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in the hills, but spend the heat of the day in the lowlands,returning home in the cool evening, necessarily encountersudden and decided changes of temperature, which assuredlyincrease the risk of contracting fever, whereas residencealtogether in the plains or towns assist acclimatisation, andplaces individuals in a position to withstand epidemic aswell as endemic influences. A medical man is often asked’by new comers to Jamaica what is the risk incurred by them
before they can be said to be acclimatised. Now the answerto such an important question should by no means beshirked, and while great care should be exercised in notexaggerating the dangers of the tropics, at the same timethe risks which undoubtedly do exist, and which always willexist under the best and most perfect sanitary improve-ments, must be candidly pointed out; for while there isdanger in needlessly alarming the newly arrived and pro-ducing fear, which of itself is a factor of disease, there is.at the same time such a thing as a false assurance ofsecurity, which entices people to act imprudently and takeliberties with themselves which cannot be indulged in withimpunity in a country where the invasion of disease is asnotably rapid as convalescence is tedious. One of the chiefthings to be guarded against is what I have already alludedto-viz., residing in the hills and working in the lowlands.Many a valuable life has been lost from this cause. Ofcourse this only applies to those officials and others whoseoccupations compel them to be in the towns ; but invalidsand pleasure-seekers, who come out to Jamaica for changeand pleasure, may find in the country districts and hillssafe retreats from the much-dreaded fevers of the country.Of course, in Jamaica all excesses should be guarded
against, and I am perfectly sure that there is no excess whichmore quickly and fatally tells on a new arrival than over-indulgence in alcoholic liquors of all kinds and descrip-tions ; it is better far for one to be a total abstainer than todepart from a strictly temperate mode of living in theslightest degree. I have often been asked " What shall Idrink ?" and it has puzzled me much to answer the ques-tion. I, however, find no difficulty in saying " Whateveryou drink, drink moderately; but do not drink brandy."Some men will drink large quantities of iced lemonadeand thus destroy their digestion. I once received a letterfrom a newly-arrived gentleman commencing " This is athirsty country," and not many months after the poor fel-low had quenched his thirst in a manner which undoubtedlykilled him. Therefore, to the new comer one cannot urgetoo strongly the necessity of being temperate in all things,for with a change of climate new propensities often arisewhich must not be indulged in, and after a time one settleedown to his old way of behaving, and all will be as wellwith him in Jamaica as it was in England or elsewhere.Another thing to be avoided is over-indulging one’s physicalstrength. One just out from England feels inclined to domore than it is proper for him to do ; but this inclinationshould be restrained; he should be told that a ten-mile walkin England can be performed with more ease than half thedistance in Jamaica. The apathy in the Creole is notlaziness, as some assert-it is the natural effect of thEclimate, which guides one instinctively, as it were, to mode.rate and economise one’s vital powers. Growth in thtropics is rapid, and so is decay if one attempts to run thErace of life too fast.The night air should be avoided even more than the mid.
day sun. An experience of fifteen years’ practice in Jamaicahas convinced me that there is more to be feared in " thpestilence that walketh in darkness" than in " the destruc.tion that wasteth at noon-day." New arrivals should noiselect, if possible, the fall of the year for going out. The3should avoid arriving in Jamaica just before or just after thOctober seasons, for it is during these periods that feversgenerally prevail. By the term " fevers" I do not necessaril3mean yellow fever; I allude more especially to remittenland intermittent fevers; but everyone who has had any experience whatever in Jamaica must know that what macause these fevers in the acclimatised and natives macause bilious, remittent, and yellow fever in the new comer
I fear I have somewhat digressed from the title of thiss’aort paper; but I have been induced, while on the subjectto jot down a few remarks which may not be uninterestingto those whose duties may take them to the " Isle oSprings."
St. Andrew, Jamaica.
HOSPITAL PRACTICE,BRITISH AND FOREIGN,
VASCULAR TUMOUR OF THE SCROTUM; REMOVAL;RECOVERY.—REMARKS.
(Under the care of Mr. RIVINGTON.)
Nnlla autem est alia pro certo noscendi via, nisi quampIurimas et morborumet dissectionum historias, tum aliorum, turn proprias collect as habere, etinter se comparate.—MoBaASNi De Sed. et Cau8. 3fforb., lib. iv. Prommiam.
STEPHEN W-, aged twenty-three, was admitted on the16th January, 1875. The posterior part of the left side ofthe scrotum was occupied by a tumour larger than a hen’segg and extending into the perineum. Over the surface ofthe swelling dilated veins were observed; whilst to thetouch the tumour felt as if composed of enlarged veinsmingled with little nodules of fibrous tissue scattered
through it. At first the patient attributed it to a blowwhich he had received on the testicle a week before his
admission, affirming that he never noticed any tumour inthe scrotum before the injury, that it came suddenly inconsequence of it, and had not since increased in size. Onreference to his father (his mother was dead), it was ascer-tained that when the patient was ten years of age he re-ceived a blow in the same spot from his brother’s kneewhilst they were in bed together; that the part swelled;and that he was attended subsequently by a surgeon, whohad leeches applied to the scrotum. Under this treatmentthe swelling subsided. The patient then admitted the cor-rectness of his father’s statement, and said that the swellinghad never wholly gone away after the first injury. It seems,therefore, most probable that the tumour was really con-genital, although it may have increased in consequence ofthe blows inflicted on it.On the 28th of January the tumour was removed en masse,
by making a longitudinal incision over it and dissectingit out. Two or three ligatures were required. A good dealof swelling occurred during the first few days, and thewound assumed rather an unhealthy aspect. A week afterremoval secondary haemorrhage occurred, and the house-surgeon, having failed to stop it with perchloride of iron,applied to Mr. Rivington’s colleague, Mr. James Adams,who happened to be at hand. Mr. Adams ligatured a largevessel at the side of the scrotum and arrested the hæmor-rhage. Subsequently, the wound granulated healthily andhealed well, but the process of repair was remarkably slow.
After removal, macroscopical examination of the tumourshowed that it was composed of lobules, connected togetherby vessels. On cutting into the lobules, exit was given tovenous blood. The surfaces of the divided lobules werenot uniform in their appearance. One or two exhibited theopen mouths of vessels of considerable size, whilst othersseemed to be made up of a congeries of enlarged capillaries.Some microscopical preparations of the lobules examined
were made by Mr. Needham, and their appearance accordedwith the naked-eye characters. The larger vessels referredto above were evidently veins irregularly dilated, their wallspresenting here and there bundles of muscular fibres,whilst in other parts no trace of such elements could befound. Small collections of fat and fibrous tissue were in-termingled with the vessels within the lobules. The struc-ture of other lobules was that of ordinary venous naevi.Remarks by Mr. RIVINGTON.—It might have been con-
jectured, A priori, that vascular tumours would occur withthe greatest frequency in the neighbourhood of a part ofwhich erectile tissue is a normal constituent. This is notthe case with the scrotum. The comparative rarity withwhich a vascular tumour is met with in the scrotum may bejudged from the fact that the subject was treated for thefirst time by Mr. Curling in the third edition of his standardwork on Diseases of the Testis. Only four cases are therereferred to, occurring respectively to M. Robert, M. Ricord,Mr. Henry Johnson, and Mr. Holmes, and to Mr. P. Hewett.
M. Verneuil, who described M. Ricord’s case, regards theaffection as in all cases congenital. Mr. Curling con-
curs in this opinion, and much may be advanced in itsfavour. Two of the cases recorded were undoubtedly con-genital, and in the other two the absence of direct evidencedoes not appear to affect very much the strong presump-tion in favour of a like origin. The history of the caserelated above is parallel to that obtained by M. Robert.His patient was twenty years of age, and the tumour hadbeen noticed for twelve years only. My patient was twenty-three, and the tumour first came under his observationwhen he was ten years of age, and then only in consequenceof the contusion of the part to which he attributed itsformation. In this view of the patient there was in all
probability an element of error as well as of truth. He wasincorrect in his belief that the inception of the tumour wasdue to the blow, but so far correct in that it was at thistime that the swelling became large enough to attract hisattention. All persons are not observant, and a smallswelling at the back of the scrotum, not interfering withcomfort in any ordinary position, and unaccompanied bydiscolouration of the skin, would readily escape detectionuntil injury or inflammation brought it under notice. Itseems to me very likely that an increase of a vasculartumour in the scrotum would naturally occur during de-velopment of the genital organs and at the approach ofpuberty. Such increase would render the tumour obnoxiousto inflammation or swelling from slight contusion andvenereal excitement. One other point may be noted. Arethese tumours to be regarded as a surplus formation of the’erectile tissue native to the part, or as unrelated to naturalerectile tissue as vascular tumours in other situations?
NATIONAL ORTHOPÆDIC HOSPITAL.WRY-NECK OF INFANTILE ORIGIN IN AN ADULT ;
TENOTOMY ; RECOVERY; REMARKS.
(Under the care of Mr. F. R. FISHER.)CASES of wry-neck caused by spastic contraction of one
sterno-mastoid muscle during infancy, and lasting till adultlife, are now rarely met with, in consequence of the reco-gnition of the importance of overcoming the muscular con-traction at an early age. Since its relief has been shown tobe easily attainable by means of tenotomy and appropriatesurgical treatment, it is seldom that an opportunity occursof observing the serious amount of mischief that resultsfrom wry-neck, if the contraction be allowed to continueunrelieved from infancy to adult life. Such an opportunitydid present itself in the case of a young woman, agedtwenty-one years, recently under Mr. Fisher’s care, at theabove-named hospital. From the following brief accountit will be seen that the resulting deformity was very great,but an interesting feature was the presence of markedsymptoms of mental disturbance, which arose from an over-sensitive appreciation of the deformity.At birth, no deformity was noticed, but between the
age of six weeks and nine months there were frequent andsevere convulsive fits. At the latter period the mother firstobserved that the head was not straight, and as the de-formity increased, the child was taken to a metropolitan.surgeon. No treatment was advised. The same opinionwas again taken when the girl was eight years old, andagain when she was fourteen, but no measures were recom-mended that could afford relief. When she was twenty,instrumental treatment was adopted for ten months, underthe advice of another surgeon, but little progress was madein reducing the deformity. In July, 1876, being at thattime twenty-one years old, she applied at the hospital. Theleft sterno-mastoid muscle was then very rigid and stronglycontracted, its sternal attachment being especially pro-minent ; the right sterno-mastoid was much atrophied, theclavicular portion being scarcely traceable. The head wasdrawn down to the left side, thrown forwards, and rotatedto the right. On measnremeut the left mastoid processwas three inches and a quarter from the left sterno-clavicularjoint, the distance between the corresponding points on theright side being six inches and a quarter. The left side ofthe face was smaller than the right, and by contrast appearedwasted. The left features were dragged below the level of
the corresponding ones on the opposite side of the face ; theunder jaw was rotated to the right and pushed forwards, theupper and lower teeth could not be brought into proper appo-sition, a space of a quarter of an inch existing between theupper and lower incisors. There was severe rotatory curva-ture of the spine in the cervical region, compensatod for bya long sweeping curve in the dorsal and a shorter curve inthe lumbar regions, the convexity of the cervical and lumbarcurves being to the right, that of the dorsal to the left side.On July 13th, Mr. Fisher divided the tendon of the left
sterno-cleido- mastoid, aloud snap accompanying the division,which was followed by sharp contraction of the muscle.Some bands of fascia and muscular fibres, which becameprominent after section of the sterno-mastoid tendon, werethen divided about one inch below the mastoid process. Thesmall wounds were dressed in the usual manner, and thepatient ordered to remain in bed.On July 20th, one week after the operation, measurements
taken between the same points as before were on the leftside four inches and a quarter, on the right side five inchesand a quarter, showing a marked improvement as the resultof the operation.
Instrumental treatment was now commenced, the in-strument used being of the pattern devised by Mr. WilliamAdams (made by Ernst). This apparatus possesses the ad-vantages of being perfectly adjustable to the deformity,and completely controlling the movements of the head. Itis unnecessary to give a detailed report of the treatment;I may state briefly that on December llth, five months fromthe date of operation, there was a scarcely appreciabledifference between the measurements on the right and leftsides, they being respectively five inches and a quarter, andrather more than five inches and one-eighth. So far as
position of the head is concerned, this result was thereforemost satisfactory.On April 3rd, when the patient was last seen, great im-
provement had taken place in the distortion of the face.The obliquity of the features was not so marked ; the leftside of the face had become more plump; and although, ontrying to close the jaws, a space still existed between theupper and lower incisors, yet the position of the lower jawhad so much improved (being no longer rotated to the right,and pushed forwards as before) that the lower row of teethwere not opposite their fellows in the upper jaw. Thespinal curvature was also much lessened, the improvementin this respect being far greater than had been anticipated.The mental disturbance, to which allusion has been made,
was a most interesting point in this case. When young,her manner was sensible and intelligent; she possessedgood intellectual ability, and received a high-class educa-tion, so far as to qualify her for the situation of a governess.As she grew up her deformities increased, the obliquity offeatures and other facial distortion, together with the spinalcurvature, being very noticeable. Although treated withkindness and sympathy by her friends, she, from a morbidfear of being noticed, became shy and unsociable, avoidingas much as possible the society of others. Being at thatage when her sex are especially anxious about their personalappearance, and obtaining no hope of relief from her de-formity, the idea that she was an object for remark wasfirmly impressed on her susceptible mind, giving rise to acondition of mental alienation that might almost be de-scribed as that of melancholia. To take a situation asgoverness was, of course, out of the question. When firstseen by Mr. Fisher she had a singularly despondent ex-pression, and she was most anxious to obtain a decidedopinion that her deformed condition could be improved; andwhen tenotomy was suggested as the only means of relief,she eagerly desired that the operation should be performed,an unavoidable delay being to her a cause of great dis-appointment. As her bodily deformity improved, the emo-tional disturbance of her nervous system became markedlylessened. When last seen she was composed in manner, andhad lost her former downcast expression. Her parents alsofound a most decided change for the better. She recoveredfrom her previous depressed condition of mind and becameof a bright and cheerful disposition.
It is unnecessary to speculate on probabilities to showhow important it is to overcome, as early as possible, con-traction of the sterno-mastoid when ailsing in infancy.Every year the difficulty of relieving the deformity becomesgreater, not merely from increased shortening of the sterno-