James Yearsley
1848 The Lancet  
64 to go to Margate, at which place -she took one or two warm baths. She returned to town in July, no better. Dr. Conquest then ordered her to Brighton, and to try the shampooing baths. Here she was under Mr. Lawrence, surgeon of that town, who told her that the complaint was inflammation of the sciatic nerve. One day, as the patient was getting out of the bath, she struck her left foot against something, and immediately felt a shock in the right hip, as if she had been electrified; and she
more » ... rified; and she felt positive, to use her own words, that the hip was dislocated. This she mentioned to Mr. Lawrence ; but that gentleman, having examined it, said there was no displacement whatever. She was ordered carriage exercise, friction, &c., which were also recommended by Dr. Conquest. Finding the pain in the hip and knee, after exertion, insupportable, having no rest during the night, and the relief afforded by medicines precarious, she consulted a shoemaker, who has acquired considerable reputation as a doctor in obstinate cases. This man, who, I understand, " drives a pair," (which, perhaps, is an additional recommendation of his skill,) made no doubt of his being able to effect a cure, and strapped up the limb with plaster. This he tore off in a day or two, and seeing a moisture on the skin, exclaimed, <<It's all right; this is what I wanted!" He then rubbed the limb with some liniment or unguent, and requested his patient to call again. The lady, beginning to have some misgivings, and thinking, most probably, with Phsedrus, that no cobbler should go beyond his last, very prudently discontinued his services, and she soon returned to London. I was afterwards sent for. I saw Mrs. B-in the evening. She was sitting on a Sofa, with an air-pillow placed under the hip. I requested her to rise, and try to walk; she could not put her foot to the ground without pain and difficulty, but nevertheless, with a little support, she hobbled a few paces. I then desired her to sit down, and lift up her leg. This she could not do without putting her two hands under the thigh, and raising it in that way. On inquiring into the general state of her health, I found the bowels inactive; the appetite precarious and capricious ; digestion bad; the breath emitting a peculiar odour; and the countenance sallow. On feeling the pulse, I found it 100 in a minute, hard, and that sort of labouring or struggling pulse which is found when great functional disturbance exists, dependent on some important organic lesion. I ordered three grains of calomel with a little sugar that night, at bedtime, and a solution of Epsom salts and carbonate of magnesia, as an ordinary aperient. I requested Mrs. Bwould remain in bed on my next visit, and have a female friend with her, as it would be necessary I should make a more accurate investigation. I saw her three days afterwards. I examined the uterus, and found it tuberculated. On passing my finger high up the rectum, I distinctly felt a hard, knotted ovary; I could feel no irregularity of the sacrum or coccyx, but she complained of much pain in that situation, as if the bones were loose. I then requested to see the breast. On the right side I found a hardened mass, which she said was the result of inflammation during her first three confinements; that no inatter had ever formed; but that subsequently-i.e., with her last seven children-she was obliged to suckle on the left side. About an inch from this mass was a small, hard, flattened, and moveable tumour, which had been discovered by the patient about six months before; and at the same time I observed the cartilage of the first rib on the left side protruding. She did not complain of any pain in the breast unless it was pressed hard, but she felt darting pains occasionally in the first rib, chest, and neck, on the same side. The patient being somewhat fatigued, I deferred the examination of the hip until my next visit; this was a week after my first introduction to her. The following were the appearances that presented themselves:-Right limb somewhat smaller than the opposite; foot turned neither inwards nor outwards. This position was the same when the patient stood erect. The limb shortened two inches. A tape passed from the base of the patella to the external malleolus, had the same length as on the opposite side; from the anterior superior spinous process of the ilium, to the base of the patella, two inches shorter; from the trochanter major to the base of the patella, the same; so that the deficiency must have been in the neck and head of the femur, which I concluded were partly absorbed. The trochanter a little drawn up, but not very remarkably so. No pus formed, and no swelling. I made a slight extension, which elongated the limb at least an inch, but, on desisting, it again retracted to its former position. Having expressed, without reserve, the nature of the case-namely, that the patient had scirrhous breast, tuber-Culated womb, cancer of the hip and rib, and that there were no hopes of her recovery, I deemed it necessary, for the patient's comfort, that a medical man on the spot should be in attendance, and that I would see her whenever she thought mv opinion could be of service. I attended with Mr. Wallace till she died, which was on the 4th of February last. The treatment adopted during my attendance could only be palliative, and keeping the limb at perfect rest. The con. stipation was treated by aloes and soap; colocynth, soap, and croton oil, about two drops in a dozen and a half pills; three grains of chloride of mercury twice or thrice, to remove scybala; and opium and its preparations as occasion and want of sleep pointed out. I found the opium to cause constipation, and that it did very little in tranquillizing the patient; hyoscyamus was perhaps better. Paroxysms of excitement, dyspnoea, hysterical chokings, total loss of appetite, and vomiting, at last wore down the patient, the immediate cause of death being effusion into the left cavity of the chest. A day or two previous to her decease she was slightly comatose, and twelve hours before that event there was great pulsation at the epigastrium. The pulse became weaker, but never lost its character to the last; it alternated between 95 and 100, and sometimes rose to 115. She twice bled at the nose and mouth, and had also slight haemorrhage for two days from the uterus; this was a month previous to her death. I ascribed this bleeding to an effort of Nature to relieve the great vascular excitement induced by the process of absorption going on in the hip-joint. Post-mortem examination of the body, in which I was assisted by my friend, Mr. Thomas Abraham, of Old Broad-street:-On removing the integuments from the hip, the cellular membrane was found slightly anasarcous; sciatic nerve quite healthy. I then cut away the insertions of the glutei and five small rotators, the quadratus femoris, iliacus, psoas, &c., and laid bare the joint. Head of the bone in situ; neck absorbed; the head moving on the shaft, but not entirely detached, being also connected with the capsular ligament, ligamentum teres; capsular ligament and acetabulum free from disease; no pus or fluid of any kind either external or internal to the capsule. I removed the bone by sawing it two inches below the trochanters, dividing the capsular ligament around the acetabulum, and cutting through the round ligament. Both tumours in the right breast were found of the true scirrhous character. Cartilage of first rib protruded, owing to a scirrhous deposit on the inner side, making it double its usual thickness. Glandular concatenation on the same side of the neck diseased, but not enlarged. A pint of serum in the left cavity of the chest; a very little in the right. Pylorus contracted and hard. Scirrhous deposit in the spleen; fatty kidney; uterus and ovaries tuberculated. I refrain from making any remarks on this case, otherwise than, had there not been a mistake in the early diagnosis, this lady would have been spared long and painful journeys, exercise, and friction; while perfect rest was the only rational means of keeping the diseased bones from grating one upon another, which caused the patient much agony, in addition to an useless expense of journeys, when she might have had the benefit of a comfortable home, surrounded by her family and friends.
doi:10.1016/s0140-6736(02)70232-8 fatcat:6unz54xdqvfxlceudkjcwdopeq