Embed Size (px)
their passage onwards being arrested. The absence of sick-ness was remarkable; but the frequent eructation, and theembarrassment in respiration, caused by the distended abdo-men encroaching more and more upon the cavity of the chest,occasioned the greatest distress. Inflammatory action wasabsent for the first few days, and very limited throughout,until perforation of the intestine took place. The urine wassecreted in abundance. Purgatives having failed, reliance waschiefly placed in opium and injections. Amussat’s operationwould have had a fair chance of success; but it was not pressedwith much fervour in consequence of a suspicion of malignantdisease. The tumour consists principally of phosphate of lime,and is probably a degenerated gland.East Dereham, Norfolk, 1856.
ON SYNCOPE S E N I L I S.
BY ROBERT BEALES, M.D., Congleton.THE various manifestations of gastric irritation are familiar
to most practitioners. These manifestations, for the most part,pass under the terms "indigestion," "gastric irritation,""gastrodynia," &c. I was much interested by a paper whichappeared lately in THE LANCET, by J. Higginbottom, Esq.,F.R.S., of Nottingham, on the subject. Like most of the
papers from the pen of that gentleman, it was marked byoriginality and shrewd observation.Two cases having occurred recently in my practice, similar
to those recorded by Mr. Higginbottom, I am induced to for-ward them to THE LANCET, as confirmatory of his view of thesubject, and the efficient treatment recommended.
Hitherto this affliction has been unnamed; Mr. Higgin-bottom proposes to call it " Syncope Senilis" when it attacksold people. The term seems a suitable one, although I am in-clined to think that the syncope does not begin at the heart,but that the nervous centres are primarily affected through thepneumogastric, evidenced by the slight convulsions and ten-dency to coma which I have generally observed. Medicalnomenclature is proverbially difficult, and unless Dr. MarshallHall,whose attention has been so long directed to this subject,and whose facility of expressing complex symptoms by shortand learned terms is as remarkable as the other manifestationsof genius, can suggest a better, the profession will do well toadopt it.The most recent cases I have had are the two following :-
Mr. E-, aged 78, suffering from the usual impairment of func-tions attending old age, having lost all his teeth, but possessinga vigorous appetite, was seized, about two months ago, betweennine and ten at night, with what his friends called a fit. I
happened to have called on this patient about four o’clock ofthe same day, and found him dining off a portion of a loin ofmutton, nearly all fat, which had been cooked several days,with pickles and an unusual quantity of potatoes, and a secondcourse of pastry. I cautioned him at the time, fearing thatthere might be "syncope senilis." I was not, therefore, sur-prised to receive the message, in the evening, to come imme-diately, for Mr. E- was apparently dying. 1 found him partlyconscious, with slight twitchings, laboured breathing, feeblepulse, and cold clammy surface. Knowing the cause, I atonce administered an emetic of ipecacuanha. In about tenminutes he ejected the contents of the stomach, very much inthe same condition in which they had been introduced. Thenext day the patient was in his usual health.Another case was that of a poor woman, who gets her living
by washing. After standing at the tub all day, being some-what hungry, she partook heartily of new bread, returning, assoon as the meal was finished, to her work. Shortly after-wards she dropped on the floor. Brandy was freely adminis-tered, and I was sent for. I found her very like a personrecovering from syncope ; inquiry elicited the fact of the new
, bread, and the treatment of the case was then clear. I gavean emetic ; she speedily vomited, and relief was instantaneous ;reaction followed, and no further treatment was required.The concluding observations in Mr. Higginbottom’s paper
are worthy the attention of those who are frequently con-sulted about the most suitable diet for the aged, and the bestmeans of protracting their existence. Assurance Companieswould be much benefited by the attention of the profession tothis subject. The value of many " lives" is diminished ten orfifteen years through error in diet, leading to attacks of syn-cope senilis.
A MirrorOF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
KING’S COLLEGE HOSPITAL.
COMPACT OSSEOUS TUMOUR OF THE UPPER JAW, OF THREE
YEARS’ GROWTH, IN A GIRL AGED THIRTEEN YEARS; RE-
MOVAL; A TOOTH FOUND IMBEDDED IN ITS CENTRE; CURE.
(Under the care of Mr. FERGUSSON.)
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. Be Sed. et Caits. Morb. lib. 14. Prooeminm.
ON many former occasions we have illustrated our " Mirror"
with examples of removal of the upper and lower jaw-bones,most of which contained some points of special interest; but itis seldom we have had such a rare opportunity of collectingtogether such cases of extreme interest as on the present occa-sion, occurring in the persons of young girls, in whom one sideof the upper jaw was more or less affected in each, where aremoval was practised in all, and where the recovery, we mayabsolutely say, was marvellously rapid in the whole three.In the two first the disease was precisely similar, being firm,
dense, and compact bony tumours of the antrum, the durationbeing three years in the first and twelve months in the secondcase. Mr. Fergusson deemed it advisable to remove them, whichhe accomplished when the patients were completely underthe influence of chloroform, administered by the experiencedhand of Dr. Snow. Every surgeon knows that the removal ofthe jaw is one of the greatest achievements of modern surgery;it is comparatively only a few years ago that this operationwas considered at all; and now, tumours of the upper and lowerjaw-bone, which formerly were permitted to consign the unfor.tunate patient to a protracted and wretched death, are at onceremoved by the surgeon, without hesitation.A point of special interest in all the cases we record to-day,
is the manner of making the external incisions, especially asthe patients were young females. Of all the methods adopted,that of laying open the cheek in such a manner as the surgeonmay fancy, often leaves large and unsightly scars. We neednot enumerate the different forms chosen by various distin-guished surgeons, but will refer to the plan Mr. Fergusson hasbeen in the habit of practising, and which he has the merit ofhaving originated. He has remarked, that in all instancesof removal of the upper jaw which had come under hisnotice the scar was very conspicuous, and it seemed to himthat it might in a great measure be avoided or concealed. Theviews he had formed he tested, with the most satisfactoryresults, in the following manner, as described in the thirdedition of his" Practical Surgery:" Instead of cutting the lipimmediately under the ala, he slits it open exactly in themesial line in the hollow under the columna, and then carriesthe knife along one side of the base of the columna into thenostril next the tumour, when he proceeds with the operationof its removal. By opening the nostril in this way, as muchrelaxation is gained as if the knife had been carried from theroot of the ala an inch up the side of the nose, and as muchfacility is given for the future steps of the operation as if anincision of three inches in length had been made through thelip and side of the nose, whilst the grand object is gained ofleaving the slightest possible conspicuous appearance after-wards.
Tile situation of the incision is such that the cicatrix isscarcely to be seen; that was the case in these two instances,especially so in the second, where the union has been so per-fect that it would require a highly practised eye to tell thatthe knife had ever been used at all. All surgeons concur inthe propriety of leaving the least possible mark in such opera-tions as these, but they do not recognise the principle in prac-tice. In the first case, the patient was discharged from hospitalcured, twenty-five days after the operation, with scarcely anydeformity; and in the second, although the disease was muchmore extensive, a complete recovery from the effects of theoperation was obtained in twelve days. We have to thank
Mr. W. P. Goodall, the house-surgeon of the hospital, for thebrief notes of the following cases :-
Eliza C-, aged thirteen, admitted May 14th, 1856, witha tumour of the upper jaw on the left side, which has beencoming three years. It implicates chiefly the alveolar border,and is very slightly prominent. There is no encroachment onthe palate or orbit, and the nostril is quite clear. She hasnever suffered any pain from the tumour, and seems to be ingood health.May 24th.-The patient having been placed under chloro-
form, Mr. Fergusson divided the upper lip, in the median line,with a scalpel, and, continuing the incision in the left nostril,dissected the tissues off the tumour. Having introduced anarrow saw into the nostril, he cut through the alveolus, andthen, with curved bone forceps, isolated the tumour from thesurrounding bone, and having grasped it with strong forceps,(technically called the " lion forceps,") tore it from its attach-ments. Small portions of diseased bone were then removedwith curved and angular bone forceps, and some very tenaciousmucus was removed from the antrum. The cautery was usedto check the hæmorrhage, and the lip brought together withhare-lip pins. The tumour appeared to be of a bony nature,and very dense. Upon a section being made, a tooth wasfound embedded in its centre.25th.-The patient had a quiet night. No hæmorrhage from
the mouth, which has been syringed out with tepid water.27th. -Everything going on favourably. Hare-lip pins re-
moved to-day. Patient sleeps well, and is able to take beef-tea. Mouth syringed out with myrrh lotion.30th.-Mouth not nearly so tender as it was; patient able
to get up and eat solid food.June 14th.—Mouth not at all tender; no discharge; eats
without pain; wound in lip quite healed, leaving only a linearscar.
18th.—Discharged, cured. Deformity is hardly perceptibleexternally, the scar on the lip being the only mark left. Thecheek is nearly as full on one side as the other, and the patientis able to swallow with ease, and to talk with tolerable dis-tinctness.
COMPACT OSSEOUS TUMOUR OF THE WHOLE OF THE UPPER JAW,OF TWELVE MONTHS’ GROWTH, IN A GIRL, AGED SIXTEENYEARS; REMOVAL; CURE.
(Under the care of Mr. FERGUSSON.)Elizabeth H-, aged sixteen, admitted June 12th, 1856,
with a tumour of the upper jaw on the right side. The tumourhas been growing for twelve months, and has given no pain:it appears to be an osseous growth, involving the upper part ofthe jaw, and the alveolar border slightly. The mouth is notencroached upon, but the growth has pushed the inferior tur-binated bone inwards, so as to be clearly seen in the nostril.The teeth of the affected side are all sound; the first molar iswanting, having been extracted about eight months ago. Thenasal process of the superior maxilla appears to be enlarged,and the tumour projects towards, without, however, implicatingthe malar bone, thus rendering the cheek more prominent inthat situation. She has enjoyed good health.June 21st.—Chloroform being given, Mr. Fergusson divided
the lip in the median line, and then dissected the tissues of thecheek from off the tumour. A cut was then made with Hey’ssaws through the alveolus, from the nostril into the mouth, andanother cut in a horizontal direction, about half an inch belowthe margin of the orbit, after which the large curved boneforceps were applied to the back part of the tumour, and alarge portion of it removed with the end of the lion forceps.There being still some of the disease left, the bone forceps wereapplied several times, and by this means all the disease was atlength removed. The disease appeared to consist of an hyper-trophy of the osseous structures, the bone being excessivelydense. The disease involved nearly the whole of the maxillaand a large portion of the malar bone, which was therefore re-moved as far as implicated. The hæmorrhage was very free,but was controlled by a ligature and the application of thecautery to two or three points. The lip was brought togetherwith hare-lip pins in the usual manner, one suture being ap-plied in addition to the upper part of the section. After beingremoved to bed, the patient vomited a large quantity of blood,which had been swallowed during the operation. Ordered iceto swallow, and cold water to wash the mouth out with; wine,six ounces.June 22nd. -Had a tolerably good night ; is able to swallow
liquids with tolerable facility; has had no more sickness.24th.-Mouth syringed out with tepid water to get rid of
the shreds of slough; month less tender; is able to swallowbetter.
28th.-Patient able to get up and walk into the theatre; isable to swallow with tolerable facility.
July 3rd.—Patient quite recovered from the operation. Thelip is perfectly healed, the face only very slightly fallen in;articulation rather indistinct.
7th.-Is quite well. The cavity left by removal of thetumour is gradually filling up. Her voice is becoming moredistinct. The line of incision through the lip would scarcelybe noticed.We will remark in relation to this case, that when the girl
was undergoing the operation, notwithstanding that the mouthand throat were filled with blood, she did not give a singlecough during the whole period of its performance, being com-pletely under the influence of chloroform; this will show thatthere is not that danger which is so much feared by some sur-geons, especially out of the metropolis. In fact, we have seenthis operation many times, and many others about the face,with the administration of chloroform, with good results.
LONDON HOSPITAL.EPITHELIAL TUMOUR OF THE PALATE IN A JEWESS, AGED SIX-
TEEN YEARS; EXCISION OF A PORTION OF THE SUPERIOR
MAXILLA; EXAMINATION OF THE TUMOUR BY DR. ANDREW
(Under the care of Mr. CURLING.)IN the preceding cases, the jaw-bone itself was the subject
of disease requiring an operation of a formidable character to,eradicate it. The following case, however, differs from eitherof the foregoing in the fact that the bone ivas only affected toa slight degree; but from the peculiar nature of the affection,it was deemed necessary to remove a portion only of the supe-rior maxilla-that part of it immediately in contact with thecancerous mass. The growth of this, which had attained thesize of a hen’s egg, had occurred within a period of two months,although there seems to have been indications of its earliercommencement; it had somewhat increased in size ever sinceher admission into the hospital. As in the others, the curewas perfect and rapid, with very little deformity indeed; andthe operation was done without chloroform. Many surgeonsavoid its use in operations about the face and throat, but whengiven by an experienced and careful person, we think there isnot so much danger as is anticipated. On this occasion, never-theless, the poor girl gave evidence of such genuine courage,that Mr. Curling preferred operating without it. For thenotes of this interesting case we are indebted to the kindnessof Mr. W. W. Harkness, the dresser of the patient.A good-looking Jewess, aged sixteen, was admitted into the
hospital April 15th,1856. Six months before she was seized withtoothache in the right upper jaw, which was followed by swell-ing of the face. For two years she has occasionally had slightbleeding from the gums; but this was considered of no conse-quence until two months ago. At that time, a swelling com-menced just above and behind the upper incisors, and increasedtowards the soft palate. Five weeks ago it was lanced, but onlyblood proceeded from it. Fourteen days afterwards, she wasseen by Mr. Coulson, who again lanced it; but this operationwas followed only by bleeding. The day before admission, agrooved needle was introduced, but nothing but blood escaped ;this flowed freely and per saltum, and it was necessary to usepressure with the finger to stop the haemorrhage. The swellingappeared of the shape and size of a hen’s egg, apparently pro-jecting from the hard palate, occupying the whole of the righthalf of the roof of the mouth, and extending across the mesialline to a small portion of the left half; posteriorly it extendedto the edge of the hard palate, but did not seem to implicatethe soft palate. On passing a probe along the floor of the nose,no tumour could be felt. The tumour felt rather dense andelastic, and firmly attached to the bone. It did not projectexternally. A small ulceration existed in the mucous mem-brane of the palate, which covered the lower half of the tumour.Two or three attacks of rather extensive haemorrhage tookplace apparently from the back of the tumour, for which asaturated solution of nitrate of silver was used. There hasnever been very much pain in the tumour.
April 19th.—The first and second right upper molar teethwere extracted ; the first was quite loose and the second wasadherent to a small portion of the alveolar process, which cameaway with it. A good deal of haemorrhage and pain, withswelling of the face, followed the operation.
, The other surgeons having concurred in the propriety of ex-’=’