422 of notice, that, although the superfluous growth is in some respects favourable to the supposition that such organs do exist, in other respects it does not favour that view. The beard, for example, existed at birth, and at eight years old was 2vo inches long-thus anticipating the period of puberty in- stead of accompanying or following it, and proceeding altoge- ther in advance, and apparently independently, of special organic influence. The beard was, and still is, confined to certain parts of the face, and is absent on others, where, in accordance with special influence, in a male, it should have been present, as on the upper lip and under the lower. On the whole of the anterior part of the trunk above the umbilicus, where, in accordance with the same influence, it should be even espe- cially abundant, it is wholly or very nearly wholly absent. These circumstances conspire to weaken the supposition that there are concealed male structures, and to strengthen the probability that the superfluity of hair belongs to the acci- dental class. Accidental Gro2vths of Hctir.-Accidental growths of hair are nearly, if not entirely, confined to the skin, the mucous membranes, and the interior of cysts. The physiology of the latter two is not without its extreme, if not insuperable, diffi- culties, and indeed many of the productions found in these situations having been ascertained not to be hair, but only resemblances to it, has involved the subject in extreme un- certainty, as well as difficulty. Those cases in which hair is said to have grown on the tongue, the pharynx, and the in- terior of the intestinal canal, where no hair follicles exist, may also be regarded as instances difficult, of not impossible, of solution. As in the present instance there is not anything to indicate that the hirsute peculiarity has for its origin concealed mas- culine structure, except the situations which it occupies, it may be regarded as analogous to other examples of similar growth, which appear to be purely accidental. We may I therefore regard it as very doubtful whether special primary organic structure is necessary to the production of hirsute growths, even of masculine character. Several cases considered to be accidental have been attri- buted to frights prior to the birth of the child-modes of accounting for them which have been participated in by the mother. Other examples of hirsute growths not congenital, have been attributed to disease affecting the system generally; others to local disease. ACCIDENTAL HIRSUTE GROWTHS NOT CHARACTERISTIC OF SEX. I had occasion to see, some years since, a child which had at birth a patch of hair on the shoulder, which when the child was about four years of age was nearly as large as the palm of a small hand; the hair was fawn colour, and in thickness and length closely resembled the hair of that animal; indeed, the patch looked very much like a piece of fawn-skin in its natural state. This was attributed by the mother to her having been startled by a fawn which unexpectedly skipped by her. She states that at the moment she involuntarily raised her hand, and touched the part of her shoulder corresponding to that on which the patch of hair described grew. M. M. R. Villerme speaks of a child which had several patches of hair on its person. He says:-" J’ai vu, a Poitiers en 1808, un malheureux enfant de six a huit ans, qui avait un grand nombre de ces marques disposees en plaques brunes saillantes, de grandeur diverse, eparses sur tout le corps a l’exception des pieds et des mains; et qui etaient toutes cou- vertes de poils plus courts et moins gros que cenx du sanglier, mais qui avaient de 1’analogie avec eux. Ces poils et les marques sur lesquelles ils naissaient occupaient peut-etre un cinquieme de la surface du corps."-Dictionnaire des Sciences 316dicales, vol. xliii., Art. Poil, p. 509. Dr. F. Bird mentioned to me the case quoted by Dr. Cummin, in his " Lectures on Forensic Medicine." It was published first at Venice, in 1815, and was much discussed in the German journals soon after. In the course of legal proceedings it transpired, that " a lady of twenty-seven, much admired for her beauty, had, on her person, from the breast to the knees, a profusion of black, thick, and bristly hair."* A case is recorded by Mr. South, of a male child, John Sparrow, born (Sept. 6, 1818) at Longford, in Suffolk, .. who at the time of his birth was completely covered with hair, and the back of his head particularly with black hair, about the length usual to children of four or five months."*)- Hi1"sute Growth; characteristic of sex, but apparently accidental. -Avery remarkable case is recorded in which a female had not * London Medical Gazette, vol. xix. 1836-7, p. 263. † Medico-Chirurgical Transactions, vol. xii. p. 76. only hair all over her body, but also a very profuse and thick beard, and indeed on every part of her face; the description states that it was so, and is accompanied by an engraving representing it as being so. It is to be inferred, however, that the limbs were not in the same state, as the hands and forearms are represented as being free. "In the year 1655 was pub- licly shown, for money, a woman named Augustina-Barbara, the daughter of Balthazar Ursler, then in her twenty-second year. Her whole body, and even her face, was covered with curled hair, of a yellow colour, and very soft, like wool; she had, besides, a thick beard that reached to her girdle, and from her ears hung long tufts of yellowish hair. She had been married above a year, but then had no issue. Her husband’s name was Vaubeck; he is said to have married her merely to make a show of her, for which purpose he travelled into various countries, and among others visited England." This account of her is published amongst the " Portraits, Memoirs, and Characters of Remarkable Persons, from the reign of Edward the Third to the Revolution," by Mr. James Caul- field.* He proceeds to say, " If I conjecture right, she is that very hairy girl mentioned by Bartoline, and appears to me not to differ from her whom Borelli describes by the name of Barba; who,he believed,improved, if not procured that hairiness byart. But whether she is the same that the famous Vitrilius saw at Rome and Milan I dare not affirm, for he hath nowhere men- tioned this countrywoman of his that I know of." (To be continued.) DISPLACEMENT OF BOTH HUMERI. By HAMERTON GREENWOOD, Esq., Bradford. THREE cases of simultaneous dislocation of both humeri have lately appeared in THE LANCET, but in neither case is it stated whether a previous luxation had occurred. The accompanying case came under my notice a short time since. Dec. 9th, 1851.-Ephraim R-, aged twenty-seven, about the middle height, and very muscular, had been drinking with some companions: as they were going home, and in the vicinity of the hospital, he slipped over some orange-peel, fell on his back upon the pavement, and, on his companions picking him up, wished to be taken to the infirmary immediately, as both arms were put out. When he was brought into the accident room, I found both humeri dislocated into the axilla; he being very faint, I at once reduced them, without much trouble, by placing the knee in the axilla, the patient being seated on a bench, one hand on the shoulder, to fix the scapula, the other depressing the elbow over the knee; the left arm I had pre. viously reduced once some six months previously, that being the first time of its occurrence, but the right had been luxated =ten or eleven times. Bradford Infirmary, Yorkshire, April, 1852. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, et dissectionum historias, tum aliorum proprias, coliectas habere et inter se comparare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium, ROYAL FREE HOSPITAL. Fissure of the Soft and Hard Palates, and of the Alveolar Arch; Operation upon the Velum and Osseous Parts. (Under the care of Mr. GAY.) THOSE who are conversant with the principal operations of surgery know full well that there are very few which present so imany difficulties, as regards manipulation, as those which are performed in the cavity of the mouth, or within the vagina and uterus. Both regions require patience, temper, and dexterity; but as operations upon the cavity of the mouth almost preclude the use of chloroform, and since fits of coughing are almost sure to occur, patience and perse- verance are more necessary for the oral than the uterine * Vol, ii. p. 168.
Transcript
422
of notice, that, although the superfluous growth is in somerespects favourable to the supposition that such organs doexist, in other respects it does not favour that view. Thebeard, for example, existed at birth, and at eight years old was2vo inches long-thus anticipating the period of puberty in-stead of accompanying or following it, and proceeding altoge-ther in advance, and apparently independently, of special organicinfluence. The beard was, and still is, confined to certain partsof the face, and is absent on others, where, in accordancewith special influence, in a male, it should have been present,as on the upper lip and under the lower. On the whole ofthe anterior part of the trunk above the umbilicus, where, inaccordance with the same influence, it should be even espe-cially abundant, it is wholly or very nearly wholly absent.These circumstances conspire to weaken the supposition thatthere are concealed male structures, and to strengthen theprobability that the superfluity of hair belongs to the acci-dental class.
Accidental Gro2vths of Hctir.-Accidental growths of hairare nearly, if not entirely, confined to the skin, the mucousmembranes, and the interior of cysts. The physiology of thelatter two is not without its extreme, if not insuperable, diffi-culties, and indeed many of the productions found in thesesituations having been ascertained not to be hair, but onlyresemblances to it, has involved the subject in extreme un-certainty, as well as difficulty. Those cases in which hair issaid to have grown on the tongue, the pharynx, and the in-terior of the intestinal canal, where no hair follicles exist,may also be regarded as instances difficult, of not impossible,of solution.As in the present instance there is not anything to indicate
that the hirsute peculiarity has for its origin concealed mas-culine structure, except the situations which it occupies, itmay be regarded as analogous to other examples of similargrowth, which appear to be purely accidental. We may Itherefore regard it as very doubtful whether special primaryorganic structure is necessary to the production of hirsutegrowths, even of masculine character.
Several cases considered to be accidental have been attri-buted to frights prior to the birth of the child-modes ofaccounting for them which have been participated in by themother. Other examples of hirsute growths not congenital,have been attributed to disease affecting the system generally;others to local disease.
ACCIDENTAL HIRSUTE GROWTHS NOT CHARACTERISTIC OF SEX.
I had occasion to see, some years since, a child which had atbirth a patch of hair on the shoulder, which when the childwas about four years of age was nearly as large as the palm ofa small hand; the hair was fawn colour, and in thickness andlength closely resembled the hair of that animal; indeed, thepatch looked very much like a piece of fawn-skin in its naturalstate. This was attributed by the mother to her having beenstartled by a fawn which unexpectedly skipped by her. Shestates that at the moment she involuntarily raised her hand,and touched the part of her shoulder corresponding to that onwhich the patch of hair described grew.M. M. R. Villerme speaks of a child which had several
patches of hair on its person. He says:-" J’ai vu, a Poitiersen 1808, un malheureux enfant de six a huit ans, qui avait ungrand nombre de ces marques disposees en plaques brunessaillantes, de grandeur diverse, eparses sur tout le corps al’exception des pieds et des mains; et qui etaient toutes cou-vertes de poils plus courts et moins gros que cenx du sanglier,mais qui avaient de 1’analogie avec eux. Ces poils et lesmarques sur lesquelles ils naissaient occupaient peut-etre uncinquieme de la surface du corps."-Dictionnaire des Sciences316dicales, vol. xliii., Art. Poil, p. 509.
Dr. F. Bird mentioned to me the case quoted by Dr. Cummin,in his " Lectures on Forensic Medicine." It was publishedfirst at Venice, in 1815, and was much discussed in the Germanjournals soon after. In the course of legal proceedings ittranspired, that " a lady of twenty-seven, much admired forher beauty, had, on her person, from the breast to the knees,a profusion of black, thick, and bristly hair."*A case is recorded by Mr. South, of a male child, John
Sparrow, born (Sept. 6, 1818) at Longford, in Suffolk, .. whoat the time of his birth was completely covered with hair, andthe back of his head particularly with black hair, about thelength usual to children of four or five months."*)-
Hi1"sute Growth; characteristic of sex, but apparently accidental.-Avery remarkable case is recorded in which a female had not
* London Medical Gazette, vol. xix. 1836-7, p. 263.† Medico-Chirurgical Transactions, vol. xii. p. 76.
only hair all over her body, but also a very profuse and thickbeard, and indeed on every part of her face; the descriptionstates that it was so, and is accompanied by an engravingrepresenting it as being so. It is to be inferred, however, thatthe limbs were not in the same state, as the hands and forearmsare represented as being free. "In the year 1655 was pub-licly shown, for money, a woman named Augustina-Barbara,the daughter of Balthazar Ursler, then in her twenty-secondyear. Her whole body, and even her face, was covered withcurled hair, of a yellow colour, and very soft, like wool; shehad, besides, a thick beard that reached to her girdle, and fromher ears hung long tufts of yellowish hair. She had beenmarried above a year, but then had no issue. Her husband’sname was Vaubeck; he is said to have married her merely tomake a show of her, for which purpose he travelled intovarious countries, and among others visited England." Thisaccount of her is published amongst the " Portraits, Memoirs,and Characters of Remarkable Persons, from the reign ofEdward the Third to the Revolution," by Mr. James Caul-field.* He proceeds to say, " If I conjecture right, she is thatvery hairy girl mentioned by Bartoline, and appears to me notto differ from her whom Borelli describes by the name of Barba;who,he believed,improved, if not procured that hairiness byart.But whether she is the same that the famous Vitrilius saw atRome and Milan I dare not affirm, for he hath nowhere men-tioned this countrywoman of his that I know of."
(To be continued.)
DISPLACEMENT OF BOTH HUMERI.
By HAMERTON GREENWOOD, Esq., Bradford.THREE cases of simultaneous dislocation of both humeri have
lately appeared in THE LANCET, but in neither case is it statedwhether a previous luxation had occurred. The accompanyingcase came under my notice a short time since.
Dec. 9th, 1851.-Ephraim R-, aged twenty-seven, aboutthe middle height, and very muscular, had been drinking withsome companions: as they were going home, and in the vicinityof the hospital, he slipped over some orange-peel, fell on hisback upon the pavement, and, on his companions picking himup, wished to be taken to the infirmary immediately, as botharms were put out. When he was brought into the accidentroom, I found both humeri dislocated into the axilla; he beingvery faint, I at once reduced them, without much trouble, byplacing the knee in the axilla, the patient being seated on abench, one hand on the shoulder, to fix the scapula, the otherdepressing the elbow over the knee; the left arm I had pre.viously reduced once some six months previously, that beingthe first time of its occurrence, but the right had been luxated=ten or eleven times.
Bradford Infirmary, Yorkshire, April, 1852.
A MirrorOF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, coliectas habere et inter secomparare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium,
ROYAL FREE HOSPITAL.
Fissure of the Soft and Hard Palates, and of the Alveolar Arch;Operation upon the Velum and Osseous Parts.
(Under the care of Mr. GAY.)
THOSE who are conversant with the principal operations ofsurgery know full well that there are very few which presentso imany difficulties, as regards manipulation, as those whichare performed in the cavity of the mouth, or within thevagina and uterus. Both regions require patience, temper,and dexterity; but as operations upon the cavity of themouth almost preclude the use of chloroform, and since fitsof coughing are almost sure to occur, patience and perse-verance are more necessary for the oral than the uterine
* Vol, ii. p. 168.
423
region. But we can at least fully see into the mouth, whilst thereverse happens very often with operations performed upon thefemale organs of reproduction.Among the surgical measures which the interior of the
mouth may require, staphyloraphy is one of the most im-portant, and affords us an example of the beneficial influenceof modern anatomical and physiological investigation. Not
many years ago, this was one of the operations which wasundertaken with the greatest reluctance, as failure was therule, and success the exception; but since Mr. Fergusson hasshown that the spasmodic traction of the soft palate could, bythe division of certain muscles, be greatly diminished, andeven completely abolished, the operation is frequently per-formed, it is very often crowned with success, and scores ofpatients reap the benefit of the improved mode of operating.But human ingenuity has hitherto failed in devising meansof bringing about the union of the hard palate; and personsafflicted with this congenital defect must be content, afterunion of the two halves of the velum has been effected,to complete the improvement of voice and deglutition bywearing an obturator in the osseous fissure. The latter, how-ever, may sometimes be so large, and the septum nasi soawkwardly attached, that an attempt must be made to rectifythe defect, and render the gap of such dimension as to allowthe patient to wear an obturator. Such a case has lately pre-sented itself to Mr. Gay; and he succeeded, by a series ofoperations, in diminishing the fissure to such a degree as tofacilitate the application of an obturator, by the aid of whichthe patient’s voice has been considerably improved-the moreso as perfect union of the fissured soft palate was subsequentlyobtained. Mr. Lane, house-surgeon to the hospital, has kindlyfurnished us with the following details, which will certainlybe read with much interest :-Mary B--, aged nineteen years, a stout, healthy-looking
girl, was admitted October 8, 1851, under the care of Mr.Gay. She is affected with a congenital fissure through bothhard and soft palates and the alveolar arch, laying into onethe oral and left nasal cavities. The fissure in front corre-sponded to the interval between the left lateral incisor andcanine teeth, and was complicated with a considerable projec-tion forwards of the incisive portion of the superior maxillarybone. The left lateral incisor has been extracted when shewas young. This state of parts had originally been furthercomplicated by hare-lip; but the latter had been very suc-cessfully operated upon by Mr. Gay some months previously.The girl’s speech was unintelligible to strangers, and deglu-
tition attended with much difficulty and inconvenience. Thecleft in the hard palate was rather to the left of the mesialline, leaving the septum nasi attached to its right margin.
]Bfro Gay resolved to make the attempt of lessening thiswide gap in the hard palate, and proceeded as follows :-After the necessary division of the soft parts, the projectingincisive piece of jaw was sawn partially through from itspalatal surface, about an inch from the free border, the axisof the saw being nearly at right angles with the outside of thealveolar arch. This having been effected, the incisive portion Iof bone was forcibly broken down and brought in contact withthe opposite side, to which it was united by binding togetherthe contiguous teeth, viz., the left lateral incisor and rightcanine, with silver wire.Three weeks after these measures, the soreness of the parts
having nearly subsided, a second operation was performed.Mr. Gay’s object in the present instance was to attempt theclosure of the fissure in the hard palate, by bringing down thelower portion of the septum nasi. To accomplish this, themucous membrane of the septum was divided by a horizontalincision, nearly three-quarters of an inch above the margin ofits cleft; the vomer was then cut through by means of bone-forceps, curved laterally, after which the upper portion of theseptum was forcibly brought down by means of an instrument,bent at right angles, passed over it above. Considerable forcewas required, and Mr. Gay made several attempts before hesucceeded in bringing the cut margin of the septum to the leftside of the cleft. To the latter it was united by one strongsuture; but no union took place. After the separation ofthe suture, the septal piece slightly rose out of position.Some aphthous ulceration of the inside of the left cheek
and gums now occurred, which was much relieved by a gargleconsisting of dilute hydrochloric acid and tincture of myrrh,of each two drachms, distilled water, eight ounces.On the 25th of the same month, a second attempt was made
to unite the parts by suture, but without success; the de-pressed piece did not, however, on this occasion, as before,rise out of its position till some time afterwards, when itgradually left a narrow fissure on its left. This fissure in-
creased in breadth towards the front, owing to the shelvingoff of the anterior edge of the vomer.Early in November, one month after admission, Mr. Gay
operated on the fissure of the soft palate. It was foundthat on irritating the flaps by means of a pointed instrument,each was drawn upwards and outwards in a spasmodic manner,so as to become nearly lost in the sides of the pharynx.
After section of the levator palati muscle of one side, thecorresponding flap became incapable of being drawn up in thespasmodic way alluded to, and presented a strong contrast tothe one of the opposite side when similarly irritated; andafter division of both levatores palati muscles, the flaps wereobserved to fall considerably, so as materially to reduce thesize of the cleft; but this was more especially the case at theposterior part.The pillars of the fauces were then carefully divided on
each side with curved blunt-pointed scissors, after which, inconsequence of the width of the cleft, and to facilitatethe approximation of the soft parts immediately behind,Mr. Gay cut off each half of the velum palati from its corre-sponding palatal bone, by making a transverse incision oneach side close to the osseous surface.The margins of the cleft were then pared and brought
together by means of five sutures, according to ProfessorFergusson’s method. The bleeding from the incisions wasrather greater than usually occurs in such cases, but was con-trolled by the use of iced water, and had completely stoppedbefore the sutures were tied.No more inflammation ensued than was required for the
union of the parts. The sutures were removed on the sixthday, when the flaps were united, except a small point in thecentre, which granulated rapidly, and soon closed. Nutrientfluids were given from the first, in small quantities, at frequentintervals, and after the ninth or tenth day, the patient tooksolid food.The girl was discharged in January, 852, the cleft of the
soft palate having completely closed; the left alveolar arch isalso almost in its normal state in appearance, and the greaterportion of the cleft in the bony structures has also beenremedied. The opening remaining is about large enough toadmit a horse-bean, and from this there extends a linearfissure along the margin of the depressed septum. Theseapertures will be closed by means of a small obturator,which will render the case almost unparalleled as regardsits success.There is already some improvement in her articulation, the
result of practice in pronunciation given her by the house-surgeon, Mr. G. F. Lane. -
MIDDLESEX HOSPITAL.Fracture of the Tubercle of the Tibia. Case of Fracture of the
Patella, with an Anchylosed Knee.(Under the care of Mr. CAMPBELL DE MORGAN and Mr. SHAW.)
IT is customary for systematic writers on surgery, whentreating of fractures and dislocation, to infer, from the expe-rience of previous cases, which bones, and what part of them,are most likely to be fractured in a given accident. The rulesgiven by these authors are certainly very useful; but it shouldalways be understood that the whole, or a portion of a bone,may become more liable to fracture by alterations in its inti-mate structure occasioned by cancer, scrofula, scurvy, or thepoison of syphilis. If, for instance, we consider for a momentthe very common accident of tripping, which is so often fol-lowed by fracture of the patella, we shall find that the mus-cular force which in these cases causes the breaking of thatsesamoid bone, may be exerted towards another portion ofextensor cruris muscle, where the structure has been changedby disease, and the powers of resistance consequently lessened.A very instructive instance of such phenomena was latelyafforded by a patient of Mr. de Morgan, for the trippingcaused neither fracture of the patella nor rupture of its liga-ment, but a giving way of the tubercle of the tibia, whichprocess must, according to all appearance, have been some-what modified in its cancellous structure by the scrofulousdiathesis under which the patient is evidently labouring. Thefacts are shortly these:-William C-, aged seventeen years, and a tailor by trade,
was admitted April 7th, 1852, under the care of Mr. deMorgan. The patient is thin and pale, and has numerouscicatrices around his neck resulting from scrofulous abscesses.There is also a deeply depressed cicatrix on the forehead, aconsequence of an extensive loss of osseous substance; thewound and subsequent necrosis having followed on a fallupon some bricks when the patient was twelve years of age.
