case, treatment. I quote this as a typical case of by Dr. Kelvington. In his report both the what may be done if we can only succeed with tongue and glands give evidence of epithelioma this treatment; that is, instead of a serious of long standing, which exactly corresponds operation of removal of the whole tongue, a with his unfortunate history. comparatively trivial one of this nature. I will J.K.—This is another similar case. A man take this opportunity of saying that I do not at aged 53 originally sustained a crushing present take a too hopeful view of tongue cases; accident on his head, and last year a small they are not the class of cases that I prefer malignancy formed under his tongue, for which for this treatment. he was attended by Dr. Duncan in 1901. In J.K.—This is a man aged 47. I was asked October, Mr. O'Hara operated and removed it, to see him by Mr. O'Hara on May 28. He but it returned so badly that he removed the appeared to be suffering from a cancerous entire floor of the mouth, dividing the jaw at growth, inside on the lower jaw, on the left side. the symphysis on May 19th. It returned again It was evidently of the nature of an epithelioma, rapidly, and Mr. O'Hara sent him to me at and the glands were considerably enlarged. the end of July. I then found him in a very One point in his favour was that it had only hopeless state, and I hesitated to attempt to existed a few months, but was rapidly spreading. do anything for him, it looked so utterly hopeMr. O'Hara contemplated removing a portion less. The whole of the region under the jaw. of the jaw as evidently the best thing to be seemed a mass of malignant disease. Disdone, but before doing so asked me to give the charged large quantities of fætid pus and blood X-rays a trial. Before commencing I took a through the opening in the old wound of the small clipping of the growth, which was kindly last operation, which was breaking down, and examined for me by Dr. Kelvington, and pro- small portions of malignant growth sprouting nounced to be epithelioma, and in a very out through it. Apparently another month or active state. My own opinion is strongly two at the farthest would see the end of the that, if the case had been left to the However, at Mr. O'Hara's earnest usual course of events, at the rate it was request I said I would try the effect of the rays progressing all doubts would be very soon on it, and the improvement was immediate and removed. I gave him preliminary treatment decided from the very first. I started on July with the X-rays, and it progressed most favour 21st and gave it to him every day. The disably. On June 12 Mr. O'Hara removed the charge lessened, and to my surprise the growth enlarged and infected glands, and also scraped steadily subsided and got smaller and smaller. and curetted the jaw bone, and after a week I Small pieces of bone came away. I took a resumed the X-ray treatment. The case pro- skiagram of the symphysis of the jaw, which gressed most satisfactorily towards recovery, the you can now see, and the condition disclosed and mouth completely healing up, and the malig- the improved state of affairs encouraged us to nancy disappeared entirely. think the case was not so hopeless after all. H.I.—This case was sent me by Dr. Hodson, Some days ago Mr. O'Hara again cut down a man about the same age as last, but the on to the symphysis of the jaw, which seemed disease has existed nearly three year, and this to locate the seat of the disease, and removed has made the case almost a hopeless one. It only the silver wire suture, which you see in the was epithelioma of the tongue. About one- skiagram, and a small piece of necrosed bone, third of the tongue on the left side was already both which I have here. That is all that gone, as if cut out by a gouge right down far was done except that whilst under chloroforin back to the root of the tongue. I started the Ι I gave the ends of the jaw a thorough exposure treatment on July 1st, and from the first it to powerful X-rays for about ten minutes, soon began to put on a healthier appearance, that is, right into what appeared now to be the and the foul and characteristic smell dis- seat of the disease, and the wound was then appeared almost entirely. This is a common closed up. So far the result seems to have been and hopeful sign in these cases. I followed a most satisfactory; the wound has healed by similar line of treatment as I did in the previous primary union and has a healthy appearance, case, and on July 24th Mr. O'Hara operated and there has been no discharge from it since; and removed the sub-maxillary glands, tied the and the patient says he feels so much better lingual artery, which was nearly ulcerated that he feels as if he ought to go to work. In through, and merely curetted the tongue. I this treatment one of the most striking facts I resumed treatment a week after, and the have noticed is how directly the advance of the present position is this : The wound has healed disease is arrested, even although the difference well, and the side of the tongue is now nearly cannot be seen by the patient. Now he es I have here sections of the tongue presses himself as feeling remarkably well and and glands, kindly made for me and examined different to what he was for a long time pre healed up a viously. It is premature to say much about There was some difficulty in labour owing to the large size of the child, who was delivered by forceps by Dr. Wigg, the mother having been in labour nine hours. Beyond observing that he was a very large baby, nothing particular was noticed about the child at birth, but he weighed 14 lb. On the fifth day after birth the right leg was first seen to be rather larger than the left; then it was noticed that his right arm was larger than the left, and the right cheek larger than the left cheek. When five months old the child weighed 28 lb. The child is nursed by his mother, and is carried equally often in the right and left arm. Posture has nothing to do with the deformity. en A CASE OF COMPLETE ONE-SIDED GIGANTISM WITH ENLARGEMENT OF THE OPPOSITE SIDE OF THE BRAIN. M.R.C.P. (Lond.), M.R.C.S. (Eng.), Adelaide. SEVERAL cases of defective growth of the whole of one side of the body are on record, and these have been found at the autopsy to have been associated with deficient development of the opposite side of the brain. But the reverse condition, thatofone-sided overgrowth, including enlargementof the opposite cerebral hemisphere, is certainly one of the utmost rarity. The subject of this condition, which is exhibited At present he shows well-marked deformities to the Branch to-night, is an infant aged seven (they are much more evident than appears from months, a boy, the youngest of a family of three. the accompanying photograph). The left side His mother, who is a healthy woman, and is of the cranium (including the frontal, parietal, present with her child to-night, attributed her temporal and occipital regions) is much larger child's deformity to a shock which she received at than the right side. The anterior fontanelle is the sight of a friend who had been accidentally widely patent, but it does not bulge externally. killed. This occurred at the time when she The posterior fontanelle is just patent. There was two months pregnant. Her nine months appears to be slight proptosis of the left eye. of pregnancy differed but little from the previous The pupils are equal, and both react readily to ones, with the exception that on this occasion light. The ears are of equal length. The right her abdomen was unduly large-larger than it cheek, jaw and gums are distinctly larger than was during the previous pregnancies. At the the left. There are no teeth. The right side fifth month, and again at the seventh month, of the tongue is very greatly enlarged, and the mother tells us there were some false labour when the tongue is protruded it deviates to the pains, for which she obtained medical treatment. left, obviously owing to the great bulk of G on left ences its right half. The right shoulder, arm, but the more homely questions of diagnosis of forearm, wrist, hand, fingers and nails are sore throats, of rashes, of phthisis, the treatmuch larger than the left. Deltoid tubercle ment of broken limbs and so on, and one is of acromion to end of styloid process of sometimes tempted to wish that the years at ulna right side measures 20 cm.; the hospital had been somewhat differently side, 17 cm. The enlargement appears to spent. Among those common cases that include skin, subcutaneous tissue, muscle, frequently require careful consideration and and certainly also bone. Little difference is to treatment, and of which we see little at a be noted in the size of the two sides of the general hospital, and with which we all have chest : the chest appears to be well formed and to deal, are miscarriages or abortions. normal. There is no transposition of viscera. Doubtless my own experience is similar to The right side of the abdomen is slightly larger that of many others. Shortly after getting my than the left; this is more particularly noticed degree I went to act as locum tenens for a man in the skin and the subcutaneous tissue, which with a large practice. One of my first experiforms a loose fold above the right Poupart's was to be called to one of his best ligament; not present on the left side. There patients, who was said to have miscarried at is an umbilical hernia. The right buttock, leg, about the second month. I was shown, foot, toes and toenails are very much larger wrapped up in a diaper, what then appeared to than the left. The difference in size of these me a very extraordinary-looking lump of tissue, parts is very striking. The right leg is not only as I had never seen anything of the kind larger but longer (by about. 5 cm.) than the before. The lady herself, probably more left. The enlargement appears to affect skin, experienced than I then was, said she thought connective tissue, muscle and bone. There is it had all come away. I readily agreed, and no paralysis of any muscle, and the muscular fortunately for both of us it had, and in a week's time she was well again. child is, however, more clumsy with the right On starting practice for myself, I soon found side, and if he attempts to reach out for an that such experiences multiplied, and I began object with the right arm the movement is less after a time to make notes of these cases. In decided than it would be if the left arm were this I have collected short notes of 96 cases, used. The knee jerks are present, but are less a brief analysis of which I bring before you readily obtained on the right side than on the left. for your consideration to-night. There is then an enlargement of almost the In doing so, I may say that my object has whole of the right side of the body, together not been to make out that my methods and with the opposite (left) side of the cranium, and, results have always been the best, but simply therefore, also of the left side of the brain ; to give my impressions founded upon the and, one may infer, also an enlargement of the experience furnished by these cases, and not right side of the spinal cord. For it is incon- gathered at all from books, hoping to receive ceivable that the enlargement of the brain is many valuable hints from members afterwards due merely to a neurolgia overgrowth; it is far for my better guidance in the future. There more probable that the nerve cells and their are certain parts of our work of which this is axis cylinders—the upper neurones-are one, such as the giving of anæsthetics and the larged; and, if the upper neurones, probably management of labour, in which we all get also the lower ones. considerable practice, and form decided (Rend before the South Australian Brunch of the British Medical opinions, even to each one thinking that he does these things better than most other men, so I hope to hear many opinions and suggesRECORDS FROM GENERAL PRACTICE.-- tions to-night. CASES OF ABORTION. I take, then, abortion to mean, " the arrest By J. A. Cameron, M.B., B.C. (Camb.), Ipswich, of gestation, and the expulsion of the embryo Queensland. at a period antecedent to its viability—that is, before the end of the sixth month."-Rentoul. During those haleyon days of one's medical And, of course, an abortion is said to be complete career, when one is walking the wards of a when both embryo and membranes are exhospital as dresser, clerk and house officer, it pelled, and incomplete when the embryo is appears to be vastly important to know all expelled and the membranes are retained. about the latest and most wonderful feats of An abortion is concealed when the embryo surgery, and all the curiosities of medicine and perishes in the uterus, and when both it and bacteriology; but when one gets into general the membranes are retained, and expelled practice it is soon discovered that it is not these perhaps some months later. Four out of the things that occupy much time and attention, 96 were of this nature. en Association, women. Causation. – The causes divide into four The ovum may be expelled in a mass during groups—criminal and maternal, fæetal and the second and third months, but after the paternal causes. I do not, however, propose fourth month the embryo is generally expelled to enter into them in detail. I think there can and the membrane retained for some time after. be little doubt that the bougie or ladies' I have known women at this stage to walk silent pills account for the greater number. about for three or four days with the placenta Materual causes may be general, such as fevers in the womb after the foetus has been expelled. and other diseases, and local, for example, In any case the placenta is usually retained fibroids, endometritis following induction, in- longer in abortion than in labour at term. flammation following attempts at prevention, Having during the last five years known of and lesions and displacements of the uterus. three cases, in two of which extra-uterine gestaThe fætal and paternal causes are many in tion without severe symptoms was at first number, but not so frequently met with as the mistaken for a miscarriage, and another in two former groups. Herman gives 20 per which a miscarriage was diagnosed by two men cent. as the normal frequency of abortion to as a tubal pregnancy till the embryo came labours at term. An American writer, quoted away, I do not think it superfluous to mention by the Lancet, gives the proportion as ten mis- that we should ever remember the possibility carriages to 27 labours in native-born American of confounding the two conditions; for in extrawomen, and the same proportion among negro uterine gestation, also, bleeding from the vagina Other authorities variously estimate with expulsion of decidual tissue is often the frequency from 1 in 4 to 1 in 80. My accompanied by the pain of uterine contraction, figures are not sufficiently large to draw any as in abortion. conclusions of value, but I am inclined to Results and Treatment. The two great imthink that 1 in 4 does not over-estimate the mediate dangers to be apprehended are loss of frequency here. Multiparæ abort more fre blood and septic poisoning, with its long train quently than primiparæ, as is to be expected. Éleven of my series were first pregnancies. of possible evils. The more remote dangers, such as subinvolution of the uterus, I do not The second and third months seem to be the intend to touch upon. period at which most cases occur ; 57 out of 96 Bleeding may be profuse enough to cause took place then. grave primary anæmia, or if prolonged may in Symptoms.- The symptoms vary greatly with that manner undermine health. Primary severe the stage of pregnancy, and the condition of hæmorrhage cannot always be prevented. Four the foetus and placenta. Shortly after the first of my cases were blanched from loss of blood month the bleeding is not usually great in from a sudden copious hæmorrhage before I amount; at the third and fourth month it was called in. I do not propose even to mention usually continues from beginning to end of the various septic troubles that may arise, or labour; at the fifth and sixth month a dis- their treatment, as I have been fortunate enough charge of liquor amnii frequently takes place, to have very little experience of them, and they and, generally speaking, the more advanced were most thoroughly expounded here not long the pregnancy the more closely it resembles ago. In abortions even more than in labours labour at term. If sudden violence causes at term I believe we ought to be free from the abortion, there is often as a first symptom a supervention of sepsis. Except in a few cases great gush of blood, in which the ovum may of criminal abortion instrumentally induced, we escape, a sharp pain being felt at the time. are free from what I believe is the chief cause It is well to remember that before the end of puerperal sepsis : the examining finger of a of the second month, the placenta not being dirty midwife. Few doctors nowadays are so formed, hæmorrhage is from the entire uterine careless or ignorant as to neglect proper surface, while at a later period it is from the surgical cleanliness in their obstetric work, but placental site. This point ought to be borne in in country practice, at least, it is almost mind in treating the cases. Hæmorrhage may impossible to prevent the woman in attendance begin before or after the pains, and free from making vaginal examinations before hemorrhage is generally accompanied by sending for the doctor. Fortunately, she does strong contractions. not often do so in cases of abortion. Three of A fatus may die and be retained for several my cases had a bad-smelling discharge, with days or even weeks. In one of my cases the high temperatures, when I was called to them fetus apparently died at the fifth month and first. I had reasons for suspecting that they was retained till term. I will refer to this case had all been self-induced, but all improved again later. The expulsion of a dead fætus is a rapidly when the uterus was emptied. Only generally slower, with less loss of blood, and one case of the 96 became septic after beginning with slower involution of uterus afterwards. treatment, and that was the case referred to 66 а above. A woman who had had eight children, still being bad, after adequate consultation it the last one stillborn at term, became pregnant was decided to induce. In connection with this in January, 1899. The abdomen went on case, a paper by Doran, in Vol. II, No. 1, of the enlarging till May, when she thought she felt British Obstetrical Journal, entitled "Pregnancy slight fætal movement twice. No further in- after removal of both ovaries for Cystic crease in size took place, and in July, i.e., two | Tumour,” is of interest. I am now inclined to months later, slight bleeding began, and think that my first case would pass the Lancet's gradually became more profuse, with passage standard, but not the second, and blame of "stuff like skin,” to use her own words. myself accordingly. ” This continued till September, when, the nine The one case put by itself is the only other months being past, she became alarmed. The the notes of which I shall trouble you with. A uterus then was at the level of the umbilicus, young woman, anxious for children, had four and felt like a five and a half months' pregnancy, times miscarried. Becoming pregnant a fifth and had been so for four months, and the os time, the uterus enlarged gradually to the admitted two fingers. She had come a long umbilicus, but she had several severe bleedings way and was anxious to be dealt with promptly; during the time, especially about the second and so under chloroform an attempt was made to third month. She believed she felt fatal empty the uterus with indifferent success, as movements. Her figure was that of a woman the foetus and membranes were soft, and broke about five or six months pregnant. No further up in pieces. Prolonged suppuration and a enlargement took place, and about a month serious illness followed. The uterus appeared after, what she thought was her full time, she to be converted into an abscess cavity, which consulted me. A rounded fairly solid body, discharged pure pus from the os whenever the somewhat ill-defined, and slipping about under douche tube was inserted, and which finally the hand, could be felt through the abdominal emptied itself by a spontaneous opening in the wall, about the size of the fotal head at term, left groin. She, however, recovered completely, lying in the middle line, and reaching almost and in May of this year was delivered instru- to the umbilicus, the hand dipped in above the mentally of a healty child at term with a normal pubes meeting with very little resistance. By lying-in. No other case had a rise of tempera- the vagina, the cervix was felt not shortened or ture after emptying the uterus thoroughly. softened, and the lump could not be definitely Of the 96 cases, 30 were complete abortions, made out as closely attached to the cervix. 37 were instrumentally completed, 13 digitally, About three months after the lump was much 13 by rest in. bed with ergot, or ergot with smaller and harder to feel. Then after seven plugging the vagina, two were induced by me, months amenorrhæa, irregular bleeding started and one is not included. again, ending after four weeks almost conTake the last three first. In discussing a tinuous bleeding in a flooding, with the passage doctor's duty in inducing abortion in difficult of a fleshy bag 3 inches long by 24 inches cases, the Lancet for January 1898, says : The walls were about one-third inch " When the patient's life is necessarily exposed thick, the surface was rough, and it contained to great danger if the pregnancy is allowed to clot and a small shrivelled fætus. It was fresh continue, it is proper to terminate it after and had no bad smell. It was passed about adequate consultation”; and this seems a safe 20 months after she thought she had become rule for guidance. Both my cases were about pregnant. The specimen was preserved for the third month. One was a woman with a further examination, but unfortunately was large intramural fibroid, which grew rapidly destroyed by mistake. This appears to me to be during pregnancy. I do not intend to discuss an instance of the fleshy mole described by whether one is ever justified in inducing labour Berry Hart in Vol. I, No. 5, of the British when a fibroid is present, but will simply say Obstetrical Journal. He describes it thus : that labour had twice before been induced by * A thickened fleshy-looking structure averagother men for the same condition, that she re- 6 cm. in diameter and 1.5 em, in thickness. fused operative treatment of the tumour, that It is evidently placental in nature, with a rough she suffered sufficiently to make her desire shreddy aspect. It is sometimes expelled as a relief although anxious to have a child, and pear-shaped mass made up of placenta and that the opinion of three other medical men reflexa. When laid open a small fætus is often was obtained. found.” lle goes on to say: “The symptoms The other patient's state of health was such are quite distinctive. The patient has the that a distinguished Brisbane practitioner had symptoms of early pregnancy, and then of previously removed both her ovaries to prevent threatened abortion during the second or third her becoming pregnant. As she persisted in month. She usually imagines she has escaped doing so in spite of his skill, and her health miscarrying, but the uterus does not increase across. a |
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