22

ST. BARTHOLOMEW’S HOSPITAL.

Strumous Enlargement of Axillary Glands.(Under the care of Mr. LAWRENCE.)

When patients apply for relief with a tumefied state of theglands of the axilla, the diagnosis will generally lie betweenstrumous enlargement of glands and glandular sarcoma, (abscessand malignant disease are sufficiently obvious.) Now, as it hasusually been found that in scrofulous tumours a whole cluster ofglands is enlarged, and that these are subject to fits of swellingand subsidence; whilst in glandular sarcoma one or two glandsonly increase in size, and their growth is very regular, the dis-tinction will be made without much difficulty.We noticed, a short time ago, among Mr. Lawrence’s patients,

a woman, about forty years of age, who offered a good exampleof strumous enlargement of the glands of the axilla. The swell-ing was about the size of an orange, hard, moveable, and hadbeen noticed for about a twelvemonth ; it had increased but veryslowly, but of late the tumour had grown very rapidly. Therewas very little pain ; none of a lancinating character had everexisted ; the skin was neither inflamed nor discoloured; andMr. Lawrence, after having consulted with his colleagues, deter-mined to remove the morbid growth, though it was foreseen thatthe dissection would be of a very delicate description.The patient was brought into the operating theatre, and Mr.

Lawrence, having made a longitudinal incision over the tumour,about four inches in length, proceeded to detach the morbid massfrom its surrounding attachments. The hsemorrhage was nowand then very considerable, and numerous vessels were tiedwhilst the dissection was being carefully pursued. The enlargedglands were found to reach very deeply, and it required an un-usual amount of patience and caution to extirpate the diseasedparts. A cluster, about the size of a small orange, was at lastcompletely detached, but when this was accomplished, Mr. Law-rence noticed that a further agglomeration of hypertrophied anddiseased glands lay more posteriorly and superiorly. Thoughthe knife must now come in the immediate vicinity of the vessels and nerves of this region, the enlarged glands could not be left ’,behind; the dissection was therefore continued, and, after thetying of some vessels, the second mass was likewise removed.The administration of chloroform (which, in this instance, proveda very great boon. as the operation was of necessity protracted)freed the patient from any sensation of pain, and she was re-moved in pretty good condition.

Mr. Lawrence stated to the pupils, after the removal of thepatient, that the deposit found in the glands, on a section beingmade, presented some analogy with that which is generally foundin strumous testicle. In some of the glands that yellow matterwas soft and disintegrated, and a number of them was in a stateof suppuration. Mr. Lawrence mentioned that he had never metwith such a considerable enlargement and degeneration of axillaryglands. It was difficult to say of what precise nature the changewas which had here taken place, and the operation had been re-solved upon because he (Mr. Lawrence) and his colleaguesthought that the patient’s constitution would not bear up againstthe extensive suppuration which would have taken place, hadthe parts been left to themselves. On close examination, Mr.Paget classed the disease in the category of strumous enlarge-ment.The patient progressed very favourably for some time after the

operation; she had then a severe attack of erysipelas, from whichshe slowly recovered, and was discharged about two months afteradmission, the wound being completely closed, and her generalhealth in a satisfactory state. ____

LONDON HOSPITAL.

Fracture of the kIZ7.ull; Epilepsy; Delirium tremens; Recovery.(Under the care of Mr. ADAMS.)

In injuries of the head, and the subsequent cerebral symp-toms, complications may arise which are calculated to makethe surgeon pause, and weigh the pros and cons of the lineof treatment he is adopting. Compression either by bone,blood, or pus, is sometimes so evident, that the practice is ex-tremely simple; but it is not so when the injury inflicted uponthe skull has produced violent inflammation of the cerebrumor its membranes; for the symptoms may be of such a kind,as will be seen by the following case, as to require the ad-ministration of stimulants, though the cerebral mass, or itsenvelopes, are known to be in a state of inflammation. Thesuccess which attended the treatment adopted, in this in-stance, will doubtless be looked upon as instructive, and ofgreat practical value.

The subject of the case is a stoker, twenty-nine years ofage, who was admitted, on the 3rd of March, under the careof Mr. Adams; and the history, as collected from Mr. ThomasBell, the dresser, is as follows:-It appears that the patient,who had been accustomed to drink largely, was about hisusual occupation of cleaning and attending to the boilers,when his foot slipped, and he fell the height of six feet, hishead coming against the sharp angle of the boiler. He wasstunned for a short time, but soon recovered from the shock,so much so as to be able to walk to the hospital without as-sistance. On examining the nature of the injury, it was foundthat the scalp, together with the pericranium, were detachedto the extent of four inches and a half, and a fissure was ap-parent, running directly across the superior part of the leftparietal bone. From the lacerated scalp-wound considerableand even alarming haemorrhage occurred about ten minutesafter the patient’s admission, and the loss of blood requiredthe ligature of the divided vessel. Compresses of lint, securedby adhesive plaster and the capitine bandage, were thenapplied. The constitutional symptoms, upon admission, wereslight drowsiness for the first quarter of an hour, followed,soon afterwards, by partial delirium, strongly marked by thepatient’s constant wish of going to his work. It was then re-marked that one pupil was dilated, whilst the other was in acontracted state.An hour after the wound was dressed, the dressers on duty

were hastily summoned by the nurse, as the patient had anepileptic fit, from which, however, he quickly recovered. Hewas immediately given five grains of calomel, his head shaved,and kept constantly wet with a spirit lotion. The next daythe patient had a second epileptic fit, towards the afternoon.This was of short duration, and he soon fell again into adrowsy state, from which he was, however, very easily roused,Small doses of calomel and antimonials, in saline mixture,were now ordered, the bowels being freed by a brisk purga-tive. Mr. Adams perceiving, on the second day, that symp-toms of delirium tremens were at hand, ordered opium; andas the pulse became very weak, and at times hardly per-ceptible, ammonia and nitric acid, in camphor mixture, weregiven in addition. The delirium became soon very violent,and it was found necessary to remove the patient to a separateroom, and administer forty minims of tincture of opium.During the next few days, the violence of the delirium some-

what abated; the wound healed almost completely, but thepulse remained very weak, and the tongue tremulous. Inaddition to his ammonia, the patient was now ordered fourounces of wine. Eight days after admission, a peculiar glisten-ing appearance was noticed about the eye, and a slight erysipe-Jatous blush around the wound, though the man was nowmuch quieter. The same evening, delirium, with tremblingof the whole frame, again came on, the erysipelas made pro-gress towards the forehead and face, and the pulse was veryweak. Cold lotions were ordered for the head, and the patientto have two ounces of brandy. The erysipelatous inflamma-tion now extended over the neck and chest; the patientwandered much, and complained of pain in the head and wantof sleep.This very precarious state lasted about five days, during

which, opium, ammonia, and brandy (the man having been avery hard drinker), were freely administered. These alarmingsymptoms began, however, now to give way; the patient hadan alvine evacuation, containing a large quantity of blood, theerysipelas rapidly receded, the pulse became firmer, and thetongue cleaner. Bark, ammonia, and nitric acid, were con-tinued, and the stimulants gradually replaced by porter and anourishing diet. The strength returned slowly; the woundhealed up except a small sinus communicating with a piece ofnecrosed bone, and thirty-seven days after admission thepatient was declared convalescent.We see, that in this instructive case the unusual symptoms

which followed the accident forcibly swayed the treatment,irrespectively of the nature of the primary lesion, and thatthe previous habits and idiosyncrasy of patients should alwaysbe kept in mind when they are by sudden casualties placedunder our care.

____

CHARING-CROSS HOSPITAL.Excision of the Head, and Portion of the Shaft, of the Humerus.

(Under the care of Mr. HANCOCK.)In a former Mirror (THE LANCET, May 25th, 1850, p. 642)

we reported a case of excision of the malleolus, and part of theastragalus, performed by Mr. Thomas Wakley, and we statedthat we should °° soon have to bring before our readers several