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THE AUSTRALIAN

MEDICAL JOURNAL.

JUNE, 1871.

ORIGINAL COMMUNICATIONS.

ON PARALYSIS WITH APPARENT HYPERTROPHY OF THE MUSCLES.

By WILLIAM SMITH, M.B.

Honorary Surgeon to the Hospital for Children, Curator of the Pathological Museum of the Melbourne Hospital, and Demonstrator of Anatomy

in the University.

The following case illustrates a form of disease which is rarely met with and little understood. I had not seen an instance of the kind till the end of the year 1867, when two children, affected in the same manner as the boy of whom I write, were exhibited to the members of the Pathological Society of London. Since then, though for some time surgeon to one of the London hospitals for children, I had not witnessed another example, till that I now treat of came under my notice. Heller, Seidel, Billroth, Griesinger, and Cohnheim, had previously observed cases of it, but it was through Dr. Duchenne (of Boulogne) that the attention of the profession in England was first directed to the subject. A communication from him to the Pathological Society was read by Mr. Lockhart Clarke,*

at a meeting preceding those at which the cases I have referred to were exhibited. It was then stated that Dr. Duchenne had been studying the disease for 11 years, and was about to publish a work on the subject. That workt I have not been able to procure in Melbourne.

John B—, 8 years of age, is attending as an out-patient at the hospital for children, and is under the care of my colleague Dr.

Singleton, who has kindly permitted me to take notes of the case.

As an infant he was well and strong, and nothing abnormal was observed until he reached the age of 5 years ; then the calves were noticed to be enlarged, and in an irregular manner, so as to occasion

" lumps." After this—the mother cannot state how long—the

* Path. Soc. Trans., vol. xix.

t "De la Paralysie Musculaire Pseudo-Hypertrophique, ou Paralysie Myo-Sclerosique."

VOL. XVI.

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162 DR. W. SMITH on Paralysis [June, child exhibited a weakness in walking, which has gradually in creased ; and now, though he walks a good deal during the day, he falls frequently, and when down, cannot raise himself unaided unless there be some object near, which he can seize with his hands. His mode of walking is also peculiar and characteristic, being a kind of exaggerated waddle, in which the body is at each step thrown in a marked manner to that side on which is the leg that is put forward, while the head is thrown back. There has been an absence of pain and tremors in the muscles, of head-ache, and of pain in the region of the spine. The general health has been good. At the present time he eats, drinks, and sleeps well ; and though shy, seems to possess an average amount of intelligence. He is rather thin than otherwise, but the fat in the gluteal regions is sufficiently abundant to make it difficult for me to ascertain the state of the muscles there. His height is 3 ft. 10/ in. The left arm measures just below its centre 6/ in. in circumference, and the right slightly less ; the left forearm at its largest part 7 in., the right 61 in. At the lower half of the posterior surface of each upper arm, there is a distinct prominence formed by the triceps at that part, which besides being disproportioned in size to the other muscles of the arm, feels firmer than they, especially during contraction. There is a slight enlargement of the muscles of the left forearm, but I detect no difference in the degree of firmness on the two sides, perhaps because the forearms generally feel harder than other muscular parts of the body. The biceps, deltoid, and muscles of the thorax appear to be normal ; they are small it is true, but not more so than I have seen in many healthy children of the same height and age. The mother has observed no want of power in the upper extremities, but thinks her boy " as strong in the arms " as one of his age should be. The calves are considerably enlarged, the left measuring a little more, and the right slightly less, than 12 inches in circumference.

The muscles on the front of the leg are large and firm ; but it is to those at the back, that the increase in size is chiefly due, the gastroc- nemii standing out prominently, especially at the junction of their muscular and tendinous parts. They feel firmer than in health, especially when they contract. Besides being thickened, the right gastrocnemius is shortened ; for the heel is drawn up producing talipes, and the foot cannot, even by strong pressure, be brought at right angles to the leg. On examining the thigh while the patient was sitting, I could not satisfy myself of the existence of enlarge- ment there, but as soon as the boy stood up, it was easy to perceive a bulging in the situation of the lower part of the vastus externus, and of the muscles of the back of the thigh. In the latter place the swelling occupied the middle third only. The adductors do not appear to be affected. I cannot ascertain the condition of the glutei because of the adipose tissue covering them, but the erector spinae is unmistakably prominent. The line of junction of the muscular and aponeurotic parts of the obliquus externus is, I think, more distinct, on each side, than it should be. He stands with the legs far apart, the body being supported on the left chiefly, while the right is bent at

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1871.] With Apparent Hypertrophy of the Muscles. 163 the knee, its toes only touching the ground. The lumber spine is much arched. He walks in the manner I have described, with the object of balancing the body at each step. The power over the affected muscles seems to be less after they have been at rest for a time, as if there were a stiffness, then, which afterwards wore off. It it impossible to ascertain exactly the movements which are most difficult of performance, or to measure the amount of power possessed, because the patient is so shy that he will not attempt to do as he is desired. There is no pain in the muscles either when at rest or during action, and the sensibility of the skin appears to be normal.

The special senses are unaffected. There are neither tremors, nor spinal tenderness. The teeth are not such as are met with in cases of hereditary syphilis. The legs, which are usually left uncovered, are sometimes mottled ; but evidently only from exposure, as the colour of the skin of the thighs, and other covered parts, is quite natural. There is no history of paralysis in the family.

The above notes, though faithfully descriptive of the patient's condition three months ago, do not apply exactly to his present state. I have seen him within the last three weeks, and find that he is now unable to walk or stand. Seven months since he could raise himself without seeking support from surrounding objects.

The muscles are also rather less firm than they were. The general health remains good.

The treatment of a case of this kind must be in the highest degree empirical until its pathology is understood ; and viewed from its pathological aspect, it at once suggests the following questions :

1. What is the nature of the changes which have taken place within the muscles ?

2. Are the muscles the parts primarily and principally affected, or must we look beyond them to the nervous system for an explanation of the origin of the symptoms ?

In reply to the first, a priori reasoning suggests what microscopic examination has confirmed, viz. : that the enlargement is not a veritable hypertrophy, for with an increase of true muscular tissue there should be an increase, rather than a loss of power. Duchenne, anxious to satisfy himself on this point, removed small portions of the affected muscles from the living subject, by means of a small instrument, which he calls the emporte-piece histologique. A few post mortems have also been made. In cases thus examined, there has been more or less atrophy.of the muscles, the fibres appearing shrunken, the longitudinal and transverse strim indistinct, and the sarcolemma sometimes entirely empty. As an exception to this, it must be mentioned that in one instance—that examined by Cohn- heim*—a few of the fibres appeared larger than they should be.

The most conspicuous change consists in the presence of a large quantity of fibrous and connective tissue, the result of a hypertrophy of that normally present between the muscular fibres. Occasionally, especially during the later stages of the disease, some fat vesicles

* Verlaandl. d. Berliner Med. Ges., 2, 1866.

M 2

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164 DR. W. SMITH on Paralysis [June form in the meshes of this material, just as they form in the inter- stices of connective-tissue elsewhere ; and in one case the fat vesicles were abundant, and the connective-tissue only moderate in quantity.

The essential change, however, is usually a hypertrophy of the interstitial connective-tissue, which becomes more fibrous than in health, and is associated with atrophy of the muscular fibres. Even when fat therefore is present, the change must be distinguished from that of fatty degeneration, for the fat is in the form of adipose tissue between the fibres, and the latter, though shrunken and atro- phied, exhibit neither granules nor globules in their interior.

We have thus at least four varieties of structural change occurring in muscular tissue, in connection with the different forms of paralysis.

1st. Granular degeneration of the fibres, seen in the disease known as progressive muscular atrophy. 2nd. Fatty degeneration of the fibres occurring in fatty atrophic paralysis. 3rd. Atrophy of the fibres with hyperplasia cf the intervening connective tissue, seen in cases of the disease now under consideration. 4th. Shrinking and disappearance of some of the fibres, with formation of adipose tissue between those that remain. This occurs in the commoner forms of paralysis, and from disuse of muscle without nervous lesion. A marked example of it from long confinement of the limb in splints, is recorded in the Dublin Quarterly Journal, November 1869.

In reply to the second question, it may be said that, reasoning from this single case, we should be justified in regarding the disease as one affecting the muscles primarily ; for if the changes in them should be of the same kind as have been observed in the specimens that were submitted to microscopic examination, there is sufficient alteration of structure to account for the loss of power, and the muscular enlargement is said to have preceded the paralysis.

Duchenne, however, describes the increase in volume of the muscles as occurring subsequently to the loss of power; and it will be better, therefore, to postpone the further consideration of this matter, till the nature and order of succession of the symptoms have been discussed.

The symptoms presented by John B— resemble, in most respects, those previously met with in other cases of this disease.

There is an enlargement of some of the muscles, commencing in those of the lower extremities, and attended with a loss of power.

The general health is at first good, and ordinarily remains so, till the paralysis extending and becoming more complete, the patient becomes gradually weaker, and finally succumbs to an attack of some inter- current affection. Some of the affected children have exhibited muscular weakness from infancy, while in others it has first shown itself several years after birth. The progress of the disease is slow, but, judging from recorded experience, unerringly sure towards a fatal result, if the muscular enlargement has once commenced. The electric irritability has, when tested, proved normal, except in a very late stage of the disease. In some patients there has been a distinct mottling of the skin, with diminution of temperature of the affected parts. The waddle, straddle, and lumbo-sacral curve, are generally

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1871.] With Apparent Hypertrophy of the Muscles. 165 well marked, and have for their object the poising of the body, the two first acting in. a lateral, and the last in an antero-posterior direc- tion. The sensibility is usually intact, but in one case (recorded by Dr. Russell) the patient complained " that the feeling had gone out of his hands, and that his feet were numbed ;" aching pains in the affected limbs were also experienced in this, and in another instance (contributed by Dr. Dyce Brown). With one exception, the disease has been seen only in childhood, and in every case the subject has been a male. Seidel observed it in three members of a family, Heller in two, Russell in two, and Adams in two. Russell's patients also had two uncles who died paralysed, at the ages of 16 and 17 ; they are said to have had no muscular enlargement, but to have walked on their toes, and swayed in walking.

Duchenne, who has paid considerable attention to this disease, recognizes three stages ; a first, in which there is muscular weakness without enlargement, a second during which the enlargement super- venes, and a third marked by an extension of the loss of power, without further increase in size, and attended, sometimes, with a shrinking of the previously enlarged muscles. The first stage, A,s thus described, was either absent or unobserved in the boy who forms the subject of this paper. The mother is very positive in her assertion, that no perceptible loss of power occurred till after the increase in volume had been noticed ; and considering how great a difference in size exists between the calves of children of the same height, it must be asked, I think, whether in Duchenne's cases there may not have been a moderate enlargement at the time when the muscular weakness was first observed. In this case the mother is not aware that the triceps is affected, the increase in size being insufficient to attract the eye, though sufficiently distinct to be detected readily by palpation.

In eleven recorded cases, we have the following information as to the parts affected, and the mode of attack.

Case 1—Under the care of Dr. James Russell,* " Zachariah , aged 11, a well made boy . . . His mother is sure that he walked perfectly up to the last six months . . . Up to a week before admission, he could walk across the street. To the last he has been very useful with his arms, nursing the baby, etc.

His mother declares that the boy walked on his toes from the beginning of the paralysis, and that the calves of his legs began at once to increase. There was also marked projection of the hips from the time when the failure was first noticed. . The boy has a sharp expression of face, and a state of intellect above the average. . . The erector spinee is very prominent even as he sits. . . . The integuments of the lower extremities are remarkably mottled."

Case 2—Also treated by Dr. Russell, " T. R., aged 10, his legs first failed at the age of 3 or 4, and he grew worse by degrees.

They began to grow large at a very early period in the history of

* Medical Times, May 29, 1869.

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166 DR. W. SMITH on Paralysis [June, his disease, but have only become so very large' the last four years.

He has never fully lost the power of walking. . . . He can now walk three or four miles, but is easily thrown down. . . . The right grasp is decidedly more feeble than the left, though he throws stones and spins tops. The muscular enlargement is confined to his calves, which also present unnatural firmness. In the thighs, the quadriceps extends or projects so much as to cause a very apparent deformity, but it is not firmer than natural. . . . Intelligence is said to be good, but he is very shy, and unmanageable before strangers."

Case 3—Contributed by Dr. Dyce Brown.* "J. C. M., met. 26, . . . quite healthy up till about a month before being sent to prison. About this time he began to feel stiffish' in walking . . and he continued to feel his walking difficult, and his legs were getting weak, but he did not observe any muscular enlargement till a month after being sent to prison. At this time he told me that he thought his thighs were much larger than natural. . . . I examined his thighs at this time, and found them to be unmistakably larger in girth than natural. To the feel, the muscles felt firm, almost hard. Three weeks later the calves of the legs had followed in the same enlargement, and were very firm and hard to the feel.

. . . The oblique abdominal muscles were also visibly enlarged.

About the beginning of September (three months after admission), he complained of his arms feeling weak, and that he was unable to do his task. I found the biceps of both arms larger than natural, and rather firm especially on flexion. . . . The skin was of normal colour. 12th January, 1870— . . . He complains now of weakness of sight, especially of right eye."

The state of the eyes is described as follows :—" Right S. = Retinal vessels small ; pigment external to optic disc. Otherwise healthy. Left S. = i2.Vessels of retina small. Capillary edge of choroid showing pigment maceration. Colour vision perfect."

Case 4—Described by Dr. Duchenne, " a boy aged 11 years, affected with paralysis and muscular degeneration from his earliest infancy. The apparent hypertrophy of the muscles is general."

Case 5—Under the care of Mr. William Adams, " boy aged 7f years. Both calves are greatly hypertrophied, measuring 101 inches in circumference. . . . Both thighs look disproportionately small, and the muscles are soft and flaccid, contrasting remarkably with the condition of the calves. The nates are also small and soft, but not in a remarkable degree, and the spinal muscles are in a similar condition. In both upper extremities the muscles of the forearm appear to be developed beyond their normal size, and a little below the elbow joint, the muscles are prominent and tense . . . . whilst the muscles of the upper arm appear to be dis- proportionately small, and are comparatively soft and flaccid, though not in a very marked degree, and both the biceps and triceps

• Edinburgh Medical Journal, June 1870.

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1871.] With Apparent Hypertrophy of the Muscles. 167 appear to be in an early stage of atrophy or degeneration. The deltoid muscle in both arms is peculiarly prominent, and stands out in bold relief, its outline being distinct, and its structure firm to the touch. The disposition to trip and fall in walking has been noticed for a year or more."

Case 6—Recorded by Dr. Duchenne, " A boy aged 8 years. At- tacked by paralysis with degeneration of muscles at about the age of six years. All the muscles of the inferior extremeties, the glutei and the lumbar muscles of the spine, acquired progressively a considerable size about a year after the weakness of the upper"

(evidently misprint for lower) " extremities began. This condition remained stationary for several years, after which the paralysis reached the upper extremities and became general. The patient died at the age of 14."

Case 7—Contributed by Dr. Duchenne, " A boy aged 9 years. The volume of the gastrocnemii increased enormously a few months after the appearance of the paralysis of the inferior extremities.

The glutei and the lumbar muscles of the spine at the same time increased in size, but in a less degree."

Case 8—Under the care of Dr. Duchenne, " A boy aged 71 years . . . began to walk very late. Intellect dull, and muscular weakness from his earliest infancy. At the age of 4 years, there was very evident increase in the size of his calves, and of the glutei and lumbar muscles of the spine. After remaining for some years stationary, the paralysis reached the upper extremities and abolished all movement. He died at the age of 13 years."

Case 9—Attended by the late Dr. Hillier,* " A boy aged 10 years and 11 months. He has always apparently enjoyed good health, except in respect to muscular power. He could not stand till he was 21 months old, and from this age he began to walk im- perfectly When about 3 years old, and until he was 8 or 9 years, his calves were larger than those of other boys of his age, and looked very round and bulging when he stood upright.

From the age of 6 or 7 years he became less and less able to walk.

He went to school till he was 10 years old. His arms were strong, but they were of moderate size till he was almost 5 years old, since which they have wasted gradually ; they have become decidedly weaker during the last twelve months. . . . At the present time he looks tolerably healthy, and as he lies in bed, he can move his limbs in any direction, but with no great force. His calves are very large in proportion to his other muscles, although not absolutely large for a boy of his age, yet they are certainly large when it is remembered how little he has used them. At the upper and inner part of each crista ilii, there is a slight bulging apparently from enlargement of the erector spin and quadratus lumborum muscles."

Case 10—Observed by Dr. B. W. Foster,± a dull strumous-looking boy, aged 9 years . . . was very weak as an infant on his legs,

* Trans. Path. Soc., vol. 19, London.

j Lancet, May 8, 1869.

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168 DR. W. SMITH on Paralysis [June, and was quite 2 years old before he walked alone . . . was able when 6 years of age to walk nearly a quarter of a mile, resting frequently and supporting himself by the wall. . . . When 6 years old his legs began to increase in size. . . . In hospital the boy was found to be dull in intellect, but cunning . . . his hearing slightly defective. . . . The integument of the lower extremities was noticed to be remarkably mottled. . . . This condition did not extend to the trunk, and was but slightly marked in the upper extremities. . . . The erector muscles of the spine were hypertrophied and bard. The glutei muscles were also greatly hypertrophied. The muscles of the thigh were firm, but not increased in size. The muscles of the calf were greatly enlarged ; the boy could not stand on his heels even when supported, he naturally stood and walked on his toes.

Case 11—Exhibited at the Pathological Society of London, by Dr. Langdon Down.* " Boy 11 years old, and the malady has been coming on gradually . . . There was great loss of power in the arms, which he could only raise by swinging. . . . The gastroc- nemic and dorsal muscles were most hypertrophied. The boy had a dull heavy look, and a sallow pasty complexion. . . . The affected muscles did not respond to electricity."

In Case 1, therefore, the enlargement occurred at least as early as the loss of power ; in Case 2 it is said to have taken place " at a very early period in the history of the disease ;" in Case 3 the thighs, examined for the first time three months after the com- mencement of the "stiffness," were found " unmistakably larger in girth than natural ;" in Case 4 the enlargement and paralysis were observed at the same time ; in Case 5 the calves were greatly hypertrophied " a year or more " after the disposition to trip and fall had been noticed, and considering the usually slow course of the disease it is at least possible that it existed in some degree when this symptom first occurred. The same may be said of Cases 6 and 7, in the first of which certain muscles are described as having

" acquired progressively a considerable size a year after the weak- ness of the lower extremities began," and of the other it is said that " the volume of the gastrocnemius increased enormously a few months after the appearance of the paralysis of the lower extremities." Cases 8 and 9 both walked late and imperfectly. In one there existed very evident increase in the size of the calves at 4, and in the other at about 3 years of age. The former, however, lived to be 13 years old, and the latter was well enough to go to school till he was 10, so that it is not unlikely that the enlargement, described in one case as being very evident at the age of 4, may have been of slow growth, and its commencement, therefore, ccetaneous with the loss of power. In Case 10, there was muscular weakness from infancy, while the apparent hypertrophy is said not to have shown itself till the child had reached the age of 6 years ; and in Case 1I, evidently in a very advanced stage of the disease,

* Medical Times, April 2, 1870.

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1871.] With Apparent Hypertrophy of the Muscles. 169 information on this point is wanting. I shall presently refer to an in- stance in which there was loss of power, and hardening of the muscles, from hypertrophy of their connective-tissue, without enlargement.

I pass now to consider in what tissue or tissues it is probable that the disease originates. Is it essentially an affection of the nervous system, the structural changes in the muscles being secondary in point of time and importance I or are the muscles primarily and exclusively affected I The following considerations if they do not lead to a conclusion, are not without interest in connection with this matter :

1. Histological changes in the muscles are present in all cases, while in the autopsies that have been hitherto made, no disease has been detected in the nervous system. In estimating the value of the latter circumstance, we must remember the difficulty which attends microscopic examinations of the nervous system, and the fact that only a few post mortems have been made.

2. The sphincters appear to escape, and this even when, as in Case 4, nearly every visible voluntary muscle is attacked.

3. The general sensibility and special senses are not usually affected.

4. The loss of power takes neither the para nor hemi-plegic form, and does not occur in certain muscles grouped together by having a common supply of nerves. The same, however, must be said of progressive muscular atrophy, which, though long regarded as a primary disease of muscle, is now considered to be of nervous origin. In that affection, too, the sphincters and sensibility are generally intact.

5. In 6 of the 11!cases given above, the state of the intellect is not mentioned ; in one it is described as being " above the average ;" in another it is said to have been " good ;" in a third, " dull ;" in a fourth, the patient was " dull but cunning ;" and in a fifth, " dull, heavy, indolent and apathetic—answering questions in an intelligent manner." In the boy John B—, shyness is the only mental peculiarity.

6. The electro-muscular contractility is unaffected, except when the disease is very far advanced.

7. Though Duchenne has described the loss of power as preceding the muscular enlargement, in John B— the enlargement was observed first, and in the upper extremities there exists now a distinct increase in size, not observed by the mother, and without perceptible loss of power. For the reasons already mentioned it may be said to be possible, and perhaps probable, that even when the swelling was observed by the parents after, it may have actually preceded, the muscular weakness.

I find from indirect sources that Duchenne's monograph contains a history of 13 cases, some of which were not under his own care ; they probably include those described in his paper read before the Pathological Society. I cannot obtain an account of the symptoms of the German patients. Altogether, I am inclined to think that

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170 DR. W. SMITH on Paralysis [June, the data at present available are too scanty to afford material for a satisfactory reply to the question respecting the nervous or muscular origin of the disease. Admitting the nervous system to be primarily at fault, we have still to inquire in what part of it the lesion exists.

Duchenne is of opinion that the sympathetic system is affected, paralysis of the vaso-motor nerves occasioning congestion and consequent hypertrophy of the connective tissue. The mottled state of the skin, which has been observed in some instances, has been regarded as favouring this view. But it may be asked why hypertrophy does not attack the subcutaneous cellular tissue as well as that within the muscles. The suggestion that the disease is a result of syphilis, has not been borne out by clinical experience.

The affections which most resemble paralysis with apparent hypertrophy of the muscles are progressive muscular atrophy, and fatty atrophic paralysis.

Progressive muscular atrophy usually occurs in adults, generally attacks the upper extremities first, is attended with tremors of which the patient is unconscious, and has shrinking instead of enlargement of the affected muscles. Paralysis with apparent hypertrophy of the muscles exhibits the reverse of these phenomena.

There is one case on record* in which there was loss of power with unnatural firmness of the calves, and great hypertrophy of the connective tissue of the muscles, without enlargement.

Fatty atrophic paralysis, regarded by some as only a variety of progressive muscular atrophy, attacks children, appears first in the lower extremities, but causes no increase in volume of the muscles.

A case, supposed to be of this kind, was brought under the notice of the Pathological Society of London in the year 1847 and again mentioned by Meryon, in his paper read before the Medico- Chirurgical Society in the year 1851. The muscles were described as having undergone fatty degeneration, but were not submitted to microscopic examination, and it is said that " the calves were larger than natural, and had during the progress become permanently contracted." I think it probable, therefore, that it was really an instance of paralysis with apparent hypertrophy of the muscles—a disease at that time unrecognized. It was peculiar in having the upper extremities first affected.

" Essential paralysis" of childhood is not likely to be mistaken for pseudo-hypertrophic paralysis. The suddenness of the attack, the greater completeness of the paralysis, the subsequent wasting of the muscles, and the diminution of electro-muscular contractility are sufficiently characteristic.

Paralysis with apparent hypertrophy of the muscles has the following synonyms :—Paralysie myosclerosique, paralysie pseudo- hypertrophique, paraplegie hypertrophique de l'enfance, lipomatosis, lipomatous atrophy, and paralysis with degeneration of muscles.

Duchenne considers the disease curable, if it be recognized and treated before the muscular enlargement has commenced ; but the

' Medical Times, May 29, 1869.

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1871.] MR. MACGILLIVRAY on Cases of Removal of Tongue. 171 diagnosis at this period must be difficult and uncertain. The drugs hitherto tried have proved useless. I am not aware that galvaniza- tion has been employed, and it is not likely to be more efficacious than faradization, the plan of treatment adopted and recommended by Duchenne.

The accompanying photograph, very carefully taken by Mr.

Dunn, of Swanston-street, illustrates the pseudo-hypertrophy of the calves.

103 Collins-street East, May.

ON TWO CASES OF REMOVAL OF THE TONGUE.

By P. H. MACGILLIVRAY, A.M.

Surgeon to the Bendigo Hospital.

In the Medical Journal, for October, I recorded a case of success- ful removal of the whole tongue, by Syme's method. At the time of publication of the paper, the divided surfaces of the jaw had not firmly united. Some weeks afterwards the man called at the hospital, and there was then firm union. He could also talk remarkably well.

Shortly after this case, by a curious coincidence, two others pre- sented themselves for operation. In one, there was scirrhus con- fined to the anterior portion of the tongue, and the submaxillary gland on one side was enlarged and hard. The man recovered satis- factorily from the operation ; but there was the same difficulty as to the union of the jaw. After some time the submaxillary gland became much more enlarged, and was, therefore, removed. The patient was discharged from the hospital in a satisfactory condition, except that the sides of the jaw were still movable. In the other, there was epithelioma of limited extent, but situated rather far back on the tongue. It was thought advisable to try a partial operation at first, and this was done by one of my colleagues, under whose care he was, previous to admission to the hospital. The disease rapidly extended. Complete excision was then performed by my colleague, Mr. J. Stuart, but it was found impossible to remove some diseased tissues about the back of the mouth, without the greatest risk of opening the internal carotid. The patient recovered from the opera- tion, but the disease has since been steadily progressing over the floor and back of the mouth.

Where cancerous disease of the tongue is of limited extent, and especially if in the anterior part, no doubt it can easily be removed by the knife, ligature or ecraseur ; and any one would be reluctant to remove the whole organ under these circumstances. If the disease extended at all far back, or even if seemingly confined to the anterior part of the tongue, unless of small extent, I would myself recommend total ablation of the organ. Partial removals of the tongue are well known to be exceedingly unsatisfactory, and the recurrent disease usually runs a very rapid course. For the com- plete removal, no operation presents the same facilities as Syme's.

Unless the lip and jaw are divided and the cavity of the mouth

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172 MR. MACGILLIVRAY o9t Two Cases of [June, fairly exposed, the tongue can only be removed by the ligature or ecraseur as in Regnoli's or Nunneley's operations. The ligature, I believe, is seldom used in the larger operations on the tongue, and the action of the ecraseur in preventing haemorrhage is exceedingly uncertain. For my own part, I would never use it where it was possible to employ the knife, and to tie the divided vessels. In a successful case of removal of the greater part of the tongue, by Regnoli's operation, which I recorded in the Journal for December, 1864, haemorrhage occurring a few hours after the operation was nearly fatal. I have several times, in other parts of the body, seen troublesome haemorrhage follow the use of the ecraseur, no matter how carefully and slowly the chain has been tightened. .The great advantage of Syme's operation is that the surgeon is enabled to remove the entire tongue by the knife, and that it gives every facility for the ready ligature of the divided vessels. Its great draw- back, undoubtedly, is the difficulty of securing speedy union of the cut surfaces of the jaw. Possibly this may have been in part owing to the bones having been tainted with the cancerous cachexy, although I hardly think this had much, if anything, to do with it.

The drill-holes and ligature, I think, more probably were injurious in causing exfoliation of the edges, and thus retarding or preventing union. In any other case I would not use them. Instead of sutures and plate attached to an outside splint, I would use an interdental splint secured by screws passing between the necks of the teeth, as described by Mr. Heath* to have been used by Mr. Barrett, dental surgeon to the London Hospital, in some cases of fracture ; the whole chin being supported by an ordinary four-tailed bandage. My colleague Mr. Stuart suggests that the division of the jaw might be made from above and below, so as to form an obtuse angle, in this fashion ( so that the opposite sides might, as it were, dovetail with each other. In dividing the jaw, an ordinary straight saw will be found to be very inconvenient from the handle striking on th%sternum. The saw figured by Fergusson,t was used in the two operations here detailed, and answered the purpose admirably.

After the operation, of course the patient must be kept in a warm room with the temperature properly regulated and protected from draughts, so as to lessen the risks of pulmonary complications.

I now give the detailed account of the cases.

CASE 1.—Scirrh,us of Tongue.—Thomas D., aged 40, shoemaker, admitted from Graytown, on 19th December.

About twelve months ago, he first felt pain in his tongue, which, however, did not cause much inconvenience until about four months previous to his admission, when the point ulcerated. Since that time the ulcer has been gradually increasing in depth, and the pain becoming more severe.

On examination, the point of the tongue was found to be occupied by a cup-shaped excavation, extending equally on either side, through

* Injuries and Diseases of the Jaws, p. 40.

f Practical Surgery, 5th edition, fig. 378.

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1871.1 Removal of the Tongue. 173 the whole thickness. There was little or no discharge from this surface. The whole of the tongue for about an inch behind this was very hard. The submaxillary glands were enlarged on both sides, on the right being larger and harder. He complained of great pain, shooting to the ears, worst to the right. There was consider- able salivation, and his speech was a good deal affected.

There could be no doubt that the affection was scirrhus, and on consultation, it was decided to recommend removal of the whole tongue. The man at once consented, and it was done on 28th December.

The operation was done under Chloroform, and I was assisted by Messrs. Stuart, Eadie, and Penfold. A central incisor having been extracted, an incision was made through the lip, to the hyoid bone.

A hole was then drilled on either side of the symphysis, for the subsequent passage of a ligature to connect the halves of the jaw.

Unfortunately in drilling the first, the drill broke short off, and the point which had about half pierced the bone, could not be removed.

A small piece of wire was inserted into each drill-hole, to facilitate the subsequent finding it. The jaw was then divided at the sym- physis with a fine saw, having the handle bent up from the blade.

A stout ligature was passed through the tongue. The halves of the jaw being held aside by tapes,* the incision was extended backwards between the mylo-hyoid, genio-hyoid and genio-hyo-glossi muscles.

The attachments of the tongue in front (mucous membrane, &c.) were divided, and then the attachments on either side, those on one side being first separated, and the lingual artery tied as divided.

Both lingual arteries having been secured, the whole tongue was separated from the hyoid bone. The hzemorrhage having ceased, the halves of the jaw were approximated, and retained in apposition by a stout carbolised cat-gut ligature, passed through the drill-holes.

A silver wire was also passed round the incisors. Wire sutures were passed in the usual way through the lip and chin, the ligatures being brought through the posterior part of the incision, which was left open. A piece of dry lint was put over the chin, and some cotton wadding to exclude the air, on the posterior extremity. An ordinary four-tailed bandage was then applied.

On examining the tongue after removal, the anterior third showed the characteristic structure of scirrhus. It cut quite hard, and the cut surfaces at once became cupped in the centre. Microscopically it consisted of a fibrous stroma, with numerous nucleated cells, many of which were caudate. The muscular fibres for some distance were degenerated and granular.

29th December.—He had a pretty good night, sleeping a little.

At six this morning, a pint of milk was given through a catheter passed into the pharynx. There is a little bronchitis. Pulse 104.

During the day he had more milk and strong beef tea. Directions were given for him to steam his throat, holding his mouth over a narrow-necked jug. In the evening his pulse was 130, and the

* These take up less room than spatulas or assistant's fingers, and their use was suggested to me by Mr. Penfold.

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174 MR. MACGILLIVRAY on Two Cases of [June, bronchitis worse. He complained of great pain over the right side of the chest. Spongio-piline wrung out of hot water was ordered to be continuously applied to the throat and chest, and the mouth to be frequently steamed.

30th December,—Has had a good night. Cough a little better.

Pulse 120. This forenoon he swallowed some wine and water him- self, and in the afternoon and evening took milk and beef tea in the same manner. In the morning, the wound was dressed. The lip was united, but the sutures, which were causing no irritation, were left for security ;

31st December.—Bronchitis a good deal better, although still a good deal of cough. Pain gone from the chest. Pulse 100. Taking food from a spoon well. Several sutures removed.

1st January, 1871.—Has had a pretty good night, but the cough has been worse. Pulse about 90, weaker. Appetite not so good.

Base of both lungs dull on percussion, the dulness most marked in the right. Only a trace of chlorides in the urine. To have brandy instead of wine ad libitum. An enema was given in the forenoon and acted freely.

4th January.—Since last report, has improved. There has been troublesome cough with purulent expectoration. Last night his cough has been a good deal less, and to-day the bases of the lungs are resonant. Two days ago, I first noticed an elongated swelling in the right side of the floor of the mouth, red and pointed forwards, presenting much the appearance of a ranula. Pulse about 100, tolerably good. Takes milk, beef-tea and brandy (12-18 oz. daily).

Two ligatures came away to-day, and the last of the sutures were removed.

7th January.—The last ligature separated to-day. One edge of the jaw slightly overlaps the other.

8th January.—Incision in the neck entirely closed. Swelling in the floor of the mouth much smaller. Sat up for three hours.

14th January.—Cough has been troublesome, and has been relieved by a Squill and M orphia mixture. Mr. Henry Carter has fitted a silver plate to go over the teeth, and fasten to a metal splint under the chin.

19th January.--Since last report has been progressing favourably.

There is no union in the jaw.

Shortly after this, I was obliged to leave Sandhurst for some time, and did not see the patient again until the 25th March. There was then no union of the jaw. There was a small sinus opening from below, and through this a piece of dead bone came away a few days since. The inside of the mouth is perfectly sound. The submax- illary gland on the right side is much larger, and distinctly fluctu- ates at one place ; it is hard round the base, and in the part felt through the floor of the mouth. He has still a cough, with purulent expectoration. Otherwise he is in good health and strong.

28th March.—Under Chloroform, I punctured the fluctuating part of the submaxillary tumour, and gave exit to some sero-purulent fluid. As there was still a considerable, very hard mass, I removed

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1871.] Removal of the Tongue. 175 the whole gland. The operation was tedious, owing to the adhesions, especially to the lower jaw. In the floor of the mouth, at one part, there was only the mucous membrane left, and for about an inch the periosteum was separated from the jaw which was left bare and rough. Part of the digastric muscle, with its tendon, was imbedded in the diseased structure and cut out. The whole wound was mop- ped out with Chloride of Zinc (10 grains to the oz. of water).

31st March.—All the sutures, except one, were removed to-day.

Union of the edges has taken place by the first intention. The mouth is drawn to the left side. The edges of the jaw overlap slightly, the left being posterior. Some exfoliations were removed to-day. A loose incisor was also removed.

He was discharged on the 15th April, as he said he would be quite fit to follow his occupation. There was still a little thin dis- charge from the submaxillary gland. There was no osseous union of the jaw, but there was pretty firm fibrous union.

CASE 2.—Epathelioma of Tongue.—Henry P., aged 38, admitted 16th November.

About six months before admission, he first noticed a hard lump on the left side of his tongue. For this he consulted a surgeon who burnt it with Nitrate of Silver. Previous to the application of the caustic, the surface was unbroken.

There was an open sore on the left side of the tongue at the junction of the middle with the posterior third. It was about the size of a sixpence, with hard tuberculated edges. The submaxillary glands, were very slightly enlarged. There was great pain shooting to the ears. There was a good deal of offensive discharge from the ulcer.

He had been seen before, and it was arranged that on admission an operation should be performed by Dr. H. Boyd, his previous.

attendant, for the removal of the cancerous portion of the tongue.

Under Chloroform, an incision was made by Dr. Boyd, through the cheek, about 2/ inches backwards from the angle of the mouth.

The facial artery was divided, and both ends ligatured. A curved needle carrying a thread was then passed through the centre of the tongue opposite the sore. The thread having been passed, the chains of two ecraseurs were dragged through by it. These were tightened, one in front and the other behind. The cut edges of the cheek were united by wire sutures. On the second day after the operation, there was smart haemorrhage which was stopped by the application of Liquor Ferri Perchloridi. The wound in the tongue did not cicatrise, and after some days the ulceration extended further back over the tongue. At a consultation on the 15th December, it was decided to recommend removal of the whole tongue. On the 17th, the patient got leave to see his friends, and was persuaded by them to consult a clerical gentleman, who told him no operation could possibly do him any good, and gave him some medicine which he said would be more likely to benefit him. Finding that he was rapidly getting worse, on the 27th, he again presented himself at the hospital, begging that the operation should now be done. The

whole of the posterior part of the tongue on the left side was now

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176 MR. MACGILLIVRAY on Cases of Removal of Tongue. [June, found to be involved as well as part of the fauces. It was explained to the patient that the case was a very unpromising one, the disease having advanced considerably since he left the hospital.

He was very urgent to have the operation done, and it was accordingly agreed to.

The operation was done on 28th December, by Mr. J. Stuart, consulting surgeon to the hospital, assisted by Messrs. Eadie, MacGillivray, and Penfold. It was done in the same manner as in the last case. There was great difficulty in securing the left lingual artery, in consequence of the soft and friable state of the tissues.

After the tongue was separated from the hyoid bone, it was found necessary to remove a considerable portion from the floor of the mouth, and the fauces. There still remained a small portion of very doubtful appearance, but as it was in dangerous proximity to the in- ternal carotid, and any attempt to remove it would have probably opened that vessel, it was left alone. There was a good deal of oozing, and Liquor Ferri Perchloridi was freely applied, especially over the parts where the tissues were at all in a doubtful state. The halves of the jaw were then approximated by the carbolised cat-gut ligature, and the wound in the lip and chin treated as in the last case. After re- moval to bed, he suffered great pain. A subcutaneous injection of one-sixth of a grain of Morphia was therefore given.

Microscopic examination showed epithelial cells, with caudate cells, round nucleated cells, nuclei and granules. Some well-marked laminated capsules were also seen.

29th December.—Pulse 100. Considerable discharge from the mouth, but no heemorrhage. Very little pain. Fed with milk and beef tea, through a catheter and funnel.

30th December.—Has to-day drunk wine and water, milk and beef tea himself Wound dressed ; great part united in front.

31st December.—Complains to-day of pain at intervals, shooting to the left ear ; a little bronchitis. Several sutures were removed.

Cannot take beef tea which makes him sick. To have milk, tea, and brandy and water.

1st January, 1871.—Coughs a little. Complains of pain in the neck, on each side of the incision. Three ligatures came away, and most of the sutures were removed. To have purgative enema.

4th January.—The remaining two ligatures came away to-day.

The last sutures were removed on the 2nd ; cough now getting better. Does not complain of much pain, and that is chiefly about the angles of the jaw. Discharge moderate in quantity, and not offensive. Has been taking abundance of milk and beef tea, and large quantities of brandy (12 oz. and upwards daily).

7th January.—Incision in lip and neck entirely healed, except a small part of the posterior extremity which is not skinned over.

No union in the jaw.

8th January.—Sat up for three hours to-day.

14th January.—Has had some diarrhoea, with considerable tenes- mus and tympanites, which, however, yielded to treatment. Mr. H.

Carter fitted a plate to the lower jaw as in the last case.

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1871.] Du. FIEILY on a Case of Placenta Prcevia. 177 19th January.—Has suffered greatly from accumulation of hardened forces and scybalm in the rectum. Enemas containing large quantities of oil were used, and it was necessary to clear out a quantity. The disease seems to be commencing again in the left side of the fauces where, at the operation, it was found to be impossible to remove the whole of the doubtful tissues.

I have no report of the case, owing to my absence from Sand- hurst, until the 25th March. The patient was then discharged from the hospital in the following state. The external wound in the chin and neck quite healed. Pretty firm fibrous union between the halves of the jaw. The left side of the fauces and floor of the mouth ulcerated extensively, the surface in part presenting a cauli- flower appearance. The submaxillary gland on that side much enlarged, the swelling spreading behind the angle of the jaw, and not distinctly defined downwards. There is considerable pain, sometimes very severe, in the throat and the ear, as well as in the neck. There is occasional hmmorrhage, to the extent sometimes of about an ounce.

He has continued to attend occasionally as an out-patient. Several exfoliations have separated from the jaw. The disease has been steadily extending, and the pain is very great, requiring the constant use of Morphia. Nevertheless, he has been able to attend to his business as a book-keeper.

I have lately seen all three cases. In the first, operated on in July of last year, and reported in the October number of the Journal, there is now considerable enlargement of the submaxillary glands on both sides, and of the glands of the neck. The union of the jaw is quite perfect. Case 1 of this paper, presented himself at the hospital on 16th May, a month after his discharge. There was then great enlargement of the glands on both sides of the neck.

Indeed, considering the state in which he left the hospital, I was astonished to find that so great a development of malignant disease could have taken place in so short a time. In both, the inside of the mouth remains sound.

The English March journals, just received, contain a brief report of a paper on a case of Excision of the Tongue, read by Mr. Henry Lee at the Clinical Society. Mr. Lee and several other surgeons seem to have expe- rienced the same difficulty in securing union of the divided jaw. In the course of the discussion, Mr. Erichsen mentioned that Sedillat had intro- duced a plan of dividing the jaw in the same manner as here suggested by Mr. Stuart.

A CASE OF PLACENTA PRIEVIA.

By JOHN V. FIEILY, M.R.I.A., L. & L., M.R.C.S.I, L.R.C.P. Ed.

On the night of April the 18th, I was sent for to attend Mrs. H., some miles distant from here, who was reported to me as in labour, accompanied with copious flooding. The patient was naturally of

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178 Du HEILY on a Case of Placenta Prcevia. [June, strong and robust constitution, fullblooded, a brunette, aged 27 years, and this was her second confinement.

On my arrival, I found her pale, exsanguined, very faint, semi- delirious, and restless ; lying half on her back, with the head low, and with a cold wet towel applied to the belly. Clearing away some clots adhering to the vulva and vagina, I made cautious examination.

I found the os uteri nearly as large as a crown piece ; thick, soft, and capable of further dilatation. Within the os, the placenta could be felt on every side, and no portion of the foetus was within diagnostic touch. A labour-pain produced free discharge of unco- agulated blood. The vagina was not very hot. The rectum was empty. Under these circumstances, I introduced, high into the vagina, one of Dr. R. Barnes' medium-sized elastic.plugs, inflated it fully, placed a binder and cold pad over the abdomen, and waited for half an hour, keeping the plug (filled to its utmost) in situ with two fingers. Several pains succeeded in due course, and about two teaspoonfuls of blood escaped during the half hour. Another half hour passed by, and comparatively no blood escaped. During this second half hour, my patient rallied considerably, gaining both strength and confidence, and was most obedient, except in the moment of the labour pain.

The further history is now best expressed in the woman's own words. " Four days ago, I had some shedding, not much. I lay down all day ; used vinegar and water cloths (wrung out), and the next day was all right. About one hour before you (Doctor) came, I was sitting on a chair after tea, mending some clothes, when all at once a pain came on, and I felt something run down my leg.

I looked and saw it was blood. I called my husband, desired him to send for you, and then to come and assist me to my bed-room.

Before Ralf my clothes were were off I nearly fainted, and was laid in bed as I am now (nearly undressed). Baby ought not to come for three weeks yet. Each pain brought more blood. Everything is soaked through." This was quite true. In an hour not only were the lower portions of the woman's wearing apparel, at this time remaining on, saturated with blood, but the blood had also passed (or percolated) through three pairs of blankets placed under her to save the bed, through the hair mattress, and the palliasse beneath these blankets, was, during the narration, actually drip- ping guttatim into the chamber-vessel to the depth of a couple of inches.

Bye and bye I withdrew the Barnes' plug, made fresh examina- tion ; cleared the placenta well round with the finger ; separating it slightly here and there to make the circle of detachment uniform, then introduced the large sized plug, previously cooled in water, and when in position inflated it fully. No haemorrhage of consequence eventuated from this proceeding, and at the end of an hour, first letting the air escape, I withdrew this second plug. Finding the os sufficiently dilated to allow the safe introduction of the hand, I passed it into the vagina, and freeing the placenta further, ran my

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1871.] Medical Society of Victoria. 179 fingers along the inner wall of the uterus, between the parietes and placenta, until I touched a spot where the placenta and membranes joined. These latter were tough, my nail being insufficient for their rupture. This procedure therefore was done with a long hair-pin, bent straight. A copious gush of Liquor Amuii ensued, and my hand entered the membrano-placental rent. I seized the feet, brought down one foot (the left), the other slipped from my grasp.

The first foot was secured, and the second was easily got hold of with my left hand. All this time, gentle manual pressure was con- tinuously maintained over the uterus by a nurse. The next pain expelled the child's body as far as the hips. With a little assistance three more pains completed this stage of the labour. The child was a female and dead. The uterus contracted firmly and at once. No hmmorrhage followed. The patient was bound, made dry ; had a hot brick placed to the feet to relieve threatened shivering, and the following was given at the same, time, Liq. Ergot. P.B., 3i in brandy and water. She slept from midnight until 8 o'clock a.m., when assisted by a dose of Ergot, and moderate pressure I withdrew the afterbirth, as it lay in the vagina, the membranous portion only being retained by the uterus. The usual care which such cases demand was observed, and the breasts as might be inferred gave no trouble. On the 9th day the woman was allowed to sit up for a short space.

The child attracted attention by its very protuberant belly, I ex- amined it, and found it had dropsy, and disease of the liver. This organ was much enlarged, and showed signs of recent inflammation.

I publish this ease, merely to express my own and my patient's gratitude to the inventor of these admirable plugs.

Rushworth, April 1871.

MEDICAL SOCIETY OF VICTORIA.

WEDNESDAY, JUNE 7, 1871.

ORDINARY MONTHLY MEETING..

Present : Professor Halford, Dr. Rees, Dr. Lilienfeld, Dr. P.

smith, Dr. Cutts, Dr. Burke, Mr. Morton, Mr. Blair, Dr. Wigg, Dr. Singleton, Dr. Black, Mr. Gillbee, Dr. Neild, Mr. Girdlestone, Dr. Jonasson, Dr. Bird, Dr. W. Smith. The President, Professor Raiford, in the chair.

THE LATE DR. THOMAS.

The PRESIDENT made some observations upon the recent death of Dr. D. J. Thomas. He spoke in feeling terms of the respect universally entertained for Dr. Thomas in the profession, as a sincere and earnest worker in the science he practised, and as one who always held honourable relations with his brother practitioners. As the senior member of the profession in Victoria, his name had, necessarily, a historical interest ; and as a diligent contributor to

DT 2

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180 Medical Society of Victoria. [June, the literature of medicine, he would also be remembered. Dr.

Thomas had also always shown great interest in the students attending the Hospital, and had on all occasions given them the benefit of his knowledge and experience.

Professor HALFORD read the following draft of a letter of con- dolence to Mrs. Thomas :

" June 7, 1871.

" Dear Madam,

" On behalf of the Medical Society of Victoria, I beg to offer you the sincerest sympathy in the bereavement you have just suffered, by the decease of your late husband.

"The death of Dr. Thomas is regarded by the Society as a loss to the whole medical profession, in which for so many years he held a prominent position, and to the literature of which he so largely contributed.

"Let me assure you that his memory will always be held in the most respectful remembrance.

" I am, dear Madam, respectfully yours,

" GEORGE B. HALFORD, M.D.

" President of the Medical Society of Victoria.

" To Mrs. David John Thomas. "

On the motion of Dr. NEILD, seconded by Dr. LILIENFELD, it was resolved that a copy of the foregoing be forwarded to Mrs. Thomas.

BOOKS PRESENTED.

Dr. NEILD presented, for the library of the Society, vol. xii of The Transactions of the Obstetrical Society of London ; also, a number of periodicals, English and American. On behalf of Dr.

Miicke, he presented " Investigations and Observations on the mode of propagation of Cholera," by Dr. Max. Pettenkofer.

SAMPLE OF CHLORALUM.

Dr. NEPA) submitted a specimen of solution of Chloride of Aluminium, prepared in the laboratory of Mr. Cosmo Newbery, by Mr. Joseph Sullivan, who contemplated manufacturing it on a large scale, from clay found in great abundance in the neighbourhood of this city. Mr. Newbery had analysed the solution, and found it to be identical in chemical composition with the Chloralum now so extensively being used in England as a styptic, astringent and antiseptic.

Papers were then read " On Phthisis in Victoria " by Dr. Single- ton, and " On Ununited Fracture " by Mr. Gillbee. These we are obliged, from pressure on our space, to hold over until our next number.

Dr. NEILD then read for the authc r the following :

MOW

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1871.] DR. JACKSON on Hydatid Tumour of Neck. 181 FIYDATID TUMOUR OF NECK—EXCISION—RECOVERY.

BY JAMES JACKSON, M.D., Lond. &c.

Assistant Colonial Surgeon South Australia, and Surgeon to the Mount Gambier Hospital.

William Tepping, mt 51, by occupation a shearer, was admitted into the Hospital on the 8th August, 1870. He was the subject of an immense tumour, which occupied the front and right side of the neck, extending from the inferior maxilla above, and reaching down- wards as low as the middle of the sternum. Laterally it extended from the centre of the left clavicle to the acromion process of the right scapula.

This tumour had existed for the last thirty years, and was so large and weighty, and had latterly become so painful, as to inter- fere seriously with the performance of his daily work • besides which he had become such an object of ridicule wherever he went, that he expressed himself as tired of his life, and determined at all risks to have it removed.

From the character of the tumour, I concluded that it was a hydatid formation, and this opinion was strengthened by a know- ledge of the fact that the man had spent the greater part of his life on sheep stations, where long droughts were prevalent, and had often to resort to the drinking of impure water. The skin was every- where movable over the surface of the tumour, which had attained so large a size as to push the man's head somewhat backwards. There was a slight sense of fluctuation in the tumour, but so obscure as to render its existence doubtful.

On the 9th August I excised the tumour (with the assistance of Dr. Wehl), the patient being under the influence of Chloroform.

Two incisions were made from above downwards, about ten inches in length, including an elliptical portion of skin. The tumour was then, without much difficulty, separated from the surrounding integuments, and the external jugular vein, which ran across the centre of the tumour was ligatured and divided. The tendon of the omo-hyoid muscle, which also lay across the centre of the tumour, and which was in a state of extreme tension, was also divided. The base of the tumour was then reached ; this was about five inches long, and so closely adherent to the sheath of the large cervical vessels, that I determined to put a ligature tightly around it ; this was accordingly done, and the mass removed, anterior, and as close to the ligature as possible. The patient was much prostrated after the operation, the result of haemorrhage from numberless small vessels, added to by the chloroform taken. Brandy was given, which was attended with a good result, and the man expressed him- self afterwards as feeling very comfortable. The tumour weighed six pounds, the walls of the cyst were quite two inches thick, and had in some places undergone calcareous degeneration, large bony lamellae being easily detached. The centre of the growth was occupied with a small quantity of water and collapsed hydatid cysts.

After the hmmorrhage had ceased, the wound was freely mopped out With Carbolic Acid and Oil (1 to 3), and Lister's antisepic treatment

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it

182 Medical Society of Victoria. [June,

carried out as carefully as possible ; the edges of the skin were approximated by ligatures prepared antiseptically.

August 10th.—Febricula, with flushing of the face ; pulse 100.

Ordered :-

R Mist. Camph., 31.

Sp. /Eth, Nit., 31.

Liq. Am. Acet.,

Milk and beef tea ad libitumQ uarta quaque hors sumendus.

.

August 12th.—Not so well. Face a good deal flushed. Com- plains of pain in the left side. The breathing is accelerated, and there is marked dulness over the base of the left lung, with weakened respiratory murmur. No friction sound can be heard. There is sometimes very slight cough, but no expectoration. Ordered :

Rep. Mist. Febrif.

Pull. Opii gr. i. Quarts quaque hors.

Emp. Lyttn lateri dolenti.

August 13th.--At 2 p.m. to day the patient was seized with a severe rigor, which lasted fully half an hour. It was attended with strong convulsive movements and chattering of the teeth. Counte- nance anxious. The skin and conjunctivas have a decidedly icteric tinge, and there is occasional delirium. Hot brandy and water was given freely during the fit, and hot bottles put to the feet. Ordered :

R Morph. Hydrochl, gr. ss.

Quinn Disulph., gr. x.

Aeon ad.,

Quaque quart& holt

As the edges of the wound looked unhealthy, and there was evidence of putrefactive changes, I removed all the sutures and washed the whole surface of the wound with a warm solution of the Liq. Sod. ChlorinatEe (1 to 8) by means of a syringe. This lotion was used every six hours during the day and night, and after each application the Carbolic Acid Oil was applied to the edges of the wound, which was again covered with Carbolic Acid putty, in tinfoil.

There was also noticeable a good deal of oedema of the right arm, with erythema of the skin covering the outer part of the clavicle and deltoid. This inflammatory surface was freely brushed with an etherial solution of the nitrate of silver, and a flannel roller applied to the arm from the fingers upwards.

From the 14th to the 17th.—No great alteration had taken place.

The rigors occurred twice or thrice daily, but were not so severe as at first, and were always followed by profuse sweats. All this time the patient was taking Quinine and Morphia, as ordered above, and was kept under the influence of Morphia. It was noticed that any attempt to diminish the dose was followed by delirium and a feeling as if rigors were about to recur. As there was a good deal of irritability of the stomach the quinine &c. was omitted, and the following draught given with the Citrate of Magnesia.

Acidi. Hydrocyan. Dil.

Liquor. Bismuthi, 3 ss.

Soda, Bicarb., gr.v.

Aqua, ad. i.

uarta quaque hors.

RM

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1871d DR. JACKSON on Hydatid Tumour of Heck. 183 August 18th.—At 5 a.m. another severe rigor, lasting 25 minutes, again came on. Hot brandy and water was given. Ordered Rep.

Haustus Morphim c Quinia 4tis laoris.

August 19th.—Very much better. Slept well all last night. Wound discharges freely. Pus looks healthy. Bowels much relieved, with copious emission of urine having a very dark colour. Pulse 96.

From this time the patient continued steadily to improve ; rigors recurred for some few days, but they were of shorter duration and much less severe than formerly.

The wound continued to discharge healthy pus, and the facial aspect improved.

There still remained considerable dulness over the base of the left lung, with slight pain on deep inspiration. For this, counter- irritation was used freely with diuretics and small doses of the Iodide of Potassium. This man eventually made an excellent recovery, and left the Hospital, not only well, but looking much younger than before the operation. I saw him a few days ago, he was perfectly well, and doing hard work.

I think this case important, not only from the large size, and unpleasant situation of the tumour, which made its removal one of considerable risk to the patient, but also from the fact that the man had well marked pymia, which rendered his condition for some days very critical. I am also of opinion, that the free exhibi- tion of Morphia and Quinine contributed, in no small degree, to his recovery. Beef-tea and wine were given him every two hours, day and night, and it was seldom that he refused it. Since the operation, I ascertained that my patient had been a hard drinker for the last twenty years.

This is the first case of pyzemia that has occurred here. Did it arise from blood-poisoning consequent upon the shock and loss of blood from the operation, or from phlebitis, following the unavoid- able ligature and division of the external jugular vein

I think there can be no doubt that the base of the left lung was the seat of small purulent deposits, which gradually underwent absorption.

The engraving shows the appearance of the patient before and after the operation.

OVARIAN TUMOUR.

Dr. Rees exhibited an ovarian tumour containing a quantity of hair. It was of the left ovary, and was taken from the body of a woman who died in the Alfred Hospital. Dr. Rees undertook to examine the internal surface of the tumour microscopically, and report at the next meeting.

The thanks of the Society were given to the several authors and exhibitors of the evening.

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