1617 HOSPITAL MEDICINE AND SURGERY. lesion. On opening the left ventricle there appeared to be a plaque between the pillars of the columnce carnese, as if <the ante-mortem clot which was found occupying the aortic ,orifice had originated at the heart’s apex. The aortic and ,pulmonary valves were otherwise quite healthy. The thrombus occupying the aorta rested in the valvular orifice, and both it and that occupying the right cavities of the heart fulfilled the pathological conditions of typical ante-mortem coagula. The heart muscle appeared to be quite good. There was no .apparent anæmia. I place this case on record without comment, as there is much food for thought in it. I cannot conclude without acknowledging the valued services of my colleague, Dr. Harris, who assisted me at the post-mortem examination, and of the counsel derived from Dr. Stokes’ ripe experience. have to thank him, too, for his courteous, though unavailing, attendance in my patient’s emergency. 8 &amford. hUl, N. A Mirror OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. MIDDLESEX HOSPITAL. TWO CASES ILLUSTRATING THE MORE SERIOUS COMPLICA- TIONS OF DENTAL CARIES. (Under the care of Mr. GEORGE LAWSON.) Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mcr- borum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.-MORGAGNI De Sed. et Ctzu8. Morb., ib. iv. Procemium. THESE cases serve to illustrate two of the most severe com. plications of neglected dental caries. In the first the amount of the necrosis was unusually extensive and involved the removal of a considerable sequestrum. In the second case the complication of cellulitis of the neck was a much more serious one, and the risks run, as proved by the -ending of the case, were much more grave. In fact, what- ever the cause of the suppuration, the condition is one which calls for most active surgical treatment. CASE 1. Dental ectries ; necrosis of lower jaw ; suppurative arthritis of temporo-maxillary articulation ; partial excision of jarc. -A woman aged fifty-two was admitted into the hospital on Nov. 8th, 1892, complaining of fixity of the jaw and swelling of the left side of the face. The patient stated that twelve months before admission °’ lumps " appeared .at the angle of the jaw and left side of the face, and at the same time she began to experience difficulty in opening her mouth ; this had been gradually getting worse. The swelling of the face had been opened in three places, and a ’considerable quantity of matter had been let out. The patient was unable to open her mouth for more than a quarter of an inch, and she only did this with difficulty. The second and third left lower molars were found to be carious. There were several sinuses round the angle of the jaw and left side of the face and neck. One of these, directly beneath the zygoma, was found to lead down to bare bone. Another sinus was situated .about half an inch behind the ramus, and there were two or three more about the angle of the jaw. On Nov. 13th the patient was anaesthetised and the jaw was wedged open ; ,at the same time the last two lower molars were ex- tracted. As the patient was still unable to open her mouth to any extent, she was again anæsthetised on the 30th. A vertical incision was made from just below the zygoma over the ramus nearly as far as the angle, and from the upper end of this incision another passed horizontally forwards just below and parallel with the zygoma. The temporo-maxi llary joint was found to be suppurating, and the inferior maxillary bone as far forwards as the inferior dental - canal to be necrosed. The bone was disarticulated, the necrosed bone was removed in three pieces, and the glenoid cavity was scraped. The wound at first suppurated freely, but the patient was discharged on Jan. 13th, 1893. CASE 2. Dental caries; alveolar abscess; angina Ludovici; .septic pneumonia ° death. -A rather weakly looking iuj.n was admitted into the Middlesex Hospital on April 13th, 1892, with a large tender swelling beneath the jaw. The patient gave a history of having felt strong and healthy until two months previously to his admission, when he began to feel "out of sorts." On April 1st he had pain in the first right lower bicuspid tooth, with some swelling beneath the jaw. He obtained some relief from a mixture obtained from a chemist, but the swelling in the neck did not subside, and on the 10th he had the tooth extracted at a hospital. The patient became weak and ill, and the swelling became more painful. He had a shivering fit on the 12th and on the following day was admitted into the Middlesex Hospital. On admission a red, tense, tender swelling was found extending beneath the whole length of the lower jaw and reaching backwards to the angle on either side. The skin over the tumour was brawny, and fluctuation could be obtained. The breath was very offensive, and on pressing over the swelling fetid pus escaped from the socket of the first right lower bicuspid. The temperature was 102° F., the pulse 120, and the respiration 36. The patient was at once anaesthetised, an incision an inch in length was made in the middle line, and an abscess cavity was opened about one inch below the surface. About an ounce and a half of fetid, brownish-coloured pus escaped. The wound was irrigated with perchloride of mercury, and fomentations were applied. After the operation the patient appeared to be easier, but the temperature and pulse remained the same. On the 14th he complained of pain behind the manubrium sterni. The pulse became irregular in volume and rhythm, and a few crepitations were heard over both chests. The wound was thoroughly irrigated, and three ounces of brandy were ordered. Later the cough became rather troublesome, and the amount of brandy was doubled. During the next two days the patient became very prostrated, and the pulse was weaker, but more regular. There was some dyspnoea, but no cyanosis. He could not lie down or sleep for more than a few minutes together. His appetite remained good. On the 17th the pulse became very weak, and dyspnoea was more marked, but no cyanosis was present; the apex of the heart beat lay in the fifth interspace, half an inch outside the nipple line. No friction was heard over the cardiac area ; the pain behind the sternum became more marked ; slight friction could be heard on the right side, and crepitation was just audible over both lungs. The expectoration was more viscid and blood- stained. Half an ounce of brandy was given every hour. On the following day the pulse became weaker, but rather more regular; the patient became delirious, and his breathing difficult and noisy. He sank and died on April 20th, 1892. Medical Societies. NORTH LONDON MEDICAL AND CHIRUR- GICAL SOCIETY. Exceptional Case of Congenital Heart Disease.-Early Stage of Clrronic Muscular Atrophy simulating Perip7)erctt Neuritis. - Case of Recurring Gangrene of the Leg allied to Raynaud’s Disease. ’AT a meeting of this society held on Dec. 14th, Dr. HENTY being in the chair, Dr. W. A. MALCOLM brought forward a man aged thirty-two, the subject of Congenital Heart Disease. Dr. Malcolm said that the patient had been under his observation for many years and had shown signs all his life of this malady. Cyanosis and enlargement of the superficial venous capillaries were very obvious. There was, in addition, marked bulbous enlargement of the tips of the fingers. The patient on one or two occasions had had profuse hasmoptysis from pulmonary congestion. Nothwith- standing these signs, on examining the heart there was marked absence of the symptoms associated with the usual forms of congenital cardiac lesions. At the time the case was shown, beyond slight deficiency in the second sound over the region of the pulmonary artery and evidence of some cardiac hypertrophy, very little that was abnormal could be detected. In spite of the absence of definite physical signs Dr. Malcolm concluded that the lesion was probably a stenosis of the pulmonary orifice with compensatory failure in closure of the septum ventriculorum or the foramen ovale, or both of these orifices.
Transcript
1617HOSPITAL MEDICINE AND SURGERY.
lesion. On opening the left ventricle there appeared to be aplaque between the pillars of the columnce carnese, as if<the ante-mortem clot which was found occupying the aortic,orifice had originated at the heart’s apex. The aortic and
,pulmonary valves were otherwise quite healthy. The thrombusoccupying the aorta rested in the valvular orifice, and bothit and that occupying the right cavities of the heart fulfilledthe pathological conditions of typical ante-mortem coagula.The heart muscle appeared to be quite good. There was no
.apparent anæmia.I place this case on record without comment, as there is
much food for thought in it. I cannot conclude without
acknowledging the valued services of my colleague, Dr.
Harris, who assisted me at the post-mortem examination,and of the counsel derived from Dr. Stokes’ ripe experience. have to thank him, too, for his courteous, though unavailing,attendance in my patient’s emergency.
8 &amford. hUl, N.
A MirrorOF
HOSPITAL PRACTICE,BRITISH AND FOREIGN.
MIDDLESEX HOSPITAL.TWO CASES ILLUSTRATING THE MORE SERIOUS COMPLICA-
TIONS OF DENTAL CARIES.
(Under the care of Mr. GEORGE LAWSON.)
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mcr-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.-MORGAGNI De Sed. et Ctzu8. Morb.,ib. iv. Procemium.
THESE cases serve to illustrate two of the most severe com.
plications of neglected dental caries. In the first the amountof the necrosis was unusually extensive and involved theremoval of a considerable sequestrum. In the second casethe complication of cellulitis of the neck was a muchmore serious one, and the risks run, as proved by the
-ending of the case, were much more grave. In fact, what-ever the cause of the suppuration, the condition is one whichcalls for most active surgical treatment.CASE 1. Dental ectries ; necrosis of lower jaw ; suppurative
arthritis of temporo-maxillary articulation ; partial excisionof jarc. -A woman aged fifty-two was admitted into the
hospital on Nov. 8th, 1892, complaining of fixity of the jawand swelling of the left side of the face. The patient statedthat twelve months before admission °’ lumps " appeared.at the angle of the jaw and left side of the face, and atthe same time she began to experience difficulty in openingher mouth ; this had been gradually getting worse. The
swelling of the face had been opened in three places, and a’considerable quantity of matter had been let out. The patientwas unable to open her mouth for more than a quarter of aninch, and she only did this with difficulty. The second andthird left lower molars were found to be carious. There wereseveral sinuses round the angle of the jaw and left side of theface and neck. One of these, directly beneath the zygoma, wasfound to lead down to bare bone. Another sinus was situated.about half an inch behind the ramus, and there were two orthree more about the angle of the jaw. On Nov. 13th the
patient was anaesthetised and the jaw was wedged open ;,at the same time the last two lower molars were ex-
tracted. As the patient was still unable to openher mouth to any extent, she was again anæsthetised onthe 30th. A vertical incision was made from just below thezygoma over the ramus nearly as far as the angle, and fromthe upper end of this incision another passed horizontallyforwards just below and parallel with the zygoma. The
temporo-maxi llary joint was found to be suppurating, and theinferior maxillary bone as far forwards as the inferior dental- canal to be necrosed. The bone was disarticulated, thenecrosed bone was removed in three pieces, and the glenoidcavity was scraped. The wound at first suppurated freely,but the patient was discharged on Jan. 13th, 1893.CASE 2. Dental caries; alveolar abscess; angina Ludovici;
.septic pneumonia ° death. -A rather weakly looking iuj.n
was admitted into the Middlesex Hospital on April 13th,1892, with a large tender swelling beneath the jaw. The
patient gave a history of having felt strong and healthyuntil two months previously to his admission, when hebegan to feel "out of sorts." On April 1st he had painin the first right lower bicuspid tooth, with some swellingbeneath the jaw. He obtained some relief from a mixtureobtained from a chemist, but the swelling in the neck didnot subside, and on the 10th he had the tooth extracted ata hospital. The patient became weak and ill, and the
swelling became more painful. He had a shivering fiton the 12th and on the following day was admitted intothe Middlesex Hospital. On admission a red, tense,tender swelling was found extending beneath the whole
length of the lower jaw and reaching backwards to theangle on either side. The skin over the tumour was brawny,and fluctuation could be obtained. The breath was veryoffensive, and on pressing over the swelling fetid pusescaped from the socket of the first right lower bicuspid.The temperature was 102° F., the pulse 120, and therespiration 36. The patient was at once anaesthetised,an incision an inch in length was made in the middleline, and an abscess cavity was opened about one inchbelow the surface. About an ounce and a half of fetid,brownish-coloured pus escaped. The wound was irrigatedwith perchloride of mercury, and fomentations were applied.After the operation the patient appeared to be easier, but thetemperature and pulse remained the same. On the 14thhe complained of pain behind the manubrium sterni. The
pulse became irregular in volume and rhythm, and a fewcrepitations were heard over both chests. The wound was
thoroughly irrigated, and three ounces of brandy wereordered. Later the cough became rather troublesome, andthe amount of brandy was doubled. During the next twodays the patient became very prostrated, and the pulse wasweaker, but more regular. There was some dyspnoea, but nocyanosis. He could not lie down or sleep for more than afew minutes together. His appetite remained good. On the 17ththe pulse became very weak, and dyspnoea was more marked,but no cyanosis was present; the apex of the heart beat layin the fifth interspace, half an inch outside the nipple line.No friction was heard over the cardiac area ; the pain behindthe sternum became more marked ; slight friction could beheard on the right side, and crepitation was just audible overboth lungs. The expectoration was more viscid and blood-stained. Half an ounce of brandy was given every hour. Onthe following day the pulse became weaker, but rather moreregular; the patient became delirious, and his breathingdifficult and noisy. He sank and died on April 20th, 1892.
Medical Societies.NORTH LONDON MEDICAL AND CHIRUR-
GICAL SOCIETY.
Exceptional Case of Congenital Heart Disease.-Early Stageof Clrronic Muscular Atrophy simulating Perip7)ercttNeuritis. - Case of Recurring Gangrene of the Leg alliedto Raynaud’s Disease.
’AT a meeting of this society held on Dec. 14th, Dr. HENTYbeing in the chair, Dr. W. A. MALCOLM brought forwarda man aged thirty-two, the subject of Congenital HeartDisease. Dr. Malcolm said that the patient had been underhis observation for many years and had shown signs all hislife of this malady. Cyanosis and enlargement of the
superficial venous capillaries were very obvious. There was,in addition, marked bulbous enlargement of the tips of thefingers. The patient on one or two occasions had had
profuse hasmoptysis from pulmonary congestion. Nothwith-
standing these signs, on examining the heart there wasmarked absence of the symptoms associated with the usualforms of congenital cardiac lesions. At the time the casewas shown, beyond slight deficiency in the second soundover the region of the pulmonary artery and evidence of somecardiac hypertrophy, very little that was abnormal could bedetected. In spite of the absence of definite physical signsDr. Malcolm concluded that the lesion was probably a stenosisof the pulmonary orifice with compensatory failure in closureof the septum ventriculorum or the foramen ovale, or both ofthese orifices.
1618 PROVINCIAL MEDICAL SOCIETIES.
Dr. GALLOWAY exhibited a man aged thirty-eight sufferingfrom a very early condition of Chronic Muscular Atrophy ofthe Muscles of the Right Hand. This case was associatedwith a certain amount of tingling along the course and dis-tribution of the ulnar neive, and to a less extent of themedian nerve. He commented upon the occurrence oftingling in early stages of chronic muscular atrophy andremarked on the liability of such cases being described a.sthose of peripheral neuritis of various forms. Mr. HENRYWIiITEHrAV criticised the remarks made by Dr. Galloway,but agreed in the diagnosis arrived at.
’
Mr. C. B. LOCKWOOD showed a preparation of a legremoved from a patient suffering from recurrmg attacks ofGangrene. The part was removed some years ago, and
recently, on account of attacks of gangrene in the leg,amputation had been performed above the knee-joint. Mr.Lockwood stated that he considered the case as one of anexceptionally severe form of Raynaud’s disease.
Mr. LOCKWOOD also showed a specimen of a Kidney hehad removed by abdominal section from a patient now inthe Great Northern Hospital. The case was remarkable forthe long duration of symptoms and the large size of the kidneyand of the calculus it contained. The patient was recoveringwell from the operation.
PROVINCIAL MEDICAL SOCIETIES.
EDINBURGH MEDICO-CHIRURGICAL SOCIETY.-This society Iheld an additional meeting on Wednesday, Dec. 20th, Dr. ’’
CLOUSTON, the President, in the chair. A number of interest-
ing cases were shown.-Dr. BYROM BRAMWELL showed afemale patient who had been successfully treated with
thyroid extract for an Obstinate Psoriasis and remarked thatall cases were not cured by this means, and that some mighteven be made wor,e. He also showed a case of Lupus ofthe Face in a woman which he had treated with thyroidextract. The case had been treated by various methods, andall with indifferent success. He was led to try thyroidextract by the fact that tubercle was frequently associatedwith myxœdema. The case had improved greatly under thetreatment, and, from the marked improvement in it, he
anticipated a final cure. He thought the amelioration mustbe attributed to the improvement in the nutrition of the skindue to the action of the thyroid extract The treatment requiredmonths. He showe d another case of Lurus in which it had notbeen begun, so that it might be seen what effect treatmentmight subsequently have on it.-Dr. J. C. DUNLOP exhibitedan infant, irs father, and grandfather, in all of whom therewere Webbed Fingers ; in the child there were also websbetween the centre tops -Dr. NORMAN WALKER showed a
patient with Rodent Ulcer before ulceration had occurred,and on whom he proposed to operate by excising the part.-Mr. CAIRD showed a man with Charcot’s Disease of both
Knee-joints, in which there was great hyperplasia of thebones, with displacement. He proposed to excise the partsand obtain ankylosis -Dr. W. RUSSELL showed Dr. Kossel’sphotographs of cases of Lupus treated in the Berlin Institutefor InfEctious Diseases with tuberculin. -The papers readwere by : (1) Dr. BYROM BRAMWELL, entitled Notes of aRemarkable Case of Sporadic Cretinism. The child was sixteenand ahalf years old and was only2a; in inheight. Hedescribedthe general appearance of the child and the extraordinarydevotion of its mother. It soon improved considerably undertreatment with thyroid. To have any decided effect upon themental condition the treatment would of course require tobe persevered in for years, and the prognosis was necessarilynot so hopeful as when treatment was begun early in life.-Dr. SLOAN gave a brief abstract from a very interesting caseci Self-inflicted BuLi6t Wound of the Head. The revolverhad been held in contact with the forehead, and the
longitudinal sinus had been opened and gave rise tLl muchhæmorrhage. The patient had, however, made an uninter-rupted recovery after the broken bones and the bullet hadbeen removed. He showed a number of experiments he hadmade with blocks of wood of various thicknesses, illustratirgthe blackening of the wood. the character of the hole madeby the bullet, and the effect on the bullet itself.-Dr.DAWSON TURVER gave an interesting practical demonstrationon the Therapeutic Methods employed in Static Electricityand explained the apparatus used.EDINBURGH OBSIETRfCAL SOCIETY.-This society met on
Dec. 13th, Dr. FREELAND BARBOUR, PresideLt, in the chair.
The following specimens were exhibited : A TubaF&estatioBiremoved entire ; a Decidual Cast of the Uterus ; MicroscopicSections of Decidual and Menstrual Casts ; Three examples ofPyosalpinx, one of Hæmato-salpinx, two Ovarian Cysts, and a.Vaginal Cyst, by Dr. N. T. BREWIS; A Cyclosomatous andanAnencepbalic Foetus, by Dr. HAULTAIN ; and A Papyraceous.and an Anencephalic Fcetus, by Dr. BALLANTYNE. The-PRESIDENT then read two papers entitled respectively "Note:of a Case of Double Rupture of the Membranes " and "On anUnusual Position of ttie Promontory Mark on the FcetatHead. "-Dr. HAULTAIN tbereupon read a paper commending-Champetier de Ribes’ Bag and explaining its method of use.--Dr. J. W. BALLANTYNE next gave an exhaustive paper on11 Influenza in its relation to Obstetrical, Gynecological, and’Pediatric Cases." The meeting closed after Dr. Ballantyn&had given an account of the dissection of a foetus amorphusanidens.NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY.-A meeting
of this society was held on Dec. 20th, Dr. W. HUNTER,.President, in the chair.-The PRESIDENT showed the Dilated(Esophagus of a Horse, which had been under the care ofMr. Cave, veterinary surgeon. The tube was strictured atthe lower end and was dilated throughout its length, butespecially about the middle, where there existed a sac as.large as a cricket-ball. This sac formed a tumour, which.was observed during life and had been known to exist forfour years. The chief symptoms were attacks of colickypain. Obstruction seems never to have become complete,and the animal died of acute enteritis.-Dr. CATTLE read apaper by himself and Dr. MILLAR on the Structure of Cancer.The microscopic appearances of the different kinds of cancerwere illustrated, by a series of thirty lantern photographs, byDr. Millar. He said that the structure of cancer variedaccording to the kind of epithelium in which it arose, but.after making allowance for differences of site it was thoughtthat the process was essentially the same wherever isoccurred. The part played by protozoa in the causation ofthe disease was briefly referred to. The paper concluded withsome remarks on the operative treatment of cancer, viewed!in the light of structure.-A discussion followed, in whichthe President, and Drs. Handford, Ransom, and Michie took,part.
__ _____
Reviews and Notices of Books.Psychiatrie: ein kurzes Lehrbuch für Studirende und Aerzte.
Vierte vollstandig umgearbeitete Auflage. (Mental Patho-logy: c:a Short Manual for Students and the Medical Pro-fession. Fourth edition, completely revised.) By EMILKRAEPELIN. Leipzig . Arthur Meiner. 1893.
THIS treatise, which contains over 700 pages of solid print(showing that Professor Kraepelin’s idea of curtness is a
liberal one), deals exhaustively with the problems suggestedby its title, and in particular deserves commendation for itshigh standard of practicality. The author, who is professor-of this subject at Heidelberg, begins by thanking his friendlyfates for placing him in a past where he has been and will beenabled to devote all his energies to clinical observation, ashe has thus been enabled to thoroughly revise and, wherenecessary, to rewrite his book from a personal point of viewwithout rummaging (storen) the works of others. The book
comprises two divisions, of which the first deals with the-
etiology and treatment of insanity generally, and the-second considers the special pathology of different forms’of the disease and the remedial measures to be adopted.In the second part the divisions seem to us to be’
needlessly numerous &.Mi elaborate. Such over-minute
arrangement of a subject may defeat its own objectand lead to confusion rather than clearness. Why, for
instance, should the exhaustion following a maniacal attack.be separated from the antecedent delirium ? ? Screly the’two conditions ought to 1e treated under one heading.The difference again between mania of a depressed kindand melancholia is very hard to see. And why shouldanomalous sexual instinct receive special treatment as a formof insanity more than any other promnent symptom ccmrnoEt
