2
307 the .etzures. When the strength improved, the fits, contrary l however to anticipation, never recurred. Xo abnormal con- formation of brain was found, and I would attribute the epi- lepsy rather to the effects of irregularity of life on an organ protected by an unusually thin cranium, and, possibly, mor- bidly susceptible of impressions. As regards treatment, little need be said. I am strongly of opinion that abstraction of blood subsequent to the operation, although recommended by some eminent surgeons, would have e induced death speedily by convulsion. Mercury was given largely at the suggestion of my colleague, Mr. Bostock, who was strongly impressed with its efficacy in such cases. The post-mortem examination would certainly indicate the pro- priety of its exhibition ; and although unsuccessful in its more specific action, yet the maintenance of a healthy state of the functions for so long may fairly be attributed in some measure to the effect of the calomel. No want of control over the sphiucters occurred at any time. The great loss of substance, together with disorganization of a large portion of the hemi- sphere, and very slight disturbance of the sensorium through- out, may be viewed as facts corroborative of the theory of duality of the brain. September, 1S58. the .etzures. When the strength improved, the fits, contrary l however to anticipation, never recurred. Xo abnormal con- formation of brain was found, and I would attribute the epi- lepsy rather to the effects of irregularity of life on an organ protected by an unusually thin cranium, and, possibly, mor- bidly susceptible of impressions. As regards treatment, little need be said. I am strongly of opinion that abstraction of blood subsequent to the operation, although recommended by some eminent surgeons, would have e induced death speedily by convulsion. Mercury was given largely at the suggestion of my colleague, Mr. Bostock, who was strongly impressed with its efficacy in such cases. The post-mortem examination would certainly indicate the pro- priety of its exhibition ; and although unsuccessful in its more specific action, yet the maintenance of a healthy state of the functions for so long may fairly be attributed in some measure to the effect of the calomel. No want of control over the sphiucters occurred at any time. The great loss of substance, together with disorganization of a large portion of the hemi- sphere, and very slight disturbance of the sensorium through- out, may be viewed as facts corroborative of the theory of duality of the brain. September, 1S58. ON A CASE OF FOREIGN BODY IN THE BRAIN; ABSENCE OF SYMPTOMS. BY ROBERT HUGHES, ESQ., F.R.C.S., SURGEON TO STAFFORD COUNTY GAOL AND GENERAL INFIRMARY, STAFFORD. IN THE LANCET of June 26th there was a report of a case in which recovery had followed an extensive wound of the brain. In the following case, which came under my notice a short time ago, it is still more strikingly shown how tolerant the brain may occasionally be, not only of injury, but also of the presence of a large foreign body, and that, too, for a consider- able length of time. Thos. G- was committed to the County Gaol to undergo six months’ hard labour. I examined him on his admission, and observed that he had a small wound on the forehead, just I above the nose ; it was covered with a piece of plaster, and did not excite any particular attention. According to his sentence, he was put to hard labour, and continued well for about three weeks. On the 5th of June he complained of headache and general malaise. This, however, was prevalent throughout the gaol, in consequence of the warmth of the weather and some temporary deficiency in the ventilating apparatus. He continued poorly for about a week, and died rather suddenly, with symptoms of compression. Assisted by Mr. S. P. Smith, I made an examination twenty- four hours after death. On opening the head and removing the dura mater, the anterior lobe of the right hemisphere of the brain was found considerably softened, it being impossible to remove it en masse; in its interior was an abscess contain- ing about six drachms of pus. On taking away the softened cerebral matter, a piece of iron was found fixed against the cresta Galli of the ethmoid, occupying a large part of the roof of the right orbit. It weighed an ounce and a half, and was contained in a cyst, which appeared to be formed (at least in part) by the pushing in of the dura mater. The cyst contained also some small pieces of necrosed bone. On the under part of the right hemisphere there could be traced an indentation corresponding with the piece of iron, and in that part of the frontal bone where the wound was situated there was found a perpendicular slit, about an inch long; this was filled up by a membranous septum. The evidence at the inquest showed that fourteen months ago the deceased went out with some companions to try a gun. He several times discharged it, but at last the gun burst, it having been over loaded. The man was wounded in the forehead and hands. He was ill for some weeks, and then recovered, and from the time of his recovery to his admission into the gaol he enjoyed pretty good health, only complaining occasionally of a sensation of weight in the head, especially on stooping. Neither his sight nor smell were interfered with. It appeared that they found all the fragments of the gun excepting portions of the breech and lock. (It was proved to be a piece of the breech that was found in the head.) The surgeon who attended him, Mr. Fletcher, of Walsall, IN THE LANCET of June 26th there was a report of a case in which recovery had followed an extensive wound of the brain. In the following case, which came under my notice a short time ago, it is still more strikingly shown how tolerant the brain may occasionally be, not only of injury, but also of the presence of a large foreign body, and that, too, for a consider- able length of time. Thos. G- was committed to the County Gaol to undergo six months’ hard labour. I examined him on his admission, and observed that he had a small wound on the forehead, just I above the nose ; it was covered with a piece of plaster, and did not excite any particular attention. According to his sentence, he was put to hard labour, and continued well for about three weeks. On the 5th of June he complained of headache and general malaise. This, however, was prevalent throughout the gaol, in consequence of the warmth of the weather and some temporary deficiency in the ventilating apparatus. He continued poorly for about a week, and died rather suddenly, with symptoms of compression. Assisted by Mr. S. P. Smith, I made an examination twenty- four hours after death. On opening the head and removing the dura mater, the anterior lobe of the right hemisphere of the brain was found considerably softened, it being impossible to remove it en masse; in its interior was an abscess contain- ing about six drachms of pus. On taking away the softened cerebral matter, a piece of iron was found fixed against the cresta Galli of the ethmoid, occupying a large part of the roof of the right orbit. It weighed an ounce and a half, and was contained in a cyst, which appeared to be formed (at least in part) by the pushing in of the dura mater. The cyst contained also some small pieces of necrosed bone. On the under part of the right hemisphere there could be traced an indentation corresponding with the piece of iron, and in that part of the frontal bone where the wound was situated there was found a perpendicular slit, about an inch long; this was filled up by a membranous septum. The evidence at the inquest showed that fourteen months ago the deceased went out with some companions to try a gun. He several times discharged it, but at last the gun burst, it having been over loaded. The man was wounded in the forehead and hands. He was ill for some weeks, and then recovered, and from the time of his recovery to his admission into the gaol he enjoyed pretty good health, only complaining occasionally of a sensation of weight in the head, especially on stooping. Neither his sight nor smell were interfered with. It appeared that they found all the fragments of the gun excepting portions of the breech and lock. (It was proved to be a piece of the breech that was found in the head.) The surgeon who attended him, Mr. Fletcher, of Walsall, has very kindly furnished the following additional facts. He states : " I was called to see Thos. C-, I think on Easter Monday last year. I found him suffering from a wound caused by the bursting of a gun, the breech of which had blown out and struck him about the middle of the forehead. The external wound was ragged, much contused, and about an inch in dia- meter. The frontal bone was fractured, and that part of it immediately behind the external wound was deficient, as if it had been carried away by some solid body which had passed through the bone, and which, in my opinion, was still within the cranium. The man wae perfectly conscious, and gave a distinct account of the accident, and this consciousness he con- stantly retained. He suffered no pain, and the only incon- venience of which he complained was a sense of an immense weight in the head; to use his own words, ’his head felt to be a ton weight, and so heavy that he could not raise it from the pillow.’ He had not throughout the attendance a bad symptom; he slept well, and took whatever was allowed; it was, in fact, a case requiring no medical or surgical inter- ference. During the attendance several fragments of bone came away from the wound, also a small piece of iron, which I took to be a portion of the gun-lock plate, and a small piece of wood. I continued to attend him about two months, at which time he was able to go about his usual employment. The wound did not perfectly heal, and continued to discharge a little when I last saw him. The only dressing applied to the wound was cold water and lint." The above case is, I think, particularly interesting, there having been throughout no symptoms which would lead to the supposition that so large a foreign body was within the cranium. The position of the iron was also remarkable. I should rather have expected to find it on the left side, for the gun being applied to the right shoulder, the pieces would fly in a direction from left to right. No doubt the cresta Galli was struck, and this altered the course of the projectile. has very kindly furnished the following additional facts. He states : " I was called to see Thos. C-, I think on Easter Monday last year. I found him suffering from a wound caused by the bursting of a gun, the breech of which had blown out and struck him about the middle of the forehead. The external wound was ragged, much contused, and about an inch in dia- meter. The frontal bone was fractured, and that part of it immediately behind the external wound was deficient, as if it had been carried away by some solid body which had passed through the bone, and which, in my opinion, was still within the cranium. The man wae perfectly conscious, and gave a distinct account of the accident, and this consciousness he con- stantly retained. He suffered no pain, and the only incon- venience of which he complained was a sense of an immense weight in the head; to use his own words, ’his head felt to be a ton weight, and so heavy that he could not raise it from the pillow.’ He had not throughout the attendance a bad symptom; he slept well, and took whatever was allowed; it was, in fact, a case requiring no medical or surgical inter- ference. During the attendance several fragments of bone came away from the wound, also a small piece of iron, which I took to be a portion of the gun-lock plate, and a small piece of wood. I continued to attend him about two months, at which time he was able to go about his usual employment. The wound did not perfectly heal, and continued to discharge a little when I last saw him. The only dressing applied to the wound was cold water and lint." The above case is, I think, particularly interesting, there having been throughout no symptoms which would lead to the supposition that so large a foreign body was within the cranium. The position of the iron was also remarkable. I should rather have expected to find it on the left side, for the gun being applied to the right shoulder, the pieces would fly in a direction from left to right. No doubt the cresta Galli was struck, and this altered the course of the projectile. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. ST. BARTHOLOMEW’S HOSPITAL. EPITHELIAL CARCINOMA OF THE TONGUE REMOVED BY THE ECRASEUR ; RECOVERY. (Under the care of Mr. PAGET.) Nulia est alia pro certo nosceudi via, nisi quam plurimas et morborum et dissectionum historias, tam aliorum proprias, collectas habere et inter se com- parare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proaemium. Nulia est alia pro certo nosceudi via, nisi quam plurimas et morborum et dissectionum historias, tam aliorum proprias, collectas habere et inter se com- parare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proaemium. THE tongue, like other organs of the body, is subject to various diseases, which demand medical and surgical inter- ference. Amongst these may be enumerated inflammation, true muscular hypertrophy, tumours of various kinds, and malignant disease, especially cancer. The majority of opera- tions upon the tongue are performed for the last of these, a disease by no means common, yet occasionally presenting itself for treatment in our large hospitals. Though most common in old people, as is the peculiarity of cancer, it is sometimes ob- served in the young, when the age is apt to mislead, unless the unmistakable nature of the affection renders the diagnosis pretty clear. There is good reason to believe that, in whatever manner it may appear, carcinoma of the tongue originates in the follicular structures, whence it gradually spreads to the other tissues. If left till in too advanced a condition for the removal of a portion only, then the entire excision of the organ has been practised, as was performed by Mr. Syme, of Edin. burgh, on two occasions, whose cases have already appeared in this journal, (THE LANCET, vol. i. 1858, p. 46, and vol. ii. p. 168.) In his remarks on extirpation of the whole tongue, Mr. Syme feels himself warranted in asserting, that even in the event of success, as the permanency of relief would still admit of question, he thinks no hesitation is necessary in de. ciding against the repetition of this proceeding. THE tongue, like other organs of the body, is subject to various diseases, which demand medical and surgical inter- ference. Amongst these may be enumerated inflammation, true muscular hypertrophy, tumours of various kinds, and malignant disease, especially cancer. The majority of opera- tions upon the tongue are performed for the last of these, a disease by no means common, yet occasionally presenting itself for treatment in our large hospitals. Though most common in old people, as is the peculiarity of cancer, it is sometimes ob- served in the young, when the age is apt to mislead, unless the unmistakable nature of the affection renders the diagnosis pretty clear. There is good reason to believe that, in whatever manner it may appear, carcinoma of the tongue originates in the follicular structures, whence it gradually spreads to the other tissues. If left till in too advanced a condition for the removal of a portion only, then the entire excision of the organ has been practised, as was performed by Mr. Syme, of Edin. burgh, on two occasions, whose cases have already appeared in this journal, (THE LANCET, vol. i. 1858, p. 46, and vol. ii. p. 168.) In his remarks on extirpation of the whole tongue, Mr. Syme feels himself warranted in asserting, that even in the event of success, as the permanency of relief would still admit of question, he thinks no hesitation is necessary in de. ciding against the repetition of this proceeding.

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the .etzures. When the strength improved, the fits, contrary lhowever to anticipation, never recurred. Xo abnormal con-formation of brain was found, and I would attribute the epi-lepsy rather to the effects of irregularity of life on an organ protected by an unusually thin cranium, and, possibly, mor-bidly susceptible of impressions.As regards treatment, little need be said. I am strongly of

opinion that abstraction of blood subsequent to the operation,although recommended by some eminent surgeons, would have einduced death speedily by convulsion. Mercury was givenlargely at the suggestion of my colleague, Mr. Bostock, whowas strongly impressed with its efficacy in such cases. The

post-mortem examination would certainly indicate the pro-priety of its exhibition ; and although unsuccessful in its morespecific action, yet the maintenance of a healthy state of thefunctions for so long may fairly be attributed in some measureto the effect of the calomel. No want of control over thesphiucters occurred at any time. The great loss of substance,together with disorganization of a large portion of the hemi-sphere, and very slight disturbance of the sensorium through-out, may be viewed as facts corroborative of the theory ofduality of the brain.

September, 1S58.

the .etzures. When the strength improved, the fits, contrary lhowever to anticipation, never recurred. Xo abnormal con-formation of brain was found, and I would attribute the epi-lepsy rather to the effects of irregularity of life on an organ protected by an unusually thin cranium, and, possibly, mor-bidly susceptible of impressions.As regards treatment, little need be said. I am strongly of

opinion that abstraction of blood subsequent to the operation,although recommended by some eminent surgeons, would have einduced death speedily by convulsion. Mercury was givenlargely at the suggestion of my colleague, Mr. Bostock, whowas strongly impressed with its efficacy in such cases. The

post-mortem examination would certainly indicate the pro-priety of its exhibition ; and although unsuccessful in its morespecific action, yet the maintenance of a healthy state of thefunctions for so long may fairly be attributed in some measureto the effect of the calomel. No want of control over thesphiucters occurred at any time. The great loss of substance,together with disorganization of a large portion of the hemi-sphere, and very slight disturbance of the sensorium through-out, may be viewed as facts corroborative of the theory ofduality of the brain.

September, 1S58.

ON A CASE OF

FOREIGN BODY IN THE BRAIN;ABSENCE OF SYMPTOMS.

BY ROBERT HUGHES, ESQ., F.R.C.S.,SURGEON TO STAFFORD COUNTY GAOL AND GENERAL INFIRMARY, STAFFORD.

IN THE LANCET of June 26th there was a report of a case inwhich recovery had followed an extensive wound of the brain.In the following case, which came under my notice a shorttime ago, it is still more strikingly shown how tolerant thebrain may occasionally be, not only of injury, but also of thepresence of a large foreign body, and that, too, for a consider-able length of time.

Thos. G- was committed to the County Gaol to undergosix months’ hard labour. I examined him on his admission,and observed that he had a small wound on the forehead, just Iabove the nose ; it was covered with a piece of plaster, and did not excite any particular attention. According to his sentence,he was put to hard labour, and continued well for about threeweeks. On the 5th of June he complained of headache andgeneral malaise. This, however, was prevalent throughoutthe gaol, in consequence of the warmth of the weather andsome temporary deficiency in the ventilating apparatus. Hecontinued poorly for about a week, and died rather suddenly,with symptoms of compression.

Assisted by Mr. S. P. Smith, I made an examination twenty-four hours after death. On opening the head and removingthe dura mater, the anterior lobe of the right hemisphere ofthe brain was found considerably softened, it being impossibleto remove it en masse; in its interior was an abscess contain-ing about six drachms of pus. On taking away the softenedcerebral matter, a piece of iron was found fixed against thecresta Galli of the ethmoid, occupying a large part of the roofof the right orbit. It weighed an ounce and a half, and wascontained in a cyst, which appeared to be formed (at least inpart) by the pushing in of the dura mater. The cyst containedalso some small pieces of necrosed bone. On the under partof the right hemisphere there could be traced an indentationcorresponding with the piece of iron, and in that part of thefrontal bone where the wound was situated there was found aperpendicular slit, about an inch long; this was filled up by amembranous septum. The evidence at the inquest showedthat fourteen months ago the deceased went out with somecompanions to try a gun. He several times discharged it, butat last the gun burst, it having been over loaded. The manwas wounded in the forehead and hands. He was ill for someweeks, and then recovered, and from the time of his recoveryto his admission into the gaol he enjoyed pretty good health,only complaining occasionally of a sensation of weight in thehead, especially on stooping. Neither his sight nor smell wereinterfered with. It appeared that they found all the fragmentsof the gun excepting portions of the breech and lock. (It wasproved to be a piece of the breech that was found in the

head.)The surgeon who attended him, Mr. Fletcher, of Walsall,

IN THE LANCET of June 26th there was a report of a case inwhich recovery had followed an extensive wound of the brain.In the following case, which came under my notice a shorttime ago, it is still more strikingly shown how tolerant thebrain may occasionally be, not only of injury, but also of thepresence of a large foreign body, and that, too, for a consider-able length of time.

Thos. G- was committed to the County Gaol to undergosix months’ hard labour. I examined him on his admission,and observed that he had a small wound on the forehead, just Iabove the nose ; it was covered with a piece of plaster, and did not excite any particular attention. According to his sentence,he was put to hard labour, and continued well for about threeweeks. On the 5th of June he complained of headache andgeneral malaise. This, however, was prevalent throughoutthe gaol, in consequence of the warmth of the weather andsome temporary deficiency in the ventilating apparatus. Hecontinued poorly for about a week, and died rather suddenly,with symptoms of compression.

Assisted by Mr. S. P. Smith, I made an examination twenty-four hours after death. On opening the head and removingthe dura mater, the anterior lobe of the right hemisphere ofthe brain was found considerably softened, it being impossibleto remove it en masse; in its interior was an abscess contain-ing about six drachms of pus. On taking away the softenedcerebral matter, a piece of iron was found fixed against thecresta Galli of the ethmoid, occupying a large part of the roofof the right orbit. It weighed an ounce and a half, and wascontained in a cyst, which appeared to be formed (at least inpart) by the pushing in of the dura mater. The cyst containedalso some small pieces of necrosed bone. On the under partof the right hemisphere there could be traced an indentationcorresponding with the piece of iron, and in that part of thefrontal bone where the wound was situated there was found aperpendicular slit, about an inch long; this was filled up by amembranous septum. The evidence at the inquest showedthat fourteen months ago the deceased went out with somecompanions to try a gun. He several times discharged it, butat last the gun burst, it having been over loaded. The manwas wounded in the forehead and hands. He was ill for someweeks, and then recovered, and from the time of his recoveryto his admission into the gaol he enjoyed pretty good health,only complaining occasionally of a sensation of weight in thehead, especially on stooping. Neither his sight nor smell wereinterfered with. It appeared that they found all the fragmentsof the gun excepting portions of the breech and lock. (It wasproved to be a piece of the breech that was found in the

head.)The surgeon who attended him, Mr. Fletcher, of Walsall,

has very kindly furnished the following additional facts. Hestates : " I was called to see Thos. C-, I think on EasterMonday last year. I found him suffering from a wound causedby the bursting of a gun, the breech of which had blown outand struck him about the middle of the forehead. The externalwound was ragged, much contused, and about an inch in dia-meter. The frontal bone was fractured, and that part of itimmediately behind the external wound was deficient, as if ithad been carried away by some solid body which had passedthrough the bone, and which, in my opinion, was still withinthe cranium. The man wae perfectly conscious, and gave adistinct account of the accident, and this consciousness he con-stantly retained. He suffered no pain, and the only incon-venience of which he complained was a sense of an immenseweight in the head; to use his own words, ’his head felt tobe a ton weight, and so heavy that he could not raise it fromthe pillow.’ He had not throughout the attendance a badsymptom; he slept well, and took whatever was allowed; itwas, in fact, a case requiring no medical or surgical inter-ference. During the attendance several fragments of bonecame away from the wound, also a small piece of iron, which Itook to be a portion of the gun-lock plate, and a small piece ofwood. I continued to attend him about two months, at whichtime he was able to go about his usual employment. Thewound did not perfectly heal, and continued to discharge alittle when I last saw him. The only dressing applied to thewound was cold water and lint."The above case is, I think, particularly interesting, there

having been throughout no symptoms which would lead to thesupposition that so large a foreign body was within the cranium.The position of the iron was also remarkable. I should ratherhave expected to find it on the left side, for the gun beingapplied to the right shoulder, the pieces would fly in a directionfrom left to right. No doubt the cresta Galli was struck, andthis altered the course of the projectile.

has very kindly furnished the following additional facts. Hestates : " I was called to see Thos. C-, I think on EasterMonday last year. I found him suffering from a wound causedby the bursting of a gun, the breech of which had blown outand struck him about the middle of the forehead. The externalwound was ragged, much contused, and about an inch in dia-meter. The frontal bone was fractured, and that part of itimmediately behind the external wound was deficient, as if ithad been carried away by some solid body which had passedthrough the bone, and which, in my opinion, was still withinthe cranium. The man wae perfectly conscious, and gave adistinct account of the accident, and this consciousness he con-stantly retained. He suffered no pain, and the only incon-venience of which he complained was a sense of an immenseweight in the head; to use his own words, ’his head felt tobe a ton weight, and so heavy that he could not raise it fromthe pillow.’ He had not throughout the attendance a badsymptom; he slept well, and took whatever was allowed; itwas, in fact, a case requiring no medical or surgical inter-ference. During the attendance several fragments of bonecame away from the wound, also a small piece of iron, which Itook to be a portion of the gun-lock plate, and a small piece ofwood. I continued to attend him about two months, at whichtime he was able to go about his usual employment. Thewound did not perfectly heal, and continued to discharge alittle when I last saw him. The only dressing applied to thewound was cold water and lint."The above case is, I think, particularly interesting, there

having been throughout no symptoms which would lead to thesupposition that so large a foreign body was within the cranium.The position of the iron was also remarkable. I should ratherhave expected to find it on the left side, for the gun beingapplied to the right shoulder, the pieces would fly in a directionfrom left to right. No doubt the cresta Galli was struck, andthis altered the course of the projectile.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.EPITHELIAL CARCINOMA OF THE TONGUE REMOVED BY

THE ECRASEUR ; RECOVERY.

(Under the care of Mr. PAGET.)

Nulia est alia pro certo nosceudi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proaemium.

Nulia est alia pro certo nosceudi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proaemium.

THE tongue, like other organs of the body, is subject tovarious diseases, which demand medical and surgical inter-ference. Amongst these may be enumerated inflammation,true muscular hypertrophy, tumours of various kinds, andmalignant disease, especially cancer. The majority of opera-tions upon the tongue are performed for the last of these, adisease by no means common, yet occasionally presenting itselffor treatment in our large hospitals. Though most common inold people, as is the peculiarity of cancer, it is sometimes ob-served in the young, when the age is apt to mislead, unless theunmistakable nature of the affection renders the diagnosispretty clear. There is good reason to believe that, in whatevermanner it may appear, carcinoma of the tongue originates inthe follicular structures, whence it gradually spreads to theother tissues. If left till in too advanced a condition for theremoval of a portion only, then the entire excision of the organhas been practised, as was performed by Mr. Syme, of Edin.burgh, on two occasions, whose cases have already appeared inthis journal, (THE LANCET, vol. i. 1858, p. 46, and vol. ii.p. 168.) In his remarks on extirpation of the whole tongue,Mr. Syme feels himself warranted in asserting, that even inthe event of success, as the permanency of relief would still

admit of question, he thinks no hesitation is necessary in de.ciding against the repetition of this proceeding.

THE tongue, like other organs of the body, is subject tovarious diseases, which demand medical and surgical inter-ference. Amongst these may be enumerated inflammation,true muscular hypertrophy, tumours of various kinds, andmalignant disease, especially cancer. The majority of opera-tions upon the tongue are performed for the last of these, adisease by no means common, yet occasionally presenting itselffor treatment in our large hospitals. Though most common inold people, as is the peculiarity of cancer, it is sometimes ob-served in the young, when the age is apt to mislead, unless theunmistakable nature of the affection renders the diagnosispretty clear. There is good reason to believe that, in whatevermanner it may appear, carcinoma of the tongue originates inthe follicular structures, whence it gradually spreads to theother tissues. If left till in too advanced a condition for theremoval of a portion only, then the entire excision of the organhas been practised, as was performed by Mr. Syme, of Edin.burgh, on two occasions, whose cases have already appeared inthis journal, (THE LANCET, vol. i. 1858, p. 46, and vol. ii.p. 168.) In his remarks on extirpation of the whole tongue,Mr. Syme feels himself warranted in asserting, that even inthe event of success, as the permanency of relief would still

admit of question, he thinks no hesitation is necessary in de.ciding against the repetition of this proceeding.

Page 2: ST. BARTHOLOMEW'S HOSPITAL

308

After the expression of such an opinion from so high anauthority in this matter, we think it is the duty of every sur-geon to resort to early removal of the affected portions whenthe patients are seen in good time, (as was adopted by Mr.Paget on this day week,) more particularly if the tumour orcancerous growth has been increasing rapidly, and the morelikely to spread over the surface, when it might assume thecharacters of the encephaloid variety of the disease.Removal being determined upon, the choice of effecting this

is offered by the ligature, the knife, and the ecraseur. This, ofcourse will very much depend upon the views entertained bythe surgeon himself; examples of each, however, have ap-peared in our "Mirror." We may refer to a rather awkwardlysituated growth, which was removed successfully by the liga-ture by Mr. Erichsen, at University College Hospital, in Juneof last year, (THE LANCET, vol. i. 1857, p. 604.) The knife isusually set aside, because of the haemorrhage; but we will ven-ture the observation, from what we have seen of the ecraseurused upon the tongue, that there is by no means an absence ofhaemorrhage after it is withdrawn; and this can be the betterunderstood when we remember how peculiar is the structure ofthe tongue, which may be said to be granular, and likely tobreak down during the crushing process, and therefore exposedto severe laceration. In a brief report, however, given in thefirst volume of this journal for the present year (page 129) byMr. Gascoyen, of the removal of the entire tongue by M.Maisonneuve, and a part of another by M. Chassaignac, inParis, both with this instrument, there seemed to be very littlebleeding indeed. At St. Thomas’s Hospital in May, 1857,Mr. Simon removed about two-thirds of the tongue from a managed fifty, extensively affected with epithelial cancer, in theform of two ulcers, extending far backwards. The ecraseurwas being used; but its substance was found so soft and friable, ’,that the chain tore its wav through at once without being ’,worked; this was attended with little bleeding. The tonguewas then tied at its base and cut away in front; but veryalarming haemorrhage occurred from the slipping of the liga-ture, which nearly proved fatal, but eventually arrested bytying numerous vessels and applying the actual cautery. It isfair to state that this bleeding was not due to the ecraseur.The man left the hospital with the wound perfectly healedthree weeks afterwards, and able to eat and speak wonderfullywell. One of the sublingual glands was enlarged ; it did notincrease immediately after the operation. The relief waslooked upon as temporary, and it would be interesting to know ’’

his present condition if still alive.The patient under Mr. Paget’s care was a woman, in good

health, aged about fifty-eight years, admitted on the 10th inst.She stated that her present disease began as a small pimple orlump on the right side of the tongue three months ago; it

gradually enlarged, but has grown rapidly within the last fort-night, attaining the size of a walnut, and became ulcerated.It projected as a white growth from the surface of the tongue,as if covered with a sort of efflorescence, and was a well-marked example of epithelial cancer, She consented to haveit removed.On the llth, chloroform was carefully administered by Dr.

Martin, and kept up at intervals throughout the entire ope-ration, which consisted in passing a needle and thread throughthe centre of the base of the tumour, and pulling the chain ofthe ecraseur after it. This was then attached to the instru-ment, and adjusted around the posterior half of the growth,and then cut through after the lapse of some minutes. Thechain was now applied around the anterior half, and the com-plete detachment was accomplished in about the same time asthe posterior portion. There was some haemorrhage, but ofmoderate extent, and which appeared to cease after a shorttime.On examining the diseased mass, it was found completely

removed. A section gave the ordinary aspect of epithelialcarcinoma of the tongue. In some remarks made by Mr.Paget, he stated that the ecraseur was well adapted to remove eit, as it did away with the large amount of bleeding whichgenerally takes place from the tongue when that organ is cutacross.

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After the expression of such an opinion from so high anauthority in this matter, we think it is the duty of every sur-geon to resort to early removal of the affected portions whenthe patients are seen in good time, (as was adopted by Mr.Paget on this day week,) more particularly if the tumour orcancerous growth has been increasing rapidly, and the morelikely to spread over the surface, when it might assume thecharacters of the encephaloid variety of the disease.Removal being determined upon, the choice of effecting this

is offered by the ligature, the knife, and the ecraseur. This, ofcourse will very much depend upon the views entertained bythe surgeon himself; examples of each, however, have ap-peared in our "Mirror." We may refer to a rather awkwardlysituated growth, which was removed successfully by the liga-ture by Mr. Erichsen, at University College Hospital, in Juneof last year, (THE LANCET, vol. i. 1857, p. 604.) The knife isusually set aside, because of the haemorrhage; but we will ven-ture the observation, from what we have seen of the ecraseurused upon the tongue, that there is by no means an absence ofhaemorrhage after it is withdrawn; and this can be the betterunderstood when we remember how peculiar is the structure ofthe tongue, which may be said to be granular, and likely tobreak down during the crushing process, and therefore exposedto severe laceration. In a brief report, however, given in thefirst volume of this journal for the present year (page 129) byMr. Gascoyen, of the removal of the entire tongue by M.Maisonneuve, and a part of another by M. Chassaignac, inParis, both with this instrument, there seemed to be very littlebleeding indeed. At St. Thomas’s Hospital in May, 1857,Mr. Simon removed about two-thirds of the tongue from a managed fifty, extensively affected with epithelial cancer, in theform of two ulcers, extending far backwards. The ecraseurwas being used; but its substance was found so soft and friable, ’,that the chain tore its wav through at once without being ’,worked; this was attended with little bleeding. The tonguewas then tied at its base and cut away in front; but veryalarming haemorrhage occurred from the slipping of the liga-ture, which nearly proved fatal, but eventually arrested bytying numerous vessels and applying the actual cautery. It isfair to state that this bleeding was not due to the ecraseur.The man left the hospital with the wound perfectly healedthree weeks afterwards, and able to eat and speak wonderfullywell. One of the sublingual glands was enlarged ; it did notincrease immediately after the operation. The relief waslooked upon as temporary, and it would be interesting to know ’’

his present condition if still alive.The patient under Mr. Paget’s care was a woman, in good

health, aged about fifty-eight years, admitted on the 10th inst.She stated that her present disease began as a small pimple orlump on the right side of the tongue three months ago; it

gradually enlarged, but has grown rapidly within the last fort-night, attaining the size of a walnut, and became ulcerated.It projected as a white growth from the surface of the tongue,as if covered with a sort of efflorescence, and was a well-marked example of epithelial cancer, She consented to haveit removed.On the llth, chloroform was carefully administered by Dr.

Martin, and kept up at intervals throughout the entire ope-ration, which consisted in passing a needle and thread throughthe centre of the base of the tumour, and pulling the chain ofthe ecraseur after it. This was then attached to the instru-ment, and adjusted around the posterior half of the growth,and then cut through after the lapse of some minutes. Thechain was now applied around the anterior half, and the com-plete detachment was accomplished in about the same time asthe posterior portion. There was some haemorrhage, but ofmoderate extent, and which appeared to cease after a shorttime.On examining the diseased mass, it was found completely

removed. A section gave the ordinary aspect of epithelialcarcinoma of the tongue. In some remarks made by Mr.Paget, he stated that the ecraseur was well adapted to remove eit, as it did away with the large amount of bleeding whichgenerally takes place from the tongue when that organ is cutacross.

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ST. THOMAS’S HOSPITAL.ULCERATION BETWEEN ALL THE TOES OF BOTH FEET

IN A GIRL.

(Under the care of Mr. MACKMURDO.)A VERY curious and instructive case is at this moment

under treatment in this hospital. It is instructive because it

A VERY curious and instructive case is at this momentunder treatment in this hospital. It is instructive because it

shows how webbed fingers and toes may occur in adult life.A girl, twenty years of age, but looking as if seventeen, wasadmitted on the 6th instant, with ulcerated surfaces betweenall the toes of both feet, the ulcerations lining either side ofthe toe in contact with the opposite one. On separating themwith the finger, a red and very raw surface was exposed, ex-tending just beyond the edge of the opposed surfaces of thetoes. They were tender, and felt very sore, completely dis-abling he.from walking. About six weeks ago, these ulce.rations commenced in the form of single blisters or blebs,which burst, the cuticle becoming detached, and leaving a rawsurface beneath. There was no traceable cause, unless per-haps some irregularity of the menstrual function, but in otherrespects the girl’s general health was pretty good. She wasordered small doses of aloes-and-myrrh pill, with mercurywith chalk, twice a day, and the use of zinc ointment, care-fully spread on strips of lint, to be placed between the toes asfar as possible, so that any tendency to union of the opposedsurfaces might be avoided. Under this treatment she is im-proving, and will eventually, it is to be hoped, get well.Now, this affection is by no means frequently to be seen, and

the diagnosis as to its real nature is somewhat conjectural.The situation of the ulceration is that of soft corns, where thecuticle is soft and spongy, but they do not appear so suddenly,nor would they occur between all the toes. The probabilityis, that an eruption of a phlyctenular character took place,characterized by the formation of blebs, which burst, andowing to the peculiarity of the secretion in this situation,together with the natural moistness of the skin, assumed anulcerative character. There is more than a probability inthis view, because at the margins of the ulceration, at theupper and under surfaces of the toes, is a slight appearance ofwhitish lamellae, as is noticed in the eruptions of pemphigus.In the pemphigus infantilis, the soles of the feet are sometimescovered with bullae. In this girl, the blebs were single, andisolated to either side, and are thus diagnosed from herpes fromthe absence of any group of vesicles.

This affection must not be confounded with simple eczema,which is found frequently in other places, as on the arm andforearm, also between the fingers, but rarely between the toes.An ulceration is sometimes witnessed between the toes as theresult of syphilis, as we have heard Mr. Curling state, butthen the cause is clear and the treatment obvious.

If ulceration is neglected in this situation, it is most liable toend in complete union of the opposed surfaces, and the formation of webbed toes. In adults, when this deformity occurs,its origin can be distinctly traced sometimes to intra-digitalulceration.

Since the foregoing was written, we have met with the caseof a little girl, five years of age, in the Charing-cross Hospital,under the care of Mr. Barwell, with ulceration between all thetoes, but depending upon ecthyma, the general health beingbad. Tonics were principally relied upon to effect a cure, andthe ulcerations healed.

shows how webbed fingers and toes may occur in adult life.A girl, twenty years of age, but looking as if seventeen, wasadmitted on the 6th instant, with ulcerated surfaces betweenall the toes of both feet, the ulcerations lining either side ofthe toe in contact with the opposite one. On separating themwith the finger, a red and very raw surface was exposed, ex-tending just beyond the edge of the opposed surfaces of thetoes. They were tender, and felt very sore, completely dis-abling he.from walking. About six weeks ago, these ulce.rations commenced in the form of single blisters or blebs,which burst, the cuticle becoming detached, and leaving a rawsurface beneath. There was no traceable cause, unless per-haps some irregularity of the menstrual function, but in otherrespects the girl’s general health was pretty good. She wasordered small doses of aloes-and-myrrh pill, with mercurywith chalk, twice a day, and the use of zinc ointment, care-fully spread on strips of lint, to be placed between the toes asfar as possible, so that any tendency to union of the opposedsurfaces might be avoided. Under this treatment she is im-proving, and will eventually, it is to be hoped, get well.Now, this affection is by no means frequently to be seen, and

the diagnosis as to its real nature is somewhat conjectural.The situation of the ulceration is that of soft corns, where thecuticle is soft and spongy, but they do not appear so suddenly,nor would they occur between all the toes. The probabilityis, that an eruption of a phlyctenular character took place,characterized by the formation of blebs, which burst, andowing to the peculiarity of the secretion in this situation,together with the natural moistness of the skin, assumed anulcerative character. There is more than a probability inthis view, because at the margins of the ulceration, at theupper and under surfaces of the toes, is a slight appearance ofwhitish lamellae, as is noticed in the eruptions of pemphigus.In the pemphigus infantilis, the soles of the feet are sometimescovered with bullae. In this girl, the blebs were single, andisolated to either side, and are thus diagnosed from herpes fromthe absence of any group of vesicles.

This affection must not be confounded with simple eczema,which is found frequently in other places, as on the arm andforearm, also between the fingers, but rarely between the toes.An ulceration is sometimes witnessed between the toes as theresult of syphilis, as we have heard Mr. Curling state, butthen the cause is clear and the treatment obvious.

If ulceration is neglected in this situation, it is most liable toend in complete union of the opposed surfaces, and the formation of webbed toes. In adults, when this deformity occurs,its origin can be distinctly traced sometimes to intra-digitalulceration.

Since the foregoing was written, we have met with the caseof a little girl, five years of age, in the Charing-cross Hospital,under the care of Mr. Barwell, with ulceration between all thetoes, but depending upon ecthyma, the general health beingbad. Tonics were principally relied upon to effect a cure, andthe ulcerations healed.

LONDON HOSPITAL.CYSTIC DISEASE OF THE BREAST, WITH HYPERTROPHY

OF THE PROPER GLANDULAR TISSUE , AMPU-TATION ; RECOVERY.

(Under the care of Mr. CURLING.)IT is a matter of essential importance for the surgeon to be

enabled to diagnose a benign from a malignant tumour of thebreast; and it is not the less so for the patient also, if he canpredict with tolerable certainty whether the disease will returnor not. A growth of the breast which requires careful studyon account of its occasional resemblance to cancer, is the chro-nic mammarv tumour, or mammary glandular tumour, as it iscalled, or the sero-cystic disease of Sir B. Brodie, all of whichterms are equally expressive as to its character. Its essentialelement is hypertrophy of the glandular structure itself, withan equal enlargement of the fibrous tissue, which envelops andintersects the gland, in the meshes of which cysts filled withfluid, varying in size, are liable to form, although they are notinvariably present. Sometimes cysts occur in the breast, de-veloped within the gland ducts themselves, situated in variousparts of the breast ; these, again, are different from tose metwith between the lobules associated with hypertrophy of thegland tissue. The distinction is important in the anatomy ofthe breast, and admits of a comparison with the vesicular andinterlobular form of emphysema of the lungs, in their disposi-

tion.1 Although we have recorded cases from time to time in our

IT is a matter of essential importance for the surgeon to beenabled to diagnose a benign from a malignant tumour of thebreast; and it is not the less so for the patient also, if he canpredict with tolerable certainty whether the disease will returnor not. A growth of the breast which requires careful studyon account of its occasional resemblance to cancer, is the chro-nic mammarv tumour, or mammary glandular tumour, as it iscalled, or the sero-cystic disease of Sir B. Brodie, all of whichterms are equally expressive as to its character. Its essentialelement is hypertrophy of the glandular structure itself, withan equal enlargement of the fibrous tissue, which envelops andintersects the gland, in the meshes of which cysts filled withfluid, varying in size, are liable to form, although they are notinvariably present. Sometimes cysts occur in the breast, de-veloped within the gland ducts themselves, situated in variousparts of the breast ; these, again, are different from tose metwith between the lobules associated with hypertrophy of thegland tissue. The distinction is important in the anatomy ofthe breast, and admits of a comparison with the vesicular andinterlobular form of emphysema of the lungs, in their disposi-

tion.1 Although we have recorded cases from time to time in our