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ABSTRACTS OF The "Bromn" Lectures.
DECEMBER 27, 1884. ABSTRACTS OF
The "Bromn" Lectures. BY VICTOR
HORSLEY, M.B., B.S., F.R.C.S.,
PROFESSOR-SUPERINTENDENT
LECTURES 1. AND If. THE THYROID GLAND ; ITS RELATION TO THE PATHOLOGY OF MYXtEDEMA AND CRETINISM. THE previous ignorance of the importance of the thyroid gland in the economy was only swept away by the attention aroused by Kocher and the two Reverdins. Mr. Horsley arranged the matter under consideration into five divisions. The first division treated of the anatomy and position of the thyroid gland. The bilobed form of the gland was held together by a capsule of connective tissue, which sent its trabeculse into the substance dividing and supporting the gland tissue; the septa of connective tissue were the paths for the bloodvessels and lymphatics. The lymphatics have been proved by Barber, Boéchat, and Frey to assume the shape of large lacunae at the very margin of the alveoli. The thyroid body imitates in its development a racemose gland, and was probably of a glandular nature. Virchow and Boéchat believe that the acini of the gland intercommunicate. Théophile de Bordeu believed that minute ducts brought about a communication between the thyroid and the trachea, and Ricou postulated the same idea of a duct-like communication between it and the larynx. The structures and relations, together with the histological phenomena attending the development, also supported the view that the thyroid was a gland. The glairy fluid of the acini is said by Kuhne and Eichwald to contain mucin, though Gorup - Besanez saw a difference in its solubility in acetic acid. Baber’s theory, to the effect that the mucinoid contents of the acini were secreted by the epithelium and reabsorbed by the lymphatics, was supported by the foregoing considerations. Simon seems to have been the author of the view formulated Liebermeister and Guyon, which regarded the thyroid body as a regulator of the cerebral circulation. The view has also been held by Simon that the thyroid gland secretes a something necessary for the nutrition of the brain, but the changes in the central nervous system, after thyroidectomy, may be of a secondary nature. Luschka believed that the thyroid might act in a mechanical fashion, staving off the pressure of the contracting cervical muscles from the carotid arteries. The possible influence of the thyroid in hsemapoiesis was also referred to. Most of the foregoing views do not completely harmonise with what is known of the powers of the thyroid. The effects of thyroidectomy were next considered. What happened if the thyroid were completely removed ?1 Kocher showed that man becomes a cretin. Schiff, Wagner, Sanguirico, and Canalis removed the thyroid of dogs, and found that the animals became idiotic and died comatose. Mr. Horsley’s experiments on the monkey showed that a condition, called by Mr. Ord myxoedema, arose when the thyroid was extirpated. The method of operating was next detailed. The post-mortem examination proved the limitation of the lesion to the gland. No ligatures were used. The Perfect antiseptic precautions were carried’out. theory which ascribes the origin of myxoedema to the sympathetic system is inadequate in the light of the evidence afforded by Mr. Horsley’s operations. Schiff’s first set of experiments cannot be quoted, as no pains were taken to prevent septic poisoning. The symptoms following thyroidectomy in the monkey were tremors, (which came on in five days), pallor, leucocytosis, followed by oligaemia, paresis, puffiness about the eyelids, with swelling of the abdomen and increasing mental dulness. The temperature tends to become subnormal towards the end, which is usually ushered in by coma from five to seven weeks after the operation. The symptoms were next notably altered, being swollen, jelly-like, bright shining, examined in detail. The nerve symptoms were the first to and excessively sticky. The increase of the altered connecattract attention. Fibrillar twitchings of the muscles may tive tissue is most marked in the triangles of the neck and be observed in the dog as the first symptoms, and Wagner over the bypochrondria. The same condition is observed in states that the tremors are succeeded by clonic spasm, teta- the tissues of the mediastinum and omentum, as well as nus, and nnally rigidity. In the.monkey a slight fibrillar along the coronary arteries and the auriculo-ventricular groove. Atrophic changes could be seen when the fatty tissue No. 3200.
by
,
OF THE BROWN INSTITUTION.
uext in the feet, and then in the jawe. These tremors merge into a constant tremor, which has resemblance to the ankle clonus. Paroxysms of muscular tremor and even convulsive movements have been observed, aud tracings made, but’t With regard to the tetanus was never een in monkeys. origin of the muscular movements, Schiff had found that they continued after section of the motor nerves, and Mr. Horsley after removing the cortical centres for the upper arm observed that they still remained. Voluntary move. ments diminished the tremors, but the inhalation of ether increased their activity, whilst reflex irritation stopped them altogether. The conclusion is that the movements are energised from the medulla oblongata or spinal cord. The rate of the tremors per second was the same as that in dogs (Lovèn), and is believed by Mr. Horsley to correspond with the tremors of paralysis agitans and allied conditions in Paresis of gradual onset, varying in intensity directly man. with the force of the tremors, and rigidity, always coexist. There is never complete paralysis, but wristdrop and the "paralytic posture"may be seen. Hemiplegia occasionally appeared, and then the tremors on the paralysed side disappeared, except from the jaws. Sensation may be a little blunted, and touch may be delayed when the tremors are in an advanced stage. The superficial reflexes were diminished; the knee-jerk was present, but never the ankle clonus. The centres of the lumbar region and medulla appeared to be unaffected. Slow hebetude ending in varying degrees of imbecility with easy disturbance of temper were the disorders related to the cortex of the brain. There was a steady fall in blood pressure and in the number of red discs for about fourteen days. Leucocytosis accompanied and kept pace with the oligsemia. The " buffy coat" was better marked, owing to the lessened tendency of the blood to coagulate. Mucin is not a normal constituent of blood, but was present after thyroidectomy, in quantities varying with the duration of life. There was an increase in the serum globulin, though other proteids remained normal in amount. The serum albumin was found by Dr. Halliburton not to be separable into three forms. The sudden appearance and disappearance of dyspneea were interpreted by Mr. Horsley to be of bulbar origin, owing to the abaence of other physical signs. The recurrent larnygeal nerves were always found to be healthy, and the larynx was normal in every way. The hypertrophy of the salivary glands was a novel feature, and due to extreme production of mucin, whilst, strange to say, the parotid comes to secrete mucin. The appetite fails immediately after the operation, but soon revives, only however to become ravenous prior to its final failure just before death. Credé, Zesas, and others have observed a connexion between the spleen and the thyroid, and Mr. Horsley has detected an increase in the splenic dulness during life, which was found atter death to be due to general enlargement of the spleen. Distension of the intestines with hypertrophy of the omentum were the chief factors of the abdominal swelling. The small amount of peritoneal fluid contained mucin. The urine was normal in quality, and with the exception of occasional transient glycosuria and a normal quantity of mucin, nothing remains to be said on this score. The genitalia were normal. The marked pallor of the skin, which was apparently of normal humidity, the swelling of the face and eyelids, and the atrophy of the hair were dilated upon. It was curious to observe the atrophy and greyness of the hair about the buttocks, and one was reminded of the bedsores of man. The temperature curves show after operation a slight rise, followed by a fall to the normal. The morning fall and evening rise are exaggerated when the tremors set in. In monkeys Mr. Horsley does not find a high fever when the tremors are on, in this respect differing from what Schiff has described in the dog. The temperature slowly falls after the tremors have reached their height until a subnormal heat of body is registered prior to death, which is ushered in by cold surface and extremities, though shivering was never The constant and small perversions of nutrition give seen. rise to a clinical picture which has its counterpart in the myxoedema of man. At the post-mortem examination of the monkeys the subcutaneous tissues are found to be
1134 death has followed simple injection; and Billroth’s method may be followed by serious inflammation. Before injectiug it would be well to adopt Demme’s plan of waiting to see whether a vein has been wounded or not. Mr. Horsley believes that the sudden death is due to thrombosis, the result of the entrance of iodine and not air into the circulation. The total removal of the thyroid ii condemned, as good results may be obtained by removal of a portion. Mr. Sydney Jones’s operation of excision of the isthmus between silk ligatures has been most successful.
which remained was examined microscopically; these appearances were typically seen in the fat about the auriculoventricular grooves. No changes were seen in the bursa, but congestion of the synovial membranes was present without effusion. The bones and cartilages showed no positive alterartons. An increase was observed in the connective tissue of the mu4el: s. The connective tissue of the whole body may be said to be increased with a, mucoid degeneration of the ground substance and atrophy of fat. The enlargement of the salivary glands has 1>.;en noticed, and chemical analysis showed that the parotid of the monkeys in question contained as much as 1 21 rwr 1000 of mucin. The proportion of mucin in the submaxillary gland was increased from ’01 to 4’6 per 1000. There is swelling of the mucous membrane of the alimentary canal, and much slime in the motions. The brain and spinal cord were pale and sornewhat wasted, and the meshes of the pia mater were distended with fluid. No sign of disease was detected in the musculo-spiral nerve or in the sympathetic system. The other nervous tissues have not yet been completely
examined. The various theories advanced as to the nature of cretinism and goitre were next passed in review. Myxeedema, cachexia strumipriva, and cretinism were outlined from the accounts given respectively by Ord, Kocher, and Hilton Fagge, and the conclusion that all these proThese cesses were of identical nature was arrived at. morbid processes are most probably dependent upon profound changes set up by injury to or ablation (actual Kocher’s view that a or virtual) of the thyroid body. chronic asphyxia led to the cachexia strumipriva as a result of the atrophy and softening of the trachea was not, accepted by Mr. Horsley, on the ground that the trachea and gullet may remain healthy, and that chronic stenosis of the trachea is not followed by "myxoedema."Dr. Hadden’s theory of capiltary spasm does not hold good, because the sympatheties were found to be healthy, and because Schiff’s experiments on irritation of the sympathetic nerves did not give rise to "myxoedema." The increase of connectivetIssue must be regarded as an epiphenomenon of the changes fou.,d in myxoedema. ]Bfr. Horsley next draws up a tabular statement of certain facts which may be found a useful aid in further investi-
gation
:-
1. The
thyroid gland
appears to consist of two distinct
portions : (a) glandular, having the function of excreting mucin (?); (b) highly vascular lymphoid nodules, having a lit-itiatogenous function.
2. Excision of the gland is followed by an increase in the amount of mucin in the tissues, an increase in the activity of the muciparous glands, and the assumption of a muci-
parous function by glands which usually yield no mucin. 3. Excision of the glands is followed by the profound chauges in the blood already indicated. 4. Excision of the gland is followed by nerve symptoms, indicating changes in the lowest motor centres, which cause tremors, with rigidity and paresis, as well as alterations in the higher cortical centres with the production of imbecility, alld ultimately death in the comatose state. Having thus summarised the changes, Mr. Horsley states his belief that myxoedema and its allies are due to the loss of the thyroid body-a virtual, if not an actual, loss. No doubt vai-o-motor or trophic lesions may be the immediate cause of the changes, but even then the functional or actual want of a thyroid body would be the parent cause of the troph’c or vaso-motor disorder. The view that the thyroid gld.ud is an excretory organ received strong support from the experimental facts. The removal of one lobe of the thyroid causes enlargement of the other, and the subsequent removal of the second lobe is followed by myxcedema. May it not therefore be that the thyroid excretes a mucinoid material which is harmful to the organism, and that the loss of this excreting function entails death? The surgical treatment of the thyroid gland was next discussed. The conditions calling for treatment are hypertrophy or adenoma, with or without some amount of cystic degeneration or fibroid overgrowth, cystic disease, malignant newr growths. Removal was the only method for the last conThe partial or total removal of the tumour is said, to have cured one case of exophthalmic goitre, and partial, excision is perhaps the only treatment which holds out at possibility of cure. Simple goitre may be treated by injection or removal. Injection may be simple or combined withl .
dition.
.
laceration
by
a
needle,
as
practised by Billroth.
Suddenl
LECTURE III. TRAUMATIC FEVER. The expression "traumatic fever" has universally been employed to denote the febrile state which usually follows an injury to the body with or without a lesion of the skin or mucous membranes. The term at present embraced fevers of widely different natures, as Lucas Championniere proved by describing puerperal fever, pysemic fever that of septicaemia, and urethral fever under the same title. Erichsen separates septic, traumatic, and urethral fevers. Mr. Horsley limits the term traumatic fever to fever following a simple injury and uncomplicated by septic or other possible sources of pyrexia A simple injury would imply one in which there was a solution of continuity of any tissue without exposure to the environment. A classification of fevers following injuries gave: (1) traumatic fever, (2) aseptic fever, (3) septic fever, (4) neurotic fever. The second fever is that which accompanies a wound treated perfectly anti. septically ; Volkmann believes that a pyrogen is developed at the site of an injury, and then absorbed. But it must be remembered that a fracture and an amputation wound differ in this respect, that the latter has chemical substances brought directly in contact with it, and although carbolic acid is said to lower the temperature, yet it must be confessed that its presence adds a new element for consideration. Taking 168 cases of simple fracture, Mr. Horsley finds that about 92 per cent. were marked by febrile reaction, Volkmann and another, who only examined eleven cases, found the per centage to be 78 ’5, while Angerer gives the proportion as 70. per cent. ; ten cases only were investigated. Stickler found that twelve out of thirteen had fever, which gives a percentage of 92. Chauffd.ld believes that racial characteristics would explain the differences. Two groups of cases are separable in Mr. Horstey’s cases ; the first group being characterised by rapid rise of temperature and little or no swelling, the second group being attended with swelling and a slow rise of temperature. In the first group attention to a composite chart constructed from sixty cases showed in one variety a rapid rise in an hour to a high point, and the rise attained gradually to a higher level duriog the next twenty hours, thence onwards there was a gradual fall to the normal in about 160 hours, or nearly a week. Another variety of the same kind of pyrexia was observed where the rise in temperature was slower by a few hours, and lasted only about three days and a half. The first or severer variety generally occurred in individuals below the age of thirty. In the second variety the large number of cases were above the age of thirty-five. In the differences between these two types of the first group we may see another instance of the diminished activity of the metabolism of the tissues in more advanced ages. In the type of the second group a rapid rise nearly to 100’ is observed ; then the curve steadily rises for two days, with slight remissions, to 101°. From this point it falls more rapidly until it reaches 99° at about the eightieth hour ; and though this fall to the normal always occurs, yet it is soon followed by a second rise to above 100°, but seldom reaching 101°. This second rise is peculiar, con. stant, and almost invariably occurs at the 112th hour. From this second acme the temperature falls in two or three days to the normal. The total duration of this third type of fever averages seven days and a half, but very frequently it is prolonged to the tenth or twelfth day. The statistics showed that this ty pe occurs most frequently in the young and old, whilst the middle aged escape ; the majority occurred below the age of thirty-live. The presence of greater swelling in these cases indicates, ecuteris paribus, a great amount of damage, and tissues are more likely to be damaged in those individuals whose age approaches either extreme of life. Was there any explanation for the absence of febrile reaction in the 9 per cent ? The average age of those who had no fever
1135 In half the cases there was sufficient swelling attention. The femur and tibia were each fractured three times; the fibula once, and both bones of the leg five times. Of the twelve patients nearly all appeared to have enjoyed good health. In the group of cases which includes the first two types of fever the sharp ends of the fragments of the broken bones irritated the torn branches of And there is more or less exnerve and ruptured muscle. travasated blood, and the idea of more or less absorption of fat from the damaged marrow must be entertained. So that there are three possible exciting causes of a rise of temperature :-(1) Moderate stimulation of an afferent nerve ; (2) absorption of extravasated blood ; (3) so-called fat embolism. Severe stimulation of afferent nerves causes depression of temperature, whereas gentle stimulation causes a rise of temperature in the part supplied by the nerve. The possibility of heat centres in the spinal cord and else,. where, which can be influenced in a reflex manner, was spoken of as affording an explanation. Angerer has shown that the artificial production of a haematoma is followed by marked fever within four hours. Albert and Stricker have observed a rise of 1° C. in a dog as the result of the exposure of a vessel with a view of injecting into it. Absorption and nerve actions may have played parts in these cases. A rapid rise followed by a gradual fall is probably due to anything but the absorption of a pyrogenic substance. Mr. Horsley could adduce nothing to support the theory of fat embolism as a cause of" the fever. In the surgical condition known as "tension" the possibility of a centripetal stimulation causing fever was great. Idiosyncrasy, too, received its best explanation on the neurotic view of the first two types of traumatic fever. The peculiar type of fever of the second group of cases was ascribed to the development and progress of the oedema, or swelling. Angerer injected under the skin of the forearm of Fehleisen sufficient defibrinated ox blood to cause a tumour of the size of an apple ; this gradually disappeared in a few hours, and was succeeded by a secondary swelling of the arm, together with severe constitutional symptoms of fever. The temperature chart of this case was identical with that of Mr. Horsley’s third type, and the pathology of both was pro. bably the same. Tension or absorption might be at work in the production of part of the febrile course. The occurrence of oedema is very comprehensible when the damage to the walls of the bloodvessels, with the thrombosis of some vessels and extravasation of blood from others, is borne in mind. was
forty.
to call for
special
-
LECTURE IV. ON URETHRAL FEVER. .. In the fever known as urethral fever it would appear that more of we have a probable example the influence of the In what Mr. Horsley calls the "fulminervous system. nating" form of urethral fever the rise of temperature occurs immediately upon the operation, and the possibility of a septic influence is regarded as extremely small and improbable. Confirmatory evidence is afforded in the fact that the most rapid and severe form of urethral fever may follow the passage of a blunt instrument without any wounding of the mucous membrane. The fulminating form of urethral fever occurs in 63 per cent. of the cases by catheterism; the mild subacute form is caused by internal urethrotomy in 76 per cent. of the cases. The two forms of urethral fever already mentioned are absolutely distinct from ursemic fever or any kind of fever which may accompany renal disease. In the fulminating form the temperature shoots up to its highest point (above 104°), on the average in four hours and a half. In the next two hours it falls nearly half way back again, and then the normal is gained gradually by the end of twenty hours. The average age of the patient is fortytwo. The symptoms of stricture are almost invariably of recent date, the average duration being eighteen months. Sir Wm. Fergusson had observed that the greatest constitutional disturbance occurred in those cases which had not undergone previous treatment. Mr. Horsley states that 40 per cent. of the fulminating variety had not been treated at all; 40 per cent. had been unauccesstully catheterised, and the remainder had been treated only a short time for urgent retention of urine. In the second variety the pyrexia rises at a rate at least five times as slow as the first form ; the rise is frequently preceded by a fall due to shock. The temperature as indicated by the diagram is seen to fall 1° in three hours, and then to occupy nearly double that time in
the normal, from which point it rises slowly at first, but afterwards more rapidly towards the highest point,
regaining
which is usually reached about the twenty-third hour. The small preliminary rise at about the’eleventh hour is very constant, and is possibly the ordinary evening rise postponed by the influence of the shock due to the operation which was almost invariably performed about 2 P.M. Age would appear to have but little to say in the etiology of this variety ; as a matter of fact the average age was lower than that of the first form-namely, thirty-eight compared with
forty-two.
We should not expect to find that the difference between the two forms is in any way dependent upon age. The age of the stricture, however, probably has a great deal to do with the etiology of the subacute variety which usually follows operation on an old stricture, the average age of the stricture being eight years. The less degree of fever is probably dependent also upon the nature of the operation, which was internal urethrotomy in 76 per cent. of the cases. The characteristic rigor with which we are so familiar after operation on the urethra most commonly occurs just before the acme of the fever is reached, whether we consider the fulminating or subacute variety. The duration of the rigor has been observed to be proportionate with the intensity of the pyrexial disturbance. Sir Joseph Fayrer and others have remarked upon the influence of malaria in the causation of urethral fever. Cases in which no fever followed the operation appear to find their explanation in the long duration of the stricture (nine years and a half on the average), and in the nature of the operation, which was continuous dilatation and internal urethrotomy in about two-thirds of the cases. Cases of external urethrotomy and perineal section, being frequently complicated with other conditions, To sum up, we may say are best left out of consideration. that the most severe urethral pyrexia follows catheterism most commonly, and occurs in persons of middle age suffering from very recently developed strictures ; while the less severe form occurs, as a rule, after internal urethrotomy in strictures of very long standing, and which have been freely treated. Finally, the apyretic state is commoner in still older strictures and after either internal urethrotomy or continuous dilatation with catheters. Dealing next with the pathology, Mr. Horsley draws attention to the anatomical and physiological conditions involved in the question. The existence of centres all along the spinal cord which are concerned with the formation of heat has been rendered most probable from the experimental researches of Naunyn, Quincke, Wood, and Heidenhain, as well as by clinical observations, and the paper by Hale White is mentioned in this regard. Whether the spinal centres are of a thermo-genetic or thermo-inhibitory nature still remains doubtful, though the latter view is most probable. The spinal centres are governed by supreme centres situate in the cortex cerebri. These centres may be influenced by reflex irritation, and Mr. Horsley is of opinion that urethal fever owns a neurotic cause. Septic inoculation or absorption of blood are clearly incompetent to explain the severe fever which follows catheterisation with a blunt instrument where no blood is drawn. This belief is strengthened by the fact that the rise of temperature in the case of absorption does not take place till twenty-four to forty-eight hours have elapsed, whereas the curve of severe urethal fever reaches its height within four hours. More. over, the fulminating form occurs in association with the first treatment of recent strictures, when the nerves about the stricture are, so to speak, in an abnormally excited state. Previous treatment, too, would tend to lessen the force of each succeeding interference, and so anything like a severe stimulation of the nerve fibres would be avoided. The safest and most fever-free operations are continuous and very gradual dilatations and internal urethrotomy. Roser has shown, in opposition to Sédi1lot’s view of septic absorption, that in other simple operations, such as amputation of the penis and lithotomy, typical urethral fever is never seen. Surely this immunity is due to the freedom of the incision and consequent absence of traction upon the nerves in the mucous In internal urethrotomy we have a close membrane. parallel, complicated, however, by the wedge-like action which inflicts a stretching in addition to the incision. Wtth regard to the influence of the administration of ether, and to the fact that Mr. Holt had performed this operation 670 times with but two deaths, the following considerations are urged. Dr. G. Johnson long ago showed that chloroform tended to suppress rigors, and it has been proved that ether,
1136
alcohol, morphia, quinine, and other alkaloids tend to prevent the development of pyrexia and its accompaniments. These facts favour the neurotic theory of fever, as does also the circumstance that no matter what the source of the fever the alkaloids mentioned still exert their controlling force. When Mr. Holt did not use an anaesthetic the occurrence of The large urethral fever was by no means uncommon. size of the stricture and the plan of preparing patients by the use of quinine and opium may account for the absence of fever and for the low mortality of his operations in Mr. Holt’s hands. Malherbe gives it as his opinion that internal " urethrotomy is as " pyrogenous as divull’ion or rupture of the stricture, but Mr. Horsley’s statistics do not support this idea. Having referred to Mr. Marcus Beck’s observations, Mr. Horsley passes on to give certain conclusions at which he arrived as the result of observations on the quantity and quality of the urine in five cases of internal urethrotomy. As a rule the amount of urine excreted is diminished for one week following the operation. In the one case which had no fever, the amount of urine was greatly increased for ten days after the operation. The less degree of hypersemia may posxiby explain this augmentation. The discharge of nitrogen it variable for the first few days after the operation, but it soon becomes normal, and then slightly increases. Urethral fever is a reflex symptom, just as much as renal ** congestion and altered excretion are. In respect of treatment the patient should be prepared by kept in bed, put under the influence of quinine, previously catheterised gradually up to No. 4 E., given one-third of a grain of morphia an hour before the operation, and operated upon under the influence of ether, or, better, chloroform. The operation should be internal urethrotomy. No instrument should be left in, and none should be passed for four days. Diffusible stimulant and external heat should be aided by the employment of chloroform or morphia if a rigor set in.
If No. 7 requires to be dealt with, the points c and I may be selected for a similar purpose, and so on. By thus proceed. ing on a uniform system the sutures are unlikely to drag, andunder proper aftfr-treatment the wound heals with a very trifling cicatrix. When the sutures are passed continuously from one side to the other, a pouch almost invariablv remains at the end, and mars the line of union. A needle-holder3 is serviceable in the introduction of the sutures; and when the skin is tough, as in Syme’s amputation at the ankld-joint, it is an invaluable auxiliary. Curved needles are the most convenient to work with, and to be preferred tothe straightvariety. Chromicised catgut when properly prepared is the most convenientsuture to work with. It is easy of manipulation,. and the pliancy which it possesses permits of a nice degree of relationship being established between the edges of wounds. Under favourable circumstances its presence occasions no uneasiness, and we are never compelled, as in the case of wire, to take down the dressings in order to remove it, because that part of the thread which is in contact with the tissues becomes absorbed. In this way the upper portion is set free, and will at the end of a certain time b& found lying loose on the surface of the skin. Stitches of silver wire are not secured with the same facility as those of gutt
FIG. 1.
being
Remarks ON THE
GENERAL PERFORMANCE AND TREATMENT OF AMPUTATIONS. BY JAS. WHITSON, M.D., F.F.P.S.G., F.R.M.S., ASSISTANT-SURGEON,
GLASGOW ROYAL INFIRMARY.
(Concluded from p. 1082.)
Suturing of the Flaps. all IN operative procedure it is desirable to leave a small scar, and with this end in view the suturing of the flaps ought to be carefully attended to. An accurate but easy apposition of their edges is necessary for successful union, and the first requisite for securing this is abundance of skin.l If too much pressure comes to be exercised on the stitches their division becomes imperative, even at the expense of additional cicatricial tissue, because the proximity of the margins under these circumstances is no longer desirable, and unless promptly freed will result in tensioD.2 It is fortunate for the patient, however, that sutures when unfairly taxed have a tendency to cut their way outwards. Before passing the stitches a pair of stout artery forceps may be placed in the centre as well as at either angle of the flaps (Fig. 1). This manoeuvre greatly facilitates the apposition of the margins, and sutures may then be inserted at the points A, B, and C. Two ought to follow at D and E, the spaces being regularly divided in this way till the whole line is completed. If cellular tissue be allowed to protrude an indelible cicatrix is the result, but this may be almost entirely avoided by Ktretcbiog the edges one upon the other during the process. If, for example, mn ,.ø
nhnnt. tn inonrh atif.rh ’) (T?iN
11
nn
!1IQ1Qt.Qn+’ u,.;l1 0;1’1
1 Should the element of covering happen to be deficient in a stump, button sutures will to some extent relieve the strain on the surrounding
parts. 2
Any tendency towards inflammation will be speedily revealed by the thermometer, and if the temperature is observed to rise much beyond the normal the stump had better be examined. If tension exists it should be relieved at once.
A stands for the centre of the flaps. H and I represent their outer and inner corners, while Band c indicate points respectively equidistant from H and A,
The letter
and from I and A. The order followed in the insertion of the sutures is indicated by the numerals.
while the stiffness and general want of adaptability peculiar to metallic sutures render their ends liable to catch on the dressings and make the extraction painful to the patient. Cteteris paribus, sutures of a definite thickness maintain their hold best; but the stronger the thread of wire which is used the more intractable does it become, and the less equally does it press on the structures within its grasp; faults which cannot be attributed to catgut, inasmuch as its pliancy continues the same in all its sizes, and an equable compression is exercised by it throughout its entire circumference. Prof. 3 The needle-holder manufactured by Leiter of Vienna is an excellent instrument, simple in its construction, and easily worked. Dieffenbach’s needle-holder, as described by Billroth (Surgical Pathology, page 47), is
also to be recommended. 4 A Rood deal of the material which is sold under the name of "chromicised catgut" is defective in one of two ways. If insufficiently chromicised, it yields to the action of the tissues in forty-eight orr seventy-two hours ; and on the other hand, if hardened overmuch it is wanting in pliancy. By Macewen’s method of preparation catgut is allowed to steep from four to seven days in the chromic acid mixture, the length of time during which it is retained there being determined by the degree of resistance it is thought desirable to impart to it. When taken out of this solution the gut should be washed, and if allowed to dry before being inserted into phenol and glycerine (1 to 10) it is apt to
remain somewhat hard.
The "Bromn" Lectures. BY VICTOR
HORSLEY, M.B., B.S., F.R.C.S.,
PROFESSOR-SUPERINTENDENT
LECTURES 1. AND If. THE THYROID GLAND ; ITS RELATION TO THE PATHOLOGY OF MYXtEDEMA AND CRETINISM. THE previous ignorance of the importance of the thyroid gland in the economy was only swept away by the attention aroused by Kocher and the two Reverdins. Mr. Horsley arranged the matter under consideration into five divisions. The first division treated of the anatomy and position of the thyroid gland. The bilobed form of the gland was held together by a capsule of connective tissue, which sent its trabeculse into the substance dividing and supporting the gland tissue; the septa of connective tissue were the paths for the bloodvessels and lymphatics. The lymphatics have been proved by Barber, Boéchat, and Frey to assume the shape of large lacunae at the very margin of the alveoli. The thyroid body imitates in its development a racemose gland, and was probably of a glandular nature. Virchow and Boéchat believe that the acini of the gland intercommunicate. Théophile de Bordeu believed that minute ducts brought about a communication between the thyroid and the trachea, and Ricou postulated the same idea of a duct-like communication between it and the larynx. The structures and relations, together with the histological phenomena attending the development, also supported the view that the thyroid was a gland. The glairy fluid of the acini is said by Kuhne and Eichwald to contain mucin, though Gorup - Besanez saw a difference in its solubility in acetic acid. Baber’s theory, to the effect that the mucinoid contents of the acini were secreted by the epithelium and reabsorbed by the lymphatics, was supported by the foregoing considerations. Simon seems to have been the author of the view formulated Liebermeister and Guyon, which regarded the thyroid body as a regulator of the cerebral circulation. The view has also been held by Simon that the thyroid gland secretes a something necessary for the nutrition of the brain, but the changes in the central nervous system, after thyroidectomy, may be of a secondary nature. Luschka believed that the thyroid might act in a mechanical fashion, staving off the pressure of the contracting cervical muscles from the carotid arteries. The possible influence of the thyroid in hsemapoiesis was also referred to. Most of the foregoing views do not completely harmonise with what is known of the powers of the thyroid. The effects of thyroidectomy were next considered. What happened if the thyroid were completely removed ?1 Kocher showed that man becomes a cretin. Schiff, Wagner, Sanguirico, and Canalis removed the thyroid of dogs, and found that the animals became idiotic and died comatose. Mr. Horsley’s experiments on the monkey showed that a condition, called by Mr. Ord myxoedema, arose when the thyroid was extirpated. The method of operating was next detailed. The post-mortem examination proved the limitation of the lesion to the gland. No ligatures were used. The Perfect antiseptic precautions were carried’out. theory which ascribes the origin of myxoedema to the sympathetic system is inadequate in the light of the evidence afforded by Mr. Horsley’s operations. Schiff’s first set of experiments cannot be quoted, as no pains were taken to prevent septic poisoning. The symptoms following thyroidectomy in the monkey were tremors, (which came on in five days), pallor, leucocytosis, followed by oligaemia, paresis, puffiness about the eyelids, with swelling of the abdomen and increasing mental dulness. The temperature tends to become subnormal towards the end, which is usually ushered in by coma from five to seven weeks after the operation. The symptoms were next notably altered, being swollen, jelly-like, bright shining, examined in detail. The nerve symptoms were the first to and excessively sticky. The increase of the altered connecattract attention. Fibrillar twitchings of the muscles may tive tissue is most marked in the triangles of the neck and be observed in the dog as the first symptoms, and Wagner over the bypochrondria. The same condition is observed in states that the tremors are succeeded by clonic spasm, teta- the tissues of the mediastinum and omentum, as well as nus, and nnally rigidity. In the.monkey a slight fibrillar along the coronary arteries and the auriculo-ventricular groove. Atrophic changes could be seen when the fatty tissue No. 3200.
by
,
OF THE BROWN INSTITUTION.
uext in the feet, and then in the jawe. These tremors merge into a constant tremor, which has resemblance to the ankle clonus. Paroxysms of muscular tremor and even convulsive movements have been observed, aud tracings made, but’t With regard to the tetanus was never een in monkeys. origin of the muscular movements, Schiff had found that they continued after section of the motor nerves, and Mr. Horsley after removing the cortical centres for the upper arm observed that they still remained. Voluntary move. ments diminished the tremors, but the inhalation of ether increased their activity, whilst reflex irritation stopped them altogether. The conclusion is that the movements are energised from the medulla oblongata or spinal cord. The rate of the tremors per second was the same as that in dogs (Lovèn), and is believed by Mr. Horsley to correspond with the tremors of paralysis agitans and allied conditions in Paresis of gradual onset, varying in intensity directly man. with the force of the tremors, and rigidity, always coexist. There is never complete paralysis, but wristdrop and the "paralytic posture"may be seen. Hemiplegia occasionally appeared, and then the tremors on the paralysed side disappeared, except from the jaws. Sensation may be a little blunted, and touch may be delayed when the tremors are in an advanced stage. The superficial reflexes were diminished; the knee-jerk was present, but never the ankle clonus. The centres of the lumbar region and medulla appeared to be unaffected. Slow hebetude ending in varying degrees of imbecility with easy disturbance of temper were the disorders related to the cortex of the brain. There was a steady fall in blood pressure and in the number of red discs for about fourteen days. Leucocytosis accompanied and kept pace with the oligsemia. The " buffy coat" was better marked, owing to the lessened tendency of the blood to coagulate. Mucin is not a normal constituent of blood, but was present after thyroidectomy, in quantities varying with the duration of life. There was an increase in the serum globulin, though other proteids remained normal in amount. The serum albumin was found by Dr. Halliburton not to be separable into three forms. The sudden appearance and disappearance of dyspneea were interpreted by Mr. Horsley to be of bulbar origin, owing to the abaence of other physical signs. The recurrent larnygeal nerves were always found to be healthy, and the larynx was normal in every way. The hypertrophy of the salivary glands was a novel feature, and due to extreme production of mucin, whilst, strange to say, the parotid comes to secrete mucin. The appetite fails immediately after the operation, but soon revives, only however to become ravenous prior to its final failure just before death. Credé, Zesas, and others have observed a connexion between the spleen and the thyroid, and Mr. Horsley has detected an increase in the splenic dulness during life, which was found atter death to be due to general enlargement of the spleen. Distension of the intestines with hypertrophy of the omentum were the chief factors of the abdominal swelling. The small amount of peritoneal fluid contained mucin. The urine was normal in quality, and with the exception of occasional transient glycosuria and a normal quantity of mucin, nothing remains to be said on this score. The genitalia were normal. The marked pallor of the skin, which was apparently of normal humidity, the swelling of the face and eyelids, and the atrophy of the hair were dilated upon. It was curious to observe the atrophy and greyness of the hair about the buttocks, and one was reminded of the bedsores of man. The temperature curves show after operation a slight rise, followed by a fall to the normal. The morning fall and evening rise are exaggerated when the tremors set in. In monkeys Mr. Horsley does not find a high fever when the tremors are on, in this respect differing from what Schiff has described in the dog. The temperature slowly falls after the tremors have reached their height until a subnormal heat of body is registered prior to death, which is ushered in by cold surface and extremities, though shivering was never The constant and small perversions of nutrition give seen. rise to a clinical picture which has its counterpart in the myxoedema of man. At the post-mortem examination of the monkeys the subcutaneous tissues are found to be
1134 death has followed simple injection; and Billroth’s method may be followed by serious inflammation. Before injectiug it would be well to adopt Demme’s plan of waiting to see whether a vein has been wounded or not. Mr. Horsley believes that the sudden death is due to thrombosis, the result of the entrance of iodine and not air into the circulation. The total removal of the thyroid ii condemned, as good results may be obtained by removal of a portion. Mr. Sydney Jones’s operation of excision of the isthmus between silk ligatures has been most successful.
which remained was examined microscopically; these appearances were typically seen in the fat about the auriculoventricular grooves. No changes were seen in the bursa, but congestion of the synovial membranes was present without effusion. The bones and cartilages showed no positive alterartons. An increase was observed in the connective tissue of the mu4el: s. The connective tissue of the whole body may be said to be increased with a, mucoid degeneration of the ground substance and atrophy of fat. The enlargement of the salivary glands has 1>.;en noticed, and chemical analysis showed that the parotid of the monkeys in question contained as much as 1 21 rwr 1000 of mucin. The proportion of mucin in the submaxillary gland was increased from ’01 to 4’6 per 1000. There is swelling of the mucous membrane of the alimentary canal, and much slime in the motions. The brain and spinal cord were pale and sornewhat wasted, and the meshes of the pia mater were distended with fluid. No sign of disease was detected in the musculo-spiral nerve or in the sympathetic system. The other nervous tissues have not yet been completely
examined. The various theories advanced as to the nature of cretinism and goitre were next passed in review. Myxeedema, cachexia strumipriva, and cretinism were outlined from the accounts given respectively by Ord, Kocher, and Hilton Fagge, and the conclusion that all these proThese cesses were of identical nature was arrived at. morbid processes are most probably dependent upon profound changes set up by injury to or ablation (actual Kocher’s view that a or virtual) of the thyroid body. chronic asphyxia led to the cachexia strumipriva as a result of the atrophy and softening of the trachea was not, accepted by Mr. Horsley, on the ground that the trachea and gullet may remain healthy, and that chronic stenosis of the trachea is not followed by "myxoedema."Dr. Hadden’s theory of capiltary spasm does not hold good, because the sympatheties were found to be healthy, and because Schiff’s experiments on irritation of the sympathetic nerves did not give rise to "myxoedema." The increase of connectivetIssue must be regarded as an epiphenomenon of the changes fou.,d in myxoedema. ]Bfr. Horsley next draws up a tabular statement of certain facts which may be found a useful aid in further investi-
gation
:-
1. The
thyroid gland
appears to consist of two distinct
portions : (a) glandular, having the function of excreting mucin (?); (b) highly vascular lymphoid nodules, having a lit-itiatogenous function.
2. Excision of the gland is followed by an increase in the amount of mucin in the tissues, an increase in the activity of the muciparous glands, and the assumption of a muci-
parous function by glands which usually yield no mucin. 3. Excision of the glands is followed by the profound chauges in the blood already indicated. 4. Excision of the gland is followed by nerve symptoms, indicating changes in the lowest motor centres, which cause tremors, with rigidity and paresis, as well as alterations in the higher cortical centres with the production of imbecility, alld ultimately death in the comatose state. Having thus summarised the changes, Mr. Horsley states his belief that myxoedema and its allies are due to the loss of the thyroid body-a virtual, if not an actual, loss. No doubt vai-o-motor or trophic lesions may be the immediate cause of the changes, but even then the functional or actual want of a thyroid body would be the parent cause of the troph’c or vaso-motor disorder. The view that the thyroid gld.ud is an excretory organ received strong support from the experimental facts. The removal of one lobe of the thyroid causes enlargement of the other, and the subsequent removal of the second lobe is followed by myxcedema. May it not therefore be that the thyroid excretes a mucinoid material which is harmful to the organism, and that the loss of this excreting function entails death? The surgical treatment of the thyroid gland was next discussed. The conditions calling for treatment are hypertrophy or adenoma, with or without some amount of cystic degeneration or fibroid overgrowth, cystic disease, malignant newr growths. Removal was the only method for the last conThe partial or total removal of the tumour is said, to have cured one case of exophthalmic goitre, and partial, excision is perhaps the only treatment which holds out at possibility of cure. Simple goitre may be treated by injection or removal. Injection may be simple or combined withl .
dition.
.
laceration
by
a
needle,
as
practised by Billroth.
Suddenl
LECTURE III. TRAUMATIC FEVER. The expression "traumatic fever" has universally been employed to denote the febrile state which usually follows an injury to the body with or without a lesion of the skin or mucous membranes. The term at present embraced fevers of widely different natures, as Lucas Championniere proved by describing puerperal fever, pysemic fever that of septicaemia, and urethral fever under the same title. Erichsen separates septic, traumatic, and urethral fevers. Mr. Horsley limits the term traumatic fever to fever following a simple injury and uncomplicated by septic or other possible sources of pyrexia A simple injury would imply one in which there was a solution of continuity of any tissue without exposure to the environment. A classification of fevers following injuries gave: (1) traumatic fever, (2) aseptic fever, (3) septic fever, (4) neurotic fever. The second fever is that which accompanies a wound treated perfectly anti. septically ; Volkmann believes that a pyrogen is developed at the site of an injury, and then absorbed. But it must be remembered that a fracture and an amputation wound differ in this respect, that the latter has chemical substances brought directly in contact with it, and although carbolic acid is said to lower the temperature, yet it must be confessed that its presence adds a new element for consideration. Taking 168 cases of simple fracture, Mr. Horsley finds that about 92 per cent. were marked by febrile reaction, Volkmann and another, who only examined eleven cases, found the per centage to be 78 ’5, while Angerer gives the proportion as 70. per cent. ; ten cases only were investigated. Stickler found that twelve out of thirteen had fever, which gives a percentage of 92. Chauffd.ld believes that racial characteristics would explain the differences. Two groups of cases are separable in Mr. Horstey’s cases ; the first group being characterised by rapid rise of temperature and little or no swelling, the second group being attended with swelling and a slow rise of temperature. In the first group attention to a composite chart constructed from sixty cases showed in one variety a rapid rise in an hour to a high point, and the rise attained gradually to a higher level duriog the next twenty hours, thence onwards there was a gradual fall to the normal in about 160 hours, or nearly a week. Another variety of the same kind of pyrexia was observed where the rise in temperature was slower by a few hours, and lasted only about three days and a half. The first or severer variety generally occurred in individuals below the age of thirty. In the second variety the large number of cases were above the age of thirty-five. In the differences between these two types of the first group we may see another instance of the diminished activity of the metabolism of the tissues in more advanced ages. In the type of the second group a rapid rise nearly to 100’ is observed ; then the curve steadily rises for two days, with slight remissions, to 101°. From this point it falls more rapidly until it reaches 99° at about the eightieth hour ; and though this fall to the normal always occurs, yet it is soon followed by a second rise to above 100°, but seldom reaching 101°. This second rise is peculiar, con. stant, and almost invariably occurs at the 112th hour. From this second acme the temperature falls in two or three days to the normal. The total duration of this third type of fever averages seven days and a half, but very frequently it is prolonged to the tenth or twelfth day. The statistics showed that this ty pe occurs most frequently in the young and old, whilst the middle aged escape ; the majority occurred below the age of thirty-live. The presence of greater swelling in these cases indicates, ecuteris paribus, a great amount of damage, and tissues are more likely to be damaged in those individuals whose age approaches either extreme of life. Was there any explanation for the absence of febrile reaction in the 9 per cent ? The average age of those who had no fever
1135 In half the cases there was sufficient swelling attention. The femur and tibia were each fractured three times; the fibula once, and both bones of the leg five times. Of the twelve patients nearly all appeared to have enjoyed good health. In the group of cases which includes the first two types of fever the sharp ends of the fragments of the broken bones irritated the torn branches of And there is more or less exnerve and ruptured muscle. travasated blood, and the idea of more or less absorption of fat from the damaged marrow must be entertained. So that there are three possible exciting causes of a rise of temperature :-(1) Moderate stimulation of an afferent nerve ; (2) absorption of extravasated blood ; (3) so-called fat embolism. Severe stimulation of afferent nerves causes depression of temperature, whereas gentle stimulation causes a rise of temperature in the part supplied by the nerve. The possibility of heat centres in the spinal cord and else,. where, which can be influenced in a reflex manner, was spoken of as affording an explanation. Angerer has shown that the artificial production of a haematoma is followed by marked fever within four hours. Albert and Stricker have observed a rise of 1° C. in a dog as the result of the exposure of a vessel with a view of injecting into it. Absorption and nerve actions may have played parts in these cases. A rapid rise followed by a gradual fall is probably due to anything but the absorption of a pyrogenic substance. Mr. Horsley could adduce nothing to support the theory of fat embolism as a cause of" the fever. In the surgical condition known as "tension" the possibility of a centripetal stimulation causing fever was great. Idiosyncrasy, too, received its best explanation on the neurotic view of the first two types of traumatic fever. The peculiar type of fever of the second group of cases was ascribed to the development and progress of the oedema, or swelling. Angerer injected under the skin of the forearm of Fehleisen sufficient defibrinated ox blood to cause a tumour of the size of an apple ; this gradually disappeared in a few hours, and was succeeded by a secondary swelling of the arm, together with severe constitutional symptoms of fever. The temperature chart of this case was identical with that of Mr. Horsley’s third type, and the pathology of both was pro. bably the same. Tension or absorption might be at work in the production of part of the febrile course. The occurrence of oedema is very comprehensible when the damage to the walls of the bloodvessels, with the thrombosis of some vessels and extravasation of blood from others, is borne in mind. was
forty.
to call for
special
-
LECTURE IV. ON URETHRAL FEVER. .. In the fever known as urethral fever it would appear that more of we have a probable example the influence of the In what Mr. Horsley calls the "fulminervous system. nating" form of urethral fever the rise of temperature occurs immediately upon the operation, and the possibility of a septic influence is regarded as extremely small and improbable. Confirmatory evidence is afforded in the fact that the most rapid and severe form of urethral fever may follow the passage of a blunt instrument without any wounding of the mucous membrane. The fulminating form of urethral fever occurs in 63 per cent. of the cases by catheterism; the mild subacute form is caused by internal urethrotomy in 76 per cent. of the cases. The two forms of urethral fever already mentioned are absolutely distinct from ursemic fever or any kind of fever which may accompany renal disease. In the fulminating form the temperature shoots up to its highest point (above 104°), on the average in four hours and a half. In the next two hours it falls nearly half way back again, and then the normal is gained gradually by the end of twenty hours. The average age of the patient is fortytwo. The symptoms of stricture are almost invariably of recent date, the average duration being eighteen months. Sir Wm. Fergusson had observed that the greatest constitutional disturbance occurred in those cases which had not undergone previous treatment. Mr. Horsley states that 40 per cent. of the fulminating variety had not been treated at all; 40 per cent. had been unauccesstully catheterised, and the remainder had been treated only a short time for urgent retention of urine. In the second variety the pyrexia rises at a rate at least five times as slow as the first form ; the rise is frequently preceded by a fall due to shock. The temperature as indicated by the diagram is seen to fall 1° in three hours, and then to occupy nearly double that time in
the normal, from which point it rises slowly at first, but afterwards more rapidly towards the highest point,
regaining
which is usually reached about the twenty-third hour. The small preliminary rise at about the’eleventh hour is very constant, and is possibly the ordinary evening rise postponed by the influence of the shock due to the operation which was almost invariably performed about 2 P.M. Age would appear to have but little to say in the etiology of this variety ; as a matter of fact the average age was lower than that of the first form-namely, thirty-eight compared with
forty-two.
We should not expect to find that the difference between the two forms is in any way dependent upon age. The age of the stricture, however, probably has a great deal to do with the etiology of the subacute variety which usually follows operation on an old stricture, the average age of the stricture being eight years. The less degree of fever is probably dependent also upon the nature of the operation, which was internal urethrotomy in 76 per cent. of the cases. The characteristic rigor with which we are so familiar after operation on the urethra most commonly occurs just before the acme of the fever is reached, whether we consider the fulminating or subacute variety. The duration of the rigor has been observed to be proportionate with the intensity of the pyrexial disturbance. Sir Joseph Fayrer and others have remarked upon the influence of malaria in the causation of urethral fever. Cases in which no fever followed the operation appear to find their explanation in the long duration of the stricture (nine years and a half on the average), and in the nature of the operation, which was continuous dilatation and internal urethrotomy in about two-thirds of the cases. Cases of external urethrotomy and perineal section, being frequently complicated with other conditions, To sum up, we may say are best left out of consideration. that the most severe urethral pyrexia follows catheterism most commonly, and occurs in persons of middle age suffering from very recently developed strictures ; while the less severe form occurs, as a rule, after internal urethrotomy in strictures of very long standing, and which have been freely treated. Finally, the apyretic state is commoner in still older strictures and after either internal urethrotomy or continuous dilatation with catheters. Dealing next with the pathology, Mr. Horsley draws attention to the anatomical and physiological conditions involved in the question. The existence of centres all along the spinal cord which are concerned with the formation of heat has been rendered most probable from the experimental researches of Naunyn, Quincke, Wood, and Heidenhain, as well as by clinical observations, and the paper by Hale White is mentioned in this regard. Whether the spinal centres are of a thermo-genetic or thermo-inhibitory nature still remains doubtful, though the latter view is most probable. The spinal centres are governed by supreme centres situate in the cortex cerebri. These centres may be influenced by reflex irritation, and Mr. Horsley is of opinion that urethal fever owns a neurotic cause. Septic inoculation or absorption of blood are clearly incompetent to explain the severe fever which follows catheterisation with a blunt instrument where no blood is drawn. This belief is strengthened by the fact that the rise of temperature in the case of absorption does not take place till twenty-four to forty-eight hours have elapsed, whereas the curve of severe urethal fever reaches its height within four hours. More. over, the fulminating form occurs in association with the first treatment of recent strictures, when the nerves about the stricture are, so to speak, in an abnormally excited state. Previous treatment, too, would tend to lessen the force of each succeeding interference, and so anything like a severe stimulation of the nerve fibres would be avoided. The safest and most fever-free operations are continuous and very gradual dilatations and internal urethrotomy. Roser has shown, in opposition to Sédi1lot’s view of septic absorption, that in other simple operations, such as amputation of the penis and lithotomy, typical urethral fever is never seen. Surely this immunity is due to the freedom of the incision and consequent absence of traction upon the nerves in the mucous In internal urethrotomy we have a close membrane. parallel, complicated, however, by the wedge-like action which inflicts a stretching in addition to the incision. Wtth regard to the influence of the administration of ether, and to the fact that Mr. Holt had performed this operation 670 times with but two deaths, the following considerations are urged. Dr. G. Johnson long ago showed that chloroform tended to suppress rigors, and it has been proved that ether,
1136
alcohol, morphia, quinine, and other alkaloids tend to prevent the development of pyrexia and its accompaniments. These facts favour the neurotic theory of fever, as does also the circumstance that no matter what the source of the fever the alkaloids mentioned still exert their controlling force. When Mr. Holt did not use an anaesthetic the occurrence of The large urethral fever was by no means uncommon. size of the stricture and the plan of preparing patients by the use of quinine and opium may account for the absence of fever and for the low mortality of his operations in Mr. Holt’s hands. Malherbe gives it as his opinion that internal " urethrotomy is as " pyrogenous as divull’ion or rupture of the stricture, but Mr. Horsley’s statistics do not support this idea. Having referred to Mr. Marcus Beck’s observations, Mr. Horsley passes on to give certain conclusions at which he arrived as the result of observations on the quantity and quality of the urine in five cases of internal urethrotomy. As a rule the amount of urine excreted is diminished for one week following the operation. In the one case which had no fever, the amount of urine was greatly increased for ten days after the operation. The less degree of hypersemia may posxiby explain this augmentation. The discharge of nitrogen it variable for the first few days after the operation, but it soon becomes normal, and then slightly increases. Urethral fever is a reflex symptom, just as much as renal ** congestion and altered excretion are. In respect of treatment the patient should be prepared by kept in bed, put under the influence of quinine, previously catheterised gradually up to No. 4 E., given one-third of a grain of morphia an hour before the operation, and operated upon under the influence of ether, or, better, chloroform. The operation should be internal urethrotomy. No instrument should be left in, and none should be passed for four days. Diffusible stimulant and external heat should be aided by the employment of chloroform or morphia if a rigor set in.
If No. 7 requires to be dealt with, the points c and I may be selected for a similar purpose, and so on. By thus proceed. ing on a uniform system the sutures are unlikely to drag, andunder proper aftfr-treatment the wound heals with a very trifling cicatrix. When the sutures are passed continuously from one side to the other, a pouch almost invariablv remains at the end, and mars the line of union. A needle-holder3 is serviceable in the introduction of the sutures; and when the skin is tough, as in Syme’s amputation at the ankld-joint, it is an invaluable auxiliary. Curved needles are the most convenient to work with, and to be preferred tothe straightvariety. Chromicised catgut when properly prepared is the most convenientsuture to work with. It is easy of manipulation,. and the pliancy which it possesses permits of a nice degree of relationship being established between the edges of wounds. Under favourable circumstances its presence occasions no uneasiness, and we are never compelled, as in the case of wire, to take down the dressings in order to remove it, because that part of the thread which is in contact with the tissues becomes absorbed. In this way the upper portion is set free, and will at the end of a certain time b& found lying loose on the surface of the skin. Stitches of silver wire are not secured with the same facility as those of gutt
FIG. 1.
being
Remarks ON THE
GENERAL PERFORMANCE AND TREATMENT OF AMPUTATIONS. BY JAS. WHITSON, M.D., F.F.P.S.G., F.R.M.S., ASSISTANT-SURGEON,
GLASGOW ROYAL INFIRMARY.
(Concluded from p. 1082.)
Suturing of the Flaps. all IN operative procedure it is desirable to leave a small scar, and with this end in view the suturing of the flaps ought to be carefully attended to. An accurate but easy apposition of their edges is necessary for successful union, and the first requisite for securing this is abundance of skin.l If too much pressure comes to be exercised on the stitches their division becomes imperative, even at the expense of additional cicatricial tissue, because the proximity of the margins under these circumstances is no longer desirable, and unless promptly freed will result in tensioD.2 It is fortunate for the patient, however, that sutures when unfairly taxed have a tendency to cut their way outwards. Before passing the stitches a pair of stout artery forceps may be placed in the centre as well as at either angle of the flaps (Fig. 1). This manoeuvre greatly facilitates the apposition of the margins, and sutures may then be inserted at the points A, B, and C. Two ought to follow at D and E, the spaces being regularly divided in this way till the whole line is completed. If cellular tissue be allowed to protrude an indelible cicatrix is the result, but this may be almost entirely avoided by Ktretcbiog the edges one upon the other during the process. If, for example, mn ,.ø
nhnnt. tn inonrh atif.rh ’) (T?iN
11
nn
!1IQ1Qt.Qn+’ u,.;l1 0;1’1
1 Should the element of covering happen to be deficient in a stump, button sutures will to some extent relieve the strain on the surrounding
parts. 2
Any tendency towards inflammation will be speedily revealed by the thermometer, and if the temperature is observed to rise much beyond the normal the stump had better be examined. If tension exists it should be relieved at once.
A stands for the centre of the flaps. H and I represent their outer and inner corners, while Band c indicate points respectively equidistant from H and A,
The letter
and from I and A. The order followed in the insertion of the sutures is indicated by the numerals.
while the stiffness and general want of adaptability peculiar to metallic sutures render their ends liable to catch on the dressings and make the extraction painful to the patient. Cteteris paribus, sutures of a definite thickness maintain their hold best; but the stronger the thread of wire which is used the more intractable does it become, and the less equally does it press on the structures within its grasp; faults which cannot be attributed to catgut, inasmuch as its pliancy continues the same in all its sizes, and an equable compression is exercised by it throughout its entire circumference. Prof. 3 The needle-holder manufactured by Leiter of Vienna is an excellent instrument, simple in its construction, and easily worked. Dieffenbach’s needle-holder, as described by Billroth (Surgical Pathology, page 47), is
also to be recommended. 4 A Rood deal of the material which is sold under the name of "chromicised catgut" is defective in one of two ways. If insufficiently chromicised, it yields to the action of the tissues in forty-eight orr seventy-two hours ; and on the other hand, if hardened overmuch it is wanting in pliancy. By Macewen’s method of preparation catgut is allowed to steep from four to seven days in the chromic acid mixture, the length of time during which it is retained there being determined by the degree of resistance it is thought desirable to impart to it. When taken out of this solution the gut should be washed, and if allowed to dry before being inserted into phenol and glycerine (1 to 10) it is apt to
remain somewhat hard.