194

St. Thomas’s Hospital, under the care of Mr. Solly, on the 5th of March, ib59. He gives the following account of his illness:-About two years ago, he began to experience considerable

pain in the left shoulder joint. After a short time, this painwas accompanied by stiffness, which continued, more or less,even when he was free from suffering. This condition of thejoint extended over a considerable period. The ordinary re-medies, such as liniments, afforded him temporary relief at thecommencement of the attack; but, eventually, he became un-able to move his arm without giving rise to very acute pain inthe joint. About a year, or a little more, from the onset of thedisease, an abscess formed over the anterior wall of the axilla,and quite close to the chest. This was followed by anotherabscess on the inner side of the upper arm. They openedspontaneously, and have continued to discharge up to thepresent time. After the liberation of the pus, his sufferingswere considerably mitigated, and he has now much less pain inthe joint than he formerly had. He states that he has alwaysbeen of delicate constitution, and that some members of hisfamily were said to have died of phthisis.

State on admission.-He is a pale and rather emaciated man,looking much older than he states himself to be, and presentinga decidedly phthisical expression. The form of the left shoulderis altered, and generally much enlarged. There is tendernesson manipulation, most marked over the anterior part of thejoint. Any attempt to abduct the arm, or to rotate the headof the humerus, causes him extreme pain. On the side of thechest, immediately below the free edge of the pectoralis major,is the orifice of a sinus, which appears to run up in the directionof the joint; another sinus exists on the inner side of the upperarm, and this can be traced up the bicipital groove to thejoint. He has cough and expectoration, but has never sufferedfrom hæmoptysis. Dr. Bristowe examined his chest, and re-

ported th:’.t there was a slight amount of consolidation of theupper lobe of the right lung, which was, in all probability,caused by tuberculous deposit. He was ordered full diet, apint of porter, and to take a drachm of cod-liver oil three timesa day; also to have an issue made over the anterior part of thejoint. Under this treatment his health greatly improved; heincreased in weight, lost his cough, and the dulness at theupper part of the chest sensibly diminished. The condition ofthe shoulder-joint did not materially change. He suffered a

good deal of pain at times, and the sinuses continued to dis-charge a watery nus-On the 25th of June, he was placed under the influence of

chloroform, and Mr. Solly proceeded to excise the joint. Abold elliptical incision was made about the extent of the deltoidmuscle, and the fhp thus formed was turned up, so as to exposethe joint. The ligaments were then divided, and the armbeing drawn across the chest, the head of the hnmerus wasdislocated outwards, and with Butcher’s saw a considerableportion of it was removed; a little carious bone was also exca-vated from the glenoid cavity. There was but slight hæmor-

rhage. The edges of the wound were brought together bysutures. On examining the head of the humerus, it was foundthat nearly the whole of the cartilage had been destroyed bydisease, and there was a small piece of necrosed bone, whichwas undergoing the process of separation.June 26th.-He was a little sick and faint after the opera-

tion, but appears to be comfortable this morning. The woundlooks well. He did not sleep much last night. Tongue clean,and pulse quiet.

28th.— considerable portion of the wound has united byfirst intention. He is very comfortable and cheerful; takeshis food and sleeps much better than he did before the opera-tion.

July 1st.-Making progress; the wound suppurating freely;he does not suffer any pain.5th.-He is not quite so well just now, as he is suffering

from an attack of herpes zoster; the wound, however, lookswell.19th.-The wound is nearly healed, and he seems altogether

going on most favourably.Ang. 13.-He continues to improve; the wound is all but

healed; the sinus on the side of the chest still discharges alittle watery fluid; he eats and drinks well, and walks aboutthe hospiral quite vigorously.

27th. —The wound is quite healed, and he can bear the armto be moved a little without pain.

Oct. 19th.-He will leave the hospital to-day. The woundcontinues firmly united; the arm can be moved more

freely, and he has no pain; the sinus on the side of the cheststill occasionally discharges; his health is good, and he hasgained flesh and strength considerably since the operation.

CHARING-CROSS HOSPITAL.

REMOVAL OF THE WHOLE OF THE ACROMION PROCESS OF

THE SCAPULA FOR STRUMOUS DISEASE ; INTEGRITY OFTHE SHOULDER-JOINT.

(Under the care of Mr. CANTON.)IN this case the shoulder-joint itself was not implicated,

although it is probable that a blow on the shoulder was theorigin of the mischief which surrounded it, in a constitution.no doubt eminently strumous, if the boy’s family history betaken into account. In the details given, it is most instructiveand interesting to observe how the disease was limited by thejoint tissues of the acromio-clavicular articulation on the onehand, and the spine of the scapula (where there is less cancel-lous tissue for carious affection) on the other. To attempt toheal up the scrofulous sores over carious bone affected bystruma was an impossibility. The course, therefore, was

taken of removing the whole of the latter, and it was fol-lowed by the best results. These were greatly aided by care-ful attention to the general health both before and after opera-tive measures. The acromio-clavicular articulation was filledwith pus, and it is really astonishing that the shoulder-jointshould have escaped. This case forms an excellent and suitableappendage to the two foregoing, and for the notes of it we areindebted to Mr. J. Reeve Shorto, house-surgeon to the hospital.John B-, aged eight. The general appearance of the

child was healthy ; but when an infant he had been veryweakly, and suffered under strumous enlargement and suppu-ration of the cervical glands. All the family of his maternalgrandmother are of the strumous diathesis, so also are hisbrothers and sisters. It was believed that the patient had re-ceived some form of injury to his left shoulder whilst playingwith his schoolfellows a long time previous to his admission,and he first complained of a dull, heavy, and continued painabout the upper portion of the deltoid muscle nearly fourteenmonths ago. Some swelling of this part took place, and in six’months from the commencement of pain an abscess had formedin the region of the acromion process. The matter was eva-cuated by puncture ; ponltices were used, and water, dressingalternated with ointments were subsequently employed. Itwas understood that ‘‘blue plaister’’ had been strapped roundthe joint, but was discontinued in consequence of the pain it

occasioned.Examined when admitted into the hospital, the movements

of the shoulder-joint were found to be perfect, and no pain waselicited on motion. A large scrofulous ulcer existed partlyover the acromion process and partly on the deltoid beneath,pyriform in shape, nearly three inches long, and extendingbackwards in the line of the spine of the scapula; whilst an-other smaller ulcer was situated close to and a little behindthe one described. A probe detected a carious state of thebone subjacent to the large ulcer; but the tissue beneath thesmall one appeared to be sound.The boy’s health having been for a few weeks attended to,

by the administration of medicine and the allowance of aliberal nutritious diet, Mr. Canton proceeded to remove thediseased bone by making a curvilinear incision, commencing atthe acromio-clavicular junction, and terminating where theacromion process springs from the spine of the scapula; fromthis cut, another extended downwards at right angles, to theextent of an inch, inclu.iing in it (with the former one) thelarge ulcer spoken of. The skin having been reflected, and theupper attachment of the deltoid divided, the acromion processwas found to be extensively carious; the capsular ligament ofthe shoulder joint was sound; but the acromio-clavicular arti-culation contained pus, and its ligaments were partially sloughy;the outer end of the clavicle was healthy, though its cartilageof incrustation was partially destroyed, whilst the disease ofthe acromion extended completely up to this spot. The attach-ment of the trapezins having been divided, the whole of theacromion process was removed by the cutting pliers. The dis-ease had not extended into the spine of the scapula. The softparts were brought as nearly as possible together, and the armbandaged to the side and supported by a sling.The operation was performed on the 14th of last month; and

though primary union did not occur, the whole wound hasfilled up to the level of the skin with healthy granulations,

I and a most favourable termination to the case may be fairlyanticipated.

195

Mr. Barwell made an examination of the part removed,and reports that its superior surface-i. e., the portion nextto the skin - was condensed and hardened, and the outer

solid case (normally thin) a good eighth of an inch in thick-ness. The lower portion included simply cancellous structure.The bony lamellæ of the cancelli were overgrown and concealedby a rich pink tissue, which was suppurating pretty freely;the long plates themselves were thinned and softened, someportions being detached and lying loose amongst the tissueabove referred to.

CLINICAL RECORDS.

SUPPURATION OF THE HEPATIC VEINS AND I.

STRICTURE OF THE RECTUM.

ON emergencies, cases of advanced disease are admitted intoour hospitals, in which it is oftentimes most difficult to obtainany definite history of previous illness. These often try theskill and the patience of the physician, for the sufferers arethen in the same position as young children, who of coursecannot be expected to describe their ailments. An examplein point was admitted under Dr. Barlow’s care, at Guy’s Hos-pital, the last week of January. The patient, a man, was in astate of delirium when brought in, with an occasional lucid in-terval, during which a question or two were put to him abouthis illness. His skin was yellow, and taken with a high stateof fever and delirium, Dr. Barlow thought it might be abscessor some other disease of the liver. He told some vague storyof his being subject to stricture of the rectum, but he was ap-parently suffering from the symptoms of bile poisoning, anddied a few hours afterwards.At the post mort-em examination, diffused suppuration was

found throughout the hepatic vessels; the portal vein, amongstothers, was full of grumous matter. The rectum was foundto be strictured close to the anus, and here consisted principallyof dense fibrous tissue; the mucous membrane itself was de.stroyed. There were also large piles at the anal orifice. Themucous membrane of the rectum above the stricture was

lacerated, possibly from the use of instruments to dilate thestricture out of the hospital. The hepatic suppuration was nodoubt the immediate cause of death, but it could not be fairlyargued that the state of the rectum necessarily had anythingto do with bringing about the fatal hepatic mischief, althoughwe are aware that some pathologists hold such a view.

HYDATIDS OF THE LIVER, MAKING THEIR WAYOUT ALONG THE HEPATIC DUCT INTO

THE ALIMENTARY CANAL.

A RATHER unusual case of hydatid disease of the liver, whichended fatally, was very recently under Dr. Barlow’s care atGuy’s Hospital. The patient was a man who was admittedwith symptoms of hepatic disease and local peritonitis; he hadhad jaundice a month before his admission, which passed off.He survived but a short time; and on making a post-mortemexamination, a large hydatid cyst was discovered at the upperpart of the liver, which had burst into the hepatic duct, itscontents passing thence to the common bile duct and into theduodenum. Had circumstances been otherwise favourable, are.covery might have ensued, as this was an effort of nature to getrid of a visceral parasitic invasion. Dr. Wilks stated that he hadmet with one similar case, where the hydatid membranes passedinto the alimentary canal, some of them coming away by stoul,whilst others were ejected from the stomach during the act ofvomiting. This termination of hepatic hydatids is by no meansa common one. Sometimes they burst into the peritoneum, orinto the chest. But in the human subject, although they areoccasionally diagnosed during life, we have seldom any evi-dence to depend upon beyond symptoms of chronic hepatitis.The enlargement, however, has been known to simulate ascites,and tapping has been performed to afford relief. In Dr. Bar-low’s patient the true nature of the disease was not diagnosed,because he had not been sufficiently long under observation.

PULPY DEGENERATION OF THE SYNOVIALMEMBRANE OF THE KNEE.

OPINION is much divided on the subject of the treatment ofmany of the affections of the knee-joint. Some surgeons aflvo-cate excision of the articula,tion in cases where the disease isalmost confined to the joint, and does not extend much beyond,nor involve the neighbouring tissues. Others again, who are

opposed to excision, rely upon amputation, as the disease,whatever it may prove to be, is looked upon as incurable.Both of these methods we have frequently seen adopted.Whilst a third class would prefer to give the patient a chanceof ultimate anchylosis, after many years of suffering andmisery.An example of disease confined chiefly to the synovial mem-

brane of the right knee, in a man aged thirty-five, was sub-mitted to amputation by the circular operation, whilst underthe influence of chloroform, at St. Bartholomew’s Hospital, byMr. Stanley, on the 14th January. The case was one of a gooddeal of interest, because its progress had been watched fromthe commencement. The disease was of twelve months’ dura-tion, and for six months he had been in the hospital. Mr.

Stanley considered the disease at that time to be a pulpy andthickened condition of the synovial membrane. When theman left the hospital, his joint was comparatively easy; buthe returned a short time back in great agony. Inflammationhad occurred within the joint, and, Mr. Stanley believed, hadadvanced to ulceration of the cartilages. When the pulpy

degeneration does not remain in a quiescent state, it is sure, heobserved, to turn into ulceration of the cartilages. The jointseemed but very moderately swollen, and this was chiefly con-fined to its anterior part On opening it after removal, itproved to be a well-marked example of pulpy degeneration,the thickened synovial membrane projecting into folds in theinterior of the joint. The cartilages, as anticipated, were inprogress of destruction on the condyles of the femur and headof the tibia. The synovial membrane was brown in colour, andpulpy. The ligaments were not affected, but the bone wasdiseased, and. its articular cartilages destroyed. It was an

example of that peculiar condition of the synovial membranewhich unfortunately cannot be relieved but by removal of thelimb. The man is going on well.

LIABILITY OF TUMOURS TO TAKE ON MALIGNANTACTION.

THAT benign and simple growths, which have remainedquiet, almost unnoticed, and harmless for many years, shoulddegenerate into malignant action, is a curious fact, andone that has not as yet been satisfactorily explained. Thispeculiar result is verified nearly every day in hospital practice,and amongst other situations in which it is observed, we maymention the breast. Simple mammary tumours, when re-

moved before malignant conversion has ensued, rarely or neverreturn. This is otherwise when they have become infiltrated-by cancer, for example. On the 31st of January, we saw Mr.Bryant remove a mammary glandular tumour (adenocele ofBirkett), the size of a walnut, from a young woman’s right

breast; she had had it for some time-two or three years; andits early excision is almost certain to warrant an exemptionfrom any future return. The wound has already healed up,and the patient is nearly well. On the 2nd of February, acase of an opposite kind came under our notice at the LondonHospital, in the person of a oung-looking woman, aboutthirty-five years of age, wi:h a small tumour situated at the

upper part of her right breast. She had noticed a small lumpthere as long as she could well remember, but she had not atany time deemed it worthy of attention. Latterly it com-menced to enlarge, and caused some uneasiness; and its truenature being suspected by Mr. J. F. Clarke, whose patientshe was, she was admitted into the hospital to undergo anoperation for its removal. From the peculiar feel of thetumour, and the recent rapidity of irs enlargement, Mr. Curl-ing believed it might be carcinoma, and this was verified after-wards. She would not take chloroform, and bore the opera-tion as quietly as if she bad been narcotized. The tumourwas the size of . small pullet’s egg, and a section showed itto be incipient cancer, with several minute cysts around itsmargins. Some of the glands in the axilla were enlarged.The wound was slight, and a little haemorrhage ensued from asmall artery, which Mr. Curling endeavoured to arrest by acu-pressure,-a mode recently recommended by Dr. Simpson, ofEdinburgh,-but it did not succeed. It was, perhaps, hardlya fair case to try it in, for we heard Mr. Cnrling state that,the other day, Dr. Simpson went from Edinburgh to Carlisleto witness an amputation of the thigh by Mr. Page, of thelatter city, in which acupressure proved completely successfulin arresting the bleeding. The only question in relation tothis is, whether it is likely to be permanent in effecting thedesired object. Mr. Curling’s patient has been going on ex-tremely well, and it is to be hoped there may be no recurrenceof the disease.