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CLINICAL NOTES FROM LECTURES IN THE COURSE OF CLINICAL INSTRUCTION AT ST. MARY'S HOSPITAL.
662
dorsal
nerve, is
not followed like this last
persistent effects.
injury by
so
unfortunate child is born, have it fed most carefully and snfI ficiently long each time, till enough, nearly enough, milk is of and and
many
or
,
The assertion of the patient that he had no difficulty breathing even in the beginning of his affection may only be due to his not having remembered that his respiration was difficult. Still I can say that experiments on animals show, contrary to the statement of Moritz Schiff, that respiration can continue without any marked disturbance on the side injured after the transverse division of almost the whole lateral half of the spinal cord, including the white lateral column (high up in the cervical region). In this case the natural duration of life seems to have received no abbreviative influence from the injury to the spinal cord and the consequent paralysis. When I t:rst saw him his general health was still good, although he had been paralysed twenty-one years, and when seen by Dr. Hughlings Jackson in 1865, twenty-four years after his fall, he was still in pretty good health. Several other facts also deserve mention about this case. lst. The persistence of anesthesia., notwithstanding the great amelioration as regards voluntary motion. 2nd. The persistence, also, of hyperaesthesia. 3rd. The peculiar kinds of attacks to which the patient was co long submitted-attacks of subjective sensations of heat in the ausesthetic limbs end of cramps in the paralysed limbs. 4th. The patient had reacquired the peculiar faculty of detecting on what part of the anaesthetic side were made the few impressions that he felt, notwithstanding the very slight degree of feeling. (To be concluded))
before emaciation sets in. When the lip is united it can suck, or be fed. In those cases in which the lip only is cleft, the operation may be delayed without disadvantage, because the taking of food is not interfered with. In the miserable child lately before us, about two months old, there was so much emaciation that I kept it in the hospital for a fortnight, and had it fed by a clever nurse, and so improved its conditiona little. It seemed scarcely safe to operate on such an ill-nourished subject. Whether it be better for the health of the child or not to give chloroform is not easy to decide. Sometimes I give it, and sometimes I operate without it ; but of this I am certain, that at this early age the surgeon derives no benefit from its administration. The patient is too feeble to offer any resistance. The lip is the portion of the deformity first to be operated on, and there are three steps or stages to be accomplished. Failure in any of them will be fatal to success. The first to be done is the paring of the edges, whereby it is prepared for adhesion. This procedure is very often improperly executed. The child should be secured for the operation, and the operator should stand in a convenient position. These can be accomplished only by the operator sitting, and holding the head of the infant between his knees, while the rest of the body is supported by an assistant. I operate, as you observed, with a very narrow scalpel. I transfix above, and cut downwards in a curved direction, because when the two curved surfaces are brought together, the free edge of the lip is thrown sufficiently down. When the incisions are made straight in a /-shape, the edge of the lip is not natural, but there is a retiring angle, that which generally constitutes so much after-
consumed,
deformity.
operate early,
-
-
--
-
-
--
The manner of dealing with the haamorrhage is simple. If CLINICAL NOTES FROM LECTURES IN THE the coronary arteries be compressed with the fingers, on one COURSE OF CLINICAL INSTRUCTION cheek bv the operator and on the other by the assistant, no blood will be lost, if the operation be quickly done, that can AT ST. MARY’S HOSPITAL.
the child. The operation hurt such pressure is being made. As
can
BY
HAYNES
WALTON, F.R.C.S.,
be
proceeded with while the lip is put toge-
soon as
ther, the arteries cease to bleed. Every part of the edge of the fissure must be removed, together with some of the red portion, no matter how extensive may be the incision necessary to accomplish this. Few young surgeons have courage enough
SURGEON TO THE HOSPITAL.
to take away a sufficiency. Attention should next be directed to the alveolar process. If there be the slightest projection,
HARE-LIP.
GENTLEMEN,-Last Wednesday three cases of hare-lip were ; one of them, as you know, was done by myself, and it is taken, together with others that have been under my care, for the subject of my clinical remarks to-day. The cases that I shall bring before you were all of the single complicated variety, in which were involved the lip, and the upper jaw on one side. The hard palate, and the soft, were cleft through their entire extent. The bone does not always suffer as much ; sometimes it is only partially affected. Even when the division runs through it, the soft palate may be un-
the
prominence should be brought to the level of the rest, by snipping through the arch, at the spot between the lateral incisor tooth and the canine, with the forceps, and pushing it back. [Drawings were shown of the several degrees of the defect.J On no account should any part be cut away. The teeth are to be preserved, and the mouth made more perfect by following my plan. In my last case I was able to fill up the gap in the bone, as you saw. The loosening of the lip-that is, the raising of it from the surrounding parts-should now follow, and I do not know how I can impress on you the importance of doing it to the required extent, except by asking you to remember how extensive was my dissection, and telling you affected. that without it there will be frequent failure of union. It The first question to be discussed is the period at which an must be so separated all round, even in the direction of the it will hang loosely, and admit of being transoperation should be undertaken for the closure of the lip. My nose, that posed so completely that there shall not be the slightest tenown experience tells me that it should be done as soon as possion when the parts are brought together. You will not sible after birth-that is, within the month--in all cases in that the child’s nose was fairly separated from the maxforget which, like those under consideration, the bone is divided as illary bones. well as the lip. The last proceeding is the adjusting of the wound. This Except the lip be closed the child cannot nurse, and even fails to take sufficient food in any other way, little practical fact which I give you will save you much because it cannot swallow quickly tll that is put into the trouble, and benefit your patient. Commence the adaptation from the lowest rart. Begin by making the edges below mouth; and emaciation ensues, and renders it less fitted for the correspond, and all the rest will easily fall into a proper place, operation, and is often the cause of death. Many surgeons no matter what the dissimilarity in the length of the two are deterred from operating so early from the fear of fatal conflaps. You saw how carefully I did this with a soft iron pin. vulsions ; but it is my belief that the liability to such has been To complete the operation on the outside of the lip, I used two other pins, in all three of them. In securing the pins with greatly over-rated-that their appearance is dne to loss of the ligatures, I tie each separately, and it does not matter and not to the of the and that mere irritation blood, oppration, whether this is done with a single round tie, or by twisting more lives will be saved by operating a week or two after birth the thread in the iigure of 8. I generally end the whole by than by doing so some weeks or months 1,,tter, when the child an internal suture near the edge of the lip, to ensure the healthe
operated on
marked symptoms of starvation, and is therefore ing of the mucous membrane. The best result will be got if has all unfitted to lose a drop of blood. I have myself operated you follow my steps, even better than the plans of Malgaigne and Langenbeck. The sutures are generally removed too many times before the child was a month old, and in every inTake out one pin at the end of four days, then another stance with perfect success. It has been erroneously supposed early. day, and then the stitch. A truss for pushing the cheeks that in very young children the Jlosh is so soft that the pins or forward is useful in most cases. The parts are kept quiet, , sutures readily cut through it. I say, therefore, as soon as the!and any strain on them is prevented. ,
each
dorsal
nerve, is
not followed like this last
persistent effects.
injury by
so
unfortunate child is born, have it fed most carefully and snfI ficiently long each time, till enough, nearly enough, milk is of and and
many
or
,
The assertion of the patient that he had no difficulty breathing even in the beginning of his affection may only be due to his not having remembered that his respiration was difficult. Still I can say that experiments on animals show, contrary to the statement of Moritz Schiff, that respiration can continue without any marked disturbance on the side injured after the transverse division of almost the whole lateral half of the spinal cord, including the white lateral column (high up in the cervical region). In this case the natural duration of life seems to have received no abbreviative influence from the injury to the spinal cord and the consequent paralysis. When I t:rst saw him his general health was still good, although he had been paralysed twenty-one years, and when seen by Dr. Hughlings Jackson in 1865, twenty-four years after his fall, he was still in pretty good health. Several other facts also deserve mention about this case. lst. The persistence of anesthesia., notwithstanding the great amelioration as regards voluntary motion. 2nd. The persistence, also, of hyperaesthesia. 3rd. The peculiar kinds of attacks to which the patient was co long submitted-attacks of subjective sensations of heat in the ausesthetic limbs end of cramps in the paralysed limbs. 4th. The patient had reacquired the peculiar faculty of detecting on what part of the anaesthetic side were made the few impressions that he felt, notwithstanding the very slight degree of feeling. (To be concluded))
before emaciation sets in. When the lip is united it can suck, or be fed. In those cases in which the lip only is cleft, the operation may be delayed without disadvantage, because the taking of food is not interfered with. In the miserable child lately before us, about two months old, there was so much emaciation that I kept it in the hospital for a fortnight, and had it fed by a clever nurse, and so improved its conditiona little. It seemed scarcely safe to operate on such an ill-nourished subject. Whether it be better for the health of the child or not to give chloroform is not easy to decide. Sometimes I give it, and sometimes I operate without it ; but of this I am certain, that at this early age the surgeon derives no benefit from its administration. The patient is too feeble to offer any resistance. The lip is the portion of the deformity first to be operated on, and there are three steps or stages to be accomplished. Failure in any of them will be fatal to success. The first to be done is the paring of the edges, whereby it is prepared for adhesion. This procedure is very often improperly executed. The child should be secured for the operation, and the operator should stand in a convenient position. These can be accomplished only by the operator sitting, and holding the head of the infant between his knees, while the rest of the body is supported by an assistant. I operate, as you observed, with a very narrow scalpel. I transfix above, and cut downwards in a curved direction, because when the two curved surfaces are brought together, the free edge of the lip is thrown sufficiently down. When the incisions are made straight in a /-shape, the edge of the lip is not natural, but there is a retiring angle, that which generally constitutes so much after-
consumed,
deformity.
operate early,
-
-
--
-
-
--
The manner of dealing with the haamorrhage is simple. If CLINICAL NOTES FROM LECTURES IN THE the coronary arteries be compressed with the fingers, on one COURSE OF CLINICAL INSTRUCTION cheek bv the operator and on the other by the assistant, no blood will be lost, if the operation be quickly done, that can AT ST. MARY’S HOSPITAL.
the child. The operation hurt such pressure is being made. As
can
BY
HAYNES
WALTON, F.R.C.S.,
be
proceeded with while the lip is put toge-
soon as
ther, the arteries cease to bleed. Every part of the edge of the fissure must be removed, together with some of the red portion, no matter how extensive may be the incision necessary to accomplish this. Few young surgeons have courage enough
SURGEON TO THE HOSPITAL.
to take away a sufficiency. Attention should next be directed to the alveolar process. If there be the slightest projection,
HARE-LIP.
GENTLEMEN,-Last Wednesday three cases of hare-lip were ; one of them, as you know, was done by myself, and it is taken, together with others that have been under my care, for the subject of my clinical remarks to-day. The cases that I shall bring before you were all of the single complicated variety, in which were involved the lip, and the upper jaw on one side. The hard palate, and the soft, were cleft through their entire extent. The bone does not always suffer as much ; sometimes it is only partially affected. Even when the division runs through it, the soft palate may be un-
the
prominence should be brought to the level of the rest, by snipping through the arch, at the spot between the lateral incisor tooth and the canine, with the forceps, and pushing it back. [Drawings were shown of the several degrees of the defect.J On no account should any part be cut away. The teeth are to be preserved, and the mouth made more perfect by following my plan. In my last case I was able to fill up the gap in the bone, as you saw. The loosening of the lip-that is, the raising of it from the surrounding parts-should now follow, and I do not know how I can impress on you the importance of doing it to the required extent, except by asking you to remember how extensive was my dissection, and telling you affected. that without it there will be frequent failure of union. It The first question to be discussed is the period at which an must be so separated all round, even in the direction of the it will hang loosely, and admit of being transoperation should be undertaken for the closure of the lip. My nose, that posed so completely that there shall not be the slightest tenown experience tells me that it should be done as soon as possion when the parts are brought together. You will not sible after birth-that is, within the month--in all cases in that the child’s nose was fairly separated from the maxforget which, like those under consideration, the bone is divided as illary bones. well as the lip. The last proceeding is the adjusting of the wound. This Except the lip be closed the child cannot nurse, and even fails to take sufficient food in any other way, little practical fact which I give you will save you much because it cannot swallow quickly tll that is put into the trouble, and benefit your patient. Commence the adaptation from the lowest rart. Begin by making the edges below mouth; and emaciation ensues, and renders it less fitted for the correspond, and all the rest will easily fall into a proper place, operation, and is often the cause of death. Many surgeons no matter what the dissimilarity in the length of the two are deterred from operating so early from the fear of fatal conflaps. You saw how carefully I did this with a soft iron pin. vulsions ; but it is my belief that the liability to such has been To complete the operation on the outside of the lip, I used two other pins, in all three of them. In securing the pins with greatly over-rated-that their appearance is dne to loss of the ligatures, I tie each separately, and it does not matter and not to the of the and that mere irritation blood, oppration, whether this is done with a single round tie, or by twisting more lives will be saved by operating a week or two after birth the thread in the iigure of 8. I generally end the whole by than by doing so some weeks or months 1,,tter, when the child an internal suture near the edge of the lip, to ensure the healthe
operated on
marked symptoms of starvation, and is therefore ing of the mucous membrane. The best result will be got if has all unfitted to lose a drop of blood. I have myself operated you follow my steps, even better than the plans of Malgaigne and Langenbeck. The sutures are generally removed too many times before the child was a month old, and in every inTake out one pin at the end of four days, then another stance with perfect success. It has been erroneously supposed early. day, and then the stitch. A truss for pushing the cheeks that in very young children the Jlosh is so soft that the pins or forward is useful in most cases. The parts are kept quiet, , sutures readily cut through it. I say, therefore, as soon as the!and any strain on them is prevented. ,
each