602

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.

DISLOCATION OF THE FOURTH CERVICAL VERTEBRA, AND PAR-TIAL FRACTURE; DEATH TWO DAYS AND A HALF AFTER-WARDS.

(Under the care of Mr. LLOYD.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumetdissectionum historias, tam aliorum proprias, collectas habere et interecompara.re.&mdash;Mos&ASB’l. De Sed. et Oa2<s. Morb.lib. 14. Prooemium.

IN considering injuries to the spine, it is well known thatdislocation of any of the five lower cervical vertebrae is ofmore frequent occurrence than of the two upper. The dislo-cation of the atlas from the occiput has been described only intwo instances; whilst, again, dislocations of the axis are muchmore common, and are familiar to us in hanging and similaraccidents. When dislocation of any of the five lower cervicalvertebrae occurs, it is generally associated with fracture, al-

though rarely it may happen without it. The subjoined case,the notes of which were kindly furnished us by Mr. W. J.Daniel, house-surgeon to the hospital, is one in which the fourthcervical was dislocated forwards from the fifth to the extent ofa quarter of an inch, which, although it may seem to be of

small extent, is in reality sufficient to cause mischief of so seri-ous a character to the spinal cord as to prove fatal. The edgeof the articulating surface of the fourth, and the transverseprocess of the fifth vertebras, were, as might be anticipated,fractured. The spinal cord was so much injured as to producedeath two days and a half after the accident, which was anunusual and singular one-falling on the back of the neck on alower step. This produced immediate paralysis, and someconcussion of the brain as well. This displacement was ofsufficient extent to produce complete paralysis of the upper andlower extremities; the breathing was difficult and diaphragm-atic, owing to palsy of the intercostal and abdominal muscles.This finally increased, and put an end to life. If the injuryin these cases be above the origin of the phrenic nerve, the dia-phragm becomes palsied, and death instantaneous. Here theinjury was just below the origin of that nerve, but sufficientlyclose to injure some of its filaments of origin, and graduallyproduce that result. Our wonder is that the patient survivedas long as he did.. Patrick D--, a strongly-built, heavy man, aged thirty-six, was brought to the hospital on May 20th, suffering fromparalysis consequent on an injury to his spine, and admittedinto Colston ward. It appears that on the 18th of May he wasdescending some stairs, and on getting to the third or fourthfrom the bottom, he slipped up on some orange-peel, and fell,the back of his neck coming in contact with the last step. Hisfriends stated that the paralysis was the immediate effect ofthe accident; that he was stunned for a time, but soon re-covered his consciousness; that he then remained sensible forabout six hours, after which " raving delirium" came on; thislasted only through the night, and from that time till his ad-mission here he was quite conscious. When brought to thehospital, there was loss of motion and sensation in both upperand lower extremities; retention of urine; pulse 84, and full;tongue furred; skin natural; breathing chiefly diaphragmatic;countenance slightly livid. He can swallow and talk, thoughwith some difficulty; his head appears quite clear. Abouttwo pints of offensive dark-coloured urine were drawn off, andhe was left as quiet as possible.-Eight r.M.: Difficulty inbreathing more marked; he has been sleeping a little; urine

again drawn off ’* ,May 2Ist.-Half-past twelve A.M.: Dyspnoea not increased;the face flushed; pulse 96, very full and bounding; the skindry and burning hot; eyes suffused. He now wanders a little;states that he is in no pain. For the next two hours he re-mained in about the same state; but after that time respirationbecame more and more difficult, and instead of the hot, dry

skin, he now perspires profusely. He died at about a quarterto four this morning.A post-modem examination was obtained. The fourth cer-

vical vertebra was dislocated forwards from the fifth to theextent of about a quarter of an inch. A piece of the posterioredge of the lower articulating surface of the fourth was brokenoff; and there was also fracture of the anterior portion of thetransverse process of the fifth. The spinal cord opposite theseat of injury was very much softened, to the extent of morethan an inch, forming quite a contrast to the rest of the cord,which was firm and healthy.

KING’S COLLEGE HOSPITAL.

MYELOID TUMOUR OF THE LOWER JAW IN A GIRL, SUPER-VENING UPON A GROWTH REMOVED FOUR YEARS BEFORE;REMOVAL A SECOND TIME; FATAL RESULT FROM EXHAUS-TION.

(Under the care of Mr. FERGUSSON.)THE description given of the tumour in the following case.

shows it to have been myeloid in character, and to have recurredshortly after the removal of another tumour by Mr. Pettigrewsome years before. It had now attained to a considerable sizedit was not painful, but produced great deformity and incon-venience to the poor girl, who was anxious that somethingshould be done to obtain relief. It was removed by Mr. Fer-gusson, when the patient was completely under the influenceof chloroform, the operation being associated with very freehoemorrhage. We regret to state, however, that owing to theshock and the exhaustion consequent upon the formidable na-ture of the operation itself, she died the following day-a cir-cumstance the more to be regretted, because the tumour was-found not to be malignant.

In a previous " Mirror (p. 524,) we gave the leading cha-racteristics of myeloid disease, in recording a case under Mr.Hilton’s care, at Guy’s Hospital. In all the instances thathave been recorded by Mr. Henry Gray, Mr. Paget, Lebert,and others, we believe recurrence of the disease, so far as couldbe ascertained, was unknown. We cannot assume that in thisgirl the disease was recurrent, unless we know for certainwhat were the true characters of the first tumour removed, andthus one of the most important features of the case is leftdoubtful. This is, moreover, one of the first cases recorded ofmveloid disease of the jaw, and thus differs from other instancesof the disease elsewhere in not being developed in an epiphysalextremity of a bone.As Mr. Fergusson attaches considerable importance to pre-

serving the integrity of the mouth, his incisions were so made,as described in the details of the case, as not only to avoid de-formity, but to leave the lips intact, and when the edges of thewound were brought together, no deformity was visible.We are indebted to Mr. Christopher Heath, house-surgeon to

the hospital, for the following abstract of the case :-Mary Ann H-, aged twenty-three, admitted on the 29th

of April, with a large tumour involving the right side of thelower jaw. The tumour forms a projection of considerablesize under the cheek, extending as high as the malar bone; itpresents an uniformly smooth surface, and is very hard to thetouch. On the inside of the mouth, the alveolar border isconsiderably projected towards the median line as far forwardsas the canine tooth, the bicuspid and first molar teeth beingthrown inwards, and the other molars wanting. There is nopain nor tenderness on pressure. About six years ago, atumour formed about the wisdom tooth, which increased untilit involved the angle of the jaw, and was then removed by Mr.Pettigrew. This tumour had caused her great pain by pressingagainst the teeth of the upper jaw; but the present tumour(which began to form soon after Mr. Pettigrew’s operation)has not been so painful, but is a great source of inconvenienceand disfigurement.On the 2nd of May, chloroform having been administered,

Mr. Fergusson made an incision through the lower part of thelower lip, (not dividing the red margin,) and continued it forabout two inches along the base of the jaw; two bicuspid teethhaving then been drawn, and the edges of the wound heldasunder, a small saw was used, and the jaw cut through atthe canine tooth. There was some haemorrhage from the facialand inferior dental arteries, which was arrested as far as pos-sible by the fingers of the assistants. The incision was nowcarried along the base and ramus of the jaw, nearly up to theear, and the integuments being rapidly dissected off the tumour,Mr. Fergusson grasped the cut extremity of the bone, and pro-ceeded to dislocate the tumour, running the knife behind it to

603

divide its internal attachments. By this means, the whole ofthe disease was brought away, but the ramus of the jaw givingway just above the tumour, (probably where it had been cutin the former operation,) the condyle was left in situ for themoment. Mr. Fergusson having first secured some of the

bleeding vessels, from which (particularly the internal maxillaryartery) the bleeding was very considerable, proceeded to removethe remaining portion of bone by grasping it with the "lionforceps," and thus with a few touches of the knife dislocatingand bringing it away. The remaining bleeding vessels werenow secured, and the edges of the wound brought togetherwith sutures, and covered with water-dressing. The patientwas removed to bed, and no haemorrhage of any momentoccurred, although there was an oozing of blood for some hoursafter the operation. She was a good deal’ reduced by the lossof blood, and vomited frequently, but by administration of iceand wine she improved, and passed a tolerable night, thoughstill troubled with sickness.May 3rd.-A pill containing kreasote was administered,

which checked the vomiting, and she was able to take a littlenourishment, the pulse became fuller, and her condition ap-peared satisfactory. Towards evening, however, notwith-standing the regular administration of wine, beef-tea, &c., shebecame weaker, the pulse more rapid and feeble, and she sankgradually, and died at ten r. M.

After the operation, she was unable to close the right eye,and the face was drawn to the left, owing to division of thefacial nerve. The wound was opened up after death, and itwas evident that there had been no sudden haemorrhage afterthe operation to account for death, which must be put downto the shock and exhaustion from the operation.The following is a description of the tumour, which proved

to be myeloid :-It has been developed within the bone, whichit has expanded into a thin envelope of compact bony tissueclothing its exterior. A section showed a surface of a clearwhite colour, bathed with clear serum, (not milky whenseraped,) of considerable firmness, and presenting numerousosteoid deposits.&mdash;JtfMH<<e structzcre: Is neither fibrous norenchendromatous, as most of the tumours in the lower jawappear to be. It is almost wholly built up of small cells,whose prevalent form is oval, either free in a dimly granularmatrix, or here and there contained in large parent cells, re-sembling those of fcatal marrow. Very delicate fibres occursparingly.

’

POST-MORTEM DISSECTION OF THE DOUBLE POPLITEAL ANEURISMS,WHICH RECENTLY PROVED FATAL.

(Under the care of Mr. BOWMAN.)Since our last, the following account has been furnished us

by Mr. Heath, the house-surgeon to the hospital, of the dissec- z,tion made of the aneurisms in the two limbs:&mdash;

Left Leg.-The artery above the second ligatures was filledwith a firm cylindro-conical plug. The cylinders adheredfirmly to the walls of the vessel, and the free apex nearly ’,reached the origin of the profunda artery. The two second ’,ligatures, embracing a small bit of vessel (they were one-eighthof an inch apart) had nearly separated, being held only by alittle shred of sloughing tissue above the upper third. Nearlyan inch of vessel intervened between the second and the situa-

. tiQD. of the, first ligature. This portion of vessel was soft,sloughy, and filled with a pulpy, semi-fluid, fibrinous clot; itsBpper end, soft, thin, ragged, was open. At the situation ofthe first ligature the canal was obliterated, and below thispoint there was a small bead-like clot. Below this point foricme inch and a; half, the ’inner surface of the vessel had agreyish-white appearance, and the middle coat was soft, white,and separating. Below this to the sac the vessel was normal;below the point where the first thread had been tied the cana,lof the vessel was open. The sac was the size of a large hen’s-egg; the opening into it was about one inch by three-quarters,oblong, and barred entirely by fibrine, which also filled thesac. Opposite the sac the vessel was also’uniformly dilated.

Rg7at Leg.-The vessel at the point of deliaation was notyet cut through by the ligature. Above this point the vesselwas filled by a cylindrical clot, about one inch long, and sud-denly tapering to a thin floating thread it reached nearly upas high as to the profunda. Below the ligature there was a..small bead-like clot, between which and the aneurism theartery was open. The sac had burst, and the parts immediatelyaround it were in a gangrenous state, so that it was difficult toascertain its exact relations. A large nodular mass of fibrinerested upon the opened vessel, filling what seemed to havebeen the orifice of communication between the sac and theartery, and large’ masses of spongy fibrine and grumous blood

covered the* inner surface of ihe heads of the gastrocnemitlsmuscle, which, together with the popliteus, was pulpy andsphacelated. The popliteal vein and its tributaries were pluggedwith softened fibrinous clots, and small abscesses were scatteredalong these vessels; this state existed for about four inchesabove the sac. -

We at the same time will correct an error (not our own} inthe abstract of the case given from the hospital register. Thehaemorrhage, it appears, took place from the left leg (not theright) one week after the ligature had come away, and threedays after tying the vessel on the right leg.

CLINICAL RECORDS.

LITHOTOMY IN THE YOUNG, WITH AND WITHOUT A1T1ESTHESIA..

ON the 6th June we saw lithotomy performed on three boys,two at St. Thomas’s and one at King’s College Hospital. At theformer, one boy was about seven or eight years old, from whosebladder Mr. Le Gros Clark removed a stone the size of a hoxse-bean ; the other boy was about five years old, whose bladdercontained a stone as large as a pigeon’s egg, only longer, andwhich was got out with some little difficulty, from its beingimbedded, as Mr. Le Gros Clark said, in a distinct sac, re-

quiring dislodgment before extraction. In these two caseschloroform, we were sorry to see, was not used, for the reason,as we learnt, that a previous case of stone turned out badly,which was supposed to be due to the chloroform. We can

hardly believe this to be the case, particularly if the patientwas young; for the general result of lithotomy i children is a.successful one, where this agent has been employed. The con-sequence was, the two poor boys produced a scene such asit has not been our lot to witness since the introductionof chloroform. We have seen stones extracted numberlesstimes from children, and the result has been, we may say,almost invariably successful. To give up chloroform is to doaway with one of the greatest boons conferred upon sufferinghumanity in modern times. ’

At King’s College Hospital the patient was also a boy, whohad had stone for two years, with great suffering; the calculuswas removed by Mr. Fergusson whilst the little patient wasunder the influence of amylene, and the contrast in regard toquietude and suffering was really most agreeable. If chloroformis objectionable, why not give amylene a trial, or even go backto sulphuric ether? which of all substances employed to pro-duce anaesthesia is perhaps the safest. We now and then seeanaesthetics most properly omitted in old people who, fromcertain causes, cannot take them, and also in persons so debili-tated from injury that their use would prove fatal. In themany thousands of instances in which we have seen anaestheticsemployed, none appeared more suitable cases for chloroform thanthe two boys operated upon at St. Thomas’s last Saturday.

EXCISION OF THE KNEE-JOINT.

IN our Clinical Records" of the 9th May, we referred to aease of excision of the knee-joint . of a young man who badcome up to town to get his leg amputated. We saw him inthe wards of King’s College Hospital on the 30th May, andfound the entire wound healed, and consolidation going on, hisgeneral health being good. On May 23rd, Mr. Partridge per-formed the same operation at the above hospital, in a case whichis doing well; and on the 30th, a third patient was submittedto the same proceeding by Mr. Fergusson. The patient, anelderly man, had disease of his knee-joint for nine years, whichhad exhausted his patience, but he was reluctant to part withthe limb. There was some swelling in front of the jojtnt, nocicatrices or fistulous openings, and partial anchylosis. Itseemed a fair case for resection, and that operation was per-formed in preference to amputation. In the ceurse of theoperation, small portions of the condyles of the femur were ex-cised with a part of the attached anchylosed patella. Morethan half an inch of the tibia was then removed, in the

expectation of finding a healthy surface; but there was a, patch on the bone, which the operator thought he would; remove by taking another slice away, which was done. -It

still seemed questionable in character, and Mr. Fergusson. endeavoured to scrape away the diseased bone, but in doing! so it was found to communicate with a large cavity, into

which he could plunge the whole length of his finger. He! thought this to be an abscess at first, but it appeared to be the-result of some old disease, undergoing cure most probably bY