Medico-Chirurgical Society Research Articles

It is time to retire Goodsall's Rule: the Midline Rule is a more accurate predictor of the true and natural course of anal fistulas.

On May 6, 1887 at a meeting of the West London Medico-Chirurgical Society, original observations attributed to D. H. Goodsall described an association between the secondary (external) sinus opening and the location of the primary (internal) opening of an anal fistula: posterior external sinuses had a midline origin and anterior external sinuses took a straight path to their internal origin-eponymously known as Goodsall's Rule. However, over the last century, published reports support the midline as the primary (internal) origin of all anal fistulas, thus challenging the predictive accuracy of Goodsall's Rule and prompting this expansive review. A literature search was performed for studies describing the relationship between the secondary (external) opening and the primary (internal) opening of anal fistulas, including recent reports of the positive predictive value (PPV) of Goodsall's Rule. The studies were evaluated to determine the validity of Goodsall's observations. The midline was the dominant, primary (internal) opening site of all anal fistulas with up to 95% accuracy. Goodsall's Rule was inaccurate when applied to anal fistulas with an anterior off-midline external sinus opening which tend to mirror posterior off-midline external sinuses and curve to a midline origin, rather than take a straight course to a primary (internal) opening, as predicted by Goodsall. Use of the Midline Rule had superior predictive accuracy, reflected in an increase in overall PPV of the location of the primary (internal) origin from 49% using Goodsall's Rule to 71% using the Midline Rule (57-62% for men, 31-90% for women). Goodsall's Rule falls short in predicting the natural course of anal fistulas with an anterior off-midline external sinus opening, especially for women. Given the increased risk of fecal incontinence related to surgical intervention for anterior-based anal fistulas, especially in women, dependence on Goodsall's Rule to guide the surgeon may result in "disastrous consequences". The preponderance of evidence over the last century favors the Midline Rule as a more accurate predictor of the true and natural course of anal fistulas, regardless of the location of the external sinus opening.

Ian Bruce Sneddon (1915-1987).

Ian Bruce Sneddon (1915-1987).

Niels Thorkild Rovsing: The Surgeon behind the Sign

Niels Thorkild Rovsing (1862 to 1927) was a Danish surgeon. His eponyms include the Rovsing sign of acute appendicitis, the Rovsing syndrome (abdominal pain in a horseshoe kidney), the Rovsing operation I (for polycystic kidney), and the Rovsing operation II (to separate a fused "horseshoe" kidney). He received his M.D. degree in 1885 and his Ph.D. in 1889 from Copenhagen University. Rovsing practiced surgery from 1892 to 1902 at the Queen Louise Children's Hospital and the Red Cross Hospital, both located in Copenhagen. He became Professor of Surgery in 1899 and Director of Surgery at the Royal Frederiks Hospital in 1904. Rovsing earned international recognition for his innovative urological surgery. Together with his colleague, Eilert A. Tscherning, Rovsing founded the Danish Surgical Society (Dansk Kirurgisk Selskap) in 1908. His advocacy for antisepsis and Listerism advanced his notoriety and exemplified his medical leadership. His clarion call for a modern hospital led to the construction of the Copenhagen University Hospital (Rigshospitalet) that opened in 1910. Rovsing was an Honorary Member of the Edinburgh Medico-Chirurgical Society and the Association of Surgeons of Great Britain and Ireland. Rovsing served briefly as Denmark's Minister of Education in 1920. He died in 1927 from cardiac failure and laryngeal cancer.

Peter David Handyside’s Diploma as Senior President of the Royal Medical Society

Over the last few years, the author of this article was fortunate to be offered and purchased two diplomas dating from the first half of the 19th century. Both were awarded to Peter David Handyside1 (1808-81). He had graduated in medicine in 1831 with the Edinburgh M.D. degree. Shortly after he graduated, he pursued his anatomical studies, initially in Paris and then in Heidelberg under the distinguished physician Friedrich (or Frederick) Tiedemann (1781-1861). It is believed that his earlier apprenticeship under James Syme (1799-1870) had stimulated his interest in both Anatomy and Surgery. He was awarded the FRCS Edin. (Fellowship of the Royal College of Surgeons of Edinburgh) diploma in August of 1833, and was for most of the rest of his career a practising surgeon. The subject of his probationary essay was Osteo-aneurism, and this was dedicated to Tiedemann. He commenced the teaching of Anatomy in Edinburgh in the summer of 1834, and was, on and off, for over 45 years a teacher of this subject at the Edinburgh Extra-mural School. He taught this subject until a few weeks before his death. While a medical student, he was elected Senior President of the Royal Medical Society during the Society’s 92nd Session (1828-29). He had also been awarded the Harveian Society medal in 1827, and was in 1837 appointed Secretary of the Harveian Society. During the same year, he was elected to a Fellowship of the Royal Society of Edinburgh, while in 1871 he was elected President f the Medico-Chirurgical Society of Edinburgh.

The Royal Medico-Chirurgical Society of Glasgow Research Night, March 2014: Abstracts

The Royal Medico-Chirurgical Society of Glasgow Research Night, March 2014: Abstracts

Malignant Cholera: its cause, mode of propagation, and prevention

In the Medical Gazette of last Friday, an announcement was made by Mr. Brittan of the very important discovery, that peculiar microscopic objects exist constantly in the characteristic ‘‘rice-water’’ discharges of persons affected with Malignant Cholera, and in the atmosphere of infected places. At a time when cholera is destroying hundreds of our fellow-creatures daily, and filling the land with mourning, it is the duty of every one who believes himself to be in possession of any observations which throw the smallest light on the cause of, and the means of controlling, such an awful visitation, to give them, without delay, all the publicity possible. I therefore venture to submit to the medical profession, and the public, the following remarks. The peculiar objects in question were first seen by two or three members of a committee appointed by the Bristol Medico-Chirurgical Society for the microscopic observation of subjects connected with cholera. The first drawings of them, together with the great variety of other objects, generally to be met with in the ‘‘rice-water’’ discharges, were made by Mr. J. G. Swayne and Mr. F. Brittan, in the second week of July last. These drawings, together with specimens of ‘‘rice-water,’’ were exhibited at the next meeting of the committee. At that meeting there were present Mr. J. G. Swayne, Mr. F. Brittan, Dr. Bernard, Mr. Neeld, Mr. A. Prichard, and myself. Numerous other drawings of the same kind, by Mr. J. G. Swayne and Mr. Brittan, were laid, shortly afterwards, before the Bristol MedicoChirurgical Society. The laborious observations subsequently made by Mr. Brittan and Mr. Swayne, and laid, from time to time, without reservation, before the Bristol MedicoChirurgical Society — though not enforced by any arguments to that effect — certainly did much to show that some very important relation existed between these bodies and malignant cholera. The presumption thus raised was much strengthened by the important discovery, subsequently made by Mr. Brittan, and reserved for separate publication, of the constant presence of objects of the same kind in the air of infected places. Shortly afterwards, and being at the time aware of this discovery, I detected the same organisms in great numbers in almost every specimen of drinking-water which I was enabled to obtain from Cholera-districts. First, in the drinking-water from Wellington Court, Red-cross Street, where cholera first broke out (with any violence) in Bristol; subsequently, in the water of the Float, and in the drinking-water from King Street, in the same city; since then, again, in London, in water from Lovegrove Street, and from the Surrey Canal; and lastly, in drinking-water from the Stapleton workhouse;—being all places where, at the time the water was obtained, cholera was making dreadful havoc. This led me to examine a great number of specimens of water from healthy quarters; and although I often found in it a good deal of matter of various kinds, organic and other, in no single instance did I see anything resembling the peculiar bodies in question. These are certainly facts of great interest and importance, and it is impossible to witness them without being filled with an earnest desire to discover, if possible, their real import and significance. What is the nature of the relation which these bodies bear to Cholera; and may we not have detected in them the actual cause of the disease; are questions which at once suggest themselves to the mind. In endeavouring to obtain for myself an answer to these questions, I have been led by the facts already mentioned, and by others, which will appear in the sequel to the following deductions, which it must be left for future experience and research to confirm or otherwise:—

Endocrine Aspects of Breast Cancer

A relationship between the endocrine system and breast cancer was first demonstrated by Beatson in 1896, when he obtained some benefit from oophorectomy in two patients with advanced disease. Until that time the treatment of breast cancer was limited to removal of the mamma and excision of superficial metastatic or recurrent nodules. The practice of castrating cows to maintain lactation after calving suggested to Beatson that the ovaries must be concerned in some way with the regulation of the physiological processes of the breast.Reporting his findings to the Medico-Chirurgical Society of Edinburgh, Beatson summed up:“The conclusion I draw from two cases I have brought under notice is this — that we must look in the female to the ovaries as the seat of the exciting cause of carcinoma, certainly of the mamma . . . .”

Royal Medico-Chirurgical Society of Glasgow Research Prize Evening, 7 March 2013

Royal Medico-Chirurgical Society of Glasgow Research Prize Evening, 7 March 2013

Royal Medico-Chirurgical Society of Glasgow, Annual Research Prize Night, 1 March 2012

Royal Medico-Chirurgical Society of Glasgow, Annual Research Prize Night, 1 March 2012

Simpson

This year marks the 200th anniversary of the birth of James Young Simpson, the Scottish obstetrician and medical pioneer credited with first describing the use of chloroform for general anesthesia. His story is researched and documented in Morrice McCrae’s Simpson: The Turbulent Life of a Medical Pioneer. A native of Scotland, consultant physician, and Fellow of the Royal College of Physicians of Edinburgh, McCrae was eminently qualified to tackle this subject. Although Simpson’s contributions to science and medicine are well known, McCrae fills the gaps of his personal story, placing the man in the context of 19th-century Scotland, at the beginning of the modern era of medicine. McCrae first describes the world into which Simpson was born: rural Scotland, his father a baker and his mother a descendent of Scottish gentry. McCrae credits his mother’s desire to recover her family’s position in society for instilling in Simpson a striving for greatness. He began university study in Edinburgh at 14 and chose medicine almost by chance. He attained his MD degree by age 21, and by 29 was elected to the Chair of Midwifery at the University of Edinburgh. The choice of obstetrics was also a trick of fate. The chair position was open at a time when other positions were not. His family spent the 2011 equivalent of $70,000 to win election by the town council: politics was alive and well in academic medicine even then! Simpson took a scholarly and innovative approach to medicine. His habit of addressing questions by first performing a thorough literature search was remarkable, as the information he was seeking was harbored in libraries throughout Europe and North America. Simpson read widely and quickly adopted techniques described in the surgical literature. Moreover, he often suggested to those outside his specialty how they might improve their practice — which contemporaries found irritating, especially when he was right. Simpson also used the emerging tools of statistics (“arithmetical methods”) to convince others of the validity of his arguments. For example, surgeons argued that ether anesthesia suppressed patients’ “vitality” and its use would worsen the already appallingly high surgical mortality. Simpson’s data, of course, showed the opposite; amputations performed with anesthesia had lower mortality than those without. When the conservative medical men refused to consider his position, Simpson quickly took the fight to the lay public. Within days of discovering the anesthetic properties of chloroform, Simpson had written and widely distributed a pamphlet entitled Account of a New Anaesthetic Agent as a Substitute for Sulphuric Ether in Surgery and Midwifery (1848). As a result, the public was clamoring for chloroform within weeks of its discovery. McCrae’s description of the chloroform discovery is entertaining. On the evening of November 4, 1847, Simpson and two colleagues, along with family members, sat in his dining room. They sniffed a number of chemicals that did not work, then tried chloroform and crashed to the floor. After gaining consciousness, they tried it again, the family members joining in, then celebrated until 3 a.m. Four days later, Simpson first used chloroform in obstetrics. By the time he announced its discovery to the Edinburgh’s Medico-Chirurgical Society on November 10, he had used it for “some fifty cases, ‘all with entire success.’” Although he was arguably most famous for this discovery, Simpson’s contributions include championing anesthesia/analgesia for normal childbirth; recognizing the analogy between puerperal and “surgical” fever (postoperative wound infection) and the importance of hand washing to prevent infection; and supporting women in the medical profession. Ironically, 150 years later, the leading cause of direct maternal deaths in the United Kingdom is genital tract infection/sepsis (1). A recent Joint Commission monograph addressed the challenges of hand washing because many providers still do not wash between patients (2). Women are still underrepresented in academic medicine (3), and the use of analgesia for normal childbirth remains controversial. Simpson struggled all his life with depression. On a personal level, he was devoted to his patients and family, and they to him. Most importantly, he was a reformer committed to improving the outcomes of his patients (long before “outcome” was a buzzword in medicine). The source of Simpson’s greatness, notes McCrae, was a combination of ambition and desperation. Although he never doubted his ability, he felt that others did. This often led to behavior that was arrogant, even belligerent, and, McCrae concludes, to a life more turbulent that it needed to have been. McCrae has succeeded in writing an engrossing story, enjoyable for anyone interested in the history of medicine. Illustrations of relevant people, places, and documents enliven the text, allowing us to understand the genius, humanity, and frailties of a giant of 19th-century medicine.

John Chalmers (ed.), Andrew Duncan Senior: Physician of the Enlightenment (Edinburgh: National Museums Scotland, 2010), pp. xvi + 253, £14.99, paperback, ISBN: 978-1-905267-30-9.

In 1750, Mr John Amyat, the King’s Chemist, visited Edinburgh. He is said to have remarked to Robert Burns’ publisher, William Creech, ‘Here I stand at what is called the Cross of Edinburgh, and can, in a few minutes, take fifty men of genius by the hand’. The purpose of John Chalmers’ new book might be summed up as the wish to ensure the inclusion of Andrew Duncan Senior in any such roll call of the Scottish Enlightenment. He has been successful in that task. Professor of the Institutes of Medicine at the University of Edinburgh for thirty years, Andrew Duncan was certainly a prolific author on medical matters (a full list of his writings comprises a valuable appendix to the book). However, Chalmers argues that Duncan should be remembered as much for the manner in which he expressed the values of the Enlightenment in practical initiatives for the benefit of society as for more narrowly intellectual endeavours. There were certainly plenty of the former – Duncan played a major role in the founding of Edinburgh’s first Public Dispensary, its Lunatic Asylum (now the Royal Edinburgh Hospital), and the University’s chair of Medical Police and Jurisprudence. He was the founding editor of what was arguably the first successful English language medical periodical, Medical and Philosophical Commentaries, and the principal editor of the Edinburgh New Dispensatory (a major pharmacopoeia) from 1789 to 1801. Duncan also conspicuously displayed the distinctive sociability of the eighteenth-century Scottish intellectual: he personally founded the Aesculapian Club and the Harveian Society – remaining the society’s secretary for forty-six years – was a founding member of the Royal Society of Edinburgh and the Medico-Chirurgical Society, as well as serving as President of the Royal College of Physicians of Edinburgh (twice) and the Royal Medical Society (six times). Nor were his activities confined to medicine – he began what became the Royal Caledonian Horticultural Society, as well as bathing and gymnastic clubs. An enthusiastic advocate of the health-giving properties of golf, good wine and good fellowship, he also boasted of his long membership of Beggar’s Benison – readers not familiar with this remarkable association are referred to David Stevenson’s revealing study, The Beggar’s Benison: Sex Clubs of Enlightenment Scotland (East Lothian: Tuckwell, 2001). Duncan fancied himself as a poet and a wit. To mark the visit of George IV to Edinburgh in 1822, he composed a cleverly sanitised version of the Beggar’s Benison bawdy motto: ‘Long may you live in harmony and ease / And never want, or purse, or power to please.’ A most appropriate toast to a spendthrift and licentious monarch. All of these various activities, and many more, are ably documented in Chalmers’ book. Incidentally, although Chalmers is modestly described as the book’s editor, of fifteen chapters, he is sole author of eleven and the joint author of two. Notable among the other contributions are Martin Kaufman’s essay on the work of the Public Dispensary, and James Gray’s chapter on Duncan’s medical societies. But Chalmers is to be congratulated on clearly having been as much the driving force behind the production of this volume as Duncan was in any of the initiatives he was involved in. The result has been a readable and informative volume, which sorts out many of the details of Duncan’s biography (warts and all, Duncan was vain and could be grasping and disputatious). It will be an indispensable aid to further research, not only on Andrew Duncan Senior, but also on his equally significant and almost equally industrious son, Andrew Duncan Junior.

John Bostock's first description of hayfever

John Bostock's first description of hayfever

Royal Medico-Chirurgical Society of Glasgow

Restricted accessAbstractFirst published online August 1, 2010Royal Medico-Chirurgical Society of GlasgowVolume 55, Issue 3https://doi.org/10.1258/rsmsmj.55.3.54

Osler vindicated: glioma of the leg center with Jacksonian epilepsy; removal and cure, with a 50-year follow-up

On December 14, 1883, William Osler, then pathologist at the Montreal General Hospital, presented the specimen of a brain with an almond-sized glioma beneath the right motor cortex to the Montreal Medico-Chirurgical Society. The brain specimen was from a young woman who had suffered from intermittent Jacksonian seizures for 14 years and had eventually died in status epilepticus. Aware of the pioneering removal of a tumor from the cortex reported on in 1885 by Bennett and Godlee, Osler wrote of his case, "this was an instance in which operation would have been justifiable and possibly have been the means of saving life." In 1953, a young man with Jacksonian attacks that began in his foot underwent removal of a Grade I glioma from the central fissure. The operation was performed in an awake craniotomy during which cortical mapping was used to define the motor and sensory cortices. Treatment with focal radiation followed, and afterward the patient became seizure-free, stopped taking anticonvulsant medication, and has led an active life over the past 50 years. Reference is made to the experiences of Sherrington, Cushing, and Penfield with cortical stimulation in the awake patient under regional anesthesia as an effective aid to surgery for epileptogenic lesions, tumors, and vascular malformations. Their technique allows for maximal resection with minimal neurological deficits. Over the past 20 years, this approach has been adopted effectively in many neurosurgical centers.

Royal Medico-Chirurgical Society of Glasgow Thursday 6th March 2008

Royal Medico-Chirurgical Society of Glasgow Thursday 6th March 2008

Royal Medico-Chirurgical Society of Glasgow

Restricted accessAbstractFirst published online February 1, 2008Royal Medico-Chirurgical Society of GlasgowVolume 53, Issue 1https://doi.org/10.1258/RSMSMJ.53.1.57

Royal Medico-Chirurgical Society of Glasgow Research Night - 2nd March 2006

Restricted accessAbstractFirst published August 2006Royal Medico-Chirurgical Society of Glasgow Research Night - 2nd March 2006Volume 51, Issue 3https://doi.org/10.1258/RSMSMJ.51.3.47

Medical art and history in exeter. An Exhibitgion of Books, Documents, and Pictures. 8¼ × 5½ in. Pp. 38. 1955. Exeter: Devon and Exeter Medico-Chirurgical Society. 2s. 6d

Medical art and history in exeter. An Exhibitgion of Books, Documents, and Pictures. 8¼ × 5½ in. Pp. 38. 1955. Exeter: Devon and Exeter Medico-Chirurgical Society. 2s. 6d

100 years of hormonology: a view from No. 1 Wimpole Street

100 years of hormonology: a view from No. 1 Wimpole Street

20 Hanover Square, London W1: first home of The Royal Society of Medicine

Today Hanover Square, in the heart of Mayfair, is an entirely commercial area surrounded by buildings in every style from the 18th to the 20th centuries. It is hard to imagine it as one of the first Georgian squares to have been built in the 1720s in the West End of London. Only two houses, numbers 20 and 24, survive with their original facades and both are preserved as grade II listed buildings, though number 20 lost its elegant proportions with the addition of an extra storey at a later date. Number 20 is a very important house in the history of the medical profession in London. For over 110 years it was in the possession of a medical institution—first the Royal Medical and Chirurgical Society (RMCS), then its successor, The Royal Society of Medicine (RSM). It became the meeting place for many of the specialist societies that emerged during the latter part of the 19th century, and within its walls many advances in knowledge and practice were first announced. It was only in 2001 that the RSM sold it, bringing to an end this long and venerable connection. The histories of the two societies have been written before, 1,2 most recently by Hunting3 who tells us how important 20 Hanover Square was to both societies. The RMCS first rented rooms in Gray's Inn within the City of London. It was not alone amongst professional institutions to migrate west; this was a common pattern from the end of the 17th until well into the 19th century. The residences in Mayfair and Belgravia were built by the aristocracy on their own land and, as they continued to move further from the City, so members of the professional classes moved into the houses they vacated.