314

days after the operation. On the morning of the 10th, or twenty-five days after tracheotomy, the catamenia appeared: she had one fitthat day, at half-past two P.M., and a second at half-past seven P.M.A fourth fit occurred on the llth of March; and the fifth andmost severe, at two P.M. on the 13th, twenty-eight days after theoperation. Since this time the patient has been free from anyepileptic attacks.The woman has been carefully watched during the whole of her

stay in the hospital ; and it is interesting to observe the modi-fications caused in the fit by the opening of the trachea. The facebecomes dark and livid, but not so much so as before the opera-tion. There is foaming at the mouth, the face is convulsed, andthe tongue has been bitten. She does not now utter the epilepticcry before the seizure is established ; but the limbs are convulsed,and a great noise is made during the struggle by the passing ofair through the tube. Altogether, the fits have been considerablyslighter since the operation than they were before.The patient used to fall into a heavy sleep after each fit, and

remain sleeping for several hours, being very stupid on awaking.She now sleeps for a short time after the fit, but is soon recoveredfrom its effects. Her intellect has decidedly improved: to thisall the persons in the ward bear testimony. Before the operation,she remained sullen and silent; she was, in fact, in a state

of 1fatuitv, and believed that the other patients were constantly"talking at her": she now enters into conversation, and is com.paratively rational. Before the operation, she had several fits of

I

maniacal excitement ; but she has since been quite orderly andunder the control of the nurses.The noise made through the tube, during the fit, as compared

with the former arrest of respiration, and the improved state ofthe brain, show that the oxygenation of the blood is much lessinterfered with now than formerly. The circulation of venousblood in the brain, and the strain upon the cerebral vessels, areprobably the chief reasons of the sopor which so commonlysucceeds the fit and the chronic deterioration to the brain. Fromthese, the opening in the trachea appears to guard the patient ;and perhaps this is the most positive benefit which has accrued inthe present case. She has had a less number of fits, and theyhave certainly been less severe, but a greater length of timethan has hitherto elapsed will be necessary before any positiveconclusion can be arrived at on these points. The patient willshortly be sent into the country ; but we shall probably be able togive the further results of the operation, whatever they may be.

During the severe weather in the middle of March, the patientcaught cold, and there was so much secretion in the trachea as toclog the tube, and seriously interfere with her breathing. Thetracheal secretion was extremely faetid. For two or three daysshe was dull and stupid, evidently from the imperfect respiration;but a new tube, admitting of more perfect respiration, was put inthe opening, and in two or three days she became better. Withthis exception, no local irritation of any kind has followed theoperation.

--

ST. BARTHOLOMEW’S HOSPITAL.

Femoral Hernia in an Epileptic Patient; unusual Situation ofthe Tumour.

(Under the care of Dr. ROUPELL.)IN the wide field of hospital practice, cases in which diagnosis

is somewhat difficuit are not unfrequently observed, and amongthese we must put tumours in the first rank. When the latterare situated in the abdomen, the most disheartening uncertaintyas to their nature often exists ; and even when they are properlyclassed, the physician experiences the annoyance of finding thedisease beyond his control. We need not say that tumours aboutthe head, neck, trunk, or extremities, also offer, now and then,considerable difficulties as to diagnosis, since it is mostly alterablation only that their nature is satisfactorily ascertained; butthe same amount of obscurity does not obtain respecting hernia,though great uncertainty may exist in exceptional circumstances.Such doubts are sometimes very perplexing, and many casesmight be cited in illustration, but we shall just refer to a few ofthem. Among these two occurred at Guy’s Hospital (see THELANCET, vol. ii. 1852, p. 300, and vol. i. 1853, p. 266), and onewas noticed a short time ago in Dr. Roupell’s wards. Mr. Croft,the clinical clerk, was kind enough to direct our attention to

the case, and to furnish a drawing, which accurately repre-sents the situation and relative size of the tumour. It is un-fortunate that no satisfactory history could be obtained, as thepatient’s state of mind is not such as to allow of clear statements;the only particulars of this seemingly external crural herniaare the following :-Mary Ann S-, aged fifty-four years, was admitted into

Mary’s ward, under the care of Dr. Roupell, October 7, 1852

The patient has been affected with epilepsy for several years.and it is for this malady that she was seeking relief in thishospital. Whilst under treatment it was observed that a tumourexisted in the upper and external part of the thigh. Theswelling was soft, elastic, painless, globular, and -very moveable.It was at first supposed that this growth was composed of adiposesubstance, as it had many of the characters of such tumours; but,on being handled, it was found that it yielded to a pressure up-wards, and when this pressure was continued, the tumour passedupwards and inwards towards Poupart’s ligament, and remainedwithin the abdomen. But, on the patient coughing, or resumingthe erect posture, the tumour would again escape from theabdomen and resume its place in the above-mentioned locality.(See the accompanying wood-cut.) We had frequent oppor-

tunities of examining this patient, and found no difficulty inreducing the tumour, which latter, from the s) mptcms enumerated,can hardly be called anything but a hernial protrusion. Noaccoun tot the rise and progress of the swelling could be obtainedfrom the patient; but it would appear that she had worn a trusson the left, OJ’ opposite side, for twelve years or more. No sortof uneasiness was ever felt in the tumour situated in the rightthigh; from this circumstance, and the peculiar feel of the part,it may be inferred that it consists principally of omentum. Whatpeculiaritv in the anatomical arrangement has caused this tumourto take this unusual direction ? Probably a laxity in the fasciaat the saphenic opening, which has caused the protrusion topress downwards and outwards, rather than to turn upon itselfand mount over the pubis. Without pretending t rely exclu-sively on this explanation of ours, we beg to leave the case inthe hands of our readers.

Mr. LAWRENCE’S Cccse of malignant Tumour qfthe Tiura Mater.(THE LANCET, vol i. 1853, p. 267.)

A few inaccuracies have crept into the account of this case,and we are anxious that they should not remain uncorrected.Some of these are self-evident: pmcticaUy (p. 268, half column)should have been printed practicably; and the woman was

operated upon Dec. 15, 1852, and not 1853. The patient did notdie one l.fee7;, but one nzoaath, after her return home; and whatwe called a clot of blood situated in the cerebellum was really aportion of medullary disease surrounded by a clot.

MIDDLESEX HOSPITAL.

Tumour over the Parotid Gland; Removal.

(Under the care of Mr. SHAW.)WE call attention to this case, as the patient seemed to

be affected with a cancerous degeneration of the parotid gland,and because the operation which was performed might belooked upon as an extirpation of the latter. It has, however,been often denied that the parotid gland could be safely excised,and the doubts raised on this subject are certainly very legitimate;for it is very probab’e that the removal of growths, pressingupon and almost annihilating the gland, have been taken foractual ablation of the gland itself. When we recollect the vesselsand nerves which are imbedded in the parotid, it becomes clearthat paralysis of one side of the face must unavoidably follow itsextirpation, that the external carotid must be tied, and that thesalivary secretion must considerably suffer. Nor is it possiblethat the whole gland be extirpated, from the great depth to whichits different processes are known to reach.The cases which were looked upon as instances of removal of

the parotid gland, were probably similar to the present case, inwhich a tumour of large size has gradually encroached upon thegland, and almost taken its place. We witnessed this operationwith great interest, as the tumour was so situated as to require a

dissection of a most delicate description, both as regards vessels

315

and nerves. It may be supposed, from the non-appearance ofparalysis, that the principal twigs of the facial nerve have escaped;this is an occurrence which we have lately observed on severaloccasions. From the characters presented by a section of thetumour, both to the naked eye and under the microscope, it wouldseem that this was one of those growths the origin of which iscystic, and which subsequently become the subject of cancerousdegeneration.

E. E-, aged sixty-six, a female employed in market-gar-dening, was admitted, under the care of Mr. Shaw, January 29,1853, with a tumour over the parotid gland on the left side. Thedescription noted on admission runs as follows:-The tumour is of the size of a large orange, and distinctly

lobulated; it has an elastic feel, and is moveable through thewhole extent of it base. Over two of the most prominent lobesthe skin has recently given way, forming narrow slit-like openings,from which a watery fluid, turbid with white curdy matter, anda pultaceous substance, resembling sebaceous matter, are dis-charged. Near the base of the tumour the skin is sound, butabout the apex it is discoloured, thickened, and adherent, as iffrom the effects of inflammation. The lobe of the ear has been

pushed upwards, and lies on the tumour above. There is no

enlargement or hardness of any of the adjoining glands, and noparalysis of the face.The swelling was first observed five years before admission;

it was then of the size of a chesnut. It gradually enlarged andreached, in two years, to the volume of a hen’s egg, but has

grown more rapidly for the last twelvemonth than previously.About three weeks before admission the skin inflamed and broke,but there has never been any pain in the tumour.

As the patient was, on her admission, out of health and weak,it was thought advisable to defer an operation till her strengthshould be re-established. After taking alteratives, tonics, andproper diet for three weeks, she was considered in a fit conditionfor the removal of the tumour. During that time the dischargefrom the narrow openings at the apex continued, so that the size Iof the tumour was perceptibly diminished, ind the growthbecame looser about its base. It was also remarked that theorifices through which a discharge was taking place did not pre-sent any appearance of ulceration.On the 18th of February, 1853, the patient was put under the

influence of chloroform, and Mr. Shaw proceeded to remove thetumour in the following manner :-A semicircular incision wasmade, commencing below the tumour, carried in front as far asthe skin was sound, and towards the upper and back part tobelow the ear. The skin being retracted anteriorly, Mr. Shawcut down through layers of fascia till he reached the substanceof the tumour. At first the textures were found dense and adhe-rent, and, in cutting throngh them, two arteries which requiredligatures were divided; but, as the base was reached, the cellularmembrane intervening between the base and a spurious cystformed by condensation of the structures beneath was so thinand delicate that the tumour could be detached without furtherhsemorrhage. The lips of the incision above and below, werebrought together by sutures ; in the centre the edges were aboutan inch and a half apart; and, owing to the tumour having formeda hollow for itself behind the jaw, the bottom of the wound wassituated at a considerable depth.Examination of the Tumour.-Its structure consisted of an

uniformly firm substance, somewhat crisp, resembling unripepear; the growth was mostly bloodless, of a cream-white colour,with patches here and there, where the colour, without percepti-ble difference in the density, was pure white. On scraping thesurface with the blade of a knife, a thin creamy juice exuded.The centre was excavated, and in three of the principal lobesthere were cavities which communicated with the central one.The walls were composed of the broken-down substance of thetumour, soft and discoloured with various hues of purple. Thecavities were partly filled with pulpy, sebaceous-like matter,similar to what had been discharged before the operation.

[For the following account of the microscopical appearanceswe are indebted to Mr. Sibley, late house-surgeon to thehospital.]

Under the microscope, the tumour exhibits the structure

generally observed in colloid cancer. The tissue composing itmay be arranged under three heads: firstly, large bands ofareolar tissue, which ran in different directions; secondly, a tex-ture forming the walls of small loculi, of which the growth iscomposed ; thirdly, cells closely packed together, and filling upthese loculi. In some parts the walls of the latter are almostabsent, the tissue appearing to be composed entirely of cells; inother parts, the texture forming the walls of these loculi is ingreat abundance. The bands of areolar tissue are those seen bythe naked eye, forming the stroma of the tumour, and consist ofboth white and elastic fibres. The second tissue, that formingthe walls of the loculi, contains only a small quantity of commonareolar tissue, but is mainly composed of fibrils of much largerand very uniform diameter. There are also a considerablenumber of nuclei arranged amongst this tissue. The cells fillingup these loculi are of large size and of various form; the majorityare highly granular, and contain a spheroidal nucleus with abright nucleolus ; in others the nucleus is obscured by a numberof large granules of fat, filling the cells. The diameter of theloculi varies from about twice to ten times the diameter of thecells.The case progressed very satisfactorily, and no untoward

symptoms have been observed. Three weeks after the operationthe extensive wound had contracted to the size of a shilling; theadjoining parts were soft, and presented a perfectly healthyappearance. It will be our duty to watch the fate of this patient,and we hope to be able to give a report hereafter of the ulteriorissue of the case.

_

Medical Societies.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, MARCH 22, 1853.—DR. COPLAND, PRESIDENT.

CASE OF GANGRENA SENILIS SUCCESSFULLY TREATED BY AMPU-TATION OF THE THIGH. By F. W. GARLIKE, Esq., Rick-mansworth.

(Communicated by Mr. WALTON.)

WILLIAisi A-, aged sixty-nine, labourer, an extremely ema-ciated man, of sallow complexion, marked with the small-pox,bald, and toothless, suffered since May 1 from a small painfulsore on the great toe of the right foot, accompanied with shootingpains in the leg. He continued work until May 11, when hecame under Mr. Garlike’s care. The toe was then slightly in-flamed ; the foot exhibited a dry, scaly appearance; there was nosense of feeling in the smaller toes, and the temperature wasbelow the natural standard. The left foot was similar in appear-ance, but free from any wound. No pulsation could be felt inthe right femoral artery below the superior third; the iliacarteries pulsated softly. About the middle of July the whole footwas converted as far as the instep into a black slough ; he sufferedthe most intense pain, and the delirium was almost constant;pulse 105-120. In August a line of demarcation formed acrossthe dorsum of the foot ; florid granulations presented themselves,and the pain became less. The patient took bark, ammonia, andopium. Next, a large collection of matter formed in the leg ; itburst spontaneously below the head of the tibia, and dischargeda quantity of purulent fluid. After a fortnight it healed, withthe exception of a small fistulous passage leading to the bone.In a few days a second collection formed, which pursued asimilar course. Afterwards matter collected in the knee-joint;and on September 20 the synovial membrane gave way just infront of the internal lateral ligament, and gave exit to more thana pint of pus. The patient’s health improving somewhat, Mr.Garlike determined upon amputation of the thigh. Mr.Walton, to whom the case was subjected for opinion, did notspeak encouragingly of the operation, but he thought that pure