RUPTURED SPLEEN FROM A FALL.

[JAN. 22,

1881.

rent has now been stitched), and at one root and floor of the mouth beginning to show granulations rounded opening capable of admitting the little! and the slough detaching itself ; all seemed well ; however, part finger, which is the orifice of communication of the sac withi during our operations, the house-surgeon was requested the axillary vein ; the latter was above and below this spot to see him, as he had some haemorrhage (now eight days on the separation of the tumour. The cyst contained only after operation). He went to him, and applied bome ice fluid blood-no coagula. On examining the interior there and iron solution, which seemed to restrain it. Hæmorrhage is found a layer of reddish grumous soft material, two to again recurred about eight o’clock. The amount was so three lines in thickness, unequally distributed over the profuse that our house-surgeon, Dr. Bourns, thought it cyst wall; this material is easily scraped away, and consists wise to send for me. I arrived and found my patient very of blood coagulum, showing no lamination or decolorisa- exhausted, with a very feeble pulse, and a clot of blood, tion, and presenting under the microscope only altered blackened from the solution of perchloride of iron that had blood-corpuscles (broken up and shrivelled), with much been applied, hanging out of his mouth, conscious and able dark amorphous pigment matter and some haematoidin to write his wishes and requirements on a slate. Although crystals. When this material is scraped away, the inner haemorrhage seemed to have ceased, I thought it wise to ask surface of the sac or cyst is seen to be smooth and shining - for a consultation of my colleagues, who all arrived at the i.e., has a distinct lining membrane, the flattened tesselated hospital about 11 o’clock P.M. We still found him in the and nucleated epithelial cells composing which can quite same condition as before described. The advisability of readily be recognised under the microscope. The rest of tying the linguals, which should have been done on both the cyst wall consists of well-formed fibro-elastic tissue, sides, was deferred, and instructions to leave the clot in with also smooth muscular tissue-in fact, it seems quite statu quo, and feed the patient by enemata of beef-tea and identical with the ordinary structure of the walls of a vein ; milk, with a half-drachm of tincture of opium every second so that there can be no doubt that the sac was an aneurismalhour, as also to exercise digital pressure on the carotid of like expansion from the axillary vein, and is not an adventi- one side first if any haemorrhage should again appear, and tiously formed cyst. There are no dissepiments or indications if this did not stop it to try the same on the carotid of the other side. Fortunately the patient passed the night with. of such in the interior of the sac." Remarks.—The ascertained history does not throw much out the recurrence of the bleeding. During the next few light on the origin of this remarkable growth. The result of days the mouth was left untouched, and the same enemata examination after removal points to its being a sacculated assiduously continued. On the 22nd the mouth was cleansed, and he took some venous aneurism, springing and developing primarily from the axillary vein, and not a cyst, serous or angiomatous, iced drinks, much to his relief, cold tea, and nourishing which had somehow contracted a secondary communication drinks; the tincture of opium was not discontinued. On with the veins. Assuming it to have been caused by a sac- reflecting light by means of a looking-glass into his mouth, culated expansion of the vein, it must have existed in the the slough is observed to be detached, and the red granula. axilla long before it was noticed. Its existence was pro. tions appearing. He talks now fairly well, but cautioned pulse has regained its beat ; in fact, his bably discovered only when from its size the tumour began not to do so. to bulge and press uncomfortably on the surrounding parts. heart, which has a systolic murmur with violent palpitation, Similar tumours are alluded to in the works of Paget and troubles him much, so that he is ordered a mixture of soluBillroth, but they appear to be rare, and their etiology is tion of perchloride of iron and tincture of digitalis every undoubtedly obscure. The present case deserves record on four hours, cold drinks and nourishing enemata every four account of (1) the size which the cyst attained; (2) the evi- hours. All seemed favourable towards recovery. On the 23rd the patient, having discontinued the laudanum dence which is afforded of the nature of the growth, which appears to have been a venous aneurism; (3) the expedient in the enemata, did not sleep so well during the night, but which was adopted to prevent haemorrhage ; and (4) the suc- otherwise much improved. Diarrhcea set in during the cessful removal of so large a tumour from so important a afternoon. Oct. 24th.-The patient now refuses his food, and is locality with so little disturbance, constitutional or local. This result I am inclined to attribute to the employment of troubled with violent palpitation of the heart, the floor of antiseptic precautions (Listerism); and I venture to assert the mouth granulating nicely, and looks clean. He remained that so easy and complete a cure could not have been in this condition until he died on Tuesday night, the 26th of obtained in any other way. October, fourteen days after the operation. He suffered from an aortic and mitral murmur, with a very rapid small Calcutta. pulse. At the same time the heart palpitated violently. The heart alone was removed after death, and showed EXCISION OF THE WHOLE TONGUE BY great hypertrophy and dilatation of the left ventricle, with incompetent aortic and mitral valves. THE GALVANIC ÉCRASEUR. Manchester-square, W. BY F. A. PURCELL, M.D.,

the

operation (the is

a

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His

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SURGEON TO THE CANCER

HOSPITAL, BROMPTON.

RUPTURED SPLEEN FROM A FALL. BY HENRY

IN THE LANCET for

July 5th, 1879, I described the opera. and bloodless method of excising the tion "for the painless affected with whole tongue," epithelial cancer. I need not over the same go ground again, but suffice it to say that I have had no reason to deviate in the slightest degree from the operation I there described ; I have performed it several times since successfully, but it may be interesting to record a case in which a fatal result has taken place. On Oct. 12th T. C-, aged thirty-eight, suffering from epithelioma of the entire right side of the tongue, ulcerated, with ichthyosis extending into the opposite side. Glands only slightly enlarged in the submaxillary region. It was decided to remove the entire tongue by the galvanic 6craseur. The patient being put under the influence of the ansesthetic I introduced the nozzle of the cannula through a vertical submental incision (after Nunneley) into the floor of the mouth, and, proceeding exactly as I have previously described the operation in THE LANCET of July 5th, 1879, exc sed the whole tongue, having got well behind the disThe patient came to without losing during the operaease. The submental incision was brought tion any blood. together by one horsehair suture, and he was removed to his bed. Within two days he was up and about the ward, and on October 19th I examined his mouth and found the

I

MEDICAL

OFFICER,

RUPTURE of the

TOMKINS, M.D.,

MONSALL FEVER

spleen, though

HOSPITAL, MANCHESTER.

not of very uncommon

occurrence, is case

yet sufficiently rare to warrant the following being placed upon record, the more so as it presents

two features peculiar to itself-firstly, the fatal issue did not take place until three weeks after the receipt of the injury; and, secondly, so little importance was attached to the injury that at the time of death suspicion was aroused that the patient had died from the effects of medicine obtained from an unqualified practitioner. On Oct. 21st, by order of the coroner, a post-mortem examination was made on the body of Mary M-, aged twenty-five, unmarried, who had been found dead in bed ten hours previously. The body was fairly nourished ; no external marks of violence, but very anæmic; lips, conjunctiva, &c., quite bloodless. The abdomen was somewhat distended; dull on percussion. On opening it the peritoneal cavity was found filled with dark sanious fluid and numerous large soft clots. Beneath the edge of the ribs on the left side, extending across the epigastrium, was a huge dark mass, which proved to be the spleen. In size, ing roughly, it was as large as the Jiver, and weighed at one or

speak-

135 least four pounds, probably more. On the under-surface the

and on cutting into it, it was found to be hollowed out into a large cyst filled with soft coagula. All the other organs of the body were healthy and bloodless. The history given was this :-Three weeks before she had been standing on a box some three feet high, from which she fell, striking her left side against a corner of it. She combut not severely, plained at the time of having hurt herself, and in a few minutes after resumed her work. From that time onward she complained more or less of her side, saying it "caught her breath," and that she felt as if she had "a lump there,"but her friends could detect nothing abnormal by sight or touch. There was no bruising after the fall. The night before she died she complained still more of the pain, referring it chiefly to the epigastrium, and called that evening on an unqualified practitioner, who gave her some medicine, of which she took about an ounce and a half, went to bed, and was there found dead the following

organ

was

ruptured,

morning.

At the inquest the medicine was proved to be only a simple antispasmodic mixture. The blood was unfortunately not examined, so that it is

somewhat uncertain whether this

was a case of leucaemia ; glandular enlargement was detected, and the previous history pointed to good health, but impoverished circumstances, and shortness of food. If the spleen were normal in size at the time of the accident, the above is certainly a very unusual case. The length of time also that elapsed between the receipt of the injury and the fatal termination is much longer than any I can find recorded.

pressure, the blood rapidly distended the mass again, but the latter did not exceed its ordinary limits. The mother could give no trustworthy history of the tumour, but it was unquestionably of congenital origin, and allied to It seemed to have the the ordinary naevi of this class. ordinary supply of nerves and arteries, for its sensibility and temperature were normal, and none but the usual arteries or veins could be found in any part of the healthy bordering structures. The mass was growing but had not

bled

spontaneously.

discussing several plans of treatment, and notwithstanding the fact that cauterisation by red-hot needles After

had been tried elsewhere without any appreciable result of any kind, Mr. Gay determined to cauterise by means of large blunt needles made red hot by benzine vapour. The child having been placed under the innuence of chloroform by Mr. Eastes, the portion of the cheek containing the tumour was thrust out of the mouth as far as The mass having been in this way fairly exposed, Mr. Gay pushed a thick red-hot needle, a line in breadth, deep into the tumour at several points. The blood was not squeezed out of the mass before the needle was used because it was feared that though the cautery would seal the openings in the vessels the needle had made, the reflux of the blood would reopen them, and bleeding would ensue. No

possible.

took place, although the openings were as a six- or seven-sized catheter. The whole tumour immediately swelled, but subsided again after the escape of a quantity of bloody muco-serous fluid from the burnt aperture and mucous membrane. The results, however, were not satisfactory, for after the healing of the wounds the tumour was left much as it was before the operation. After an interval of three weeks Mr. Manchester. Gay determined on repeating the cauterisation, butconfining the punctures to a limited portion of the swelling. He therefore selected the most vascular portion, and made five punctures within an area of about three-fourths of an inch OF square. On withdrawing the needle two of these punctures bled copiously, throwing out jets of dark with some crimson HOSPITAL blood of the same size as the orifices. The bleeding was, after trying several futile plans, ultimately by BRITISH AND FOREIGN. passing ligatures deep into the tissue below the bleeding Nulla antem est alia pro certo noscendi via, nisi quamplurimas et morborum parts, by means of an eyed tenaculum, armed with thick silk, et dissectionum historias, tum aliorum tum proprias collectas habere, et and tying them across the apertures. This procedure was inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proæmium followed by consolidation of the whole of the portion of the tumour that had been brought within its scope, but beyond GREAT NORTHERN HOSPITAL. this the tumour was as active as before. It then became clear that complete obliteration of the mass could only be A CASE OF TELANGIECTASIS. gained by a series of similar- procedures, each being limited (Under the care of Mr. GAY.) to a small portion only of the diseased mass. A portion was A VERY remarkable case of this disease was admitted during now selected full of large vessels nearer the back of the the last summer. The patient was a girl eight years old, other-. mouth, between the cheek and the palate, and three puncwise healthy. The disease was an entirely new growth, and tures were made in it. Again the bleeding was very pro and as there was some difficulty in using ligatures Mr, consisted of a cluster of distended veins so convoluted and fuse, suggested that the openings should be forcibly pluggect Cripps coiled on each other as to form a compact venous tumour. lint moistened with the solution of perchloride of iron. It occupied the whole of the right side of the cheek, and In this way the bleeding was stopped, the plugs being seemed to be a teratological development of the venous at allowed to remain until released of themselves. Suffice it the expense of the muscular elements, especially that of the to add that the united portion of tissue that was thus brought under the influence of the cautery solidified, but buccinator muscle ; for before the growth of the tumour the no more, and that it required several other like operations to muscular tissue receded and disappeared; so that the bring the whole into a like condition. The portion that tumour bulged outwards on the cheek very considerably, passed across from the cheek to the palate was exceedingly showing its blue colour in patches through the skin, which troublesome, and required several applications of the cautery, On the inner side of the cheek it each of which was followed by profuse haemorrhage. Even. was extremely thin. tually, however, every portion seemed to have succumbed, also bulged as a closely packed mass of large convoluted and the vascular tissue was reduced to a consolidated mass, veins, which at length protruded so far as to incommode first of clot and vessels, and ultimately of compact nævoid the child in talking and masticating by getting between tissue, minus its blood. Such was the vital tenacity of the the teeth. From the cheek the growth extended in growth that the large outlying veins on the lip had to be in order to bring about their consolidation. a broad and irregular band across the back of the mouth ligatured The child presented herself at the hospital a week ago. and the hard palate, the mucous membrane of the entire By far the largest portion had consolidated, but not the half of which was thickened and discoloured by it, and to whole. There was an island just within the mouth, and the lower lip, the half of which was also occupied by large another at the extreme back part of the cheek, which preveins, which exalted themselves considerably above the sented not only large venous coils, but were in a state of normal level. The tumour on the cheek was defined and growth. These will require at no distant period the reimpressible, so that the blood could in great part be ex- newed use of the cautery. Mr. Gay prefers the cautery to pressed from it, but not without leaving behind a con- other modes of treating these nævoid tumours, but he would siderable amount of dense doughy material, that consisted feel little hesitation in the event of such treatment being no doubt of the thickened walls of the veins and their interunsuitable in a given case to extirpate it by the ordinary vening connective tissue ; and that the whole was enclosed knife, or, if found necessary, by red-hot knife, for the supin some tough limiting envelope there could be no doubt, plying artery as well as the receiving veins did not appear for on expressing the contents and instantly relaxing the to be of abnormal distribution or size. no

bleeding large as

,

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A Mirror

PRACTICE,

stopped

.

with