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A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. BARTHOLOMEW’S HOSPITAL.SARCOMA OF THE UPPER JAW ; EXCISION ; NO RECUR-

RENCE AFTER FOUR YEARS.

(Under the care of Mr. MORRANT BAKER.)

NuUa. autem est alia pro certo noscendi via, nisi quamplurimas et mor.borum et dissectionum historias, tum aliorum tum proprias collectanhabere, et inter se comparare.-MORGAGNI De Sed. et CaU8. Morb.,lib. iv. Procemium. -

THE great interest in this case lies in the fact that,although the patient has passed the three years’ limit,before which no case can be regarded as even comparativelysafe from recurrence of malignant disease, no matter howcarefully it has been removed, there is no evidence of returnof the growth. It is the more important to place such onrecord, although we are without any definite idea as to theminute structure of the tumour, because the result ofoperations for carcinoma as well as sarcoma of the superiormaxilla is so unsatisfactory. "Out of sixty-four cases ofwhich the result is recorded, only four can be regarded(from the three-year limit) as successful, and in one ot themthe disease reappeared at the end of nine years. The pros-pect of surgical treatment is very gloomy." 1 The history ofthis case resembles somewhat that of one successfullytreated by Ohlemann,z a slowly growing tumour of thealveolar border of the jaw. For the account of this casewe are indebted to Mr. Arnold Lyndon, late house surgeon.

G. H. A-, aged thirty-six, a marine engineer, wasadmitted into St. Bartholomew’s Hospital on Sept. 19bh,1887. The patient gave the following history: Twelveyears ago he had a bad cold in his head, and on rising onemorning found that his left nostril was 11 stopped up,"and that he could not breathe freely through it. Theobstruction in the left nostril has continued up to thepresent time ; otherwise the patient has enjoyed perfecthealth until six months ago, when he noticed thatthe upper molar teeth of the left side were loose, andseemed to be pushed out of their sockets, so that he couldnot bite comfortably. About this time also a swellingappeared in the roof of the mouth on the same side.The swelling in the mouth has been rapidly increasingthe last few months, and lately the patient has beentroubled by tears running down the left cheek.Present condition -Patient is a healthy looking and power-

fully built man. The left cheek is obviously fuller than theright, and the left half of the nose is broadened andbulged outwards, and tears are constantly trickling downthe cheek. The left eyeball is not pushed upwards orforwards, and its movements are free and natural, but thepatient complains of slight dimness of vision on that side.On closer examination, a hard, rounded swelling can be feltin the left cheek below the orbit, and on examination witha speculum a fleshy-looking growth is found to occlude thepassage of the left nostril. There are no enlarged glandsin the submaxillary region. Inside the mouth an ovalswelling is seen projecting from the hard palate on the leftside. The swelling is elastic, red, and velvety in appear-ance, and everywhere covered by the mucous membrane ofthe mouth. It begins in front opposite the first bicuspidtooth and extends backwards to the soft palate, whilelaterally it is bounded externally by the alveolus of thejaw, and internally it reaches nearly to the middle line ofthe palate. The upper molar teeth on the same side are veryloose and pushed downwards, so that the greater part of thefangs are exposed.No doubt being entertained of the nature of the growth,

Mr. Baker advised the patient to submit to operation, butas the growth did not appear to involve the orbit Mr.Baker determined to do a partial excision of the upperjaw, leaving the floor of the orbit intact. On Sept. 21st,the patient being under the influence of chloroform,a gag was inserted into the mouth, and Mr. Baker punc-tured the swelling in the roof of the mouth with a narrow-

1 The Operative Treatment of Malignant Disease.2 Ibid., Butlin, p. 133.

bladed knife. The knife passed through the growthright up into the antrum, and the puncture bled freely.The gag was then removed, and the operation for partialexcision of the upper jaw by the external-flap method wascarried out in the usual way. The bone was found to bevery soft and friable, and crumbled away when seized withthe lion forceps. Much of the growth came away with thebone, and what remained was cut away piecemeal withscissors. The whole of the antrum and nostril were foundto be filled with a very soft and vascular growth, presentingall the characteristics of a rapidly growing sarcoma, bubthe floor of the orbit was not involved. There was veryfree haemorrhage during the operation, and many vesselswere secured and ligatured, but as a general oozing stillcontinued at the deeper parts of the wound, Paquelin’scautery was applied. The parts were then irrigated withcarbolic lotion, and the skin flap secured with silver wireand horsehair sutures, and dry gauze dressings applied.Nothing noteworthy occurred the next few days ; the

skin wound was dressed on the third day, and was found tohave united by the first intention, so most of the sutureswere removed, and two days later the remaining ones

also. On the evening of Sept. 27th (six days after theoperation) secondary haemorrhage came on from the woundin the mouth after a fit of coughing, and was only stoppedwith great difficulty and after the patient had lost a largequantity of blood. From this time he made an uninter-rupted recovery, and on Oct. 7th was sent to the Conva-lescent Home at Swanley.On Nov. llth, seven weeks after operation, the patient

returned from Swanley, and it was then found that ab thebottom cavity left in the mouth by the operation there wasa raised patch the size of a shilling, soft and vascular, andthe surface ragged and ulcerated. This was watched for afew days, and as it appeared to be growing it was deter-mined to destroy it with chloride of zinc. In the first in-stance a paste composed of one ounce of chloride of z;nc,two drachms of flour, and one ounce of liquor opii seda-tivus was employed. This was powerfully escharotic,but gave the patient great pain, and was not easy of

application, so the following formula, suggested by Mr.Thomas Smith, was substituted: 100 grains of chlorideof zinc, aud one ounce of flexible collodion (half strength).This was applied daily with a camel’s-hair brush, causedvery little pain, and acted very efficiently. By the middleof December the growth was quite destroyed, and a healthysurface left. On Dec. 23rd the man left the hospital, pro-vided with a diaphragm and a set of artificial teeth. The

rapid return of the disease pointed to the probability of asmall portion of the growth having escaped removal at thetime of operation, and not to a recurrence in the true senseof the word. Still, when the patient left the hospital, Mr.Baker gave a very bad prognosis, and said that it wouldprobably recur before long. From this time nothing washeard of the patient till September, 1888 (one year afteroperation), when he wrote to say that he was perfectly well,and that there was no return of the disease. In September,1889, 1890, and 1891 patient again wrote, repeating whathe said in his first letter, that he was quite well. In hislast letter, Sept. 21st, 1891, he says: " still continue ingood health, and my mouth gives me no trouble."Remarks by Mr. LYNDON.-The interest of this case lies

in the fact that four years after excision of the upper jawfor rapidly growing sircoma the patient is in perfecthealtb,and there is no recurrence of the disease. At the time ofoperation a portion of the growth was set aside for micro-scopical examination, but unfortunately was mislaid, so thatthe diagnosis could not be confirmed microscopically. Thatthe disease was malignant I think there can be no doubt.Its rapid growth in the six months before operation, itsgrowth outwards to the cheek, downwards through thehard palate to the mouth, the invasion of the sockets of theteeth, and its rapid reappearance directly after the opera-tion, together with its extremely vascular and soft andfriable nature, point conclusively to malignant disease.

NORTH RIDING INFIRMARY, MIDDLES-BROUGH.

A CASE OF FRACTURE OF THE PELVIS COMPLICATED WITHCOMPLETE DIVISION OF THE URETHRA; RECOVERY.

(Under the care of Dr. WILLIAMS.)FRACTURE of the pelvis, complicated with rupture of

the urethra, is one of the most severe of all the various

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accidents which a surgeon is called upon to treat. Theinjury is followed by great shock, and the condition of thepatient is such as to cause much anxiety from the time hefirst comes under observation until he leaves the hospital.Indeed, the surgeon’s anxiety does not end there, for theserious traumatic stricture, which is an inevitable resultof the laceration of the urethra, requires grean perseverancein its after-management, the continual and almost un-conquerable tendency to contraction of the stricture ren-

dering the frequent use of catheters a necessity. This is agood example of the result of treatment of such a ca"p, forthe account of which we are indebted to Mr. G. VictorMiller, the resident surgeon.

J. M-, aged eighteen, a fireman on a locomotive, wasadmitted into the North Riding Infirmary on April 13th,1891, suffering from fracture of the pelvis due to his havingbeen crushed between a wall and a locomotive. The patienthad all the symptoms of fracture, involving the pubic arch,together with much shock, which usually accompaniesthis severe injury. A soft catheter was introduced into theurethra, and a little urine followed by a quantity of darkblood came away. This instrument was tied in position. Infour or five hours the bladder began to distend above thepubes, and the patient to complain of pain in the hypogastricregion. As blood was still coming from the catheter, it wasevident the instrument was not in the bladder, and that theurine which came away previously was a small quantitythat had escaped into the tissues when the patient receivedthe injury. The patient was now suffering from retention.To relieve this the soft instrument was withdrawn, and anattempt made to pass a silver instrument. The attemptwas unsuccessful, and the next resort was aspirationabove the pubes. This was done, and urine came awayperfectly clear. Aspiration at intervals was carried on fortwo days, and then another attempt made to pass an instru-ment, but without success. Of course, it will be-understoodthat even if the patient could have passed urine, he waswarned not to do so, to prevent extravasation into the tissues.

It was now decided to cut down on to the membranousurethra from the perineum. This was done at once, and theurethra in this part was found wanting and a mass ofblood-clot in its place. A search was made for the tornends, which were found, a catheter being passed throughthe central end info the bladder. Any attempt to bring theends together would probably have proved useless, owing tothe laceration and distance between them ; so none wasmade. The catheter was withdrawn and a large drainage-tube put in the wound to carry the urine directly away.This went on about three weeks, all urine coming freelyaway through the perineal wound. With the finger in thewound the central torn end of the urethra could be easilyfelt (it conveyed to the finger much the same impressionthat the female urethral oritice does) and the soft catheterdirected into it. An attempt was now made to p1.SS a silverinstrument from the external meatus, and wuh success.

This was kept in for two days and then replaced by an ordi-nary English gum-elastic catheter, which was changed everyday. After passing the first instrument there was littledifficulty in passing the others, apparently from the centralend being quite rid of the surrounding clot, and also becauseof its being quite patent and fixed. To pass the instru-ment one required a good curve to it, to elbow the point alittle, and depress well between the thighs. On one or twooccasions only was it found necessary to put the finger intothe wound and tilt up the point. One might judge fromthis that the distended bladder draggel up the urethra alittle, but there was no deviation laterally. With the fingerin the perineal wound, the bare catheter to the extent ofover an inch and a quarter could be felt between the ends ofthe urethra. This state of affairs went on for about a month,the gap in the urethra slowly but gradually closing up. Thetube was removed from the pei ineal wound and allowedto close up, all the urine parsing through the catheter. Thepatient was now taught to d) aw off the urine himself duringthe day, an instrument—No. 10,11, or 12, gum-elastic—beingtied in over night. This was required on account of hisbeing able to retain urine only about three hours, and alsoto keep what would probably prove to be a very badtraumatic stricture well dilated. The instrument was notput in at night, when he could retain urine for five or sixhours. Aq the patient was now up and going about,drawing off all the urine himself when necessary, and theperineal wound was closed, it was thought he mightbe allowed to pass urine without an instrument ; and

this he did for the first time, quite freely and withoutpain or discomfort, on July 12h. He left the hospitalon July 31st quite recovered.The only complication of any note during the pro.

gress of the case was a urethral abscess about twoinches and a half from the external meatus, which sentup the patient’s temperature. It burst into the urethra,but was afterwards opened and allowed to discharge ex-ternally. A sinus remained for some time, but ultimatelyclosed up completely. He has since been seen and ex-

amined. He states that he has been at work for the last sixweeks, and feels as well as ever he did before the accident.His only trouble is the stricture, and for this he requires topass a No 10 English gum-elastic catheter every other orevery third day. He has not much difficulty in passing theinstrument into the bladder, but the stricture contractsvery soon after dilatation, which will be readily understoodfrom the severe nature of the injury to the urethra.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Actinomycosis of the Verm1jorm Appendix, of the Digestiveand Urinary Tracts, and of the Face and Neck.

AN ordinary meeting of this Society was held on Nov.10lb,Dr. Langdon Down, Vice-President, in the chair.Dr. W. H. RANSOM communicated a case of Actinomy-

cosis of the Vermiform Appendix causing Perityphlitis.The patient, aged fifty, was an active, healthy man, withno noteworthy previous medical history. He began aboutOct. 12th, 1888, to have indefinite abdominal pains, andon the 21st had sudden severe pain in the right iliac fossa,increased on Exertion, so that he was laid up. At this datedeep palpation revealed aconsiderable solid mass intheregionof the caeum, very tender to pressure. On Dec 5th there wasevidence of thrombosis of the right external iliac vein. Onthe 9 uh the region behind the csesum was exp] ()red by an aspi-rating needle without result. On Jan. 4th, 1889, the swellingof the right leg diminished, but returned on Jan. 10th. OnFeb. 19’.h a point appeared in front of the anterior superiorspine of the ilium, and two days later it burst and dis-cbarged a little dirty, offensive pus. The opening wasenlarged and an ounce of faecal-smelling pus let out. A

drainage-tube was inserted. On Feb. 28tb, under auoes-

thetics, a probe was passed and cut down upon in the loin,from which aperture a drainage-tube was inserted five inchesand a half in the direction of the csecum. A similar tubewas passed connecting the anterior and posterior aperture.From this escaped fetid and fseeal smelling pus, some

gas, a few flakes of fibrinous clot, and some soft masq(sof granulation tissue, which were not found to containany neoplasm or other contents which tended to clear up thediagnosis. The discharges contained specks of faecal matter.March 20th : A small point appeared between the bwoprevionsapertures, and was opened, but only a small amount of pusescaped, having the same character. No relief followed.On April 13th a free incision was made, the sinuses werefreely explored with the finger, and a large drainage-tubeinserted. Very little pus escaped during or after thisoperation. Some two or three days later there was fetidpus in the discharges, and this contained, besides faecalspecks, spherules or colonies of actinomyces. This opera-tion gave no relief. An infective vesicular kin eruptionappeared near the apertures, some little diarrbcea came on,and the whole condition became worse. He died on

June 21st. He was ill in all eight months, and febrile,with few and brief interruptions, for the last sevenmonths. There was no appearance during life of any othervisceral complication. There was evidence that the thrombusof the right external iliac vein bad gradually spreadcentripetally, and in less than four months had reached thevena cava Necropsy : Nothing noticed of importanceexcept in the abdomen. Liver too large, soft, greasy to

touch, contained a metastatic focus as large as a doubledfibt. There were no indications of general peritonitis. Thevermiform appendix was tortuous, bound downbyadhesiors.Behind the caecunx was found an abscess with irregularwalls and numerous communicating channels continuous