ST. BARTHOLOMEW'S HOSPITAL
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767 about a twelvemonth ago : it had, therefore, shown rapid pro- gress in attaining its present size. There were two lymphatic glands in the neck, below the body of the jaw on the right side, which had enlarged ; and the submaxillary gland was indurated. The aspect and history of the disease gave the impression- in which Mr. Gay’s colleagues and his friend Mr. Coulson, who had seen the case, concurred-that it was a malignant growth taking its origin from the cancellated tissue of the bone ; and, with this impression, Mr. Gay advised its extirpation, rather with the view of releasing the patient from a growth which threatened speedily to occlude the passages to the lungs and stomach, than with that of eradicating the disease from the system. Mr. Gay performed the operation on the 7th of August. After cutting through the integuments from each corner of the mouth downwards below the base of the jaw, and reflecting them, as well as the intermediate portion from the symphysis, back, Mr. Gay sawed the bone through on each side, keeping quite clear of the disease. This was accomplished with con- siderable difficulty. One saw broke in the process; and this was not to be wondered at when, on inspecting the bone, its tissues were found to have become exceedingly compact, so that in density it resembled ivory. As soon as this part of the ,operation had been accomplished, Mr. Gay proceeded to dissect away the growth from beneath the tongue, and from the front of the larynx, with which it was in contact, and subsequently ’, from its inferior connexions with the parts at the base of the mouth. An incision was then carried downwards along the neck from that which began at the right corner of the mouth to the diseased lymphatic glands, by which these were re- moved. The submaxillary, as it was hoped that it had only become sympathetically affected, was not interfered with. A few vessels had to be secured in the deeper parts of this some- what extensive wound ; and the parts were brought together, and secured by silver suture. A ligature, which had been put through the tongue for the purpose of controlling it during the operation, was allowed to remain in the event of its becoming necessary to overcome any tendency on the part of its dis- arranged muscular apparatus to draw it backwards towards the pharynx. The after-history of the case was, in the main, most satis- factory. The tongue did not manifest any disposition to ’become unruly; its tip, however, to the extent of an inch, sloughed. With the help of a spoon, and the constant and assiduous attention of the deaconesses who devote themselves to the care of the patients at this hospital, the patient was able early to take abundance of nourishment and the necessary .amount of stimulus, so that healing commenced quickly, and at the end of ten days had made such progress, and the patient’s health had so far recovered, that he expressed himself able to leave the hospital in order to make a more agreeable use of his visit to London. At the expiration of a further fortnight he returned to Penzance, wbere important duties called him, or at least required his supervision, which he said he was quite able to give to them. The last report, about five weeks since, announced his con- valescence, with very fair and unexpected powers of speech and mastication. An artificial portion of jaw, in lieu of that taken away, which Mr. Fox, one of the dentists to the hos- pital, says he can supply, will go far to counteract some of the ill results of so considerable a mutilation. The operation was performed under the influence of chloroform. An examination of the parts removed showed that the dis- ease originated in the periosteum, and, from the character of the cells, which with some areolar stroma constituted the en- ,tire growth, that it was unquestionably myeloid. ST. BARTHOLOMEW’S HOSPITAL. A CASE OF IDIOPATHIC TETANUS. (Under the care of Mr. HOLMES COOTE.) THE following case, for the notes of which we are indebted to Mr. Horsfall, house-surgeon, would seem to be an example ’of the condition known as idiopathic tetanus. It is the fourth of its kind which has come under Mr. Coote’s observation. William C aged fifty-four, a labourer, a very muscular man, came to the surgery on Nov. Ilth, complaining of head- - ache and stiffness of the jaws. Trismus and risus sardonicus were well marked. He had felt the stiffness two days before. Had no headache until this morning. On admission, he could move his jaw very slightly. As he went from the surgery to the ward he fell, as he said, from weakness. He recollected no injury, recent or otherwise, and has had no pain in abdomen or elsewhere until this morning. Has always been a healthy and temperate man. He was ad- mitted at twelve noon. Bowels open yesterday, and not this morning.-Half-past one P.M.: Cannot move his jaw at all. Pulse 100, very strong and full; trismus more marked ; muscles of abdomen very tense and hard ; opisthotonos very slight, but persistent; respiration entirely thoracic. - Quarter past two P.M.: One minim of croton oil was administered. - Five P.M.: Bowels not open. Croton oil repeated. Pulse as before; tongue very red and moist, protruded with difficulty; opistho- tonos more marked ; perspiring freely. - Eight P.M.: Bowels open twice since five; perspiration very profuse; pulse 124, slightly irregular in force, and very full ; shows the tip of his tongue with great difficulty; respiration thoracic, but not laboured.-Quarter past ten P.M.: Pulse 110, not so full, more natural and regular; bowels open twice since eight P.M. Nov. 12th.-Thirty-five minutes past twelve: Bowels open at half-past ten, slightly; pulse 108, as before. An ounce and a half compound senna draught administered as an enema ; half a grain of morphia injected subcutaneously.-Twenty minutes past two A.M.: Bowels not open again; respiration thoracic and free ; perspiration less ; says he feels better ; no alteration in other respects. - Four A.M.: Pulse 100, feeble ; breathing stertorous and laboured ; has breathed so for the last fifteen minutes ; opisthotonos increased and persistent ; both arms completely flexed ; hands clenched ; surface of body, where exposed, very cold; evidently moribund. He died about half-past four. Throughout the progress of this case the spasmodic contrac- tion was persistent and increasing. A careful examination of the surface of the body failed to discover any scratch or bruise. The teeth were not more carious than the average at his age. Nothing whatever was discovered in the post-mortem ex- amination that could be even hypothetically regarded as an irritating cause. There has been quite a cluster, Mr. Horsfall tells us, of cases with tetanic symptoms in this hospital of late. Besides the above, there have been three of tetanus proper-two of which were of traumatic origin,-and two of poisoning by strychnia. One of these last, the result of a dose of " Battle’s vermin- killer," was fatal; in the other, very alarming symptoms were produced by a very minute dose of liquor strychnine. We shall, probably, refer to these on another occasion. Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY. TUESDAY, DEC. 10TH, 1867. MR. SAMUEL SOLLY, F.R.S., PRESIDENT, IN THE CHAIR. (1) ON CERTAIN POINTS IN THE ANATOMY AND PATHOLOGY OF BRIGHT’S DISEASE OF THE KIDNEY; AND (2) ON THE INFLUENCE OF THE MINUTE BLOODVESSELS UPON THE CIRCULATION. BY GEORGE JOHNSON, M. D., PHYSICIAN TO KING’S COLLEGE HOSPITAL. IT is now generally admitted that cases of chronic Bright’s , disease may be arranged in two distinct classes :-1. Cases in which the kidney is large, pale, and smooth on the surface. 2. Cases in which the kidney is small, red, and granular. In the forty-second volume of the "Medico-Chirurgical Trans- actions" the author pointed out the chief features by which the two classes of cases may be distinguished. There is some difference of opinion with regard to the anatomy and pathology of the various forms of Bright’s disease. Some pathologists maintain that the small granular kidney is the result of an in- tertubular deposit. The author maintains that there is no proof of such deposit; while the red colour and the vascularity of these kidneys seen in an advanced stage afford proof that no such deposit exists. All the essential changes in this dis- ease are intra-tubular. In the 33rd volume of the "Transactions" the author first noted the fact, that in all the forms of chronic Bright’s disease the muscular walls of the minute renal arteries are hyper- trophied. He then supposed that this was the result of an effort to propel the blood onwards. It is now generally ad- mitted that the minute arteries act as stop-cocks ; that they
Transcript of ST. BARTHOLOMEW'S HOSPITAL
767about a twelvemonth ago : it had, therefore, shown rapid pro-gress in attaining its present size. There were two lymphaticglands in the neck, below the body of the jaw on the rightside, which had enlarged ; and the submaxillary gland wasindurated.The aspect and history of the disease gave the impression-
in which Mr. Gay’s colleagues and his friend Mr. Coulson, whohad seen the case, concurred-that it was a malignant growthtaking its origin from the cancellated tissue of the bone ; and,with this impression, Mr. Gay advised its extirpation, ratherwith the view of releasing the patient from a growth whichthreatened speedily to occlude the passages to the lungs andstomach, than with that of eradicating the disease from thesystem.Mr. Gay performed the operation on the 7th of August.
After cutting through the integuments from each corner of themouth downwards below the base of the jaw, and reflectingthem, as well as the intermediate portion from the symphysis,back, Mr. Gay sawed the bone through on each side, keepingquite clear of the disease. This was accomplished with con-siderable difficulty. One saw broke in the process; and thiswas not to be wondered at when, on inspecting the bone, itstissues were found to have become exceedingly compact, sothat in density it resembled ivory. As soon as this part of the,operation had been accomplished, Mr. Gay proceeded to dissectaway the growth from beneath the tongue, and from the frontof the larynx, with which it was in contact, and subsequently ’,from its inferior connexions with the parts at the base of themouth. An incision was then carried downwards along theneck from that which began at the right corner of the mouthto the diseased lymphatic glands, by which these were re-moved. The submaxillary, as it was hoped that it had onlybecome sympathetically affected, was not interfered with. A few vessels had to be secured in the deeper parts of this some-what extensive wound ; and the parts were brought together,and secured by silver suture. A ligature, which had been putthrough the tongue for the purpose of controlling it during theoperation, was allowed to remain in the event of its becomingnecessary to overcome any tendency on the part of its dis-arranged muscular apparatus to draw it backwards towardsthe pharynx.The after-history of the case was, in the main, most satis-
factory. The tongue did not manifest any disposition to’become unruly; its tip, however, to the extent of an inch,sloughed. With the help of a spoon, and the constant andassiduous attention of the deaconesses who devote themselvesto the care of the patients at this hospital, the patient wasable early to take abundance of nourishment and the necessary.amount of stimulus, so that healing commenced quickly, and atthe end of ten days had made such progress, and the patient’shealth had so far recovered, that he expressed himself able toleave the hospital in order to make a more agreeable use of hisvisit to London. At the expiration of a further fortnight he returned to Penzance, wbere important duties called him, or atleast required his supervision, which he said he was quite ableto give to them.The last report, about five weeks since, announced his con-
valescence, with very fair and unexpected powers of speechand mastication. An artificial portion of jaw, in lieu of thattaken away, which Mr. Fox, one of the dentists to the hos-pital, says he can supply, will go far to counteract some of theill results of so considerable a mutilation. The operation wasperformed under the influence of chloroform.An examination of the parts removed showed that the dis-
ease originated in the periosteum, and, from the character ofthe cells, which with some areolar stroma constituted the en-,tire growth, that it was unquestionably myeloid.
ST. BARTHOLOMEW’S HOSPITAL.A CASE OF IDIOPATHIC TETANUS.
(Under the care of Mr. HOLMES COOTE.)THE following case, for the notes of which we are indebted
to Mr. Horsfall, house-surgeon, would seem to be an example’of the condition known as idiopathic tetanus. It is the fourthof its kind which has come under Mr. Coote’s observation.William C aged fifty-four, a labourer, a very muscular
man, came to the surgery on Nov. Ilth, complaining of head-- ache and stiffness of the jaws. Trismus and risus sardonicuswere well marked. He had felt the stiffness two days before.Had no headache until this morning.On admission, he could move his jaw very slightly. As he
went from the surgery to the ward he fell, as he said, fromweakness. He recollected no injury, recent or otherwise, andhas had no pain in abdomen or elsewhere until this morning.Has always been a healthy and temperate man. He was ad-mitted at twelve noon. Bowels open yesterday, and not thismorning.-Half-past one P.M.: Cannot move his jaw at all.Pulse 100, very strong and full; trismus more marked ; musclesof abdomen very tense and hard ; opisthotonos very slight, butpersistent; respiration entirely thoracic. - Quarter past twoP.M.: One minim of croton oil was administered. - Five P.M.:Bowels not open. Croton oil repeated. Pulse as before;tongue very red and moist, protruded with difficulty; opistho-tonos more marked ; perspiring freely. - Eight P.M.: Bowelsopen twice since five; perspiration very profuse; pulse 124,slightly irregular in force, and very full ; shows the tip of histongue with great difficulty; respiration thoracic, but notlaboured.-Quarter past ten P.M.: Pulse 110, not so full, morenatural and regular; bowels open twice since eight P.M.Nov. 12th.-Thirty-five minutes past twelve: Bowels open
at half-past ten, slightly; pulse 108, as before. An ounce anda half compound senna draught administered as an enema ;half a grain of morphia injected subcutaneously.-Twentyminutes past two A.M.: Bowels not open again; respirationthoracic and free ; perspiration less ; says he feels better ; noalteration in other respects. - Four A.M.: Pulse 100, feeble ;breathing stertorous and laboured ; has breathed so for thelast fifteen minutes ; opisthotonos increased and persistent ;both arms completely flexed ; hands clenched ; surface of body,where exposed, very cold; evidently moribund. He died abouthalf-past four.Throughout the progress of this case the spasmodic contrac-
tion was persistent and increasing. A careful examination ofthe surface of the body failed to discover any scratch or bruise.The teeth were not more carious than the average at his age.Nothing whatever was discovered in the post-mortem ex-
amination that could be even hypothetically regarded as anirritating cause.There has been quite a cluster, Mr. Horsfall tells us, of cases
with tetanic symptoms in this hospital of late. Besides theabove, there have been three of tetanus proper-two of whichwere of traumatic origin,-and two of poisoning by strychnia.One of these last, the result of a dose of " Battle’s vermin-killer," was fatal; in the other, very alarming symptoms wereproduced by a very minute dose of liquor strychnine. We shall,probably, refer to these on another occasion.
Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
TUESDAY, DEC. 10TH, 1867.MR. SAMUEL SOLLY, F.R.S., PRESIDENT, IN THE CHAIR.
(1) ON CERTAIN POINTS IN THE ANATOMY AND PATHOLOGY OFBRIGHT’S DISEASE OF THE KIDNEY; AND (2) ON THE
INFLUENCE OF THE MINUTE BLOODVESSELSUPON THE CIRCULATION.
BY GEORGE JOHNSON, M. D.,PHYSICIAN TO KING’S COLLEGE HOSPITAL.
IT is now generally admitted that cases of chronic Bright’s, disease may be arranged in two distinct classes :-1. Cases in
which the kidney is large, pale, and smooth on the surface.2. Cases in which the kidney is small, red, and granular. Inthe forty-second volume of the "Medico-Chirurgical Trans-actions" the author pointed out the chief features by whichthe two classes of cases may be distinguished. There is somedifference of opinion with regard to the anatomy and pathologyof the various forms of Bright’s disease. Some pathologistsmaintain that the small granular kidney is the result of an in-tertubular deposit. The author maintains that there is no
proof of such deposit; while the red colour and the vascularityof these kidneys seen in an advanced stage afford proof thatno such deposit exists. All the essential changes in this dis-ease are intra-tubular.In the 33rd volume of the "Transactions" the author first
noted the fact, that in all the forms of chronic Bright’s diseasethe muscular walls of the minute renal arteries are hyper-trophied. He then supposed that this was the result of aneffort to propel the blood onwards. It is now generally ad-mitted that the minute arteries act as stop-cocks ; that they
