952

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

KING’S COLLEGE HOSPITAL.

Nulla autem est alia pro certo noscendi via, nisi qnamplurimas et morborun.et dissectiolLllm historias, tum aliorum tum proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium.

ON Saturday last among the cases operated on were twoof special interest. The first was the removal by Mr. JohnWood of the left scapula from a young girl from whom theupper limb had been removed five months previously for sar-coma. This is the third tin3e Mr. Wood has removed the scapula;his first case was recorded in "Mirror of Hospital Practice,"Feb. 27tb, 1875. The next case was that of an excision of the

upper end of the right femur from a man who had sufferedfrom hip disease for many years. After removal of the greattrochanter a fragment of dead bone, the size of a filbert, andevidently the remains of the head of the femur, was dis-covered embedded in the acetabulum, and removed with anelevator. In some of its clinical and pathological featuresthis case bore some resemblance to one under the care ofMr. Smith last year, and recorded in the "Mirror of Hos-

pital Practice" on January 8th last. In that instance a

large piece of dead bone was found during excision of anelbow-joint to have been the cause of inflammation and sup-puration in the joint after fracture of the internal condyle.

SARCOMA OF THE SCAPULA ; REMOVAL.

(Under the care of Mr. JOHN WOOD. )For the early notes of this case we are indebted to

Mr. Hugh Smith, surgical registrar.The patient, Sarah Ann F-, aged seventeen, was origi-

nally admitted into King’s College Hospital, under the careof Mr. John Wood, on January 9th, 1881. She was thenwell nourished, but spare, and somewhat pallid. Six monthsbefore admission she felt pain in the left shoulder; threemonths later swelling was noticed in the same place. Onadmission the outer and anterior aspects of the upper fourthof the left humerus were seen to be the seat of a roundedtumour. The skin over it was tense, the superficial veinswere enlarged, and the mass felt bard, but slightly elasticon pressure. On January 15th amputation of the left armat the shoulder-joint was performed under Listerian anti-septic precautions. Some processes of the tumour extendedinto the supra-spinatus and infra-spinatus fossæ, but therewas no evidence of any new growth springing from thescapula itself. The muscles arising from the scapula andpassing to the head of the humerus felt rather harder thannormal, and so were cut off as close to the former as possible.Microscopical examination of the tumour : Spindle-celledsarcoma, with a few round cells scattered throughout thegrowth.On the 20th the wound in the skin had healed, and on

February 26th the patient was discharged, apparently cured.She was advised to attend the hospital from time to time, inorder that the parts might be closely watched. She did not,however, return till about the middle of May, when a largetumour was found, apparently involving the whole of thescapula. The patient stated that she first noticed painabout the shoulder six weeks before.The tumour seemed to involve the whole of the scapula,

and was of semi-spheroidal shape. Across its centre theskin was nodulated, discoloured, and adherent, but therewere no enlarged glands in the neighbourhood. The tumour,which was very hard and dense, was freely movable on thechest walls. The patient was kept in the hospital a fewdays, in order to prepare her for the operation, which, asalready stated, was performed on Saturday last in the fol-lowing manner, with strict antiseptic precautions (Listerian).The patient, having been placed under the influence of an

anaesthetic, an incision was made through the skin across theclavicle about its middle. This bone was then divided bymeans of a small saw and cutting pliers. The subclavian

and the posterior scapular arteries were compressed by Mr.Royes Bell through this incision, while Mr. Wood extendedthe incision vertically downwards to the level of the lowerborder of the scapula in front. Two incisions were thenmade across thb tumour, inclining upwards and backwardsfrom the vertical incision, so as to include part of the cicatrixof the previous operation and those portions of the skin thatwere implicated by the growth. The upper and lower flapsthus formed were then dissected up from the growth, which,with the morbid scapula, was then iapidly removed from itsconnexions to the chest walls by cutting its attachmentsfrom before backwards. The serratus magnus and adjacentmuscles did not seem to be implicated. Fifteen vessels weresecured with carbolised catgut, and after the insertion ofdrainage-tubes the skin-flaps were neatly brought together,and fixed by deep and superficial sutuies of wire and silk.The wounds were covered by " protective," and then en-veloped in eucalyptus gauze. Thanks to Mr. Bell’s completecontrol of vessels, very little blood was lost, and thepatient seemed to bear the operation fairly well. Un.fortunately, however, she did not rally from the opera.tion, and died the same evening.

EXCISION OF THE UPPER END OF THE FEMUR.

(Under the care of Mr. HENRY SMITH.)The patient, a man aged twenty-six, had bad disease of

the right hip since childhood, and when admitted into thehospital some weeks since was suffering from all the svm.ptoms of advanced hip disease to an extreme degree. Thelimb was shortened, adducted across the other thigh ; thebuttock was much altered from its natural state, and wasriddled with sinuses discharging much matter. The painwas very severe. The general disturbance was great, thepatient suffering much from night sweats and cough, andsome pain in lett side of the chest; indeed, the latter sym-ptoms were such as to lead Mr. Smith to suspect pulmonarytubercle, and an operation was postponed until repeatedexaminations had failed co detect any serious lung mischief.In the performance of the operation, which was of unusaldifficulty, the section of the bone, which was extremelydense, was made through the trochanter, and when this hadbeen removed it was found that the head of the bone hadalmost entirely disappeared, and on carefully examining theacetabulum a portion of necrosed bone about three-fourthsof an inch in extent was found impacted as it were in that

cavity. It was readily removed by an elevator, and wasascertained to be the remains of the head of the femur.Mr. Henry Smith remarked that this case showed how

desirable it was to remove the trochanter in this operation.As it facilitates the exploration and removal of dead bonefrom the acetabulum at the time, and obviates the possi-bility of any portions of loose bone being retained during theafter-treatment. He bad no doubt that in this case thenecrosed head of the femur bad been retained in the ace-

tabulum for years. ____________

GREAT NORTHERN HOSPITAL.A CASE OF FRACTURE OF THE SKULL ; CURIOUS MUSCU-

LAR TWITCHINGS AND SPASM ; DEATH.

(Under the care of Mr. ADAMS.)FOR the following notes we are indebted to Mr. James

MacMunn, late resident medical officer.A collection of cases of traumatic and localised brain

lesion followed by definite muscular disturbance may beserviceable in elucidating the physiological anatomy of thisorgan.

S. J-, aged four years, was admitted in October, 1879.suffering from fracture of the skull, the history being thatthe child had a fall on its head down an area some twentyfeet in height.On admission one hour after the accident the child was in

a state of collanse. The breathing was eight per minuteand irregular ; the pulse 60, also irregular. The face waspale, the surface cold, whilst complete relaxation of thevoluntary muscles was present. Unconsciousness exited.not, however, to irritation ; thus when ammonia was held tothe nostrils the child turned its head partly aronnd as if toavoid the fumes. The pupils were dilated and reacted iiii-perfectly. There was no stertor. The progress for a timetended towards reaction, the pulse rising in frequency and

953

becoming regular, but signs of cerebral irritation soon su-

pervened, whilst the symptoms worthy of notice were : Ist.Extreme and persistent flexion of the forearm, with clonicjerking of the muscles (120 times per minute), causing thehand to be bent upon the forearm and the latter upon theann to the fullest extent. 2nd. A boring of the index-finger of the same hand in the eye of the corresponding side.The clonic spasms were powerful, and when the limb wasforcibly extended and then released it immediatelyassumed its peculiar attitude again. The legs andright arm, as indicative of the cerebral irritation, werealso slightly flexed by a tonic contraction, but not inthe least disturbed by any jerkings. Convulsions came onat times most marked in the left side, and aggravating forsome time afterwards the jerking in the lett arm. Thechild could not swallow ; the eyes, examined ophthal-moscopically, showed in the left eye comparative arterial

emptiness; both pupils contracted to artificial light, themovement being, however, sluggish, but with no appreciabledifference. There was more dilatation of the right than theleft pupil. Blood was effused into the left upper lid, andwas both subconjunctival and subcutaneous. The pulserose in frequency, and diminished in force ; the surface grewcold, and the patient died thirty-six hours after admission,in spite of the means taken to try to prolong life. Carefulexamination failed to reveal any external signs of fracturebeyond those already given ; indeed there was no appearanceof contusion either, the child having fallen on sott ground.The necropsy showed fracture in the left side, extendingfrom near the eminence of the frontal bone downwards, andthen backwards through the orbital plate, and terminatingtwo lines to the outer sides of the anterior clinoid process ;second, alarge extravasation of blood lying on the posterior partof the left frontal and the anterior third of the parietal lobesextending in a diminishing volume downwards to a rent inthe ophthalmic artery. There was blood effusion into thesheath of the optic nerve. Not the least laceration of brainsubstance was present. There was no flattening, no lesionof the convolutions on the right side: The extravasation didnot at any part extend beyond the mesial lines of the baseof the brain, nor within two inches of the longitudinalfissure above and to the side.There was therefore in this case a definitive lesion of a

cerebral hemisphere, an irritation caused by blood effusionexpressing itself in a marked rigidity and clonic spasm ofthe muscles of the arm of the corresponding side, and this inthe absence of any right-sided brain lesion, direct or trans-mitted. Had the patient been an adult it is probable thatparalysis would have existed instead of spasm, but thisparalysis would be where the spasms were, for, of course,the tracts by which impulses travel are the same at all ages.Again, were the operation of trephining decided upon, whichwas contra-indicated by the child’s low state, it would havebeen done on the right side-i. e., opposite to the spasms andconvulsions-and the extravasation would not be found.Advertence may be made to another case of fracture of the

skull, which was admitted to the Great Northern Hospitalabout the same time as the foregoing. It was that of a manwho suffered from simple melancholia and hallucination ofvision, subsequent to, and evidently dependent on, a de-pressed fracture just over the angular gyrus, and includinga portion of the supra-marginal lobule.

L’HOPITAL CANTONAL, GENEVA.OPERATIONS FOR THE REMOVAL OF THE THYROID BODY

IN GOITRE.

FOR the following notes we are indebted to Dr. AlfredWise :CASE 1.—Aged. sixty-six. There was no family history of

goitre in this case. She said she had always drunk wine,and but seldom drank water. She attributed her goitre tocarrying heavy loads on her head. She first noticed the

swelling twenty-eight years ago ; it had gradually increasedin volume without giving rise to pain or much inconvenience.She had never been uuder medical treatment. At the in-ferior part of the neck was a voluminous tumour, situatedanteriorly-circumference at the base, 43 centimetres ; ver-tically, 23 centimetres; transverse, 29 centimetres. Thetumour was movable, elastic, fluctuating, and gave the im-pression of a large sic with thick walls, having hard patches

of a cartilaginous material in their texture. Pulsation couldbe seen beneath the skin. The inferior part of the mass de-scended a little below the notch of the sternum, and on theleft side passed under the sterno-mastoid. The sterno-hyoidand sterno-thyroid muscles were in front of the tumour,forming little cords below the skin at their points of inser-tion above. No signs of compression of any organs of theneck presented themselves. The pupils were normal.On March 14th Professor Julliard made a free vertical

incision over the middle of the tumour, the enucleation ofwhich was easy uutil the deep attachments were reached.A large number of veins and some arteries were ligaturedwith catgut as soon as divided. The intemal jugular wasin cloe relation with the tumour for eight or ten centi-metres, being enlarged to the size of the thumb and pulsat-ing with each respiration. The adhesious to the tracheaand larynx were broken down with the fingers, aided byscissors, directors, &c., and the mass removed without muchloss of blood. The goitre was found to be developed fromthe left lobe of the thyroid body ; and the right lobe beinghypertrophied, was removed also. A decalcified bone drainwas introduced into the wound, the edges were brought to-gether by catgut sutures, and dressed with protective oil-silk ;sponges squeezed out in carbolic lotion; thick layers ofmushn (treated in the same way) ; gutta-percha tissueover this, and muslin bandages over all. The largetumour weighed 1200 gramme-!, and consisted of a

cyst of colloid matter, encd,psuled by tough walls of six toeight millimetres in thickness ; it presented patches of carti-lagillous material and small points of rough calcified irregu-larities. The smaller tumour weighed thirty grammes andpresented the aspect of a parenchymatous goitre withoutcysts. Carbolic spray was not used in this operation, andchloroform was given sparingly. The temperature beforeoperation was 36.2° C., evening 37’3° C.-15th: Morningtemperature 36.7° C., evening 38’00 C.-16th: Morningtemperature 37’0° C., evening 38 0° C. Fresh dressings wereapplied.—17th : Morning temperature 37’2° C., evening37’9° C. General condiditionwas satisfactory.-19th: Thewound was united by first intention except at the orifice ofthe drain. Dressing’! were discontinued and a piece ofstrapping placed over the opening.—28th : Since the lastnote the patient has been confined to bed again with pain,fever, and other symptoms indicating the formation of alarge abscess in the neck. This has been opened and abouttwenty-five ounces of healthy pus evacuated, the tempe-rature falling to 36° and 37° C.

3rd April: The discharge of pus was diminishing, and thepatient was progressing favourably.CASE 2.-Aged nineteen. In this case there was a family

history of goitre, the mother and two sisters of ten andthirteen years of age being affected. The patient statedthat the goitre commenced when she was eleven years old,and now became larger and harder at each menstrual period.The swelling was as large as a fist, and was situated on the

! left side of the median line more than on the right. It. measured twelve centimetres by fifteen, and was movable,

elastic, and fluctuating. No vessels were seen on the sur-: face, and the tumour followed the movements of deglutition.. On the 4th of March the patient was put under chloroform,; and Professor Reverdin extirpated the whole of the thyroid

body. The operation occupied three-quarters of an hour,some difficulty being experienced from the attachment ofthe tumour to the trachea and a number of veins requiringligature. The patient suffered a good deal from coughand dyspnœa, caused by irritation of the trachea, andwas very feeble after the operation. A decalcified bonedrain was inserted, the wound sutured with catgut, anddressed antiseptically. All the proceedings were carriedout under carbolic spray. Temperature 38° C. in the even-

ing.—5th : Evening temperature 397° C. in the rectum.-6th : Temperature 38.6° C.—8th: Temperature 38 2° C. Freshdressings weie applied. The wound had united by firstintention, with the exception of the orifice where the drainhad been absorbed. Cough and painful deglutition weredminishing.—10th: Temperature 37 9°C. in the axilla. Dress-

ings reapplied. Firm union had taken place, with theexception of the orifice left by the drain, from which a smallquantity of thick and slightly fetid pus escaped.—14th:Temperature 37’50 C. The patient had been up for somedays.—17 th : The secretion of pus had not ceased, but waswithout bad odour.—27th : The quantity of pus had beendiminishing since the last note, and it now caused but littleinconvenience. There was a firm healthy cicatrix above the