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DUCT CARCINOMA OF THE BREAST.
HOSPITAL MEDICINE AND SURGERY.
439
y ligature, on failure of compression, was followed by reppearance of pulsation, and the patient was cured only after xcision of the aneurysmal sac. Tne explanation of this return f pulsation-that the collateral circulation had become too the father to continue the treatment should the condition reely established in consequence of the previous compression f the artery-is probably the correct one. Erichsen points recur. The patient was then in a state of coma, but breathing quietly, and the pulse was slow. In this state he remained ut that this return of pulsation may be met with at varying periods in about two-thirds of the cases, and a slight return for eight hours, when he awoke with a start and began ,f pulsation in the sac has been noticed within twentyto ask his father where he was. He did not again fall asleep our hours. There is a second group in which the symptom for five hours, but wanted to play with his toys, dropping off at length into a sound and natural slumber. His subsequentI s found about ten days or a fortnight after the operation ; progress has been very satisfactory. Whether this method ,nd a third in which pulsation reappears in about a month or ix weeks after the ligature of the artery. He considers the of checking convulsions has ever been adopted before, I do not know, as I have been unable to find mention of it in any )rognosis to be usually favourable. Our readers may recollect of the small or large text-books. But it is certainly more L case of recurrent pulsation in which the ligature applied simple, and, in this case, quite as effectual, as the administra- )y Mr. Heath to the superficial femoral in Scarpa’s triangle tion of chloroform or the other methods advised for the iad yielded, and the artery again became pervious. This ;ase was cured by ligation of the femoral in Hunter’s canal purpose. md illustrates another way in which a recurrent pulsation in West Hill-road, Wandsworth, S.W. L sac may be caused. The second case is remarkable for the ippearance of gangrene of the limb more than three weeks 1fter the operation of ligation of the superficial femoral DUCT CARCINOMA OF THE BREAST. artery in Scarpa’s triangle. The usual period for the BY W. S. CRAWFORD, B.A. CANTAB., F.R.C.S. EDIN., supervention of gangrene after ligation in this situaSENIOR ASSISTANT SURGEON, LIVERPOOL CANCER AND SKIN HOSPITAL. tion is from the third to the tenth day. For the notes of the cases we are indebted to Mr. F. V. Bunch, surgical A FAT, unhealthy looking woman fifty years of age came registrar. under my care last month. She recently suffered from CASE l.-A man thirty-three years of age noticed a influenza, and a few years ago was an inmate of an asylum, swelling in the right popliteal space six weeks before admissuffering from a temporary attack of melancholia. She is sion to hospital ; his attention was drawn to it by pulsation married and has had three children, the youngest born when he crossed his legs. He was admitted to University many years since. Four years ago she was thrown from College Hospital on Feb. 10th last with an aneurysm in the Two years right popliteal space, which increased the circumference of a trap and bruised the right breast severely. later she first noticed a small lump about the size of a marble the limb at its most prominent part by five-eighths of an in this breast; it grew slowly until a few weeks since, inch and gave the usual signs of an aneurysm. The man when it increased in size rapidly. It was never painful. On had a loud double aortic murmur, which seemed to be due to examination the right breast was very fat, and at the upper valvular disease, as there was a separate mitral systolic and inner part close to the sternum presented a prominent murmur. There was also a history of acute rheumatism, rounded swelling; the skin was stretched over it, firmly but there were no other signs of aortic aneurysm. He gave a attached, and exhibited large veins ; the nipple was per-I history of lead colic and a doubtful history of syphilis. The fectly free-in fact there were two inches of normal breast urine was normal. He was ordered twenty grains of iodide of tissue between it and the tumour, which was firm in con- potassium twice a day, and on the 15th digital compression of sistence. No enlarged glands could be felt in the root of the common femoral artery was continued for twelve hours. The breast was removed on Hypodermic injections of morphia had to be made at intervals, the neck or in the axilla. July 28th and the axilla cleared out. The tumour was found but the compression did not cause very severe pain. The to be spherical, an inch and a half in diameter, and on aneurysm became a little harder during compression, but on section pinkish in colour, with hemorrhages scattered through- releasing the artery pulsation returned as forcibly as before. out, suggesting a soft sarcoma with extravasation of blood. On the 21st, ether having been administered, Mr. Heath Microscopically it is a well-marked example of the duct ligatured the superficial femoral artery at the apex of cancer ; the spaces are filled with blood and in some of Scarpa’s triangle with silk. Pulsation at once ceased in the them there are distinct villous growths. The epithelium is aneurysm. The limb was encased in a flannel bandage as columnar throughout the greater part of the section ; in high as the lower third of the thigh, leaving the toes out. parts the appearance might lead one to suspect that it was a The knee was slightly flexed over a pillow. No hot-water No pulsation was felt columnar-celled carcinoma from such a situation as the bottles were put into the bed. rectum. It corresponds in every particular with the descrip- in the aneurysm until Feb. 26th, when it returned tion of tumour described by Cornil and Ranvier, but it is slightly. From this date it gradually increased, until on interesting from having been situated at the circumference of March 8th it was nearly as forcible as before the the breast, so far away from the position of the larger ducts. operation, and the circumference of the limb over it was three-quarters of an inch more than on the left side. The Mount-pleasant, Liverpool. wound healed almost entirely by first intention. On March 10th the leg was fully flexed at the knee and secured in this position by a bandage. This was continued, with slight intermissions, until the 18th, when the pulsation was a little less, but the circumference of the limb was not OF reduced. On March 23rd the common femoral artery was compressed digitally for six hours. At the end of this time pulsation in the aneurysm was very faint, but it rapidly increased BRITISH AND FOREIGN. again during the night. On the 29th the aneurysm was compressed with a Signoroni’s tourniquet for one hour without 1Bul1a autem est alia pro certo noseendi via, nisi quamplurimas et mor- I much benefit. On the 31st an Esmarch’s bandage was borum et dissectionum historias, tum aliorum turn proprias collectas to the leg below the aneurysm for one hour without De Sed. et Caus. Morb., applied habere, et inter se compa.ra.re.—MOR&A6NI any effect on the sac. On April 4th, ether having been lib. iv. Procemium. administered, Mr. Horsley (who was in charge of the wards UNIVERSITY COLLEGE HOSPITAL. in Mr. Heath’s absence) made an incision over the aneurysm, ligatured the popliteal artery above and below the sac, TWO CASES OF POPLITEAL ANEURYSM. and removed the aneurysm. The wound healed by first (Under the care of Mr. CHRISTOPHER HEATH.) intention without any complications, and the patient left the IT is the opinion of many surgeons that patients suffering hospital on April 27th. He was again seen early in June ; from popliteal aneurysm are less frequently seen in our large the scars were firm and he was walking about without any discomfort. The aneurysm measured two inches in its long hospitals than was formerly the case. Certainly the number diameter ; it was sacculated, with a large opening into the treated during any one year is comparatively small. The which lay on its anterior surface. There was a layer artery, following two cases recorded by Mr. Heath are exceptionally of firm laminated clot lining its wall. At the thickest part this interesting, for in the first the Hunterian method of treatment clot measured three-quarters of an inch in thickness. The H 2
being lengthened from three or four minutes to twenty minutes, until after waiting for three-quarters of an hour without any return of the convulsions after the sixth compression of the vessels, I left the patient with instructions to
A Mirror
HOSPITAL
PRACTICE,
-
439
y ligature, on failure of compression, was followed by reppearance of pulsation, and the patient was cured only after xcision of the aneurysmal sac. Tne explanation of this return f pulsation-that the collateral circulation had become too the father to continue the treatment should the condition reely established in consequence of the previous compression f the artery-is probably the correct one. Erichsen points recur. The patient was then in a state of coma, but breathing quietly, and the pulse was slow. In this state he remained ut that this return of pulsation may be met with at varying periods in about two-thirds of the cases, and a slight return for eight hours, when he awoke with a start and began ,f pulsation in the sac has been noticed within twentyto ask his father where he was. He did not again fall asleep our hours. There is a second group in which the symptom for five hours, but wanted to play with his toys, dropping off at length into a sound and natural slumber. His subsequentI s found about ten days or a fortnight after the operation ; progress has been very satisfactory. Whether this method ,nd a third in which pulsation reappears in about a month or ix weeks after the ligature of the artery. He considers the of checking convulsions has ever been adopted before, I do not know, as I have been unable to find mention of it in any )rognosis to be usually favourable. Our readers may recollect of the small or large text-books. But it is certainly more L case of recurrent pulsation in which the ligature applied simple, and, in this case, quite as effectual, as the administra- )y Mr. Heath to the superficial femoral in Scarpa’s triangle tion of chloroform or the other methods advised for the iad yielded, and the artery again became pervious. This ;ase was cured by ligation of the femoral in Hunter’s canal purpose. md illustrates another way in which a recurrent pulsation in West Hill-road, Wandsworth, S.W. L sac may be caused. The second case is remarkable for the ippearance of gangrene of the limb more than three weeks 1fter the operation of ligation of the superficial femoral DUCT CARCINOMA OF THE BREAST. artery in Scarpa’s triangle. The usual period for the BY W. S. CRAWFORD, B.A. CANTAB., F.R.C.S. EDIN., supervention of gangrene after ligation in this situaSENIOR ASSISTANT SURGEON, LIVERPOOL CANCER AND SKIN HOSPITAL. tion is from the third to the tenth day. For the notes of the cases we are indebted to Mr. F. V. Bunch, surgical A FAT, unhealthy looking woman fifty years of age came registrar. under my care last month. She recently suffered from CASE l.-A man thirty-three years of age noticed a influenza, and a few years ago was an inmate of an asylum, swelling in the right popliteal space six weeks before admissuffering from a temporary attack of melancholia. She is sion to hospital ; his attention was drawn to it by pulsation married and has had three children, the youngest born when he crossed his legs. He was admitted to University many years since. Four years ago she was thrown from College Hospital on Feb. 10th last with an aneurysm in the Two years right popliteal space, which increased the circumference of a trap and bruised the right breast severely. later she first noticed a small lump about the size of a marble the limb at its most prominent part by five-eighths of an in this breast; it grew slowly until a few weeks since, inch and gave the usual signs of an aneurysm. The man when it increased in size rapidly. It was never painful. On had a loud double aortic murmur, which seemed to be due to examination the right breast was very fat, and at the upper valvular disease, as there was a separate mitral systolic and inner part close to the sternum presented a prominent murmur. There was also a history of acute rheumatism, rounded swelling; the skin was stretched over it, firmly but there were no other signs of aortic aneurysm. He gave a attached, and exhibited large veins ; the nipple was per-I history of lead colic and a doubtful history of syphilis. The fectly free-in fact there were two inches of normal breast urine was normal. He was ordered twenty grains of iodide of tissue between it and the tumour, which was firm in con- potassium twice a day, and on the 15th digital compression of sistence. No enlarged glands could be felt in the root of the common femoral artery was continued for twelve hours. The breast was removed on Hypodermic injections of morphia had to be made at intervals, the neck or in the axilla. July 28th and the axilla cleared out. The tumour was found but the compression did not cause very severe pain. The to be spherical, an inch and a half in diameter, and on aneurysm became a little harder during compression, but on section pinkish in colour, with hemorrhages scattered through- releasing the artery pulsation returned as forcibly as before. out, suggesting a soft sarcoma with extravasation of blood. On the 21st, ether having been administered, Mr. Heath Microscopically it is a well-marked example of the duct ligatured the superficial femoral artery at the apex of cancer ; the spaces are filled with blood and in some of Scarpa’s triangle with silk. Pulsation at once ceased in the them there are distinct villous growths. The epithelium is aneurysm. The limb was encased in a flannel bandage as columnar throughout the greater part of the section ; in high as the lower third of the thigh, leaving the toes out. parts the appearance might lead one to suspect that it was a The knee was slightly flexed over a pillow. No hot-water No pulsation was felt columnar-celled carcinoma from such a situation as the bottles were put into the bed. rectum. It corresponds in every particular with the descrip- in the aneurysm until Feb. 26th, when it returned tion of tumour described by Cornil and Ranvier, but it is slightly. From this date it gradually increased, until on interesting from having been situated at the circumference of March 8th it was nearly as forcible as before the the breast, so far away from the position of the larger ducts. operation, and the circumference of the limb over it was three-quarters of an inch more than on the left side. The Mount-pleasant, Liverpool. wound healed almost entirely by first intention. On March 10th the leg was fully flexed at the knee and secured in this position by a bandage. This was continued, with slight intermissions, until the 18th, when the pulsation was a little less, but the circumference of the limb was not OF reduced. On March 23rd the common femoral artery was compressed digitally for six hours. At the end of this time pulsation in the aneurysm was very faint, but it rapidly increased BRITISH AND FOREIGN. again during the night. On the 29th the aneurysm was compressed with a Signoroni’s tourniquet for one hour without 1Bul1a autem est alia pro certo noseendi via, nisi quamplurimas et mor- I much benefit. On the 31st an Esmarch’s bandage was borum et dissectionum historias, tum aliorum turn proprias collectas to the leg below the aneurysm for one hour without De Sed. et Caus. Morb., applied habere, et inter se compa.ra.re.—MOR&A6NI any effect on the sac. On April 4th, ether having been lib. iv. Procemium. administered, Mr. Horsley (who was in charge of the wards UNIVERSITY COLLEGE HOSPITAL. in Mr. Heath’s absence) made an incision over the aneurysm, ligatured the popliteal artery above and below the sac, TWO CASES OF POPLITEAL ANEURYSM. and removed the aneurysm. The wound healed by first (Under the care of Mr. CHRISTOPHER HEATH.) intention without any complications, and the patient left the IT is the opinion of many surgeons that patients suffering hospital on April 27th. He was again seen early in June ; from popliteal aneurysm are less frequently seen in our large the scars were firm and he was walking about without any discomfort. The aneurysm measured two inches in its long hospitals than was formerly the case. Certainly the number diameter ; it was sacculated, with a large opening into the treated during any one year is comparatively small. The which lay on its anterior surface. There was a layer artery, following two cases recorded by Mr. Heath are exceptionally of firm laminated clot lining its wall. At the thickest part this interesting, for in the first the Hunterian method of treatment clot measured three-quarters of an inch in thickness. The H 2
being lengthened from three or four minutes to twenty minutes, until after waiting for three-quarters of an hour without any return of the convulsions after the sixth compression of the vessels, I left the patient with instructions to
A Mirror
HOSPITAL
PRACTICE,
-