreme, his limbs are wasted to the bone, his cheeks are hollow, and his countenance expressive of suffering. The spine is exceedingly distorted, presenting a remarkable example of angular projection, including all the dorsal vertebræ, excepting the first and last, the most prominent ones being the fourth and fifth; there is considerable soreness on pressure in the course of the diseased vertebræ. The sternum projects forwards excessively, the ribs are much flattened externally, and project forwards and downwards, so that the extremities of the lower ones fall quite within the brim of the pelvis. The shoulders are so high that, on a lateral view, they almost prevent the ears from being seen, and the head is embedded, as it were, in a hollow formed by them; while, by the constant pressure of the ehin on the sternum, the upper part of this bone has become very much depresssed. September 27. The patient has now been three months under treatment, having been placed on an inclined plane and had gentle extensions by means of regulated weights, with pressure on the prominent part of the sternum; the state of his general health has also been attended to by correcting and improving his digestive organs. The symptoms already enumerated are all much improved; his breathing is less difficult and his sleep more composed; his shoulders which were as high as his ears are much lower and he feels, that when he has cccasion to rise for necessary purposes, he has strength for it; he has increased in height two inches. December 27. A cast has this day been taken of the patient, and certainly nothing but a comparison of this bust with the one taken when he first came under my care can give an adequate idea of the improvement which had taken place. His general health is much better; his breathing, which was, to use his mother's expression 66 awful," is now quite easy; he has nearly lost his cough, is much less subject to colds; he sleeps well all night and his spirits are excellent. to say, without subjecting him to a single hour's pain during the whole time he has been under treatment. The following are the particulars of the second case: C. O., aged twenty-three years, was born a fine child in November, 1820. When five weeks old she had a severe inflammation of the lungs, from which she was not expected to recover; this attack left her exceedingly weak. In April, 1823, she had a fall by which her clavicle was fractured; she now became very ill, having a severe bowel complaint by which she was confined to her bed,-was very much emaciated, and, subsequently, unable to walk for upwards of three months. This illness was followed by the measles, after which she had a long confinement, attended with eruptions on the face and head, the exact nature of which it is now difficult to determine. She afterwards improved somewhat, but has never been entirely free from pain in her limbs, and indeed throughout the whole body since. In 1826, so much deformity had taken place in her back and limbs, that she had jointed iron supports made, which passed round the abdomen and down to each foot; she wore them from nine to twelve months, but was obliged to give up their use. About this time she had a fall upon her knee, which was much hurt, and soon after another, by which her thigh was fractured; she again suf fered a long confinement, and was subsequently obliged to use crutches for nearly twelve months, being weak throughout her whole frame, but especially in her limbs. In 1832, she had again the misfortune to have a fall, by which her left leg was so much injured, that she has not been able to put it to the ground since, being obliged to be wheeled about in a carriage made for the purpose. Since the autumn of 1835, she has not been out of the house; such indeed, have been her sufferings, that since June, 1837, she has only been once (in November, 1842) off the crib on which she now lies, and although the removal was effected with the greatest care, she was three or four days before she recovered from the pain which it occasioned. She is never able to lie down entirely, but has four or five pillows, generally the latter number, and cannot rest without them. sufferings are, and have been chiefly in the chest and abdomen, though her back and limbs have been nearly as bad; the pains and distress are almost unceasing, so that she has rarely any respite even for an hour. In January, 1842, she had the Her February 29, 1844. All his symptoms continue favourable; his strength has increased so much that be can walk across the room with perfect ease, and is quite erect, although some protuberance of the spine still remains; notwithstanding the developement of his body generally, his chest has diminished an inch and three-eighths in its antero-posterior diameter, having increased proportionably in its transverse diameter; he has grown since Septem-influenza, and was very ill for three weeks or a ber last, nearly two inches. June 20. On this day week he will have been under my care twelve months, when the particular treatment of the case will be discontinued, as he can now run about with activity, and is in every respect better. month, and had an almost constant cough for six weeks, with pain in the chest, and an increase of nearly al! her symptoms, and was many months before she regained even her usual strength. May 1, 1844. The patient this day came under my care. The distortion of her spine to the left is This great change has been effected, I am happy of extreme extent; the ribs, especially the carti SPINAL DEFORMITY. laginous portion of them, on the same side, and the whole abdomen, project excessively, and so much is the body twisted, that the left nipple is directly underneath the anterior border of the axilla on that side, while the umbilicus is in a perpendicular line with these two parts, so that it is displaced fully four and a half inches to the left; the ribs of the right side, in curving over to the opposite side, form a deep fossa above the right hip, where the folds of the integuments, from being in constant contact, and from the frequent friction which takes place between them, are often inflamed, and give rise to almost constant soreness. The right hip projects extremely, and above it there is very considerable incurvation of the spine. The bones, both of the arms and fore-arms, are distorted, and both thighs have an anterior curve; the tibia and fibula of the left leg are also much curved in the same direction, and rather outwards, so that the sole of the foot is somewhat bent inwards. This, however, is much more the case with the right side, for, at about two inches above the ankle, the bones of the leg are suddenly distorted inwards at so acute an angle, that the sole of this foot looks inwards and upwards towards the left shoulder, and she can see it as she reclines on her crib. The patient suffers from very severe attacks of spinal irritation, giving rise to extreme pain in various parts of the chest, abdomen, and bead, with corresponding tenderness along the course of the spinal column, and she has frequent attacks of hysteria. The tongue is white and furred, appetite very bad, thirst considerable, bowels irregular, sometimes not being moved for four or six days. She was now removed from the crib, which had been, for seven years, her chair by day and her bed at night, and placed upon an inclined plane, and in a few days gentle extension was made by means of slight weights attached to the feet, axillæ, and head, the use of which was at first limited to an hour or two per diem, but which have since been increased both in weight and in the periods during which they have been used; besides which, frictions, compresses, and other means, were adapted and applied to the most projecting parts, and in addition to these, close attention has been paid to her general health, and the state of her digestive organs. Gentle purgatives, together with tonics and slight stimulants, (quinine, with tincture of cardamoms, camphor, and sulphuric æther,) have with this view been administered. Great pains were also taken to promote the expansion of the chest. June 8. Under this plan the most satisfactory improvement has been, and is taking place. Her health is better, her appetite improved; the functions of the stomach and bowels are more efficiently performed, the spinal irritation and consequent pains in the chest and abdomen extraordinarily diminished, and of the hysterical attacks, from which sbe so frequently suffered, she has had but one single return. Such was the deformity of her chest, 213 and the state of her lungs, that, on the first of May, on taking a deep inspiration, she was able to expire only 25 cubic inches of air, while such has been the increase in the capacity of the chest, she is this day able to expire rather more than 50. This is ascertained by means of a glass vessel, marked with cubic inches, from 10 to 200; this is filled with water, and inverted in a pneumatic trough; the patient then fills his or her chest, and breathes through a glass tube into the meter; the quantity of water displaced showing, of course, the capacity of the lungs. June 20. The form of the chest, &c., of the patient, continuing so obviously to improve, I have this day a third time ascertained its capacity in the way above-mentioned, and am glad to say that there is again an increase of 20 cubic inches over the number last named, as she is now able to expire rather more than 70. There is much less projection of the chest and abdomen to the left, the umbilicus being within two inches of the median line, and the left nipple has resumed more of its natural position, besides which, the breasts are commencing to be slightly developed, they having before been as flat as in a girl of ten years of age. The deformity of the left tibia and fibula is diminished; and, as regards the angle in the right, which before was so acute that the little finger could not be placed in it, there is now a space of at least three-quarters of an inch. The following measurements will give an accurate idea of the relative proportions of the different parts of the body, as regards the length on the right side. The first row of figures exhibits the state she was in on the 1st of May; the second, that on the 20th of June. From the above table it will be seen that the body, from the knee upwards, has increased six inches, while the convex angle, formed by the bend in the right leg, has diminished one inch, consequently the increase in the entire length of the patient, since the first of May, is five inches. It is satisfactory to be able to state that I have not the least hesitation in believing that she will continue to improve; and I shall have pleasure, at some future period, in transmitting an account of the further progress she may make. The distortion about the pelvis is so great, that it cannot be said to add to her length at all. 214 REMOVAL OF THE UTERUS BY LIGATURE. SUCCESSFUL REMOVAL OF THE UTERUS BY LIGATURE. By JONATHAN TOOGOOD, M.D., Bridgewater. The following case, although not similar to that published by Mr. Crosse, in the Journal of the 12th of June, affords an additional example of the safety and propriety of removing the uterus under certain cir cumstances. "The mass removed was about two pounds weight, the shape of the uterus, but its structure much altered in character, the cavity being quite obliterated, and the os uteri become almost cartilaginous. No bad symptoms ensued, and she told me yesterday, the 22nd, that she was as well as when she was sixteen. "On examination, no uterus can be discovered, but the vagina seems to terminate in a short cul de sac." At the time I met Mr. Parsons in consultation, the patient was in a very suffering state from general irri- About sixteen years ago I was requested to visit Miss L., aged about forty, who was represented to be suffering from a considerable swelling, which prevented er from passing any water. The introduction of the catheter was rendered somewhat difficult from the protrusion of a large mass from the vagina, but after a 1.ttle time I succeeded in drawing off between two and three pints of water, and then proceeded to make a more accurate examination. I found that the uterus was completely prolapsed, and hanging down between the thighs. There was not much difficulty in returning it, or retaining it in its natural situation by a large globuLar India-rubber pessary, which I directed to be removed occasionally and replaced. I heard nothing more of my patient for three years, when I was again desired CASE OF PERITONEAL DROPSY.' to see her on account of a profuse and most offensive discharge, which had existed for some time. To my By EDWARD DANIELL, Esq., Newport Pagnell. very great surprise I discovered that the pessary had In offering the following case to the profession, I am Bever been removed, which at once explained the aware that I am adding but very little to the general cause, and I was actually obliged to deliver her of it stock of knowledge in peritoneal dropsy, but as the with the forceps. From that time, as I subsequently case was successful, and that after only one operation, learnt, it was never replaced, consequently, the uteras I thought the particulars of it would not be unacceptwas frequently coming down, and prolapsing be-able, for to practical men one fact is of more value yond the external parts, and she had acquired the than a thousand suggestions. habit of returning it by sitting over an open space, and pushing it back with her fingers. This course was pursued until the 13th of April last, when it came down, and, after making repeated ineffectual attempts to return it for three days, she sent for my late partner, Mr. Parsons, who gives me the following statement : "On Wednesday, April 17th, I was sent for to see Miss L., a maiden lady, nearly sixty years old, who I had before known to have been suffering from a prolapsus of the womb; on my arrival I was informed that this had come down on the Saturday previously, during a violent fit of coughing, and that all her attempts to reduce it, had failed. On examination I discovered a very large protrusion of a pyriform shape, and extending from the vagina to at least seven or eight inches. The surface was not very sensitive, but was of a red, florid colour, and in some parts ulcerated and eechymosed from repeated attempts to effect its rednetion, and from which some hæmorrhage occasionally occurred. Every endeavour on my part to return it being fruitless, I ordered some leeches and cold applications to be used, hoping, in a day or two, by these means, to reduce its bulk, so as to enable me to return it. None of these remedies, however, succeeded, and as, on a more careful examination, I discovered that the neck of this large mass, as it entered the vagina, rather diminished in size, I requested a consultation with my friend Dr. Toogood, who had formerly attended the patient, who agreed with me on the practicability and safety of removing the whole by ligature. Accordingly, on Sunday the 21st, we applied a ligature very firmly round the neck of the swelling, just within the vagina, and took away the protruded part immediately. , 37 years of age, was delivered on the 3rd of April, 1835, of her fifth child; the case was simple, and the labour not protracted; a month passed on without any symptom of an unpleasant character. She was enabled to pay several friendly visits to ladies who had favoured her with kind enquiries during her confinement, and on one of these visits was overtaken by a shower, which made her damp and uncomfortable, but anticipating no evil, she did not regard it. She was however seized on the following day with severe pain over the whole abdomen, which seemed at length to concentrate itself in the left groin. The pain was so intolerable that she could not stand erect, and there was tenderness on pressure, costiveness, and pyrexia, symptoms clearly indicating inflammation of the peritoneum. She was bled in the arm, leeched, cupped, and blistered, and, as the attack was combined with considerable cerebral disturbance, her hair was close cut off, spirit lotions applied to the head, and the general antiphlogistic plan pursued. By this process the inflammatory symptoms gave way, but they were only yielding to exhibit another formin of disorder, too common where membranes analogous to the peritoneum, are the seat of active mischief. Tumefaction of the abdomen became visible in a week after the inflammatory symptoms had subsided, fluctuation was perceptible, and I need not add, that from the obstinate nature of such cases generally, the final result was referred to with very gloomy anticipations. Small and repeated doses of mercury were given without any obvious effect upon the system; ptyalism could not be induced; elaterium in its usual forms was administered, and neutral diuretic salts combined CASE OF TWINS, IN WHICH THE PLACENTA SIR, SURGICAL JOURNAL. with every agent generally employed to rouse the torpid condition of the kidneys, but without effect. Recourse was then had to small and repeated doses of iodide of potassium, and an ointment compounded of the same salt was directed to be rubbed freely over the abdominal region. The effect of this ointment TO THE EDITOR OF THE PROVINCIAL MEDICAL AND was to produce extensive cutaneous irritation, and the tenderness was so great, that the patient begged to have it laid aside. It was, however, repeatedly used when the condition of the skin would permit it. In spite of these measures the accumulation gained ground; the patient became cachectic, and so exceedingly reduced in flesh, that it became obvious that she would sink, if the disorder could not be overcome by other means, than those hitherto employed. I therefore proposed an operation, being convinced that if any good was to be derived from removing the accumulation by such process, it would be better to do it without the least delay. I consulted my friend, Dr. R. on the subject, who bestowed much pains in considering the case; he thought with me that it would not be possible to avoid an operation, but suggested a plan of treatment which might have a fortnight's trial, and then if no good resulted, to proceed at once to paracentesis abdominis. There is not anything new either in the following case, or the treatment of it, but perhaps it might have been managed better; and if so, my want of due care on the occasion may be a caution to others who meet with similar cases; for it is easier to see afterwards what might have been done, than to do everything well at the time of such an occurrence. From these considerations I send the case for your decision, whether or not the publication of it may be desirable, remaining, Sir, the lower part of the uterus, round the os uteri; the os uteri nearly as large as a half-crown piece; the membranes neither broken nor protruding. There was a coloured though not excessive discharge. She was desired to get into bed, and to take some gruel, which was not to be hot. I was requested on the 24th of May, 1844, to see a woman, (the wife of a butcher, named Hawksley,) who was supposed to be in labour of her fourth child, and who had suffered from frequent uterine pains The medicine, however, produced no effect; it did which had prevented her from sleeping during the last not even stimulate the kidnies to more activity than twenty-four hours. The child's head was felt prewhat had been done previously, while the accumula-senting at the brim of the pelvis; not pressing upon tion was increasing daily, and the distention of the abdomen distressing. Therefore, on the 17th of June, just eight days after Dr. R. had seen her, and six weeks from the commencement of the attack, I performed the operation, assisted by my excellent friend, Mr. Rogers, of this town, when fourteen pints of dark coloured fluid, resembling in appearance water, in which aloes and saffron were infused, were abstracted. The patient bore the operation well, the abdomen was well bandaged; she was put to bed, and from that time to her perfect recovery, not one important symptom occurred. She has since had two other children, and with the exception of occasional constipation, which indeed has always been her peculiar habit, she enjoys at this time perfect health. The secretion of milk, which was scanty during her illness, became most abundant after her recovery, and she was enabled to suckle her infant her usual time. Remarks:-This case has suggested to me one material point in the treatment of peritoneal dropsy, viz., not to uselessly protract an operation. Effusion may be considered as one of the accidents of inflammation, and occurs without any hydropic disposition; but if water be suffered to remain for months in the cavity of the abdomen, vitiating and emasculating the bowels, and weakening the energy of the absorbent vessels, it appears obvious the accumulation will return, and an hydropic diathesis be induced. I am also inclined to think that the previous medical treatment had its share in this successful recovery, for although the mercury and iodine were incapable of exercising an influence on the vast body of water deposited, who shall say that when that water was removed they were not active agents in preventing a return? Newport Pagnell, Bucks, June 25, 1844. On calling again after a lapse of some hours, the membranes were rather protruding, but the pains were still inefficient. The woman told me that one of her intimate friends had remarked that day, "From your size, you do not appear to me to be at your full time;" and she named that remark to me, just at the moment when I was thinking that the uterus was over distended, and more probably so by two children than by an unusual quantity of liquor amnii. On examining her body externally, it felt large at the sides, and as if the uterus contained twins. As the edge of the os uteri had become thinner, the membranes were ruptured, and in about one hour a child was expelled; the navel-string was tied and cut, when the untied end bled so freely as to require a ligature. On passing a finger along the cord, about half the placenta was felt in the vagina; as, however, the abdomen was not much less in size, I made my left arm bare and passed my hand beyond the placenta into the uterus; when feeling a second head, I again ruptured the membranes, and then feeling what I thought was a knee, pulled it down, and found a hand in the vagina. Having returned my hand, having found two knees, and having ascertained that they belonged to one child; I used a good deal of force in turning the child with its legs downwards, the disturbance of which, produced some pains, and a second child was soon expelled, bringing the first placenta before it. There was profuse hæmorrhage during the extraction of the second child. The other placenta was readily peeled off, from the fundus of the uterus, and was |