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No.1343. MAY 26, 1849. Hospital Reports. ROYAL FREE HOSPITAL. CASES IN SURGERY TREATED AT THIS HOSPITAL BY JOHN GAY, ESQ. Reported by THOMAS CARR JACKSON, Esq., M.R.C.S.E., Resident Surgeon. Cancerous ulceration of the lower lip; history and progress of the disease; operation for its removal; cure. WILLIAM C aged fifty-eight, a labourer by occupation applied to Mr. Gay, at the hospital, Sept. 7th, 1848, for admis sion, in the hope of having some relief afforded for an ulcera. tion of a cancerous nature of the lower lip. On examination the cancerous destruction is found to have involved the struc tures in the neighbourhood to a considerable extent. The centre of the lower lip, chin, and front portion of the lowe] jaw-bone, as far as the inferior border of the symphysis, are completely eaten away, leaving the bone bare, the edges of the ulcerating portion of the chin and skin in the vicinity being united to the corresponding portions of the bone itself. The portions of lip remaining on either side of the central fissure are much enlarged and indurated, the edge being everted giving the appearance already described. The central portion of the jaw-bone in front is in progress of destruction, and of a dull, yellowish colour. The discharge is very offensive and copious, and the man’s condition is so disgusting to him, that he is willing, and indeed anxious, to submit to any operation that would relieve him of the diseased mass. He states that the first appearance of the disease was in the form of a pimple near the angle of the mouth, on the left side, three years ago; it was hard and painless, and remained stationary for twelve months, at which time it began to ulcerate, and extended itseli gradually towards the median line. He had caustics applied at intervals by different medical men, and subsequently he applied to one of the hospitals, where several attempts were made to destroy the diseased parts by caustics of a powerful nature. The ulceration, however, now rapidly extended itself destroying the lower lip and adjacent structures, presenting the usual appearances of cancerous ulceration in an advanced form, and producing a most unsightly and hideous appearance, Mr. Gay having attentively examined the parts, and consider- ing the chances of relief which an operation held out, deter- mined to endeavour to remedy the old man’s distresses. Sept. 13th—The patient being placed under the influence of chloroform, by Mr. Robinson, Mr. Gay, assisted by Messrs, Wakley and Coulson, began his operation, by making an in- cision, on both sides of the cheek, directly backwards from the angle of the mouth, for the distance of an inch and a half. The divided vessels were at once secured from the extreme point of these incisions; others were made downwards, meet- ing at a point about an inch behind and below the chin, embracing the whole of the diseased skin. The diseased soft parts were then dissected away from the osseous parts, to which they were connected by a few strokes of the knife. It was then found necessary to remove about an inch and a half of the central portion of the jaw-bone, which was speedily effected with a small saw. The wound was large, and it became somewhat problematical how it should be filled up, whilst the formation, and almost the position of the mouth, were left at the taste and discretion of the operator, by de- taching the under portions of the cheek on either side, and drawing them together and upwards at the same time, bringing the two cut edges of the jaw-bone into apposition, it became apparent that plenty was left to fill up the vacuity. Mr. Robinson, the dentist, then skilfully fastened the two ends of the jaw-bone together by casting ligatures around the teeth. This done, and the parts being brought together by suture, the patient presented an appearance which justified the anticipation of relief from his disgusting malady without much disfiguration. The lower lip, which was formed by a straight cut surface, was arranged so as to be even with the teeth of the lower jaw. No teeth were extracted previous to the commencement of the operation, Mr. Gay stating that he had not, in his practice, found it necessary in operations on the lower jaw. The effects of the chloroform having subsided, the patient was put to bed; and two hours subsequent to the operation, expressed, by signs, that he was comfortable. A draught, containing one grain of muriate of morphia, was given at bed-time. 14th.—Has passed a comfortable night, and is free from pain. , _ . _ 15th.—Bowels have not been relieved since the operation. The wound, which was dressed this morning, looks healthy; slight discharge of a healthy character from its surface. To have a dose of house-medicine. Diet to consist of strong beef-tea, light puddings, and four ounces of wine daily. The details of the subsequent treatment of this case are needless. The wound was dressed daily, and the greater part healed by the first intention, a few exuberant granulations re- quiring the application, from time to time, of the nitrate of silver. The case progressed very favourably, and the man left the hospital, a few weeks after, at his own request, with the relief perfect, so far as the removal of the disease was concerned by operation. The tongue could be partially pro- truded at the time of his leaving the hospital, and articulation, although confused, was tolerably good, considering the inter- ference with the parts concerned in the operation. It ought also to be mentioned that immediately, and for some time after the operation, he was unable to swallow, so that it became necessary to place his food (which was for the most part of a liquid kind) in the upper part of the pharynx,, by means of a long tube constructed for the purpose. Case of scirrhous enlargement of the sublingual gland; present appearance ; history, progress, and symptoms of the disease; operation ; sudden death of the patient five days after. Thomas A-, aged fifty-nine, was admitted into the hospital November 5th, 1848, under the care of Mr. Gay. The disease for which he seeks relief is a tumour within the mouth, about the size of an egg, occupying the whole of the concavity of the lower jaw on the right side, and being wedged in, as it were, between its angle and symphysis, apparently taking its origin from the mucous membrane forming the floor of the mouth, and pushing the tongue deeply backwards towards the pharynx, the tip being curled up in a peculiar manner. It extends laterally, overlapping the alveolar edges, and upwards to the roof of the mouth. The appearance is that of a firm, fungoid-looking growth. Its surface is rough, and studded with innumerable dirty bluish-grey papillae, of a warty cha- racter, the discharge from which is copious, and very foetid. He is by trade a mastmaker; married; has six children, and has led a regular life; always enjoyed a comfortable home; has never been affiicted with disease in his younger days beyond a clap. Father and mother both healthy; one sister had a tumour of the upper jaw, of what nature not known, but she is now alive, and aged fifty-four years. He first perceived a small growth beneath the tongue five years and a half ago, which, after two or three months’ exist- ence, began to grow rapidly, having the appearance (to use his own expression) of a small mushroom. It caused him no pain, but annoyed him by interrupting the power of articula- tion, and, in some measure, the process of deglutition. He became a patient of the London Hospital five years ago-that is, a few months after its first appearance. It was removed by a ligature passed around its base, and the patient considered himself cured. About four months ago, he again perceived a tumour arising from the place from which the previous one had been removed, having the same effect upon his speech and deglutition; he thinks that in another fortnight it would choke him if left unchecked. He expresses himself as in good health as ever he was in his life, but in consequence of the size and position of the tumour, he is unable to swallow solid food, however small, from his inability to command the morsel or revolve the tongue, although possessing a good appetite and desire for it, which makes him feel weak and irritable; bowels regular; countenance cheerful, and free from the cachectic appearance of malignant disease. Mr. Gay, who attentively examined the man, and finding no evidence of secondary glandular affection in the vicinity, was of opinion that it would be better to remove the mass with the knife by careful dissection, but being at first uncertain whether the growth had contracted any adhesions to the bone itself, he- stated his intention of being prepared to remove any portion of the jaw which might be necessary to its perfect eradication.. November.-The patient being placed under the influence of chloroform by Mr. Robinson, Mr. Gay, assisted by Messrs. Wakley and Coulson, removed the growth in the following manner. A ligature of whip-cord was first passed through the base of the tumour, so as to command it. An incision was then made from the angle of the mouth, on that side, and carried out. wards to a sufficient extent to afford the operator room in the subsequent stages. The facial artery, which bled very freely, was at once secured. Mr. Gay then proceeded, but with con- siderable difficulty, (owing to the small space for manipulation,) to dissect away the tumour from the inner surface of the jaw-
Transcript
Page 1: ROYAL FREE HOSPITAL

No.1343.

MAY 26, 1849.

Hospital Reports.ROYAL FREE HOSPITAL.

CASES IN SURGERY TREATED AT THIS HOSPITAL BY JOHN GAY, ESQ.Reported by THOMAS CARR JACKSON, Esq., M.R.C.S.E.,

Resident Surgeon.

Cancerous ulceration of the lower lip; history and progress ofthe disease; operation for its removal; cure.

WILLIAM C aged fifty-eight, a labourer by occupationapplied to Mr. Gay, at the hospital, Sept. 7th, 1848, for admission, in the hope of having some relief afforded for an ulcera.tion of a cancerous nature of the lower lip. On examinationthe cancerous destruction is found to have involved the structures in the neighbourhood to a considerable extent. Thecentre of the lower lip, chin, and front portion of the lowe]jaw-bone, as far as the inferior border of the symphysis, arecompletely eaten away, leaving the bone bare, the edges of theulcerating portion of the chin and skin in the vicinity beingunited to the corresponding portions of the bone itself. Theportions of lip remaining on either side of the central fissureare much enlarged and indurated, the edge being evertedgiving the appearance already described. The central portionof the jaw-bone in front is in progress of destruction, and of adull, yellowish colour. The discharge is very offensive andcopious, and the man’s condition is so disgusting to him, thathe is willing, and indeed anxious, to submit to any operationthat would relieve him of the diseased mass. He states thatthe first appearance of the disease was in the form of a pimplenear the angle of the mouth, on the left side, three years ago;it was hard and painless, and remained stationary for twelvemonths, at which time it began to ulcerate, and extended itseligradually towards the median line. He had caustics appliedat intervals by different medical men, and subsequently heapplied to one of the hospitals, where several attempts weremade to destroy the diseased parts by caustics of a powerfulnature. The ulceration, however, now rapidly extended itselfdestroying the lower lip and adjacent structures, presentingthe usual appearances of cancerous ulceration in an advancedform, and producing a most unsightly and hideous appearance,Mr. Gay having attentively examined the parts, and consider-ing the chances of relief which an operation held out, deter-mined to endeavour to remedy the old man’s distresses.

Sept. 13th—The patient being placed under the influenceof chloroform, by Mr. Robinson, Mr. Gay, assisted by Messrs,Wakley and Coulson, began his operation, by making an in-cision, on both sides of the cheek, directly backwards fromthe angle of the mouth, for the distance of an inch and a half.The divided vessels were at once secured from the extremepoint of these incisions; others were made downwards, meet-ing at a point about an inch behind and below the chin,embracing the whole of the diseased skin. The diseased softparts were then dissected away from the osseous parts, towhich they were connected by a few strokes of the knife. Itwas then found necessary to remove about an inch and a halfof the central portion of the jaw-bone, which was speedilyeffected with a small saw. The wound was large, and itbecame somewhat problematical how it should be filled up,whilst the formation, and almost the position of the mouth,were left at the taste and discretion of the operator, by de-taching the under portions of the cheek on either side, anddrawing them together and upwards at the same time,bringing the two cut edges of the jaw-bone into apposition, itbecame apparent that plenty was left to fill up the vacuity.Mr. Robinson, the dentist, then skilfully fastened the twoends of the jaw-bone together by casting ligatures around theteeth. This done, and the parts being brought together bysuture, the patient presented an appearance which justifiedthe anticipation of relief from his disgusting malady withoutmuch disfiguration. The lower lip, which was formed by astraight cut surface, was arranged so as to be even with theteeth of the lower jaw. No teeth were extracted previous tothe commencement of the operation, Mr. Gay stating that hehad not, in his practice, found it necessary in operations onthe lower jaw.The effects of the chloroform having subsided, the patient

was put to bed; and two hours subsequent to the operation,expressed, by signs, that he was comfortable. A draught,containing one grain of muriate of morphia, was given atbed-time.

14th.—Has passed a comfortable night, and is free frompain. , _ . _

15th.—Bowels have not been relieved since the operation.The wound, which was dressed this morning, looks healthy;slight discharge of a healthy character from its surface. Tohave a dose of house-medicine. Diet to consist of strongbeef-tea, light puddings, and four ounces of wine daily.The details of the subsequent treatment of this case are

needless. The wound was dressed daily, and the greater parthealed by the first intention, a few exuberant granulations re-

quiring the application, from time to time, of the nitrate ofsilver. The case progressed very favourably, and the manleft the hospital, a few weeks after, at his own request, withthe relief perfect, so far as the removal of the disease wasconcerned by operation. The tongue could be partially pro-truded at the time of his leaving the hospital, and articulation,although confused, was tolerably good, considering the inter-ference with the parts concerned in the operation.

It ought also to be mentioned that immediately, and forsome time after the operation, he was unable to swallow, sothat it became necessary to place his food (which was for themost part of a liquid kind) in the upper part of the pharynx,,by means of a long tube constructed for the purpose.

Case of scirrhous enlargement of the sublingual gland; presentappearance ; history, progress, and symptoms of the disease;operation ; sudden death of the patient five days after.

Thomas A-, aged fifty-nine, was admitted into the hospitalNovember 5th, 1848, under the care of Mr. Gay. The diseasefor which he seeks relief is a tumour within the mouth, aboutthe size of an egg, occupying the whole of the concavity ofthe lower jaw on the right side, and being wedged in, as itwere, between its angle and symphysis, apparently taking itsorigin from the mucous membrane forming the floor of themouth, and pushing the tongue deeply backwards towards thepharynx, the tip being curled up in a peculiar manner. Itextends laterally, overlapping the alveolar edges, and upwardsto the roof of the mouth. The appearance is that of a firm,fungoid-looking growth. Its surface is rough, and studdedwith innumerable dirty bluish-grey papillae, of a warty cha-racter, the discharge from which is copious, and very foetid.He is by trade a mastmaker; married; has six children,and has led a regular life; always enjoyed a comfortablehome; has never been affiicted with disease in his youngerdays beyond a clap. Father and mother both healthy; onesister had a tumour of the upper jaw, of what nature notknown, but she is now alive, and aged fifty-four years.He first perceived a small growth beneath the tongue five

years and a half ago, which, after two or three months’ exist-ence, began to grow rapidly, having the appearance (to usehis own expression) of a small mushroom. It caused him nopain, but annoyed him by interrupting the power of articula-tion, and, in some measure, the process of deglutition. Hebecame a patient of the London Hospital five years ago-thatis, a few months after its first appearance. It was removed bya ligature passed around its base, and the patient consideredhimself cured. About four months ago, he again perceived atumour arising from the place from which the previous onehad been removed, having the same effect upon his speechand deglutition; he thinks that in another fortnight it wouldchoke him if left unchecked. He expresses himself as ingood health as ever he was in his life, but in consequence ofthe size and position of the tumour, he is unable to swallowsolid food, however small, from his inability to command themorsel or revolve the tongue, although possessing a goodappetite and desire for it, which makes him feel weak andirritable; bowels regular; countenance cheerful, and free fromthe cachectic appearance of malignant disease. Mr. Gay,who attentively examined the man, and finding no evidenceof secondary glandular affection in the vicinity, was of opinionthat it would be better to remove the mass with the knife bycareful dissection, but being at first uncertain whether thegrowth had contracted any adhesions to the bone itself, he-stated his intention of being prepared to remove any portionof the jaw which might be necessary to its perfect eradication..November.-The patient being placed under the influence

of chloroform by Mr. Robinson, Mr. Gay, assisted by Messrs.Wakley and Coulson, removed the growth in the followingmanner. A ligature of whip-cord was first passed through thebase of the tumour, so as to command it. An incision was thenmade from the angle of the mouth, on that side, and carried out.wards to a sufficient extent to afford the operator room in thesubsequent stages. The facial artery, which bled very freely,was at once secured. Mr. Gay then proceeded, but with con-siderable difficulty, (owing to the small space for manipulation,)to dissect away the tumour from the inner surface of the jaw-

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bone, and finding no connexion between the bone he graduallyseparated it as far as its base, when, by steadily and firmlydragging the tumour by means of the cord ligature, thetumour was completely separated from the parts on whichit rested. Its entire removal was completely and speedily ef-fected by a few touches of the knife. A large vessel, evidentlythe enlarged artery of the sublingual gland, bled very freely,and was secured with some smaller branches, and all bleedingbeing arrested, and the wound in the cheek brought togetherby two points of suture, the man was put to bed. To haveone grain of morphia at bed-time, in a draught. Examinationof the tumour showed it to be a primary schirrus affection,evidently of the sublingual gland. It cut with a crisp feel,and on division presented the peculiar fibrous aspect ofscirrhous growths, with the process of softening commencingin a few small spots.9th.-Has passed a comfortable night; pulse 90; does not

complain of pain; repeat the draught. " v

10th.—Wound dressed this morning; it has nearly healed;.healthy discharge from the surface within the mouth, bowelsnot relieved since the operation; rested well last night; to havea dose of the house aperient medicine; and the draught at bed-time. Beef-tea in addition to the low diet.

11th.—Bowels freely relieved twice by the aperient; pulse82; slept well; wound in the mouth discharging.13th.-The house-surgeon was called up about four A.M.,

in consequence of the night-nurse observing that the manwas breathing heavily; he was found to be insensible; pupilscontracted, and the respiration laborious, loud, and stertorous;pulse intermittent; feeble; the skin of the forehead hot, andthe extremities cool. At ten P.M. of the previous night, hewas seen, and to all appearances was going on favourably; hishead was shaved, a turpentine enema administered, andmustard poultices applied to the calves of the leg, but noappreciable change was observed, and he died about threer.M., the same day.Examination of the body showed very little to account for

the man’s sudden death, beyond some serous effusion, verysmall in quantity, into the ventricle of the brain.

Cases of scirrhus, or cancer of any form, of the salivaryglands, are said by Walshe, and other authorities on thesubject, to be rare. It may be noted that several cases ofmalignant degeneration of the parotid are on record, but noreference can be found to cases of the sublingual glandaffected with the disease in the ordinary works on surgery.

CLINICAL REPORTS OF TWENTY CASES OFSTERILITY.

BY ROBERT LEE, M.D., F.R.S.,FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THEBRITISH LYING-IN HOSPITAL, AND LECTURER ON MIDWIFERY AT ST.GEORGE’S HOSPITAL.

CASE 1.—Mrs. M-, aged twenty-four, July 29th, 1824,was married the second time ten months ago, and had livedthree years with her first husband without ever having becomepregnant. Seven months ago, the catamenia became irregular,and she began to suffer from uneasiness and distention of theabdomen on the right side, and at times thought she distinctlyfelt the movements of an infant. She was afflicted withovarian dropsy, and died, after having been tapped eight times.On examining the body, I found an enormous cyst, coveredwith coagulable lymph, filling up the abdomen, between whichand the omentum, the peritonaeum, and most of the pelvicviscera, there was an extensive adhesion. This large cystwas likewise connected with numerous small cysts, and theperitonaeum almost everywhere was thickened and studdedwith tubercles of different sizes. The omentum also presentedthe same tuberculated appearance. The uterus was indurated,and about four times the natural size. Both ovaria were con-verted into hard tuberculated masses.

CASE 2.-In the year 1825, in the Ukraine, I attended theBaroness F-, who was sterile, and who had likewise forsome time been afflicted with what was supposed to be en-cysted dropsy. I drew off by tapping a large quantity offluid, and she regained her health, and lived many years afterwithout any return of the dropsy, but had no children.

CASE 3.-July 28th, 1828, I examined the body of Mrs.N-, aged forty-three, who died of inflammation of the sub-stance of the lungs, and bilious fever. She had been marriedmany years, and was sterile. The uterus contained severalfibro-cartilaginous tumours of different sizes, some under theperitonæum, and one, about midway between the surfaces of

the uterus, of considerable dimensions. The preparation is inthe museum of St. George’s Hospital.

CASE 4.-On the 9th of August, 1828, I examined the bodyof all aged woman, who had died, after nine years’ suffering,from a large cyst and tumour in the hypogastrium. A trocarhad been introduced, but only a small quantity of fluid escaped.There was a large fibro-cartilaginous tumour, and severalsmall ones, found after death, embedded in the walls of theuterus. The right ovarium had been converted into a tumourof similar structure, which weighed six or seven pounds; andconnected with this were several cysts, containing a clearfluid. The peritonaeum was very much thickened and in-durated. Sterility had existed through life.CASE 5.-On the 21st of December, 1829, a middle-aged

woman was admitted into the Middlesex Hospital in an ex-hausted and almost insensible state, with a large globular-shaped tumour hanging by a thick neck out of the vagina,between the thighs. Three pints of urine were accumulated inthe bladder. The surface of the tumour was covered partiallywith coagulated blood, and it was extremely painful whentouched. It was at first supposed to be the uterus inverted,and attempts were made without effect to reduce it. After-wards, from a depression in the lower part of the tumour, likethe os uteri, it was supposed to be a case of prolapsus uteri,and leeches and fomentations were applied to facilitate itsreduction within the pelvis. Abdominal inflammation ensued,and she died on the 31st of December. It was reported thatthe patient was a married woman, but had been separatedsome years from her husband, and that she had led an ir-regular life, and had been subject to prolapsus uteri. It wasnot ascertained positively whether she had ever been pregnant,but it was certain that she had never carried a child to thefull period. The body was examined on the lst of January,1830. The tumour, which still hung externally, was found tobe a large polypus, attached by a thick root to the anteriorpart of the cervix uteri. The surface of the tumour wascovered by a smooth membrane, reflected over it from themucous membrane of the uterus, with which it was continuous.The uterus was dragged low down into the vagina, but itsstructure was healthy. The ovaria were enlarged, andpartially destroyed by inflammation.

CASE 6.- In March, 1831, with Dr. Scott, of Straftcn-sfreet,I saw a lady at Mortlake, aged forty-seven, who had beenmarried thirteen years, and had never been pregnant. Thecatamenia had always been regular. She had long sufferedfrom pain, and sense of distention in the right side of thehypogastrium, and of bearing-down about the uterus. Therehad also been much uneasiness about the neck of the bladder,but no difficulty in passing the urine. Several years before Isaw the patient, Dr. Scott had ascertained that the cavity ofthe pelvis was partially filled up with an irregular-shapedtumour, which adhered firmly to the back part of the uterus,and the upper part of which could be distinctly felt above thebrim of the pelvis on the right side. The lips of the os uteriwere healthy, but the orifice was unusually open, and thecervix was shortened, as in the advanced months of preg-nancy.CASE 7.-In the month of September, 1832, I was requested

by Sir Gilbert Blane to see Mrs. B-, aged sixty-two, whofor many years had suffered from constant sense of weight anduneasiness in the back, loins, and hypogastrium, with almostconstant purulent and sanguineous discharge from the vagina.She had been married for many years, and had never becomepregnant; and from the age of forty-five, when she ceased tomenstruate, she had suffered from several severe attacks ofuterine haemorrhage. On examination, the hollow of thesacrum was found occupied by a large hard tumour, connectedwith the posterior part of the uterus. The os uteri had under-gone little change; but the peculiar fcetor of the discharge,and the constitutional symptoms, led me to suspect the exist-ence of malignant disease of the body of the uterus. In thecourse of a few months, after suffering excruciating pain inthe region of the uterus, difficulty in passing the urine, with aprofuse - discharge of thin, offensive fluid from the vagina,several portions of small, irregular-shaped concretions escapedfrom the vagina, with a temporary relief of the most distress-ing symptoms. During the remainder of 1832, Mrs. B-continued to suffer severely from the same symptoms, and sheuniformly experienced relief after a calcareous concretion hadpassed from the vagina, which happened four or five timesduring that period. In the month of November, 1833, a fewdays after travelling a distance of eighty miles from thecountry, she was attacked with rigor, vomiting, exquisite ten-derness over the lower part of the abdomen, and other symp-


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