A. Macgregor
1889 The Lancet  
April 12th.-The patient was brought to me to-day. There was very little defurruity-in fact, when coming into the room nobody would notice any whatever. Un measuring from the centre of the sternal notch to the tip of the acromion process, there was found to be half an inch difference between the two sides. I put her through different exercises, and perceived that she had perfect movement of her arm on the affected side; she could lift weights, play the piano, dress her bair, and hold her arm at
more » ... nd hold her arm at right angles to the trunk-in fact, the movements were equally good with those of the opposite side. Her general health was everything that could be desired. The scar was firm, and there was no trace whatever of any recurrence. (Fig. 2 ) Half of the specimen is now in the College of Surgeons museum and the other half at the Cancer Hospital. The accompanying drawings of the specimen are about half the real size. (Figs. 3, 4.) I have thought this case worthy of record, as I believe it not only to be one of the rarest operations in surgery, but also one fraught with the greatest possible anxiety to the surgeon operating, as from the intimate relations of the growth to the large veins situated at the root of the neck, the pleure, and other important vessels and nerves, no one could undertake such an operation without considerable misgivings as to the result. In the case before us I was guided, as I have said, by several considerations to adopt the measure I did, and the result has justified me in the course I adopted. The history of the case clearly pointed to the disease commencing in the bone or periosteum ; as the growth increased it extended more downwards and forwards along the chest walls than upwards, and although a boss was distinctly felt behind the sternal attachment of the sterno-mastoid muscle, yet I felt sure I coulcl get my finger below it. It is true there was some considerable swelling of the arm, and there had lseen some puffiness of the face on the same side as the tumour, pointing to pressure upon the subelavian and internal jugular veins, and the chief anxiety in the operation was centred in the question as to how far these veins were implicated in the growth. I believed they were not ia any way involved, but that the growth, being bound down by the clavicle, was pressing on the subelavian vein as it passed over the rib. Such proved to be the case, and the subclavius muscle and other tissues intervened between the tumour and the vein, and the bone, with its growth, was easily separated without in any way jeopardising the vessel. , aged eight years, was admitted into the Aberdeen Hospital for Sick Children on Jan. 29th, 1887, and the history then given by her mother was that for two months the child had been getting weaker, frequently '.,;uffered from severe headache, and had on several occasions become suddenly sick. She had always been a delicate child, and had twice suffered from bronchitis. She was one ()f a family of nine, four of whom died at ages ranging from nine months to two years and a half, the causes of death being teething, whooping-cough, "disease of the lungs," and tubercular meningitis; of the five living at the date of the patient', admission one was suffering from phthisis and another had suppurating cervical glands. The father died of "bronchitic asthma." The mother was apparently healthy. When admitted into the hospital, the patient was a very pale and sickly-looking child, but the most careful examination revealed nothing abnormal in any of the organs or viscera of the body. After admission there was no complaint of headache, and no sickness until the morning of Feb. 5th, and the next attack was on March 6th, when the sickness was constant and the stomach immediately rejected everything swallowed. On March 8th ophthalmoscopic examination revealed optic neuritis in the left eye, but the right fundus appeared to be normal. At the same time it was noted that the patellar reflexes were exaggerated, the right more so than the left. Six days later, the patient was flushed, and lay apparentlv comatose. There was now exophthalmos on the left side, and immediately below the centre of the cornea of the left eye there was a superficial abrasion or ulcer, round which the cornea was becoming opaque and softened, and the corneal sensibility was diminished. It was also seen that the left facial nerve had become involved, that there was paresis of that side of the face; the left patellar reflex was almost lost, and the right greatly diminished. The ophthalmoscope at this date showed that optic neuritis had developed in the right eye and had increased in the left. On the day following there was considerable extension of the corneal affection in the left eye, and an exactly similar process was seen developing in the right cornea, and there was paresis of the muscles of the right side of the face. The patient swallowed readily and without difficulty. On the previous day there was involuntary micturition; there was now retention, necessitating the use of the catheter. The urine contained neither sugar nor albumen. On March l7th the left pupil was half contracted, and the lower half of the cornea was infiltrated with pus ; the right pupil was dilated, and the ulceration of the cornea on this side was extending. Both eyeballs were very much injected, and there was a copious discharge of muco-pus. The pulse was a mere thread, and could only occasionally be felt. Two days later the eyeballs were less prominent, and it was then noted that the pulse was 182 per minute. On the morning of March 21st, it was found that perforation of the left cornea had taken place, and the temperature, which for a week before was 102° and 103°, was then 100° F. The patient died at 9 P.M. on the 21st, and the temperature at death was 98°. A few days before death a bedsore formed over the sacrum. Necropsy.-Prof. Hamilton conducted the post-mortem examination, and, although every cavity and organ were examined with great care, only the state of the brain need be given here in detail. The lungs, heart, liver, spleen, and kidneys were studded with grey gelatinous tubercle nodules of the size of mustard seed ; no enlarged bronchial glands were found, and no cheesy nodule in the thorax or abdomen. The brain weighed forty-four ounces; the pia mater genera,lly over the cerebral hemispheres showed a little injection, more eepecially where the tubercles were situated; and the subarachnoid space contained a little more fluid than usual. On the surface of both hemispheres there were numbers of tubercle nodules in groups. On the left side they were found on the ascending frontal at its middle, immediately opposite the origin of the second frontal convolution, grouped in a small area of about an inch in length. There was also a second group over the occipital lobe, and a few tubercles were seen also in the Sylvian fossa, but not nearly so numerous as on the right side. On the right side the tubercles were situated over the whole of the supra-marginal gyrus, one or two over the ascending frontal close behind the upper limit of the third frontal convolution, and in the sylvian fossa they were present in large numbers along the bloodvessels, and all the membranes in this situation were studded over with them. Round about the tubercles there was little if any meningitis. The base of the brain was perfectly free from any meningitis or tubercle. The superficial origin of the nerves appeared to be perfectly normal. On incising the pons Varolii, a caseous softened cavity of the size of a large pea was found situated about its middle, mostly on the left side, hut also passing over the middle line and implicating part of the right. The locality of the tumour corresponded exactly with the origin of the fifth nerve on both sides. The cavitv of the tumour contained a quantity of yellow purulent-looking fluid. On the under surface of the cerebellum on the left side, immediately behind the floor of the fourth ventricle, there was a similar deposit, about the size of a small pea, beginning to liquefy. Remarks.-For some time after the patient was first seen it was impossible to form an accurate diagnosis ; but in the light of the family history it seemed certain that tuberculosis would sooner or later develop. When the acute symptoms set in, tubercular meningitis at once suggested itself as the cause ; but on my first using the ophtbalmoscope, I was struck by the presence of optic neuritis in the left eye and its absence in the right. Severe headache, sickness, and optic neuritis in one eye made the presence of a distinct lesion of the brain certain. When ulceration of the left cornea appeared, I at once diagnosed a lesion of the
doi:10.1016/s0140-6736(01)91351-0 fatcat:7zb5wk7adnavhcy5habv6hfe4q