CLINICAL REPORTS.
Pennsylvania College, Ninth beloiv Locust street. Service of
Professor Gilbert.
Reported by W• H. Gobreciit, M. D,
Nov. Stith. Case XXXVIII.—Congenital Teleangiectasy*
Remarks, History of Case and Operation____This is an unnatural
expansion in the capillary vascular system, producing, sooner or
later, swellings which have their seat in the skin alone, in the
subjacent areolar tissue alone, or in both, but rarely extends
more deeply. It may be congenital or non-congenital.
The color of the tumor is quite red when the arterial capillary
dilatation is the greatest; or it is bluish when the venous impli-
cation is in excess.
These tumors enlarge and pulsate, giving a crawling sensation,
even to the patient himself. And after a time, when a great
size has been attained, haemorrhage occurs from the rupture of
some spot in the thinned skin, which, however, closes again, this
haemorrhage recurring frequently.
The tumor is composed of enlarged and convoluted capillaries
held together by loose areolar tissue, and perhaps cavities filled
with blood.
The causes of Teleangiectasy are obscure; it is usually con-
genital, and is met with on all parts of the surface of the body,
but especially about the cranium and face, the skin of which is
highly vascular.
Teleangiectasy is essentially a local disease, and hence local
appliances must be looked to in effecting a cure. These are
varied in their character, and may be thus principally enume-
rated :
1.	Compression. Successful only in very slight degrees of
the disease.
2.	Destruction, with the actual and potential cauteries, when
we have subsequently an ordinary granulating and suppurating
sore.
3.	By producing sufficient inflammation in the Teleangiectasic
tissue to obliterate the vessels, by vaccination, punctures, &c.
4.	By tying the principal supplying artery. This is not so
effectual as other methods, being, in great part, palliative in its
character.
5.	By extirpation, either with the knife, or by strangulation
with the ligature. The use of the knife is not always safe, on
account of the vast number of bleeding orifices which we create,
from which alarming haemorrhage will most assuredly ensue, if
the tumor be large. If, however, this plan is employed, we must
cut wide of the pulsating mass and in the sound tissue.
Having said thus much, the case of the patient was brought to
the notice of the class. John G--------, from Ireland, aged 20,
has been affected since his birth with an erectile tumor of his
lower lip, which, small at first, has increased with his growth, and
still increases. It involves at present the skin, mucus membrane,
and subjacent areolar tissue from a little to the right of the
median line of the lower lip to somewhat beyond the left angle
of the mouth. The gums in the immediate vicinity are deeply
involved, and bleed often. The tumor is bluish red, thick, pouting,
indefinitely circumscribed, and merges somewhat into the cheek
above the oral angle; it also gives us the crawling pulsation,
and can be emptied, in great measure, of its contents by pressure.
It is stated that spontaneous haemorrhage frequently occurs.
On carefully manipulating the tumor we can trace the main
trunks of supply to the facial arteries, which vessels are found
to be much enlarged. And inasmuch as the tumor itself is so
extensive and involves so much important tissue, we shall give
the preference, at least for the present, to the operation for the
ligation of the facial artery upon each side, which is the fourth
method of treatment detailed in the preceding remarks. The
operation was then performed as follows:
The patient being seated, the jaws were firmly closed and the
anterior edge of the masseter muscle found on the left side,
whereby the exact course of the artery, and the proper position
for ligation, was known. An oblique incision, one inch and a
quarter in length, was now made in a direction downwards and for-
wards from the edge of the belly of the masseter to a little below the
base of the jaw and anterior to the muscle ; by these means were
cut, the integument, superficial fascia and m. platysma myoides.
The artery was then exposed and separated from the facial
vein, which lies upon its outer side, by means of forceps
whose blades were fashioned into a form similar to a curved
needle, the blunt extremities of which grasped the ligature, which
was passed from the outside toward the median line, and then
firmly tied. The same operation was performed upon the right
side, and after the conclusion of these the pulsation ceased, and
the size of the tumor had much diminished.
27th. The tumor is found to be smaller, and pulsation less evi-
dent than prior to the operation. Incisions nearly closed, but
ligatures still retained.
Case XXXIX.—Contusion of Right Arm________George D-----,
aged 50. This injury, which exists upon the outer aspect of the
right arm, was caused by a box weighing 800 lbs. falling some
two feet and striking the patient at the point indicated. This
occurred some two weeks since, the integument being unbroken ;
upon the third day after, swelling commenced, which progressed,
accompanied with pain and redness, until an abscess formed; this
was punctured some 48 hours back, and about half a pint of pus
evacuated, since when the cavity has been contracting and the
quantity of discharge is diminishing. The injury inflicted by
this box, similates that of a spent cannon ball. The force being
applied obliquely to the part, disorganized the areolar and mus-
cular structures beneath without any external wound ; inflamma-
tion was set up within, and abscess formed to get rid of the
destroyed tissues, which act as foreign bodies, besides being too
extensive for absorption alone.
Mrs. L., (Case XVI) who had a finger amputated for obstinate
flexion, is presented, and the stump shown to have healed per-
fectly.
Case XL.—George A--------, aged 18. This patient stepped
upon a needle, which breaking, left a fragment in his foot, whilst
crossing the floor, protected by his stockings alone, the usual
cause of such accidents. Pain is evinced upon pressure at one
point of the sole, but as this is deep, it is not deemed advisable
to cut down into it, but rather to elevate the limb, poultice the
foot, and await the formation of an abscess around the foreign
body, with the contents of which it will be discharged.
Case XLI—Noevus Maternus, in Mary Ellen B——, aged 22
months. This is one of the forms of congenital Teleangiectasy,
consisting of an enlargement of the capillary vessels in and
beneath the integument. It was first noticed as presenting the
appearance of a minute scratch ; since then it has enlarged gradu-
ally to its present size, which is that of a split filbert, placed upon
the left ala of the nose. The proper plan of treatment, it was
stated, will be to remove it without delay, which was done thus:
An incision was made around the tumor, in the sound integument
entirely, a straight needle was then passed beneath the base of
the erectile mass from above, downward and backward, which was
elevated by raising its extremities, and a surgeon’s needle, carry-
ing a double ligature, passed beneath the mass and the transfixing
pin, at right angles to the latter. The two extremities of the
respective cords (after the bight of the ligature had been cut)
were tied firmly beneath the straight pin in the track of the
integumental incision on their respective sides, the knots lying
opposite each other, and the pin withdrawn. The color was now
found to have changed from a bright red to a dull, bluish white.
In two or three days we will find that the tumor has sloughed
away, from the abstraction of all its sources of vascular and
nervous supply.
24th. The tumor has become detached, and a freely granula-
ting surface presents itself, which was touched with argent, nit.
to repress an exuberant tendency which existed. The isinglass
plaster was applied.
Nov. 24th. Case XLII.— Varus of right foot, third degree,
which occurred in a male child now aged 11 months. The opera-
tion for the cure of this affection, was performed during the last
winter before the class, in the child’s fifth week, by dividing the
tendo Achillis by Ilypodermatomy, and applying a steel sole, and
leg bar for the outside of the limb, the method of employing
which is given in the Examiner for December 1852, p. 785.
The child is shown as presenting to us almost perfect relief from
the deformity, but as there is a slight tendency to the inversion
of the foot, a stiff and high gaiter has been constructed with
whalebones in its outer side, which will retain the dorsum in its
proper relation to the axis of the limb.
Case XLIII. Reducible scrotal hernia, oblique descent.—
Dani. S-----, aged 25, states that when in his 19th year, he
strained himself, as he supposes ; about two weeks after this time,
a tumor presented itself in the right groin, which could be
made to disappear on pressure. He has worn a number of trusses,
differently constructed, but could never continue them for any
length of time ; the tumor consequently gradually increased in
dimensions, and eventually descended into the scrotum. On ex-
amination, it is found that the recumbent posture, with slight
manipulation, reduces the mass entirely, especially if we relax the
muscles concerned by flexing the thigh of the affected side on the
pelvis, and carrying the knee to the opposite limb. Hull’s truss
w’as then applied. This instrument is thought by Prof. Gilbert
to be the best, inasmuch as its construction is the least compli-
cated; it is therefore less liable to get out of order, and can be
more readily repaired should it do so, besides which it answers
effectually all the indications as an easy retentive appliance.
Simplicity being here, as in other instances, the best test of use-
fulness.
Remarks on the subject of hernia in general, and the varied
means of diagnosis, were also made in conjunction with the pre-
sentation of the case.
Case XLIV_____Mary G-----, aged 37. Contusion of shoulder and
side—produced by stumbling and falling upon a stairway. The
patient had not fracture of the ribs, since there was no local
catch in a long inspiration, and no crepitation. The motions of
the humerus were proper. Treated with the application of volatile
liniment and a bandage to the thorax and arm.
Case XLV. Abscess beneath fascia lata of left thigh.—Ellen
C-----, aged 8 years. This patient was brought to us for advice
several weeks ago. She then complained of pain at the upper
part of the thigh, which was tender to the touch. There being
also lameness, it was supposed that there might be incipient
Morbus Coxarius. The Tinct. of Iodine was prescribed as a local
application. The Comp, powder of Jalap ordered as a purgative,
and rest enjoined. To-day, we have a further development of the
case, viz., tumor, which exhibits its true condition. We shall,
however, defer any decided measures until the next Clinical day.
Dec. 1st. The left thigh presents a prominence just outside of
the median line of the limb, and about 2^ inches below the groin ;
this gives fluctuation, though perhaps rather obscurely. If pus
exists here, as we think it does, a timely opening should be made
to prevent the infiltration of the tissues, which would certainly
occur, beneath the firm fascia which binds them down so closely ;
and this puncture we should not neglect, as is often done, for
fear of the great vessels, until a large collection of pus results.
If the incision is made at the proper point outside of the axis of
the limb, and in a line parallel with the great vessels, very little
is risked. A puncture was accordingly made at the point indi-
cated above, and about two ounces of watery and curdy discharge,
with a few drops of blood, followed. The wound was dressed
with dry lint and adhesive strips.
4th. No discharge to-day at all; adhesive strip applied. There
is much less pain in the thigh.
Nov. 27th. Daniel D-----, (Case XXXII) previously exhibited
—returns with increased irritation of the lachrymal sac, resulting
from the epidemic Influenza, most probably. Creasote was re-
applied. Pil. cathart. comp. No. Ill, were ordered—and the
local application of the Alum curd directed, should the irritation
run into an inflammation.
Dec. 11th. This patient has improved somewhat; there is no
very apparent dryness of the nose; no inflammation of the con-
junctiva at the inner canthus of the eye; there is not such fre-
quent necessity of pressure upon the sac to empty it; and but a
single tear, regurgitated by pressure with the finger of the
manipulator, is clear and devoid of mucus admixture. Notwith-
standing, however, these signs of palliation, Prof. Gilbert states
it as his experience, that in cases of this character, we cannot
hope to do more than bring the affection to a stand, and to keep
it thereby treatment, going on as they inevitably do, if neglected,
to entire closure of the duct, finally resulting in fistula lachrymalis.
Dec. 1st. Congenital varus in an infant, exhibited. This is
to be operated for upon the Sth inst.
Case XLVI.—Strabismus in a child aged 4 years, exhibited,
with remarks upon its treatment.
Deformity of Neck from Burn, presented, with some history of
the case. To be operated for, on 4th inst.
Case XLVII. Severe contusion of knee joint.—Mr. M., aged
25, about eighteen months ago fell and injured the knee joint
by contusion ; from this, however, recovery soon occurred. Some
fourteen months since, he fell and contused the same joint again,
very severely. For this liniments were employed, and the pa-
tient confined himself to the house. Recovery, however, being
delayed, medical advice was sought. As synovitis was evidently
commencing, indicated by pain, swelling, heat, redness and inability
to use the joint,Prof. Gilbert at first confined the patient to his bed,
and applied the straight back splint, extending from near the pelvis
to a point just above the heel, to prevent any motion, and em-
ployed repeated blistering about the joint, as a means of coun-
ter-irritation. These blisters were followed, upon healing, by
Tinct. Iodine, pencilled over the parts. The Guano poultice was
next used, and then blisters again, the leg being extended and
motionless during the whole length of time; besides which a
constitutional treatment, consisting of Bitartrate of Potassa and
Jalap, as a revulsive, and Lugol’s solution of Iodine as a sorbe-
facient, was instituted and persevered in.
By these means, some time in last May, seven months back,
the natural size of the limb was restored, whereupon the ordi-
nary starched bandage was applied, and the joint thus kept nearly
motionless and extended, but the semi-recumbent posture was
still enjoined. For the last two months the patient has been
moving about upon the limb thus supported, perfectly free from
pain, swelling, or unpleasant symptom of any description what-
ever, and is now attending to the ordinary duties in his shoe
store in the city.
Case XLVIII. Contusion of hip joint.—Salone T----------, aged
14, was knocked off of a cotton bale, and falling, struck the left
hip, about two weeks since. The case was properly diagnosed
as contusion, by the practitioner who was called to attend him,
and a treatment by cups and counter-irritants in the vicinity of
the joint, established. As now presented, we find that the pa-
tient cannot elevate the thigh, without raising the knee by his
hands, and dragging the heel along the mattress, and this with
some pain, whilst there is none of the preternatural rigidity of
dislocation, nor the abnormal mobility of fracture, existing, the
limb being of its proper length and capable of being made to
fulfil its proper motions by external aid. Severe contusion evi-
dently has been the cause of the present disturbance of the
functions of the part, and may result in synovitis, which in any,
but especially in this boy’s constitution (scrofulous,) would be
exceedingly disastrous, falling, as the case undoubtedly would,
into Morbus Coxarius. To prevent any motion, therefore, a
starched bandage was applied in the presence of the class, and
the thigh and knee, respectively, placed in a slightly flexed posi-
tion, were there secured by a long splint, to be continued until
the consolidation of the bandage. When this has occurred, the
firm case formed by it may be cut upon the inside of the thigh,
and the sound side of the body; being then padded with cotton,
as required, it is to be re-secured by turns of a roller, and worn
for several months, the patient being confined to the recumbent
posture.
Dec. 4th. The case is progressing favorably in every respect.
Dec. 4th. J. S. (Case No. VII,) Cataract, is again shown to-day,
the operation for absorption having been repeated about two weeks
since. The lens was then effectually broken up, besides which,
the posterior layer of the capsule (having been recently involved)
was divided. The opening thus formed acts as a second pupil,
and the rays of light are concentrated upon the retina through
it; therefore the patient can see not only light, but can distin-
guish persons from other objects, and tell how many fingers are
held before him readily, without any aid from a lens. It is very
probable that the presence of this new pupil, by regulating the
rays admitted, will enable the patient to read without the aid of
glasses. Discharged cured.
Case XLIX.—Deformity of neck from burn, and operation
for its relief.—Hannah J. S---, of Kensington, aged 14 years,
was severely burned, when 2 years old, by her clothes being acci-
dentally fired. Burns are apt to be more severe in children than
in adults, since, whilst the latter, with due presence of mind,
stand and subdue the flames by the most accessible methods, the
former run wildly about for help, and increase the danger
by fanning the flames, and igniting other parts of the
clothing, which, but for this, would be, perhaps, untouched.
The burn is, therefore, not only extended superficially, but
deeply, and amounts, as in this instance, to the third or
fourth degree, where the deep tissues are involved, and abso-
lute loss of substance ensues. No doubt, had this child been
somewhat older, more serious consequences still, if not death,
would have ensued, from the reasons just given.
But the extent and depth of the burn are not the only diffi-
culties which we have to encounter in the treatment and cure of
such cases. No sooner are the sloughs thrown off by the process
of ulceration, than very exuberant, large and flabby granulations
are quickly formed, which, contracting, draw together the edges
of the ulcer, like the mouth of a purse, and then skinning over,
constitute a thick, uneven cicatrix, composed of what is termed
inodular tissue. But the work is still unfinished. Interstitial
absorption of this mass, if not previously set up, now commences,
and thus the contractility of the tissue is again increased by
these newly combined actions. As a consequence, very little new
substance eventually exists in the space occupied by the burn;
and that which is there becoming firm, hard and almost liga-
mentous, the contraction still progressing, the cicatrix is
frequently raised from the substances beneath, especially if it
have points of attachment, as upon either side of the flexure of
joints, &c. In the case before us, the most serious portion of the
burn seems to have been in the front of the neck, extending
deeply; in consequence of which, all the steps in the cure, first
described, have been successively established, and the great con-
tractility of the cicatrix has approximated the lower jaw to the
sternum in such a manner that all depression of the neck has
vanished, the chin has been shortened and drawn backward,
whilst the teeth project forward, away from the line of the arch
of the upper jaw, and the head has a general inclination forward
and downward, giving the patient a downcast look.
The long continued deformity has had the effect of measurably
arresting the growth and expansion of the lower part of the
face and jaw, and demands an operation, for the purpose of al-
lowing the progression of proper development and the produc-
tion of unrestricted powers of mastication, as well as for the
comfort of the individual and the relief of the unsightly de-
formity.
The patient being seated, a transverse incision was made with
a scalpel on the anterior part of the neck, from right to left,
about 6 inches in length, dividing the adventitious structure down
to the normal fascia beneath, and the head extended, whereby the
chin became instantaneously prominent. At a point some 2^
inches to the right of the extremity of the first cut, the scalpel
was now made to enter the integument, and an incision extended
downward on the shoulder 7 inches, then giving a rounding
cut, it was carried up parallel with and 21 inches from the first
incision, entering the transverse cut at its right extremity.
The flap thus formed was dissected up from the muscles be-
neath, rotated to the left upon its base, and placed in the gaping
wound produced by the separation of the lips of the first inci-
sion. Here, after the approximation of the edges of the wound
in the shoulder in a like manner, it was secured by 16 fine steel
needles, No. 12, and the twisted suture, with adhesive strips be-
tween them. Strips were also placed between their projecting
extremities on either side and the integument, also superficial
to them. The entire number of needles inserted both in the
shoulder and neck was twenty-two, of which only two were of
great size; one of these being placed at the angle of the
shoulder and neck cuts, and the other on the shoulder itself.
The employment of a number of small needles, is an improve-
ment on the old method of using fewer but of larger size, inas-
much as the irritation set up by the presence of the former, is
not by any means so great as with the latter.
Very little blood was lost, and, although the operation from
its extent was necessarily somewhat tedious, it was borne unu-
sually well, by one so young. Anaesthesia was resorted to during
the earlier stage of the proceedings, but was not employed there-
after. Patient retained at the College for subsequent treatment.
Dec. Sth—Since last Saturday, (4th) the patient has fallen
under the effects of the Epidemic Influenza, now so prevalent,
which has complicated the case in a very serious manner. Dis-
tressing cougb, which has a constant tendency to disturb the
union of the flap,-exists, together with marked febrile symptoms
of no favorable kind. The treatment to this time has been (on
the 6th,) Mass. Ilydrarg, gr. vj. followed in two hours by Calcined
Magnes. ^ij
On the 7th she had dark, copious and fetid evacuations, after
which some relief of all the symptoms was experienced. She
was then given :
JI. Liq. Potass. Citrat. fgviij.
Ant. et Pot. Tart. gr. j.
M. S. fgss. every two hours.
The adhesive strips were for the first time removed on to-day,
(the 8th) and re-applied. Union in about three-fourths.of the
lower border of the flap, being found nearly completed, ten of
the needles were removed after the appliance of the plasters.
Not much more than a fluid-drachm of pus has been formed up to
this time. The fever has almost entirely subsided.
Dec. 18th.—Union by adhesion has been prevented, even in
parts seemingly united by the first intention. The suppuration
set up required daily dressings. On the 12th, all the needles
were removed. The edges of the wound from which the flap was
taken, were drawn about an inch asunder by the tension of the
adjacent integument; and the extremity of the flap, by its own
elasticity, parted to a like extent from its connection with the
sound skin on the left side of the neck. By daily renewal of
adhesive plaster, and the introduction of a suture at the extremity
of the flap, the parts have been kept in apposition sufficiently
well for favorable union by second intention, so that to-day
(18th) the case may be reported as progressing very favorably
towards union of all the parts involved in this very extensive and
important operation.
Dec. 8th.—John P. (Case XXVII,) Tenotomy.—The wrist is
now shown perfectly extended, although much restricted in its
movements by the long confinement it has experienced. As the
punctures have perfectly healed, and the tendons have doubtless
united, the splint is directed to be frequently removed and
passive motion given.
Case L.—Congenital Varus of both feet, second degree, in
George W. S-----, aged 4 months. The tendo Achillis of each
limb was divided by subcutaneous section in the usual manner,
and the apparatus, whose description was given in Med. Exam,
for Dec., 1852, (page 785, article, Adhesive Plaster in Surgery,
by D. Gilbert, M. D. etc.,) applied as there directed.
Dec. 15th—Apparatus removed and reapplied. The wounds
have healed entirely, and the feet are nearly in their normal
position. The progress so far is of the most encouraging cha-
racter.
Dec. 11th—large Tu/mor of the Neck, in a female, was
exhibited, and the history of the case given.
This person will be presented for the necessary operation
hereafter.
Dec. 15th. Case LI__Malignant Tumors beneath Lower Jaw.
—Mr. G-------, aged 60, states that about a year or two since a
scirrhous tumor was formed in his lower lip. This was removed,
and the parts healed well afterward. Within the last four months,
however, tumors have formed below the jaw and near to its angle;
these are now about the size of a walnut, and have firm attach-
ments to the surrounding tissues. As the removal of these
tumors is strongly contra-indicated, the patient is advised to
abstain from all cauteries and other irritating appliances, lest
ulceration and more speedy death should ensue than if they were
left undisturbed.
The ordinary reliable alteratives, however, may bo employed,
as Donovan’s solution, Comp. Decoct, of Sarsaparilla, &c., but at
best we can only palliate and endeavor to avert death by guards
ing against improper appliances of every description.
Case LII.—Polypus Nasi.—George F--------, aged 81 years,
has a Polypus in his right nostril, which has been increasing for
about two months. Several have been removed at two distinct
sittings previously, by another physician. This, which was
removed by torsion, was found to be of the mucous variety, and
of moderate size. This case is worthy of notice on account of
the polypus appearing, for the first time, so late in life.