ST. BARTHOLOMEW'S HOSPITAL.
1
411 23rd. -Has only a drop of clear fluid in the morning. Has attempted connexion, but failed, owing to premature emission. Endoscope showed the bulb still slightly granular. Solution applied. 30th. —Endoscope showed the bulb much improved. Solu- tion applied, and to use injection of sulphate of zinc. July 7th.—Much improved. Endoscope showed bulb nearly healthy. To continue the injection. 28th.—Is well. Cavendish-place, Sept. 1866. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. ST. BARTHOLOMEW’S HOSPITAL. EXTIRPATION OF THE SUPERIOR MAXILLARY BONE FOR MALIGNANT DISEASE; HÆMORRHAGE ON EIGHTEENTH DAY; LIGATURE OF THE COMMON CAROTID ARTERY; DEATH. (Under the care of Mr. HOLMES COOTE.) Nulla autem est alia. pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, tum proprias collectas habere, et intei’ se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium. THE operation which was performed in this case is so gene- rally successful, and so very seldom complicated by serious secondary haemorrhage, notwithstanding the vascularity of the parts exposed and the free bleeding which always occurs at the time, that the record subjoined is of interest. Angus R-, aged forty-six, a cellarman at ale and beer stores, was admitted July 31st, 1866. He was an intelligent, but poorly nourished and pallid, bloodless-looking man, who in his avocation was much exposed to cold. He said that about last January, after unusual exposure to cold, he suffered severe pain of a neuralgic character in the left cheek, which he attributed to the irritation of a carious tooth; a fortnight afterwards he had the tooth extracted, but the pain of the face continued. About the beginning of June he first noticed a swelling in the mouth; there was general enlargement of that side of the face, and a small prominent red tumour below the left eyelid near the inner canthus. On examination, Mr. Coote detected an ulcerated cancerous growth affecting the left half of the palate; its absolute extent posteriorly could scarcely be ascerbained. There was an of- fensive smell from the mouth. The superior maxillary bone was generally enlarged. The small tumour of the cheek was opened, and gave exit to some thick cheesy-looking matter. A probe passed through some thickish substance readily into the antrum. The nature of the case having been ascertained, Mr. Coote, at the patient’s earnest request, removed the whole maxillary bone on Aug. 4th. The incision through the cheek was curved outwards from the canthus of the eye, in a sweep, into the mouth. The bone was soon removed, the only difficulty pro- ceeding from the soft and friable nature of the morbid growth. No bad symptom supervened, and the wound closed by first intention. On Aug. 18th there ensued some amount of haemorrhage from the mouth. It ceased on the application of ice in five minutes. On the 21st haemorrhage returned. On the 23rd, Mr. Orton, the house-surgeon, was suddenly called into the ward, and found the patient blanched and senseless from a sudden and continuous gush of blood. The pulse was not perceptible. He immediately tied the common carotid artery, and the hæmor- rhage was at once arrested. Nourishment was given, and the patient expressed himself as comfortable, but death ensued about two hours after the operation. The artery is preserved in the museum of the hospital. The source of haemorrhage was a branch of the internal maxillary artery, which opened into some of the diseased tissue. ST. THOMAS’S HOSPITAL. STRANGULATED HERNIA; OPERATION; RECOVERY. (Under the care of Mr. LE GROS CLARK.) I VERY difficult is the attempt to judge before an operation is performed where the seat of stricture in hernia will be found. An illustration of this occurred a shorb time ago in a case treated by Mr. Le Gros dark. The patient (C. M., aged forty- nine) was a butcher, who had been previously an inmate of the hospital with strangulated hernia, which, however, was reduced. On the present occasion the hernia had descended into the scrotum, and was very tense and tender. The ordi- nary symptoms of acute strangulation had existed but a few hours, but were of so urgent a character that, after an unavail- ing attempt to reduce the rupture by taxis, Mr. Le Gros Clark performed the usual operation for the relief of the patient. The acuteness of the symptoms and the suddenness of the attack suggested the idea that the external ring might be the seat of strangulation ; but its edge was divided without relief. On introducing the finger into the inguinal canal, a strong but fine fibrous band was felt stretching across and external to the neck of the sac. This band had precisely the feel of a tight horse-hair, and required the knife for its division. Imme- diately this was accomplished, the contents of the hernial sac were returned into the abdomen with great facility, and the patient made a good recovery. The position of this solitary band within the external ring, and at right angles to its pillars, renders it probable that it was one of the intercolumnar bands, exposed by the separation of the aponeurosis of the external oblique muscle. Mr. Le Gros Clark has noticed a similar re- lation in the post-mortem dissection of an inguinal rupture. WESTMINSTER HOSPITAL. SEVERE PUNCTURED WOUND OF THE BUTTOCK AND PERI- NEUM, WITH INJURY TO THE PERITONEUM, THE RE- SULT OF A FALL FROM A SECOND-FLOOR WINDOW ON TO THE AREA RAILINGS. (Under the care of Mr. BARNARD HOLT.) MARY A. B--, aged twenty-six, a servant, was admitted into the hospital suffering from the above injury. She stated that while cleaning windows on the second floor she lost her balance, and fell upon the area railings, upon which she became impaled. She was removed by the bystanders, and immediately brought to the hospital. On admission, it was found that she had received two very severe wounds, one run- ning deep between the glutei muscles, and the other entering the ischio-rectal fossa, wounding the levator ani and, as the symptoms subsequently showed, the peritoneum. ’ The whole length of the finger could be readily passed into either wound. Being greatly prostrated, although there had not been any material hæmorrhage, some ammonia-and-brandy was admi- nistered, and she quickly rallied. In the evening Mr. Holt found the patient hot and thirsty, and the wound in the but- tock, as well as that in the perineum, looked swelled and puny ; and from the latter there was a continued dripping of limpid fluid, slightly tinged with blood, this escaping in such quantities as to saturate the bed upon which she was lying. She was ordered a mixture of acetate of ammonia and opium, and fomentation to be applied to the wound. She had but little sleep, and on the following day the pulse was 120; skin hot. She complained of great thirst, was slightly delirious, and the abdomen was tender. The limpid fluid still continued to escape in large quantities. Arrowroot and milk for diet; turpentine fomentation to the abdomen ; to continue the mixture, and take half a grain of opium every three hours. In the evening she was restless and wandering ; the pain had been relieved by the turpentine, but the fluid continued to escape. On the second day she was slightly improved, but still com- plained of pain when the lower part of the abdomen was pressed. The bowels had not acted ; but Mr. Holt did not think it advisa,lale to order any purgative. The opium and fomentations were continued. The urine was quiue natural, free from blood, and passed without pain. On the third day she was still gradually improving; the watery fluid, which had previously escaped in large qnan- tities, began to diminish, and ti-,e wounds looked more healthy
Transcript of ST. BARTHOLOMEW'S HOSPITAL.
411
23rd. -Has only a drop of clear fluid in the morning. Has
attempted connexion, but failed, owing to premature emission.Endoscope showed the bulb still slightly granular. Solutionapplied.
30th. —Endoscope showed the bulb much improved. Solu-tion applied, and to use injection of sulphate of zinc.
July 7th.—Much improved. Endoscope showed bulb nearlyhealthy. To continue the injection.
28th.—Is well.Cavendish-place, Sept. 1866.
A MirrorOF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
ST. BARTHOLOMEW’S HOSPITAL.
EXTIRPATION OF THE SUPERIOR MAXILLARY BONE FOR
MALIGNANT DISEASE; HÆMORRHAGE ON EIGHTEENTH
DAY; LIGATURE OF THE COMMON CAROTID ARTERY;DEATH.
(Under the care of Mr. HOLMES COOTE.)
Nulla autem est alia. pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, et intei’se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium.
THE operation which was performed in this case is so gene-rally successful, and so very seldom complicated by serioussecondary haemorrhage, notwithstanding the vascularity of theparts exposed and the free bleeding which always occurs atthe time, that the record subjoined is of interest.Angus R-, aged forty-six, a cellarman at ale and beer
stores, was admitted July 31st, 1866. He was an intelligent,but poorly nourished and pallid, bloodless-looking man, whoin his avocation was much exposed to cold. He said thatabout last January, after unusual exposure to cold, he sufferedsevere pain of a neuralgic character in the left cheek, whichhe attributed to the irritation of a carious tooth; a fortnightafterwards he had the tooth extracted, but the pain of the facecontinued. About the beginning of June he first noticed aswelling in the mouth; there was general enlargement of thatside of the face, and a small prominent red tumour below theleft eyelid near the inner canthus.On examination, Mr. Coote detected an ulcerated cancerous
growth affecting the left half of the palate; its absolute extentposteriorly could scarcely be ascerbained. There was an of-fensive smell from the mouth. The superior maxillary bonewas generally enlarged. The small tumour of the cheek was
opened, and gave exit to some thick cheesy-looking matter.A probe passed through some thickish substance readily intothe antrum.The nature of the case having been ascertained, Mr. Coote,
at the patient’s earnest request, removed the whole maxillarybone on Aug. 4th. The incision through the cheek was curvedoutwards from the canthus of the eye, in a sweep, into themouth. The bone was soon removed, the only difficulty pro-ceeding from the soft and friable nature of the morbid growth.No bad symptom supervened, and the wound closed by firstintention.On Aug. 18th there ensued some amount of haemorrhage from
the mouth. It ceased on the application of ice in five minutes.On the 21st haemorrhage returned. On the 23rd, Mr. Orton,the house-surgeon, was suddenly called into the ward, andfound the patient blanched and senseless from a sudden andcontinuous gush of blood. The pulse was not perceptible. Heimmediately tied the common carotid artery, and the hæmor-rhage was at once arrested. Nourishment was given, and thepatient expressed himself as comfortable, but death ensuedabout two hours after the operation.The artery is preserved in the museum of the hospital. The
source of haemorrhage was a branch of the internal maxillaryartery, which opened into some of the diseased tissue.
ST. THOMAS’S HOSPITAL.
STRANGULATED HERNIA; OPERATION; RECOVERY.(Under the care of Mr. LE GROS CLARK.)
I VERY difficult is the attempt to judge before an operation isperformed where the seat of stricture in hernia will be found.An illustration of this occurred a shorb time ago in a casetreated by Mr. Le Gros dark. The patient (C. M., aged forty-nine) was a butcher, who had been previously an inmate ofthe hospital with strangulated hernia, which, however, wasreduced. On the present occasion the hernia had descendedinto the scrotum, and was very tense and tender. The ordi-
nary symptoms of acute strangulation had existed but a fewhours, but were of so urgent a character that, after an unavail-ing attempt to reduce the rupture by taxis, Mr. Le Gros Clarkperformed the usual operation for the relief of the patient.The acuteness of the symptoms and the suddenness of theattack suggested the idea that the external ring might be theseat of strangulation ; but its edge was divided without relief.On introducing the finger into the inguinal canal, a strong butfine fibrous band was felt stretching across and external to theneck of the sac. This band had precisely the feel of a tighthorse-hair, and required the knife for its division. Imme-diately this was accomplished, the contents of the hernial sacwere returned into the abdomen with great facility, and thepatient made a good recovery. The position of this solitaryband within the external ring, and at right angles to its pillars,renders it probable that it was one of the intercolumnar bands,exposed by the separation of the aponeurosis of the externaloblique muscle. Mr. Le Gros Clark has noticed a similar re-lation in the post-mortem dissection of an inguinal rupture.
WESTMINSTER HOSPITAL.SEVERE PUNCTURED WOUND OF THE BUTTOCK AND PERI-
NEUM, WITH INJURY TO THE PERITONEUM, THE RE-SULT OF A FALL FROM A SECOND-FLOOR WINDOW ON
TO THE AREA RAILINGS.
(Under the care of Mr. BARNARD HOLT.)
MARY A. B--, aged twenty-six, a servant, was admittedinto the hospital suffering from the above injury. She statedthat while cleaning windows on the second floor she losther balance, and fell upon the area railings, upon which shebecame impaled. She was removed by the bystanders, andimmediately brought to the hospital. On admission, it wasfound that she had received two very severe wounds, one run-ning deep between the glutei muscles, and the other enteringthe ischio-rectal fossa, wounding the levator ani and, as thesymptoms subsequently showed, the peritoneum. ’ The wholelength of the finger could be readily passed into either wound.Being greatly prostrated, although there had not been anymaterial hæmorrhage, some ammonia-and-brandy was admi-nistered, and she quickly rallied. In the evening Mr. Holtfound the patient hot and thirsty, and the wound in the but-tock, as well as that in the perineum, looked swelled andpuny ; and from the latter there was a continued dripping oflimpid fluid, slightly tinged with blood, this escaping in suchquantities as to saturate the bed upon which she was lying.She was ordered a mixture of acetate of ammonia and opium,and fomentation to be applied to the wound.
-
She had but little sleep, and on the following day the pulsewas 120; skin hot. She complained of great thirst, wasslightly delirious, and the abdomen was tender. The limpidfluid still continued to escape in large quantities. Arrowrootand milk for diet; turpentine fomentation to the abdomen ; tocontinue the mixture, and take half a grain of opium everythree hours. In the evening she was restless and wandering ;the pain had been relieved by the turpentine, but the fluidcontinued to escape.On the second day she was slightly improved, but still com-
plained of pain when the lower part of the abdomen was
pressed. The bowels had not acted ; but Mr. Holt did not
think it advisa,lale to order any purgative. The opium andfomentations were continued. The urine was quiue natural,free from blood, and passed without pain.On the third day she was still gradually improving; the
watery fluid, which had previously escaped in large qnan-tities, began to diminish, and ti-,e wounds looked more healthy
