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A CASE OF SARCOMA OF THE MANDIBLE IN AN INFANT.
531
EXTROVERSION OF THE BLADDER TREATED BY VESICO-COLOSTOMY. BY JOHN A. C. MACEWEN, M.B., F.R.F.P.S. GLASG., VISITING
SURGEON,
GLASGOW
DISTRICT
C.M.,
Medical Societies. MEDICAL SOCIETY OF LONDON.
HOSPITALS.
THE DIFFERENTIAL DIAGNOSIS OF THE COMMON EXANTHEMATA. following A MEETING of this Society was held on March 13th record. The patient, a girl of 17, was admitted to Duke-street Mr. JAMES BERRY, the President, being in the chair, Hospital in February complaining of constant dribbling of when Dr. E. W. GOODALL opened a discussion on this urine and pain in the back. She stated that she had been subject. He said that the common exanthemata at operated on three times previously and the abdomen the present time were scarlet fever, measles, rubella, presented several large scars, but the extroversion did not chicken-pox, small-pox, erysipelas, and enteric fever. appear to have been in any way improved thereby. There Typhus fever was now fortunately rare. He remarked was a gap of nearly an inch between the bones at the pubic on the difficulty inherent in the diseases themchiefly symphysis. The urine was loaded with pus, and the tem- selves, and added that errors in diagnosis arose most perature was swinging. Medicinal treatment improved but did not cure the urinary condition. Patient’s expression commonly from want of method in examination. In some diseases an accurate diagnosis could be made on was dull and apathetic. As the plastic operations on the abdomen had not been a single symptom, such as the buccal enanthem of successful, and it was very doubtful if a Trendelenburg measles, while in others it was the combination of operation would succeed at the age of 17. it was decided to symptoms that determined the diagnosis. The latter dissect up a flap containing the whole imperfect bladder, was especially the case in scarlet fever, enteric fever, with the ureters, and attach it to the pelvic colon, close to the rectum. It was hoped thereby to form a urinary pouch. and some cases of measles. Further, the most charwhich would assist in retaining urine and keep the ureters acteristic symptom might be absent, such as the rash free from infection. The operation proved comparatively of enteric fever ; or some factor such as vaccination easy of performance. The flap of defective bladder was against small-pox might modify the features of the turned up, its edges trimmed ; then the open mouth of the disease. It was remarkable that the bacteriologist bladder was applied to a vertical incision in the pelvic colon, could only assist the clinician in one of the eight and the two structures carefully stitched together all round. diseases enumerated-e.g., enteric fever. But this A small piece of packing was inserted for a few days. was not so great a disadvantage since the assistance Patient made a rapid and satisfactory recovery. required by the clinician in these conditions must There is now a marked improvement in her expression, obviously be available at the bedside. While the and she is able to retain urine for about four hours eruptions of chicken-pox, small-pox, enteric and at a stretch. typhus fever were pathognomonic. the same could not be said of scarlet fever, measles, and rubella. A CASE OF Scarlet Fever, Measles, and Rubella. SARCOMA OF THE MANDIBLE IN AN The rash of scarlet fever was a more or less punctate INFANT.1 erythema evenly spread over the trunk and limbs, but avoiding the face, scalp, palms, and soles. It might be BY STANLEY P. MUMMERY, M.R.C.S., L.D.S. seen on the neck, the temples, and the skin just around the ears. In some cases it was confined to the trunk and adjacent parts of the limbs. It consisted of two THE following case of sarcoinatous growth, closely elements, a uniform erythema often preceding the resembling, in its early stages, a dentigerous cyst, is later puncta by 12 to 24 hours. Minute pectechial of interest. haemorrhages might occur, especially at the root of the In February, neck, and in the skin creases about The patient was a child of 9 months. joints. Other 1920, a swelling appeared on the left side of the mouth, conditions producing a rash exactly similar were which was tapped by the local doctor, and a quantity of serum evacuated. I saw the patient with Sir Arbuthnot Lane (1) rubella in the second stage of the rash, and less. commonly measles ; (2) the prodromal rashes of measles a month later. There was a large cystic swelling, apparently and and from the left the left chicken-pox ; (3) enema rashes ; (4) drug mandible, springing occupying side of the mouth nearly to the middle line. The cheek was eruptions ; (5) recurrent scarlatiniform erythema. very prominent, and the lower eyelid pressed up. An X ray Diagnosis from the rash alone might be impossible, showed the second temporary molar imbedded in the outer but fortunately other means were available, except wall of the cyst, and the germ of the unerupted first perperhaps in the case of enema and drug rashes. The manent molar lying beneath it. most difficult to diagnose was rubella, in which the A provisional diagnosis of dentigerous cyst was made, and an operation for its removal performed the next day. first eruption of macules or papules gave place after At the operation the growth was found to be adherent a day or two to an erythema indistinguishable from behind and to exhibit a very definite membranous wall. that of scarlet fever. In the absence of other disThe contents consisted of serum and mucilaginous material. tinctive symptoms of one or other disease, diagnosis The pathological report was " small round-celled sarcoma." at this stage was impossible. The scarlatiniform Treatment by radium was undertaken, and was so far prodromal rashes of measles and chicken-pox were not successful that the swelling entirely disappeared in a fort- as a rule brilliant, and the diagnosis in the case of night. The patient was seen again on June Itth—three months measles was readily made by the presence of otherafter the operation-when the swelling had reappeared and signs, notably the buccal enanthem. In the case of was of the same size and appearance as formerly. A second varicella a diagnosis could only be made when theoperation was performed on the 16th, and radium again pocks appeared, generally within 24- hours. Enema. used. The swelling subsided again, but reappeared in a little rashes were generally unaccompanied by other symover two months. On Oct. 22nd the temporary lower canine ptoms, but he had known pyrexia and even a rigor on that side became loose, and was removed, exposing occur, especially in enteric convalescents, whose sarcomatous tissue beneath. temperature was notably unstable. Drug rashes were The patient lived until the following January, by not so commonly mistaken for scarlet fever, but he which time the pressure of the growth posteriorly on instanced one case where a rash produced by quinine,. the fauces hastened the end by partial asphyxiation. accompanied by pyrexia and circumoral pallor with a trace of albumin in the urine, was mistaken for 1 Summary of a paper read before the Section of Odontology, scarlet fever. A pin-hole desquamation followed, but. of the Royal Society of Medicine on Jan. 23rd, 1922. the diagnosis of scarlet fever was refuted by therecurrence of the rash and symptoms on the readminGerman medical papers have agreed, in order toistration of quinine, and by the fact that no furtherThe cases of scarlet fever occurred in the ward. avoid expense, to issue congress reports in common. THE
case
is of sufficient interest to merit
EXTROVERSION OF THE BLADDER TREATED BY VESICO-COLOSTOMY. BY JOHN A. C. MACEWEN, M.B., F.R.F.P.S. GLASG., VISITING
SURGEON,
GLASGOW
DISTRICT
C.M.,
Medical Societies. MEDICAL SOCIETY OF LONDON.
HOSPITALS.
THE DIFFERENTIAL DIAGNOSIS OF THE COMMON EXANTHEMATA. following A MEETING of this Society was held on March 13th record. The patient, a girl of 17, was admitted to Duke-street Mr. JAMES BERRY, the President, being in the chair, Hospital in February complaining of constant dribbling of when Dr. E. W. GOODALL opened a discussion on this urine and pain in the back. She stated that she had been subject. He said that the common exanthemata at operated on three times previously and the abdomen the present time were scarlet fever, measles, rubella, presented several large scars, but the extroversion did not chicken-pox, small-pox, erysipelas, and enteric fever. appear to have been in any way improved thereby. There Typhus fever was now fortunately rare. He remarked was a gap of nearly an inch between the bones at the pubic on the difficulty inherent in the diseases themchiefly symphysis. The urine was loaded with pus, and the tem- selves, and added that errors in diagnosis arose most perature was swinging. Medicinal treatment improved but did not cure the urinary condition. Patient’s expression commonly from want of method in examination. In some diseases an accurate diagnosis could be made on was dull and apathetic. As the plastic operations on the abdomen had not been a single symptom, such as the buccal enanthem of successful, and it was very doubtful if a Trendelenburg measles, while in others it was the combination of operation would succeed at the age of 17. it was decided to symptoms that determined the diagnosis. The latter dissect up a flap containing the whole imperfect bladder, was especially the case in scarlet fever, enteric fever, with the ureters, and attach it to the pelvic colon, close to the rectum. It was hoped thereby to form a urinary pouch. and some cases of measles. Further, the most charwhich would assist in retaining urine and keep the ureters acteristic symptom might be absent, such as the rash free from infection. The operation proved comparatively of enteric fever ; or some factor such as vaccination easy of performance. The flap of defective bladder was against small-pox might modify the features of the turned up, its edges trimmed ; then the open mouth of the disease. It was remarkable that the bacteriologist bladder was applied to a vertical incision in the pelvic colon, could only assist the clinician in one of the eight and the two structures carefully stitched together all round. diseases enumerated-e.g., enteric fever. But this A small piece of packing was inserted for a few days. was not so great a disadvantage since the assistance Patient made a rapid and satisfactory recovery. required by the clinician in these conditions must There is now a marked improvement in her expression, obviously be available at the bedside. While the and she is able to retain urine for about four hours eruptions of chicken-pox, small-pox, enteric and at a stretch. typhus fever were pathognomonic. the same could not be said of scarlet fever, measles, and rubella. A CASE OF Scarlet Fever, Measles, and Rubella. SARCOMA OF THE MANDIBLE IN AN The rash of scarlet fever was a more or less punctate INFANT.1 erythema evenly spread over the trunk and limbs, but avoiding the face, scalp, palms, and soles. It might be BY STANLEY P. MUMMERY, M.R.C.S., L.D.S. seen on the neck, the temples, and the skin just around the ears. In some cases it was confined to the trunk and adjacent parts of the limbs. It consisted of two THE following case of sarcoinatous growth, closely elements, a uniform erythema often preceding the resembling, in its early stages, a dentigerous cyst, is later puncta by 12 to 24 hours. Minute pectechial of interest. haemorrhages might occur, especially at the root of the In February, neck, and in the skin creases about The patient was a child of 9 months. joints. Other 1920, a swelling appeared on the left side of the mouth, conditions producing a rash exactly similar were which was tapped by the local doctor, and a quantity of serum evacuated. I saw the patient with Sir Arbuthnot Lane (1) rubella in the second stage of the rash, and less. commonly measles ; (2) the prodromal rashes of measles a month later. There was a large cystic swelling, apparently and and from the left the left chicken-pox ; (3) enema rashes ; (4) drug mandible, springing occupying side of the mouth nearly to the middle line. The cheek was eruptions ; (5) recurrent scarlatiniform erythema. very prominent, and the lower eyelid pressed up. An X ray Diagnosis from the rash alone might be impossible, showed the second temporary molar imbedded in the outer but fortunately other means were available, except wall of the cyst, and the germ of the unerupted first perperhaps in the case of enema and drug rashes. The manent molar lying beneath it. most difficult to diagnose was rubella, in which the A provisional diagnosis of dentigerous cyst was made, and an operation for its removal performed the next day. first eruption of macules or papules gave place after At the operation the growth was found to be adherent a day or two to an erythema indistinguishable from behind and to exhibit a very definite membranous wall. that of scarlet fever. In the absence of other disThe contents consisted of serum and mucilaginous material. tinctive symptoms of one or other disease, diagnosis The pathological report was " small round-celled sarcoma." at this stage was impossible. The scarlatiniform Treatment by radium was undertaken, and was so far prodromal rashes of measles and chicken-pox were not successful that the swelling entirely disappeared in a fort- as a rule brilliant, and the diagnosis in the case of night. The patient was seen again on June Itth—three months measles was readily made by the presence of otherafter the operation-when the swelling had reappeared and signs, notably the buccal enanthem. In the case of was of the same size and appearance as formerly. A second varicella a diagnosis could only be made when theoperation was performed on the 16th, and radium again pocks appeared, generally within 24- hours. Enema. used. The swelling subsided again, but reappeared in a little rashes were generally unaccompanied by other symover two months. On Oct. 22nd the temporary lower canine ptoms, but he had known pyrexia and even a rigor on that side became loose, and was removed, exposing occur, especially in enteric convalescents, whose sarcomatous tissue beneath. temperature was notably unstable. Drug rashes were The patient lived until the following January, by not so commonly mistaken for scarlet fever, but he which time the pressure of the growth posteriorly on instanced one case where a rash produced by quinine,. the fauces hastened the end by partial asphyxiation. accompanied by pyrexia and circumoral pallor with a trace of albumin in the urine, was mistaken for 1 Summary of a paper read before the Section of Odontology, scarlet fever. A pin-hole desquamation followed, but. of the Royal Society of Medicine on Jan. 23rd, 1922. the diagnosis of scarlet fever was refuted by therecurrence of the rash and symptoms on the readminGerman medical papers have agreed, in order toistration of quinine, and by the fact that no furtherThe cases of scarlet fever occurred in the ward. avoid expense, to issue congress reports in common. THE
case
is of sufficient interest to merit