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Medical and Physical Journal.

5 OF VOL. XXx.]

NOVEMBER, 1813.

[NO. 177.

"For many fortunate discoveries in medicine, and for the detection of nume"rous errors, the world is indebted to the rapid circulation of Monthly "Journals; and there never existed any work to which the faculty in "EUROPE and AMERICA were under deeper obligations than to the Me"dical and Physical Journal of London, now forming a long, but an "invaluable series."--RUSH.

To the Editors of the Medical and Physical Journal. (With a Plate.)

GENTLEMEN,

THE history of the annexed case is as follows. The subject of it was a middle-aged widow, and mother of several children.

Above twenty years ago, a tumor arose the size of a small pea, without any apparent cause, below the ear. The increase was slow and gradual, confining its dimensions for ten years to one small point. After that period other swellings commenced, until the size of the whole became such as is represented by the drawing. The weight and consequent pressure of the tumor produced some occasional vertigo, which was the sole inconvenience to the patient.

This case became unusually interesting, inasmuch as it was the opinion of a great number of respectable physicians and surgeons who had seen it, that an operation, should it ever be deemed practicable, would be attended with imminent danger; and the most unfavorable prognostic had been given by several others of the inevitable result of an ope

ration.

For my own part, whatever apprehensions I might have as an operator, from the situation, condition, and circumstances of the case, yet, desperate as it was, my own opinion inclined decidedly for the operation. It was considered, in consultation, as practicable, however hazardous, and it was determined that if the patient chose to undergo the ope ration, and I had no objection to undertake it, that opinion should be my sanction.

The poor woman, in contemplating the situation and probable result of her case, as represented to her by the consulting gentlemen, evinced a firm and sensible mind.

Having a numerous family to rear under narrow circumstances, she had met and borne the inconvenience and difficulty of her malady with great fortitude. After two and twenty years' industrious exertions, she had managed to

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bring up her children. They were placed and settled in safety of course she found herself at liberty to consult her own feelings, and, if necessary, to abide by any risque in relieving them. Whatever expedient she might choose to try, now solely implicated herself. With this view she sought advice, and the operation being adjudged indispensable, she submitted to it patiently.

This was at any rate an awful decision, and it may be presumed that to confront the terror of an approaching dangerous expedient, in the face of numerous unfavorable forebodings, and of as numerous friends and visitors, would require something superadded to ordinary courage; for the size and appearance of the tumor rendered the patient an object both of opinion and of curiosity.

The operation was, of course, painful in proportion to the large extent of incised surface. Care was taken in performing it to preserve as much skin from the base of the tumor as should afford a covering to the wound. The incision was begun in that part of it by which the effusion of blood wouldleast incommode the track of the scalpel. The inequalities consequent upon the lobular structure of the mass, had impressed some deep indentations within the neck; and the weight and bulk rendered it both unwieldy and inconvenient in operating.

On extirpating the tumor, a considerable arterial branch was unavoidably divided, which on the first jet of blood, and in that situation, had a formidable appearance. It was promptly restrained by pressure of the finger, until the operation was so far advanced as to make it convenient to secure it. A ligature was applied before the base of the tumor was separated, to prevent the occurrence of hemorrhage.

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The tumor being completely removed, the carotid artery was observable in its course up the neck, exposed and pulsating. The large corresponding jugular vein presented also its broad, thinner, and less conspicuous coat. This be came an object of notice only when certain compressions from motions of the neck allowed it to appear full, or to be. emptied.

The incisions were obliged to be carried in two or three angular directions on the neck and cheek, yet they formed eventually a compact cicatrix; and the parts being carefully attended to during the healing process, left no very particular deformity. They were united and well in five or six weeks after the operation. The mouth, however, was rather disfigured from a certain unavoidable division of the nerves, and of course from a corresponding abatement of their in fluence upon the muscles.

The

The weight of the tumor was three pounds and nine ounces. The patient had not any material bad symptoms during the cure.

The substance of the tumor consisted of a condensed smooth firm structure on the outermost lobes; and of a more pulpy, darker, greasy mass in the middle ones.

I have the honor to be, &c.

JAMES ATKINSON,

Surgeon to His Royal Highness the Duke of York, Senior
Surgeon to the York County Hospital and Dispensary.

To the Editors of the Medical and Physical Journal.

GENTLEMEN,

Indoking Dr. Your reserves to himself the liberty' of choosing the time and season for publishing the case of Ann Foulkes.

N looking over your Journal for the present month, I

That the proper time for publishing her case was the period when his paper upon Ischuria made its appearance, will be apparent to every one, I humbly conceive, who peruses the following statement-that his conduct towards me and others in not doing so has been very extraordinary, and that we must necessarily feel hurt at his endeavours to reflect by implication upon our professional conduct, must be equally apparent.

Early in the spring of 1812, I repeatedly heard that there was a most wonderful case of disease in this town, and that the subject of it, A. F., evinced the most pious resignation under sufferings almost unparalleled.

I knew not whose patient she was, or had been, Motives of professional curiosity induced me to call upon her. I first did so on Thursday the 19th of March, and found her suffering apparent uneasiness from a tumefaction of the epigastric region. She informed me it was occasioned by a collection of urine, which was occasionally evacuated by vomiting. That every second or third day the accumulation was so great as to oblige her to take an emetic, which always enabled her to discharge the urine by the mouth very freely; but that if she did not take the emetic, her sufferings were much increased.

This state of things, she said, had existed about twenty weeks; and that during the whole of that time she had not voided a drop of urine by the natural passage.

Her general health did not appear to have suffered so much as might have been expected, from such an extraordinary, and, I may add, almost incredible disease. Indeed it struck me as being wonderful that she evinced so few

symptoms

symptoms of general illness, considering she had been so long confined to her bed.

This circumstance I wish to direct your attention to in a forcible manner. We all know how easy it is to feign. numberless pains; but we as well know that long-continued visceral disease does universally show its effects in a direct and obvious manner.

Added to this, I have no hesitation in declaring that her digestion was at this time very healthy and perfect, from the well nourished state of the body, and from an inspection of well formed and healthy-colored fæces. It appeared to me very strange that these things could be so, whilst she complained of the dreadfully irritating effects of the discharged fluid upon the throat, fauces, and mouth. To satisfy myself upon this subject, I now thought it right to make every possible inquiry into the previous history of her diseases, and to pay great attention to these extraordinary symptoms. The more I did so, the more had I reason to fear there was some incorrectness in the relation of her story.

On the following day I called with a medical friend upon whose judgment I placed great reliance, and his astonishment was also excited.

We agreed to attend alternately at the periods of her taking the emetics. Previously, however, to doing this, we thought it essential to examine the state of the bladder by means of a catheter, and were very much surprised to find that no examination of this kind had been made in the early stage of the disease. To our great astonishment, both A. F. and her mother most obstinately refused to permit this simple operation. Our suspicions were then strongly excited, the more so, because they were very loud in their assertions of there being not a drop of urine in her bladder. They likewise affirmed that there had not been a drop of urine in that organ for several months. To strengthen this declaration, they assured us that Dr. Yeats, who had attended her very assiduously in the early period of her present illness, was of the same opinion. She was now attended solely by a druggist of this town, who, with the sanction and full approbation of Dr. Yeats, prescribed emetics, diuretics, &c. What steps were taken to assist in the ejection of the urine before Mr. Palgrave, the druggist, vrdered emetics, I know not. Although it was represented that her sufferings were very dreadful at the time the urine first stopped, it was very extraordinary that her symptoms were not such as usually attend retention and suppression of the urine.

Upon a further and more accurate examination of the

parietes

parietes of the abdomen, I now discovered that the muscles of its lower part were always put into violent action, when the tumefaction of its upper part was most apparent, and in vain I requested that they might be relaxed. This, of course, led me to suspect, that the said tumefaction or inflation was in some measure dependent upon the action of these muscles, and I was certain that their action was principally voluntary. The truth of this suspicion was made very apparent some time afterwards; I happened to call at a period when she did not, or could not contract the muscles so forcibly, and the tumefaction had disappeared. Upon an examination of the epigastric region under these circumstances, I could discover no trace of visceral disease.

I had been assured the swelling always increased in proportion to the supposed accumulation of urine; but at the time I now allude to, she had not vomited urine, according to her own report, for some days, and I could only account for the absence of the swelling, by the quiet state of the muscles below. The hypogastric region was at this time fuller than usual, and I suppose she was incapable of practising her common habit of blowing out the epigastric region, owing to there being an unusually full state of the urinary bladder.

I had the less reason afterwards to be surprised at Dr. Yeats' believing that the tumefaction was now owing to a real collection of urine, because he did, in the most positive and unequivocal manner, declare his utter disbelief of the possibility of any person being able to cause such an inflation as I constantly witnessed, whereas nothing can be more easy.

There was no doubt of the nature of the fluid which the girl and mother positively asserted she (A. F.) vomited up. It was clearly urine. It now remained to be proved that such fluid was actually discharged by vomiting.

My friend went to her house on Saturday morning the 3d of April; her mother said she had just swallowed the emetic, and that it was beginning to operate. He staid a considerable time, during which she appeared to be very sick and retched often, but neither urine, nor any thing of an urinous smell was brought up. With much persuasion he induced her to swallow some warm water; this returned by vomiting, but quite free from any admixture of urine. He then left her, perfectly convinced of the incorrectness of the whole story, as he was before assured of its utter improbability.

A few days after I went to the house, whilst she was said to be under the operation of an emetic. When I entered the chamber, her mother shewed me about half a pint of fresh, transparent, and apparently healthy urine, free from

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