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LIVERPOOL ROYAL INFIRMARY.
1031
LIVERPOOL ROYAL INFIRMARY. TWO CASES WHERE BOTH BREASTS WERE REMOVED FOR CARCINOMA; REMARKS.
(Under the care of Mr. REGINALD HARRISON). CASE I.-Mrs. M’C-, aged fifty-one, was admitted on Oct. 27th, 1881, with the following history :-About twelve months previously patient noticed a slight hardness in the left breast, which was fo’lowed in six weeks by retraction of the nipple. Shortly afterwards a similar hardness commenced in the right breast. The patient was a healthy looking woman, married, with one child. In each breast there was a well-marked scirrhous carcinoma, with retraction of the nipples, but no extension into the axilla. On Nov. 2nd Mr. Harrison removed the right breast, and on Dec. 7tb, when the patient had completely recovered from the first operation, the second breast was removed. On Jan. 5th, 1882, she was able to leave the infirmary, the wounds having - completely healed. In the October following the patient reported herself as being quite well, and without any sign
of a return of the disease. CASE 2.-Mrs. R-,
was admitted in scirrhous carcinoma of the right breast with retraction of the nipple. The hardness had been noticed for eight months previously. She had a very healthy appearance. There were no enlarged axillary glands. On the 25th the breast was removed, and in nine weeks the patient was able to leave the infirmary. She seemed very intolerant to the carbolic applications. In June, 1882, she noticed some hardness in the other breast, but nothing was done, as she thought it was inflammatory and would disappear. In September she returned to the infirmary, when the left breast was found extensively infiltrated with cancer. The axilla was free. On September 13tb, 1882, the breast was removed by Mr. Harrison. She made a good recovery, and was able to leave the infirmary on October 27th. Mr. Harrison remarked that these were the only two instances in his practice where he had removed both breasts for scirrhus. In both cases the patients presented a singularly healthy and robust appearance, in fact, to look at, them before making an examination of the breasts he should have selected them as typical examples of what healthylooking middle-aged women should be. Still, there could be no doubt, either on clinical or histological grounds, that they were seriously infected with cancer. So far as the operations were concerned, no patients could have done better. Antiseptics were employed, and no untoward symptoms were met with. The second patient on each occasion showed an intolerance to carbolic acid, which rendered its abandonment necessary before repair had sufficiently advanced; still, she Cases of this kind were made an excellent recovery. interesting, not only as illustrating what operative surgery is capable of doing in the case of rapidly growing tumours, but as bearing upon the whole subject of infection by
aged fifty-two,
November, 1881, suffering from
malignant growths.
a
_______
Medical Societies. ROYAL MEDICAL &
CHIRURGICAL
rectum.
intestine for multiple stricture with perfect success. In properly selected cases, resection would appear to be indicated in some forms of intussusception when all other means have failed, and when on opening the abdomen, the invagination is found to be irreducible; in gangrene of gut afrer strangulated hernise, in gangrene after some forms of internal strangulation, in non-malignant strictures of the small and large intestine, and in malignant strictures that are yet local. Other things being equal, the mortality after resection would appear to depend more upon faults in the details of the operation than upon any other single cause. There are two procedures: in one an artificial anus is established after resection; in the other, the two ends of the divided gut are united by sutures, and the mass returned into the abdomen. The former method has been the more successful. There are many objections, however, to an artificial anus, especially of the small intestine, and there appears to be no reason why the latter method should not prove the less fatal if the technical defects of the procedure be remedied. The operation of uniting the bowel after rejection presents these difficulties. It is not easy to maintain the two ends of the gut in accurate apposition while the sutures are being introduced. The sutures are apt to be irregular. The gut above the obstruction is usually much dilated, while that below is shrunken, and it has been found almost impossible to unite well these unequal parts. One of the most common causes of death, therefore, after the operation is due to escape of intestinal contents at the suture line. There is no reason, however, why the escape should not be as surely prevented as it is in cases of pyloric resection. "To meet some of the difficulties of the operation I have ventured to introduce the following appliance :-The gut above the part to be resected is secured by a special clamp liued with indiarubber, to avoid undue compression of the bowel. The gut below is secured in like manner, and the obstructed or gangrenous part is excised. The corresponding ends of the two clamps are then united by transverse bar, so that they form with the clamps a rigid square frame. By means of this frame the two divided ends can be very accurately approximated, and can be firmly retained in position while the sutures are being applied. As it is difficult to apply sutures to collapsed gut a sausage-shaped iodiarubher bag about three inches long is used, that can be distended to four or five times its natural size through a small tube inserted in the centre of its long axis. This bag is sufficiently distended to make it firm, and one end Ì’3 introduced into the upper segment of the divided gut, while the other is introduced into the lower segment. The tube through which the bag is dilated thus occupies the suture line. After being introduced the bag is dilated to a good size. By this means a firm plug is introduced into the gut so as to form a substantial basis over which to apply the sutures. Moreover, by increasing the degree of distension of the bag, all inequalities in calibre between the two segments of the bowel can be overcome. Before the last sutures are applied the hag is emptied of air and is withdrawn, it being capable in its shrunken state of being drawn through a hole of the dimensions of a No. 12 catheter. If the sutures are properly applied-i.e., if the mucus membrane be not included in the stitch-there should be no danger of wounding the bag. At least fifteen or twenty sutures should be used. By means of this appliance it is possible to excise portions of the colon through an incision in the middle line." In cases of stricture of the colon it is often impossible to diagnose the exact seat of the obstruction, and under such cireunntinces the abdomen has been several times opened in the middle line, and, the obstruction having been found, a second operation hs been performed in one or other loin. Resection of the gut from the loin presents many difficulties, and can scarcely be performed without establishing an artificial anus. If colectomy were always performed through the middle line it would, in cases of doubtful diagnosis at least, render one operation only necessary. The greatest fatality has been found in those cases of resection of the colon where the abdomen was first opened in the middle line, and the gut subsequently removed from the loin through another incision. The author lately resected some two inches of gut from the middle of the descending colon for epitheliomatoas stricture through an incision in the middle line. The divided ends of the bowel were united by means of the appliance described, and the gut returned into the abdomen. The man had had symptoms of obstruction for some months, and was in
SOCIETY.
Resection of Portions of Intestine. THE ordinary meeting of this Society was held on the 12th inst., Professor Marshall, F. R. S., President, in the chair. The paper of the evening, by Mr. Treves, of the London Hospital, was a careful and clear exposition of the subject of resection of the intestine, and its reading was followed by a debate that was prolonged beyond the usual hour of adjournment. Several pathological preparations ia illustration of the subject were exhibited from St. Thomas’s Hospital and University College, and a large collection of the instruments employed in abdominal operations were also shown by Mr. Lund and Mr. Meredith. The following is an abstract of the paper on Resection of Portions of Intestine, hy Mr. FREDERICK TREVES, F. R. C. S. Portions of gut have been excised for various diseased conditions from all parts of the tube, from the pylorus to the
Among the illustrative cases given of the various is Koeberle’s, who excised two metres of the small
operations
LIVERPOOL ROYAL INFIRMARY. TWO CASES WHERE BOTH BREASTS WERE REMOVED FOR CARCINOMA; REMARKS.
(Under the care of Mr. REGINALD HARRISON). CASE I.-Mrs. M’C-, aged fifty-one, was admitted on Oct. 27th, 1881, with the following history :-About twelve months previously patient noticed a slight hardness in the left breast, which was fo’lowed in six weeks by retraction of the nipple. Shortly afterwards a similar hardness commenced in the right breast. The patient was a healthy looking woman, married, with one child. In each breast there was a well-marked scirrhous carcinoma, with retraction of the nipples, but no extension into the axilla. On Nov. 2nd Mr. Harrison removed the right breast, and on Dec. 7tb, when the patient had completely recovered from the first operation, the second breast was removed. On Jan. 5th, 1882, she was able to leave the infirmary, the wounds having - completely healed. In the October following the patient reported herself as being quite well, and without any sign
of a return of the disease. CASE 2.-Mrs. R-,
was admitted in scirrhous carcinoma of the right breast with retraction of the nipple. The hardness had been noticed for eight months previously. She had a very healthy appearance. There were no enlarged axillary glands. On the 25th the breast was removed, and in nine weeks the patient was able to leave the infirmary. She seemed very intolerant to the carbolic applications. In June, 1882, she noticed some hardness in the other breast, but nothing was done, as she thought it was inflammatory and would disappear. In September she returned to the infirmary, when the left breast was found extensively infiltrated with cancer. The axilla was free. On September 13tb, 1882, the breast was removed by Mr. Harrison. She made a good recovery, and was able to leave the infirmary on October 27th. Mr. Harrison remarked that these were the only two instances in his practice where he had removed both breasts for scirrhus. In both cases the patients presented a singularly healthy and robust appearance, in fact, to look at, them before making an examination of the breasts he should have selected them as typical examples of what healthylooking middle-aged women should be. Still, there could be no doubt, either on clinical or histological grounds, that they were seriously infected with cancer. So far as the operations were concerned, no patients could have done better. Antiseptics were employed, and no untoward symptoms were met with. The second patient on each occasion showed an intolerance to carbolic acid, which rendered its abandonment necessary before repair had sufficiently advanced; still, she Cases of this kind were made an excellent recovery. interesting, not only as illustrating what operative surgery is capable of doing in the case of rapidly growing tumours, but as bearing upon the whole subject of infection by
aged fifty-two,
November, 1881, suffering from
malignant growths.
a
_______
Medical Societies. ROYAL MEDICAL &
CHIRURGICAL
rectum.
intestine for multiple stricture with perfect success. In properly selected cases, resection would appear to be indicated in some forms of intussusception when all other means have failed, and when on opening the abdomen, the invagination is found to be irreducible; in gangrene of gut afrer strangulated hernise, in gangrene after some forms of internal strangulation, in non-malignant strictures of the small and large intestine, and in malignant strictures that are yet local. Other things being equal, the mortality after resection would appear to depend more upon faults in the details of the operation than upon any other single cause. There are two procedures: in one an artificial anus is established after resection; in the other, the two ends of the divided gut are united by sutures, and the mass returned into the abdomen. The former method has been the more successful. There are many objections, however, to an artificial anus, especially of the small intestine, and there appears to be no reason why the latter method should not prove the less fatal if the technical defects of the procedure be remedied. The operation of uniting the bowel after rejection presents these difficulties. It is not easy to maintain the two ends of the gut in accurate apposition while the sutures are being introduced. The sutures are apt to be irregular. The gut above the obstruction is usually much dilated, while that below is shrunken, and it has been found almost impossible to unite well these unequal parts. One of the most common causes of death, therefore, after the operation is due to escape of intestinal contents at the suture line. There is no reason, however, why the escape should not be as surely prevented as it is in cases of pyloric resection. "To meet some of the difficulties of the operation I have ventured to introduce the following appliance :-The gut above the part to be resected is secured by a special clamp liued with indiarubber, to avoid undue compression of the bowel. The gut below is secured in like manner, and the obstructed or gangrenous part is excised. The corresponding ends of the two clamps are then united by transverse bar, so that they form with the clamps a rigid square frame. By means of this frame the two divided ends can be very accurately approximated, and can be firmly retained in position while the sutures are being applied. As it is difficult to apply sutures to collapsed gut a sausage-shaped iodiarubher bag about three inches long is used, that can be distended to four or five times its natural size through a small tube inserted in the centre of its long axis. This bag is sufficiently distended to make it firm, and one end Ì’3 introduced into the upper segment of the divided gut, while the other is introduced into the lower segment. The tube through which the bag is dilated thus occupies the suture line. After being introduced the bag is dilated to a good size. By this means a firm plug is introduced into the gut so as to form a substantial basis over which to apply the sutures. Moreover, by increasing the degree of distension of the bag, all inequalities in calibre between the two segments of the bowel can be overcome. Before the last sutures are applied the hag is emptied of air and is withdrawn, it being capable in its shrunken state of being drawn through a hole of the dimensions of a No. 12 catheter. If the sutures are properly applied-i.e., if the mucus membrane be not included in the stitch-there should be no danger of wounding the bag. At least fifteen or twenty sutures should be used. By means of this appliance it is possible to excise portions of the colon through an incision in the middle line." In cases of stricture of the colon it is often impossible to diagnose the exact seat of the obstruction, and under such cireunntinces the abdomen has been several times opened in the middle line, and, the obstruction having been found, a second operation hs been performed in one or other loin. Resection of the gut from the loin presents many difficulties, and can scarcely be performed without establishing an artificial anus. If colectomy were always performed through the middle line it would, in cases of doubtful diagnosis at least, render one operation only necessary. The greatest fatality has been found in those cases of resection of the colon where the abdomen was first opened in the middle line, and the gut subsequently removed from the loin through another incision. The author lately resected some two inches of gut from the middle of the descending colon for epitheliomatoas stricture through an incision in the middle line. The divided ends of the bowel were united by means of the appliance described, and the gut returned into the abdomen. The man had had symptoms of obstruction for some months, and was in
SOCIETY.
Resection of Portions of Intestine. THE ordinary meeting of this Society was held on the 12th inst., Professor Marshall, F. R. S., President, in the chair. The paper of the evening, by Mr. Treves, of the London Hospital, was a careful and clear exposition of the subject of resection of the intestine, and its reading was followed by a debate that was prolonged beyond the usual hour of adjournment. Several pathological preparations ia illustration of the subject were exhibited from St. Thomas’s Hospital and University College, and a large collection of the instruments employed in abdominal operations were also shown by Mr. Lund and Mr. Meredith. The following is an abstract of the paper on Resection of Portions of Intestine, hy Mr. FREDERICK TREVES, F. R. C. S. Portions of gut have been excised for various diseased conditions from all parts of the tube, from the pylorus to the
Among the illustrative cases given of the various is Koeberle’s, who excised two metres of the small
operations