Frederic Flint
1881 The Lancet  
574 to stick in the oesophagus on about a line with the upper end of the sternum. He subsequently was unable to swallow his food, and vomited it immediately. His appetite has remained good. He has not suffered much pain. On admission he has apparently lost much flesh; his skin is hot and dry. He has a circumscribed fluctuating tumour situated over the inner half of left clavicle, not infiltrating the skin ; it is not painful, and the patient had never noticed it. A few small glands are enlarged
more » ... glands are enlarged at the lower part of the posterior triangle of the neck. About a fortnight ago an abscess formed on the dorsum of the left foot, which is very red and inflamed. Tongue moist, furred, and white. Teeth not good, only two left in the upper jaw. Bowels open. Feb. 26th.-House-physician passed a bougie down the oesophagus, but it did not pass lower than on a level with the upper part of the sternum. To take one ounce of brandy three times a day, with eggs.-March 2nd : The tumour is 3" long by 1½" deep; feels elastic and soft, and at anterior end is soft and fluctuating. Deficient entry of air all over the chest ; chest expands tolerably ; no dulness ; no signs of invasion of thorax by growth ; breathing hoarse all over chest. The house-physician passed a large, then a small bougie, both to about 4¼" below epiglottis, corresponding to a point immediately above the sternum.-6th : Fluctuation of swelling ; opened by Mr. Bryant, and four ounces of pus came away.—10th: One ounce of brandy to two ounces of milk as an enema.-llth : Mr. Bryant performed first part of operation of gastrostomy, as described in the last case. The wound healed kindly without any peritoneal or other complications.—16th: Operation completed ; opening into the stomach a small one.-17th : Temperature normal; fed every two hours with four ounces of milk and an egg, and half an ounce of brandy occasionally.—18th: Injection every four hours; temperature normal; bowels open ; tongue fairly clean.-19th : Abscess on foot opened.-22nd : Temperature normal; fed six times a day, two of which consist of milk and eggs, the remainder of meat ; about four or five ounces of brandy ; weighed 98 lb.—23rd: Leg put on back splint.—25th: Up in a chair in ward.-27th : Fed four times a day.-April 21st : Weighed 103lb.— May 5th: Cough troublesome ; weaker.—10th: Died. -_ _ Necropsy by Dr. HILTON FAGGE.-Body much emaciated. A slight sore on one instep, and in the abdominal wall was a fistula to the left of the umbilicus from the operation of gastrostomy. The opening was in the centre of a small amount of scar tissue. It was the size of a No. 10 catheter, and above-that is, the upper margin had upon it an overhanging lip, which looked more like mucous membrane than skin or scar. The cranial bones were normal; no thickening. Dura mater and sinuses, arachnoid and pia'mater, were normal. Arteries of head very atheromatous at base. The brain weighed 50 oz. In the head of the outer nucleus of lenticular ganglion upon the right side there was a small-sized cyst of an old apoplexy ; its colour was brownish, and its lining membrane smooth, and in its walls were some small vessels. The smaller vessels in the interior of the brain did not look so very thick.-Spine : The spinal vertebrae had various nodosities upon their anterior margins at the line of junction with the intervertebral substances in the lumbar and dorsal regions.-Respiratory organs : Recent lymph over hinder part of left pleura. Both had in various parts, particularly over the hinder part of the lower lobe and in the outer part of the upper lobe, a considerable infection of the lymphatics with cancer. They stood out on the surface as interlacing lines of milk white or yellow colour, forming a rectangular latticework. There were, in addition, in some parts, flat plates of growth spreading in the pleura from these. The lungs felt very solid towards the root. On section they were seamed in various parts by thin lines of cancerously infiltrated septa. These had a head in appearance in various parts, and in the centre of the lung this condition was surrounded by a granular pneumonic lung, which it was difficult to say was not pneumonia. It may have been pneumonia mixed with growth. The heart weighed eight ounces and a half, and was quite healthy. The oesophagus was tightly strictured opposite the second ring of the trachea. There was very little thickening of its coats, but on slitting up the tube there was a jagged white growth in the mucous membrane, without any well-defined margin, and, in addition, a superficial ulcer in tiie mucous membrane, which ran up vertically in the covering of the thyroid and cricoid cartilage to the left side for more than an inch. The floor of this ulcer presented no cancerous attributes, but the edge of the ulcer was distinctly raised and everted with a soft fleshy growth. The trachea was not perforated, but its wall was extensively implicated. On looking at the mucous surface of the trachea the whole of it, down to the bifurcation, looked mottled and thick, and granular-looking tubercles of growth studding it all down, and from these parts the disease had invaded the external parts. The thyroid body was extensively infiltrated with a similar growth. The glands were affected, but they were not much enlarged. The actual stricture of the oesophagus was not more than half an inch in length. Above and below the parts were normal. -The liver contained three or four small circular, firm, cancerous nodules ; in other respects the liver was healthy.-The intestine was in a very interesting condition. Throughout the whole length of the small intestines, but chiefly in the lower part, were ulcers which had rather thick edges, which tended to run round the bowel, and which exposed clearly in the floor the muscular fibres of the bowel. One of these had gone deeper, and by a second ulceration in the already ulce. rated surface had all but perforated by a transverse slit, two-thirds of an inch long. The ulcers externally had a puckered aspect, but there was no material narrowing of the bowel, and one at least had very minute white grain-like bodies (? tubercles) in the subperitoneal tissue. I think it was an early tubercular affection of the lymphatics in the floor of a chronic ulcer. Near the meal valve the ulcers became more irregular and more superficial-not like any particular ulcer-and similar small superficial circular and oval ulcers ran down in the large intestine for some distance. But there was one additional peculiarity in the large bowel. The mucous membrane was smoother than usual, and sanded over with multitudes of small rough-looking grains, distinctly projecting from the surface. I hesitated to pronounce an opinion on its nature. They were too prominent, and abruptly so, for solitary glands. No lardaceous disease of liver or intestine.-Spleen : The capsule was thick. The suprarenal capsules were healthy.—The kidneys weighed eight and a half ounces. One kidney was very good. The other contained many cysts of small size, but its cortical structure was good.-Most of the joints showed osteoarthritic changes. The toes were nodular at their edges. The knees had a large part of their surface from centre outwards devoid of cartilage, and eburnated; while at the margin of the cartilage there came a nodose edge of bone. The elbows were in a similar state. The synovial membrane in knees could hardly be said to be vascular. The shoulders were also affected, the left bicipital groove being markedly prominent from new matter under the muscular attachment ' of outer lip.—With regard to the ulceration of the intestine, , I was in doubt as to its nature. The ulcer in some parts certainly involved part of Peyer's patches, and further they were well-defined, clean-looking ulcers, exposing the mus-' cular coat without any granulations-in this resembling E typhoid ulcers which had sloughed out, and not tubercular ulcers. On the other hand, the peritoneal aspect was in no , other places in favour of tubercle. The stomach at the seat of operation was firmly united to the skin. No signs of peritonitis were present. on Thursday, Feb. 24th, at a well-contested game of football. On Friday at 10 A.M. he was no more. He took an active part in the game on Thursday, and thoroughly enjoyed it; in the evening he complained of headache, and went to bed early; he vomited once or twice during the night, but did not disturb another boy who slept in a separate bed in the same room. On Friday morning he did not appear at the breakfast-table, and the head-master of the school went immediately to see him. He then complained of his head aching severely, and of having vomited, and the terrible scene, which came to so speedy an end, began. The poor boy made several heart-rending, piercing
doi:10.1016/s0140-6736(02)34219-3 fatcat:aopijsoqbfbcdew6dpwfhx4q3q