ON MR. LISTON'S METHOD OF HOLDING THE KNIFE IN LITHOTOMY

subject, and discussed the question at some length. Lastly, he referred to the origin of the fibrous cord which filled up the

Medical Societies ROYAL MEDICAL & CHIRURGICAL SOCIETY. TUESDAY, MARCH 25TH, 1856. MR.

CÆSAR

HAWKINS,

PRESIDENT.

ON A CASE OF A YOUNG WOMAN IN WHOM THE MAIN ARTERIES OF BOTH UPPER EXTREMITIES AND OF THE LEFT SIDE OF THE NECK WERE THROUGHOUT COMPLETELY OBLITERATED. BY WILLIAM S.

SAVORY, F.R.C.S.,

TUTOR AND DEMONSTRATOR OF ANATOMY AT ST. BARTHOLOMEW’S SURGEON TO THE ROYAL GENERAL DISPENSARY.

HOSPITAL,

(Communicated by Mr. STANLEY.) A. M. W, aged twenty-two, was admitted into St. Bartholomew’s Hospital on November 27th, 1854. No pulse could then be detected in any part of either arm, There was feeble pulsation in the right carotid; in the left, doubtful. A harsh systolic bruit was audible over the top of the sternum, which disappeared on tracing it downwards, and a feebler one was heard in the course of the right common carotid. She complained of general debility, of headache, vertigo, and obscure pains in various parts. She had been delicate ever since she was a child. There was satisfactory evidence to show that the pulse had ceased to beat for some years past. There was no distinct history of any previous attack to which her present condition could be referred. She remained in the hospital until she died-a period of thirteen months. During this time her strength gradually passed away. The sight of the left eye began to fail, and at length was nearly lost: an ulcer formed on the cornea, which yielded to tonic treatment. Subsequently, ulceration commenced in the integuments over the left parietal

interior of the contracted vessels. He believed it to be the remains of the blood which had coagulated in the canal, and not an exudation from the arterial tunics; and concluded by giving the grounds upon which this opinion was founded. Mr. CAESAR HAWKINS remarked that he had seen cases in which pulsation in some of the larger arteries had been lost fora time, but was again restored. Some change had taken placein these vessels different from that which obtained in the case under discussion. Mr. FERGUSSON said that the case before them showed that a person might have obliteration of a large number of important vessels, and yet live after. The pathological history of thecase was very interesting, but he thought the author had scarcely done justice sufficient to the first portion of the case by the deductions which he had drawn from it. He had entered into a minute detail, day by dty, of the symptoms presented; but he (Mr. Fergusson) did not see any necessary pathological conditions found and the relation between thewhich had existed for weeks and months. peculiar symptoms He thought all these symptoms must be familiar to surgeons as existing without any of the changes observable in Mr. Savory’s case. The history of the post-mortem appearances, was of great excellence and value, but very little attempt had. been made to explain the relations which the symptoms presented during life bore to the appearances observed after death. He doubted, indeed, if the author was quite correct in his physiology. For instance, he had regarded the obliteration of the artery in the neck as the cause of the development of necrosis in a portion of the cranium, and the subsequent ulceration of the dura mater, spreading to the substance of the brain. But ulceration of the scalp and exfoliation of bone took place irrespective of obliteration of the main artery. It was not clear that the destruction of tissue was due to this cause; at all events, that change had been seen without it. He was disposed’ to question the accuracy of the author’s views respecting the

eminence, and, resisting all remedies, gradually extended, unbone, and ultimately a portion of the brain, were de- spread of the disease from the surface to the brain, particularly stroyed. During the last few weeks of her life she was much as the circulation to the brain was supplied from such a different distressed by impaired and disordered motion and sensation on source. He regarded the structural disease of the brain as the right side. coincident, and not dependent on the same cause as the other. After death, the following condition of the arteries was re- Mr. Fergusson expressed the high opinion he entertained of til the

vealed :-The whole of the arteria innominata was much thickened, and it required considerable pressure to approximate its walls. The lining membrane was pale and smooth, but dull and opaque. The internal coat separated with the slightest force from the middle, and was almost as thick as the other two coats together. The middle and external coats were denser than natural, and slightly thickened. Owing to1 his morbid state of the tunics, a section of the vessel presented a remarkable appearance. The distinction between the coats was strikingly obvious. When the internal coat was stripped off from the middle, in a great part of the vessel irregular patches of an opaque yellowish deposit came off upon the outer surface of the inner coat, but some remained upon the inner surface of the middle. This deposit, to minute examination, presented all the characters of consolidated lymph intimately blended with the arterial tissues. It was probably in process of degeneration, for here and there many small globules of an oily nature could be detected. This morbid change extended into the right carotid and commencement of the subclavian artery. In the whole of the former vessel the same change, although to a less extent, was apparent: it was contracted and much thickened ; there was no clot in the interior; the inner surface was not reddened. About an inch or less from their origin, the right subclavian, the left carotid, and the left subclavian arteries became suddenly contracted to one-fourth or one-fifth of their natural size. This change extended throughout these vessels: through the axillary, brachial, radial, and ulnar arteries on both sides, and the left external carotid artery. The contracted canal in their interior was completely blocked up and obliterated by a fibrous cord, which extended with scarcely any interruption throughout their entire length. Thus all the main arteries of both upper extremities and of the left side of the neck were reduced to solid cords. Other morbid appearances, of less moment, were described in the paper. In his remarks upon the case the author observed that, from its history, the progress of the disease had probably been gradual, and unaccompanied by any acute or violent symptoms. He believed that the symptoms observed during life might almost all be referred to a deficient supply of blood to those parts of the body to which the obliterated arteries were distri. buted. The author then remarked upon the objection which the facts of this case opposed to Rokitansky’s views on the

the paper, but suggested that minute and tedious details might be left out in such communications. (Hear,

with advantage

hear. )

The PRESIDENT asked if any member could explain therestoration of the pulsation and circulation in an artery after they had been suspended for years. He referred to the case of’ a gentleman who had lost all trace of circulation in one upper extremity for a year, and that also, nearly, of both lower extremities. There was no mortification, but some shrivelling of the limb. The circulation was eventually restored. The obliteration could not havebeen the result of a coagulum. On what did it depend ? He would inquire of Mr. Fergusson whether he had not seen ulceration of the brain consequent upon disease spreading from the bone ? Mr. FERGUSSON replied that he had, but it had been the result of a local cause, as pressure, and did not arise from the obliteration of the carotid or other artery, as in Mr. Savory’s ’

case.

Mr. SAoORy, in reply to the objections urged against hisviews, remarked, that he had connected the symptoms during life with the post-mortem appearances observed, as far as he could or dared; and he thought he was correct in attributing the loss of nervous power, and the destruction of certain parts, to the obliteration of the vessel which, or its branches, directly supplied the parts affected. He thought that the deductions he had drawn respecting the spread of the disease to the brain were entirely consistent with correct pathology. ON MR. LISTON’S METHOD OF HOLDING THE KNIFE IN

LITHOTOMY. BY

WILLIAM

FERGUSSON,

PROFESSOR OF SURGERY IN

THE

ESQ.,

KING’S COLLEGE,

F.R.S., ETC.

of the author of this paper was to draw attention a remarkable error which had gradually in thecrept on the illustration of this operation, as works of Miller, Pirrie, Erichsen, and even that of Liston himself. The author contended that Mr. Liston cut with the, knife underhand, and not overhand, as has been represented. in all the works just named. He (Mr. Fergusson) accounted. for this mistake bv suposing that Mr- T,iston’s artist- whilst

object

to what he considered

portrayed

373

intent upon the anatomy of the parts, and the position of the point of the knife, had considered the attitude of the hand as of minor importance. Thus, that Mr. Liston had actually misrepresented his own operation; and that his pupils, whilst professing to describe it, had taken his representation as the model, and so perpetuated an error which in time might possibly lead to much misapprehension, if not to evil The paper was accompanied by excellent diagrams, representing, on a large scale, the illustrations from the works alluded to, as well as from the author’s own work; and contained many passages illustrative of the great manual dexterity of the late Mr. Liston, and highly complimentary to that surgeon. Mr. EBICHSEN considered that the Societv was indebted to Mr. Fergusson for bringing the subject of his paper under its notice. Everyone who had performed the lateral operation of lithotomy knew that its success depended mainly on an attention to minor details, as the position of the patient, &c. There did not appear to be any absolute certainty as to the exact mode in which Mr. Liston held the knife in lithotomy when he was making the deeper incisions; some who had seen him thinking he held it one way, some in another. The different changes of position might well escape the attention of the beholder who was lost in admiration at the wonderful dexterity of the operator. He believed, however, that Mr. Liston had laid down a certain principle with respect to the position of the knife, but in practice had changed it according to the circumstances which presented themselves during the operation. It was curious, if Mr. Fergusson was right, that Mr. Liston’s diagrams in University College, the plates in his work on Practical Surgery," and in his Lectures in THE LANCET, should all be wrong; for in every one of these delineations the knife was above the hand. In the first incisions he (Mr. Erich.sen) said Mr. Liston held the knife in the manner described by Mr. Fergusson, and cut downwards; in the second incision Mr. Liston used the knife as a gorget, and pushed it forward to the groove of the staff, and withdrew it in such a way as to avoid a downward cut. So forcible was this movement, that Mr. Liston always broke the knife in lithotomy, by "jobbing" it, as it were, into the groove of the staff. This was best perhaps, by less experienced surgeons, by holding the knife overhanded. Mr. Liston, he thought, suited the position of the knife to the necessities of each case. Mr. C. HAWKINS said, that in a superficial perinaeum, as in a child, the knife might be introduced underhanded; but, in a deep petineaura, it could be used overhanded with the greatest

consequences.

effected,

advantage.

Mr. FERGUSSON said that he had seen Mr. Liston operate at least forty times for lithotomy, and never saw him change the position of his hand in any one instance. Mr. Liston had known of the misrepresentation of the position of the knife in the illustration alluded to, but had not the opportunity, or at least did not take means, to correct it. He stated this on the best authority. Mr. ASHTON said that he had seen Mr. Liston operate several times: he always held the knife in the manner depicted by Mr. Fergusson.

MEDICAL DR.

SOCIETY

OF

LONDON.

SATURDAY, MARCH 29TH, 1856. CHOWNE, PRESIDENT, IN THE CHAIR.

Mr. HENRY SMITH read

a

paper

OF DILATATION AND THE ACCESSORY IN THE TREATMENT OF THE MORE OBSTINATE FORMS OF STRICTURE OF THE URETHRA.

ON THE

EMPLOYMENT

MEANS

discuss the merits of dilatation, and to consider the mode in which it acted. The comparatively little benefit which was produced by it in the more obstinate and contractile strictures arose, in a great measure, from hasty and insufficient attempts to dilate by using small catheters and metallic sounds—instru ments in themselves well adapted to the majority of cases of stricture, but capable of doing much mischief in the class of Local and general irritation, to cases he was now alluding to. a great degree, was the result of repeated attempts to pass

small metallic instruments; abscess, haemorrhage, laceration, and occasionally death ensued. Some cases were mentioned where fatal effects had followed the employment of catheters. He had seen so many unsatisfactory results proceeding from this treatment, that he had of late adopted the use of wax and flexible bougies in the early part of the treatment of complicated cases, and he was convinced that much more good could be effected, and that dilatation could be carried on in a more safe and effectual manner. Bougies, especially those of wax, caused no irritation, and the surgeon could much more readily hit the orifice of the stricture with an instrument which caused little pain, and would adapt itself in passing along to the form of the urethral canal. He had treated in this way patients who had been under the care of most experienced surgeons, but who had used small metallic instruments, which produced such irritation, that in some of the instances the patients, from absolute dread, would not permit of their use, and he had been able to carry on dilatation in this manner where it could not be effected before. When, however, he was able to get up to a No. 5 or 6, he had laid aside bougies, and carried on the remaiider of the treatment with catheters or metallic sounds. His observations applied solely to the more intractable and complicated cases, for in the majority of instances of stricture he would employ the catheter from the beginning of the treatment, and use it throughout with the best and speediest result. When, however, it became evident, as it would do in some of these cases, that dilatation alone would not succeed, we should not hastily resort to cutting, but call to our aid some less dangerous but yet powerful remedy, and this existed in potassa fusa, which the author had used for several years. He had found it of great service in cases where there was a dense and unyielding stricture, especially those situated in the penile portion of’ the canal, and which are, contrary to general recognition, by far the most undilatable. Mr. Smith wished to be particularly understood that he considered that potassa fusa should only be employed as an adjunct to dilatation. Holding this principle in view, we should not be betrayed .into using it unnecessarily, or trusting too much to it. Some cases were related where its good effects were marked. In one instance the patient had been recommended to have perineal section performed ; but he afterwards fell into the author’s hands, and got great relief from the use of potassa fusa, aiding dilatation by bougies. The author, in conclusion, made some brief remarks on the employment of permanent and rapid dilatation. He considered that there were many cases of old callous strictures where the urinary organs were not irritable, which would be greatly benefited by these modes of treatment, whether carried on in the ordinary manner of retaining a catheter for twentyfour hours and changing the size from day to day, or by the instruments used by Mr. Thomas Wakley, which latter could undoubtedly produce most powerful and rapid dilatation. His own observation of their effects had extended to one case only, and here the result was unfavourable; but Mr. Wakley had informed him that he had used them extensively, and with excellent results, and there could be little doubt that if the cases were carefully selected, rapid dilatation would succeed well, but he should apprehend, where there was an irritable urethra, or tendency to constitutional sympathy, such a mode of treatment was injurious. The author concluded his paper by relating some cases in which he had resorted to permanent dilatation with excellent results. The discussion upon this paper will appear in our next.

The author commenced his paper by making some remarks upon the various modes of treating those obstinate cases which so often baffle the surgeon, and gave it as his opinion that, in consequence of the great attention given of late years to the consideration of cutting operations, surgeons had been insenAMPUTATION OF THE FOOT AT THE ANKLE-JOINT. sibly led to place much less reliance upon the treatment of the disease by dilatation than they ought to do. The use of chloMr. HENRY THOMPSON read a paper on Amputation of the roform had also a tendency to foster the present mania for Foot at the Ankle-joint, after the manner of Mr. Syme, illusdividing strictures. Good, however, had unquestionably been trated by a case, and by diagrams explaining the method The case was briefly as follows :effected, inasmuch as many individuals who had formerly been L. 0--, a girl aged ten years, was admitted to the Maryleading a miserable existence, in consequence of inveterate and complicated stricture, had been induced to submit to operations, lebone Infirmary in April, 1855, after a residence of about four and had been restored to health; still, on the other hand, much years at Margate for her health. She had suffered from mischief had been done, as patients have been operated on un- indolent glandular swellings in various parts of the body, and necessarily, and some had lost their lives in a melancholy way, from caries of the tarsus and metatarsus for about five years. several examples of which had fallen under his observation, or Her state on admission was as follows :-The foot is greatly had come to his knowledge. The author then proceeded to swollen, and numerous sinuses exist in it. Following these

pursued.

374