PERINEAL FISTULA CLOSED BY THE ACTUAL CAUTERY AND HARE-LIP PIN
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315 UNIVERSITY COLLEGE HOSPITAL. PSEUDO-PEMPHIGUS IN AN HYSTERICAL FEMALE, THE RESULT OF VESICATION. (Under the care of Dr. HARE.) WHILE on the subject of skin-disease, we may record a curious and instructive example of malingering, on the part of one of the out-patients of this hospital, last summer, (kindly furnished us by Mr. F. B. White.) We can find no better name for her assumed disease than PSEUDO-PEMPHIGUS. The patient was a respectable young woman, aged twenty- six ; tolerably healthy-looking in appearance, but very deci- dedly hysterical : indeed, she first applied for advice in conse- quence of the hysterical symptoms and of urticaria, the latter of which she said had troubled her more or less for three years. She had not been long under treatment before she stated that an eruption, " like small bladders," had appeared on the left leg, near the outer part of her ankle. After some persuasion, she allowed the part to be examined, but before doing so, said that the bladders had burst that morning, and a kind of crust only remained : a reddish spot, nearly circular, about the size of a sixpence, and partly covered with a moistish, very thin, yellowish serum was found. At the next visit it was reported that a similar spot had come out on the left leg, its appearance having been preceded by " peculiar sensation of pricking, like that of pins and needles," at the part. There was a well-formed bulla on the thigh, surrounded by a halo of redness ; but in the colour of the fluid, and in some li other respects, as remarked at the time, the eruption differed from either ordinary pemphigus or pompholyx. The suspicion which was then excited, that the case was one of malingering, was at the next visit converted into a certainty. Two or three ’, spots of a similar character were then present ; of these, one was situated close below the left mamma, and was of a long, oval shape ; but it so happened that the mamma, which was slightly pendulous, presented, exactly at the spot where the under surface came in contact with the bulla just referred to, another minute bulla, differing in nothing, except in size, from the larger one. It was clear that the mamma had come into contact with the material used to produce vesication. No intimation was then given to the patient that the imposture had been discovered, so that, on several subsequent occasions, she came with one or more fresh bullfe. On examining some of these carefully, Dr. Hare detected as he expected to do, some remains of the vésiceating substance used. It was a black- looking matter, very minute in quantity, but quite sufficient, for, on being placed under the microscope, particles of the shining elytra of the blistering fly were unmistakably seen. On one occasion, it was expressly suggested within the patient’s hearing, that, in such cases, prior to recovery, a spot was sure to make its appearance on the shoulder. At the next visit, the patient appeared with one just over the outer edge of the left scapula. Dr. Hare remarked on the several diagnostic points between the above case and one of true pemphigus. 1. In the above case the bullæ were not so perfectly round, or oval, as in the true disease; their outline was more irregular and jagged. 2. The bullæ were more flaccid, and bagged down more than in pemphigus—were, so to speak, less plump. 3. The fluid they contained was of a deeper yellow colour. 4. There was the peculiarity that all the spots appeared on the left half of the body, which was readily explained by her being righthanded : moreover they appeared on parts which could be easily reached with the right hand, the only one which came out on the back of the trunk or limbs being the one whose appearance was "suggested" to her, and that one appeared just over the part of the scapula where she could most easily place a small blister with the right hand. 5. The accidental blistering of a part, as in the c".se of the left mamma. 6. The absolute proof of the imposition, by the aid of the microscope. Dr. Hare mentioned having seen a case some years ago, where a girl twice obtained admission as an in-patient of an hospital by blistering her face all over. On each occasion she was admitted for supposed erysipelas, but on her second visit the nature of the imposition was discovered. In the above case, as the woman was merely an out-patient she gained nothing by the device ; and the only apparent mo- tive was the morbid one of exciting sympathy, or perhaps the gratification of trying to puzzle the doctors. There is no telling what hysterical patients will not do. It is needless, however, to add, that when she was told that her imposture was de- tected, she did not again make her appearance at the hospital. CLINICAL RECORDS. PERINEAL FISTULA CLOSED BY THE ACTUAL CAUTERY AND HARE-LIP PIN. THE perineal fistula in the present instance had been only of three months’ duration, and occurred in a man aged thirty-one years, who had been the subject of stricture for eight years, and who became a patient in the Royal Free Hospital. The fistula was treated by Mr. Wakley, by paring the edges and bringing the parts together, which healed; but the premature introduction of a large bougie reopened the newly-healed parts, and the fistula returned, but was again remedied by the appli- cation of a red-hot needle to the edges of the old fistula, and bringing them together by means of a hare-lip pin, which most admirably effected the purpose. More recently we saw a case of urethral fistula, in an elderly man, at St. George’s Hospital, under Mr. Pollock’s care, the result of an injury. He was operated upon four times alto- gether, each operation being followed by a contraction of the fistula. After the third, the edges gave way during nocturnal erection. This was provided against, on the fourth operation, by making a free lateral incision, so that in the event of any pulling of the parts it will not affect the closed fistula. The edges of the fistula were pared on the 18th March, and brought together by means of silver wires, retained in position by shot. A catheter is used constantly, so that there may be no local irritation when there is a desire for micturition. Nearly all the urine, which previously passed through the fistula, is now voided naturally. EXTRA-THORACIC CYST. A YOUNG woman was admitted into the London Hospital with a cyst, the size of an orange, which had been growing for many years, a little towards the outer side of the inferior angle of the scapula. It was removed under chloroform, by Mr. Adams, on the 4th December. On being punctured in the early part of the operation, its contents ran out; and the thick membrane forming the cyst required much patience carefully to dissect away. This process, at one time, seemed to be of some magnitude ; because, at a short distance from the patient, the cyst appeared as if actually protruding from one of the intercostal spaces, so deep were its connexions. It was, how- ever, all eradicated, and the girl made a good recovery. We are not aware of any instance of a cyst partly extra- and partly intra-thoracic in situation, occurring in our hos- pitals ; if there have been any, we shall be glad to record them. Fortunately for Mr. Adams’s patient, the cyst was solely extra- thoracic ; possibly, it might have become intra-thoracic in the course of time, if it had been allowed to grow. CYSTIC DISEASE OF THE TESTICLE. CYSTIC disease of the testicle may be mistaken for hydro- cele, hæmatocele, and encephaloicl cancer. The tumour is of an oval or globular form, and not pyriform, as in hydrocele. It was globular in the case we are now speaking of at St. Mary’s Hospital, under Mr. Lane’s care. Leaving out other means of diagnosis, we will merely remark that the diagnosis will be much assisted in difficult cases by the introduction of a trocar. " A hydrocele or a hæmatocele will be at once made evident by the free escape of serum or blood, and a great re- duction in the size of the swelling," as stated by Mr. Curling. If the case be cystic disease, as in Mr. Lane’s pat.ient, orly a small quantity of serum tinged with blood will flow, which was actually the case, although the tumour was suspected to be an hæmatocele, the physical characters of which were cer- tainly not present. On January 6th, Mr. Lane cut into the diseased mass, and found it to be composed of a multitude of cysts containing a watery fluid, varying in size, and some of them seemingly communicating with each other. It resembled, as Mr. Lane remarked, a multilocular cyst. The patient was an elderly man, who had had this for some time. ’1 he entire mass was removed, with the exception of the testis, which was dissected out, but by no means possessing its natural appear- ance, and we much doubt whether the gland will recover itself, because pathology teaches us that the disease begins in the tunica albuginea, anli especially affects the ducts of the rgtc testis. The entire removal is recommended, and it would be desirable always to make a careful examination of any speci men as to its malignancy. Mr. Lane’s patient did well.
Transcript of PERINEAL FISTULA CLOSED BY THE ACTUAL CAUTERY AND HARE-LIP PIN
315
UNIVERSITY COLLEGE HOSPITAL.PSEUDO-PEMPHIGUS IN AN HYSTERICAL FEMALE, THE
RESULT OF VESICATION.
(Under the care of Dr. HARE.)
WHILE on the subject of skin-disease, we may record acurious and instructive example of malingering, on the part ofone of the out-patients of this hospital, last summer, (kindlyfurnished us by Mr. F. B. White.) We can find no better namefor her assumed disease than PSEUDO-PEMPHIGUS.The patient was a respectable young woman, aged twenty-
six ; tolerably healthy-looking in appearance, but very deci-dedly hysterical : indeed, she first applied for advice in conse-quence of the hysterical symptoms and of urticaria, the latterof which she said had troubled her more or less for three years.She had not been long under treatment before she stated thatan eruption, " like small bladders," had appeared on the left
leg, near the outer part of her ankle. After some persuasion,she allowed the part to be examined, but before doing so, saidthat the bladders had burst that morning, and a kind of crustonly remained : a reddish spot, nearly circular, about the sizeof a sixpence, and partly covered with a moistish, very thin,yellowish serum was found. At the next visit it was reportedthat a similar spot had come out on the left leg, its appearancehaving been preceded by " peculiar sensation of pricking,like that of pins and needles," at the part.
There was a well-formed bulla on the thigh, surrounded by a halo of redness ; but in the colour of the fluid, and in some liother respects, as remarked at the time, the eruption differedfrom either ordinary pemphigus or pompholyx. The suspicionwhich was then excited, that the case was one of malingering,was at the next visit converted into a certainty. Two or three ’,spots of a similar character were then present ; of these, onewas situated close below the left mamma, and was of a long,oval shape ; but it so happened that the mamma, which wasslightly pendulous, presented, exactly at the spot where theunder surface came in contact with the bulla just referred to,another minute bulla, differing in nothing, except in size, fromthe larger one. It was clear that the mamma had come intocontact with the material used to produce vesication. Nointimation was then given to the patient that the imposturehad been discovered, so that, on several subsequent occasions,she came with one or more fresh bullfe. On examining some ofthese carefully, Dr. Hare detected as he expected to do, someremains of the vésiceating substance used. It was a black-
looking matter, very minute in quantity, but quite sufficient,for, on being placed under the microscope, particles of theshining elytra of the blistering fly were unmistakably seen. Onone occasion, it was expressly suggested within the patient’shearing, that, in such cases, prior to recovery, a spot was sureto make its appearance on the shoulder. At the next visit, thepatient appeared with one just over the outer edge of the leftscapula.
Dr. Hare remarked on the several diagnostic points betweenthe above case and one of true pemphigus. 1. In the abovecase the bullæ were not so perfectly round, or oval, as in thetrue disease; their outline was more irregular and jagged.2. The bullæ were more flaccid, and bagged down more thanin pemphigus—were, so to speak, less plump. 3. The fluidthey contained was of a deeper yellow colour. 4. There wasthe peculiarity that all the spots appeared on the left half of thebody, which was readily explained by her being righthanded :moreover they appeared on parts which could be easily reachedwith the right hand, the only one which came out on the backof the trunk or limbs being the one whose appearance was"suggested" to her, and that one appeared just over the partof the scapula where she could most easily place a small blisterwith the right hand. 5. The accidental blistering of a part, asin the c".se of the left mamma. 6. The absolute proof of theimposition, by the aid of the microscope. Dr. Hare mentioned having seen a case some years ago,where a girl twice obtained admission as an in-patient of anhospital by blistering her face all over. On each occasion shewas admitted for supposed erysipelas, but on her second visitthe nature of the imposition was discovered.In the above case, as the woman was merely an out-patient
she gained nothing by the device ; and the only apparent mo-tive was the morbid one of exciting sympathy, or perhaps thegratification of trying to puzzle the doctors. There is no tellingwhat hysterical patients will not do. It is needless, however,to add, that when she was told that her imposture was de-tected, she did not again make her appearance at the hospital.
CLINICAL RECORDS.
PERINEAL FISTULA CLOSED BY THE ACTUALCAUTERY AND HARE-LIP PIN.
THE perineal fistula in the present instance had been only ofthree months’ duration, and occurred in a man aged thirty-oneyears, who had been the subject of stricture for eight years,and who became a patient in the Royal Free Hospital. Thefistula was treated by Mr. Wakley, by paring the edges andbringing the parts together, which healed; but the prematureintroduction of a large bougie reopened the newly-healed parts,and the fistula returned, but was again remedied by the appli-cation of a red-hot needle to the edges of the old fistula, andbringing them together by means of a hare-lip pin, which mostadmirably effected the purpose.More recently we saw a case of urethral fistula, in an elderly
man, at St. George’s Hospital, under Mr. Pollock’s care, theresult of an injury. He was operated upon four times alto-gether, each operation being followed by a contraction of thefistula. After the third, the edges gave way during nocturnalerection. This was provided against, on the fourth operation,by making a free lateral incision, so that in the event of anypulling of the parts it will not affect the closed fistula. The
edges of the fistula were pared on the 18th March, and broughttogether by means of silver wires, retained in position by shot.A catheter is used constantly, so that there may be no localirritation when there is a desire for micturition. Nearly allthe urine, which previously passed through the fistula, is nowvoided naturally.
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EXTRA-THORACIC CYST.
A YOUNG woman was admitted into the London Hospitalwith a cyst, the size of an orange, which had been growing formany years, a little towards the outer side of the inferior angleof the scapula. It was removed under chloroform, by Mr.Adams, on the 4th December. On being punctured in theearly part of the operation, its contents ran out; and the thickmembrane forming the cyst required much patience carefullyto dissect away. This process, at one time, seemed to be ofsome magnitude ; because, at a short distance from the patient,the cyst appeared as if actually protruding from one of theintercostal spaces, so deep were its connexions. It was, how-ever, all eradicated, and the girl made a good recovery.We are not aware of any instance of a cyst partly extra-
and partly intra-thoracic in situation, occurring in our hos-
pitals ; if there have been any, we shall be glad to record them.Fortunately for Mr. Adams’s patient, the cyst was solely extra-thoracic ; possibly, it might have become intra-thoracic in thecourse of time, if it had been allowed to grow.
CYSTIC DISEASE OF THE TESTICLE.
CYSTIC disease of the testicle may be mistaken for hydro-cele, hæmatocele, and encephaloicl cancer. The tumour is ofan oval or globular form, and not pyriform, as in hydrocele.It was globular in the case we are now speaking of at St.Mary’s Hospital, under Mr. Lane’s care. Leaving out othermeans of diagnosis, we will merely remark that the diagnosiswill be much assisted in difficult cases by the introduction of atrocar. " A hydrocele or a hæmatocele will be at once madeevident by the free escape of serum or blood, and a great re-duction in the size of the swelling," as stated by Mr. Curling.If the case be cystic disease, as in Mr. Lane’s pat.ient, orly asmall quantity of serum tinged with blood will flow, whichwas actually the case, although the tumour was suspected tobe an hæmatocele, the physical characters of which were cer-tainly not present. On January 6th, Mr. Lane cut into thediseased mass, and found it to be composed of a multitude ofcysts containing a watery fluid, varying in size, and some ofthem seemingly communicating with each other. It resembled,as Mr. Lane remarked, a multilocular cyst. The patient wasan elderly man, who had had this for some time. ’1 he entiremass was removed, with the exception of the testis, which wasdissected out, but by no means possessing its natural appear-ance, and we much doubt whether the gland will recover itself,because pathology teaches us that the disease begins in thetunica albuginea, anli especially affects the ducts of the rgtctestis. The entire removal is recommended, and it would bedesirable always to make a careful examination of any speci men as to its malignancy. Mr. Lane’s patient did well.
