George Oliver
1885 The Lancet  
had to be performed for about ten minutes and a brandy enema given. On the restoration of animation, the administration of chloroform was continued through the tube. No further trouble was experienced on this score, the breathing and pulse continuing good throughout the remaining steps of the operation. An incision was made on the right side from a point three-quarters of an inch below and half an inch in front of the external auditory meatus along the lower border of the jaw to the median
more » ... The facial artery was controlled and ligatured before any haemorrhage took place. The bone was then cleared by means of a blunt periosteal scraper, the knife being entirely laid aside, except to divide the mucous membrane and, carefully guarded, to touch the capsule of the joint from in front. One small muscular branch in the substance of the masseter had to be ligatured, but no large vessel was injured, and the bone was entirely and cleanly cleared. Detaching the temporal muscle from the coronoid process was found to be the most troublesome part of the operation. The same process was gone through on the left side, the facial line being twisted, and no ligature was necessary. The bone was removed in its entirety, and was quite free from soft parts, with the exception of a small portion of the insertion of the internal pterygoid on the left side. Not more than an ounce and a half of blood was lost during the whole operation, which occupied an hour and a half. An enormous wound, seven inches in length, resulted, which was carefully closed by ten metallic and sixteen catgut sutures, the edges being painted over with compound tincture of benzoin. The tube was left in the larynx and covered with a light pad of carbolised sawdust. The following arrangements were made:-1. A separate ward and special service of attendants. 2. The nights being unusually cold for the season of the year, and the difference between the day and night temperature being marked,'care was taken to maintain an equable temperature by means of fires and steaming the room between the hours of 5 P.M. and 9 A.M. 3. The tube was constantly protected with a light pad of sawdust and muslin bandage, and cleaned out with a feather occasionally. At the end of twenty-four hours it was changed, and on the fourth day removed altogether, the patient continuing to breathe through the opening. 4. A pint of milk and half an ounce of brandy were given every eight hours, and an enema of soup (four ounces) with brandy (half an ounce) each afternoon. 5. A solution of morphia (one drachm) was given night and morning. The woman did remarkably well from the first. There was no shock, and with the exception of a moderate amount of pain, principally in the head, she was fairly comfortable. She slept a good deal day and night and took all the nourishment ordered by her own efforts for the first thirtysix hours; but after that, owing to the presence of inflammatory swelling and the fixing of the tongue to the floor of the mouth, she was fed through a tube passed to the back of the pharynx. The wound united firmly throughout by first intention and half the sutures were removed on the third day and the remainder on the fourth, when her condition was as follows :-Temperature 100'6°; pulse 110; respiration 28. Breathing quietly, and can lie in any position with comfort, and sit up. Is suckling her baby, and has insisted in doing so since twenty-four hours after the operation. Asked for semi-solid food and is picking up strength and flesh very rapidly. Can articulate when the laryngeal opening is closed with the finger. Tongue clean and bowels regular. There is only moderate discharge from the interior of the mouth and no facial paralysis. On Oct. 14th, or six days after the operation, the temperature rose to 102v° and the respiration to 35. Patient complained of pain in the right t axilla, but nothing could be detected on examination. A mustard plaster was ordered and greater precautions were taken to avoid chill. However, symptoms of acute pleuropneumonia of right side developed themselves, and the patient died on the eighth day of exhaustion. No doubt the woman, considering herself out of danger, had thrown off her clothing during the early part of the night and had caught a chill in the early morning, when the difference in temperature was most marked. Post-mortem examination was not allowed. -BeMM.?.—As in the previous case, the opening of the larynx as a preliminary measure was of the utmost service during the performance of the operation itself, and almost a necessity afterwards owing to the tendency of the tongue to fall back on the glottis. The remarkable freedom from haemorrhage, and the fact that the facial nerve on both sides was uninjured, I attribute entirely to the use of a blunt scraper instead of a knife. It is evident from the rapid progress of the patient towards recovery that the cause of death was accidental, and I think it may be claimed that the operation itself was successful. I made no objection to the mother suckling her child, so long as she took and assimilated such large quantities of nourishment, for it is a common occurrence in this country to continue suckling after the most severe operations and injuries. Examination of the tumour showed it to be a myeloid sarcoma springing from the central portion of the maxilla, and involving the dental margin. I am indebted to Surgeon-Major P. Ramsay for his able assistance during the operation. The systemic dizcsion of bile salts from the portal organs is apparently not excessive, but the kidneys fail to keep pace with it.-Hitherto I have dealt only with the reaction of the peptone test suggesting the presence of an increased quantity of the biliary salts in the urine; as in jaundice, diseases of the liver and spleen, fever, and in diseases in which the cellular elements of the blood undergo dissolution-such as some varieties of anaemia, scurvy, and hsemoglobinuria ; the increase being absolute, even though the discharge of the biliary elements is at times lessened. Should any clinical value be attached to the renal elimination of bile salts when subnormal, or reduced to the verge of extinction? I am under the impression that a surcharge of these excreta in the blood may now and then take place from an imperfect removal of them by the kidneys, though there are no apparent indications of derangement or embarrassment of the portal organs to favour the accumulation. This is as yet, however, but little more than a surmise; and it may turn out that the detection.of an excess of these biliary derivatives in the urine is the only important clinical aspect of the subject. A subnormal reaction is met with in many apparently healthy individuals, in whom perhaps the other emunctories, the skin and the bowels, are in this respect more active than usual, or in whom there is less biliary matter to be disposed of ; also in a large proportion of those said to suffer from chronic biliousness, but who for their years probably make less bile than normal (subcholia), and in various forms of deficient constructive activity, as in ordinary anaemia and the like. Chronic renal disease.-I have been rather struck with the fact that in all the cases of cirrhotic kidney I have examined the reaction was either decidedly subnormal or nil. But in a case of waxy kidney, which I observed from its origin to its close, the reaction was always above normal -often considerably so-and the post-mortem examination afforded no indications of ursemic poisoning, nor were any observed during life. 1 If this observation be confirmed by further inquiry, perhaps the question will arise how far should the symptoms of uraemia be referable to the grave form of cholsemia that culminates in convulsions and coma? Skin disease.-So far I have always found the reaction subnormal in eczema. This is the urine of a patient now under observation, and the reduction amounts to at least one-half. Conditions that infuence the renal elimination of the biliary salts.-I think it is highly probable that neurotic influences frequently play a leading part in checking the discharge of these excreta by the kidneys; they are, however, often obscure and difficult to track. Hence the 1 Just at this time I have under observation a young lady, aged twentyone, suffering from intermittent albuminuria of hepatic origin, in whom I have noted the interesting fact that when there is not a trace of alhumen (as is always the case in the urine discharged before breakfast) the amount of the bile salts as indicated by the peptone test merely reaches the normal standard ; but when albumen appears (as it is apt to do in considerable quantity three or four hours after a meal) the proportion of the biliary elements rises considerably, becoming doubled or even trebled, and this at a time when they should appear in smaller quantity than in the morning. When after a meal there is no albumen, the bile salts are found in subnormal amount.
doi:10.1016/s0140-6736(02)17544-1 fatcat:sch4p3mql5dn5mjlvqu2nsrwwu