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ROYAL MEDICAL & CHIRURGICAL SOCIETY. TUESDAY, FEBRUARY 8TH, 1859.
CLINICAL
RECORDS.
LIGATURE ON THE SUBCLAVIAN ARTERY. IN lecturing lately on the Subclavian Artery, Mr. Adams, at the London Hospital, made the following observations on the subject of placing a ligature on that vessel ;-" You will perceive in the weekly journals the account of a case of axillary aneurism, in which a ligature was placed around the subclavian artery at St. Thomas’s Hospital. This case appeared to be progressing very satisfactorily for a few days, but I have been informed that the patient has since died of haemorrhage under some violent action of the arm. Now you will find that many cases in which a ligature has been placed around this vessel have terminated fatally from hsemorrbage. We are not much surprised at this, seeing that the impulse of the heart is so great on vessels in such close proximity to this organ as the subclavian ; seeing, also, that the clot which is formed in this vessel after ligature cannot be of much length, owing to the number of branches which spring from this artery so near to the seat of ligature. It has suggested itself to me that in such cases it would be desirable to try the application of the metallic ligature in preference to silk; and the plan I would suggest is this: to place around the subelavian a thin metallic ligature, to draw it moderately tight, and then to cut off the ends, and carefully to bring the parts together, so as to endeavour, by the aid of suitable compresses, to bring about a speedy and complete union of all the structures implicated."
I
IDIOPATHIC ULCERATION OF THE THROAT.
from Dartmouth, sixteen years of age, who has been and for the last three months has suffered from ulceration of the throat, was admitted into Guy’s Hospital, on the 19th of January, under the care of Dr. Wilks. He was in an extremely emaciated condition, and of delicate aspect and constitution. The entire faucial mucous membrane was in a state of ulceration, which originated from no appreciable cause, and has destroyed not only the entire uvula, but also some portion of the pillars of the palate. He has never had syphilis, nor is there any manifestation of disease of the lungs, or other viscera. He works in a paper-mill, and is much exposed to draughts of cold air. This makes the third case of ulcerated throat admitted into Guy’s Hospital within a few months. He is now (Feb. 1st) taking ten-grain doses of chlorate of potass, with ten minims of dilute hydrochloric acid, in an ounce of decoction of cinchona, every six hours; his throat is occasionally touched with the solid nitrate of silver, and he is using a gargle of the chloruret of soda, with evident ad. vantage, as granulations of a healthy character are beginning to spring up. His strength is being supported with four ounces of sherry-wine daily, with beef-tea, &c. There have been isolated cases of this form of sore-throat to be seen at several of our hospitals for some months past, and apparently not depending upon any specific influence. A
LAD
ailing for two years,
EPITHELIOMA OF THE HAND, THE FACE, AND THE LIPS. AT University College Hospital on the 26th January, Mr. PARACENTESIS THORACIS WITH A NEWLYErichsen amputated the left forearm of an elderly man at its INVENTED TROCAR AND CANULA. middle, by the antero-posterior flap operation, for epithelial ON the 3rd February, a man, aged twenty-five years, was cancer of the entire dorsum of the hand. This is the third case admitted, under Dr. Farre’s care, into Luke ward, St. Bartho- of this form of cancer which has occurred in the hospital within, lomew’s Hospital, with extensive effusion into the left pleura, a short period. The first was an instance in which both angles commencing in an attack of pleuritis three weeks before. The of the lip were diseased in a man aged seventy. The second symptoms were very urgent, accompanied with considerable was an enormous ulcerated tumour of the cheek (half the size of dyspnoea; the pulse 120, and the heart displaced towards the ’, a shaddock) in a man of sixty, whose cervical glands were enright side. At nine r.M. paracentesis was performed by Mr. larged, but whose general health, notwithstanding, was good. Coote, who withdrew two pints and a half of thin white pus, a The cause of the disease in each was external injury: the first character of fluid which Dr. Farre suspected to exist before the from smoking a short pipe; the second from a blow on the operation. About the same quantity flowed away through the cheek, received in a scume three years ago, a small tumour bandages and dressings afterwards. This has been followed by forming, which grew and ulcerated; and the third the result of much relief to the patient, who was quiet and easy when last a contused wound thirteen months ago on the hand, which we saw him, on the 5th instant. ulcerated, and assumed the epithelial form of cancer. It is The instrument is the invention of Mr. Thompson, of Wester- denied by some writers that external injury has anything to do ham in Kent, and has been used several times with success in with the appearance of cancer; but Mr. Erichsen thinks it is tapping the abdomen. This was the first occasion of its em- one of the commonest causes in the epithelial form of the disployment on the chest. It consists of a straight trocar and ease, but perhaps not in the true scirrhus and encephaloma. It canula, which are introduced in the usual way ; from the side of would thus seem to be a local disease, and sometimes does not the latter is attached a small gutta-percha tube of some length, return. and when the trocar is partly withdrawn (as far as the opening On the 18th January, Mr. Cock, at Guy’s Hospital, ampuof the tube), it permits the fluid to flow into it, and thus tated the male organ for this disease, an operation which is by escapes without the possibility of air entering the chest. The no means unfrequent, and is generally successful-that is to say,. the patient will be free from a return for several years, proinstrument is a simple and ingenious one. In performing paracentesis, the trocar was entered between vided the glands in the groin are unaffected at the time of rethe sixth and seventh ribs, anterior to the border of the latissi moval. mus dorsi muscle. ’
Medical Societies.
RAPID RECURRENCE OF SCIRRHUS OF THE MAMMA. THE question of greatest interest and importance in the removal of cancerous parts relates to the period of immunity from the disease which the patient may enjoy. This, on the average, would seem to be about two years, but sometimes the disease will recur in a much shorter space of time. At St. Bartholomew’s Hospital on the 5th of February, Mr. Lawrence amputated the left breast of a woman, aged thirty-seven years, for scirrhus, a portion of which had been taken away seven months before. The cicatrix above the nipple was healthy; both, however, were included in an elliptical portion of integument removed with the breast. The disease had implicated some of the axillary glands, which were likewise carefully extirpated. The patient was a stout, apparently healthy, female, with a redundancy of adipose tissue. On the same occasion, the right breast of a corpulent woman, aged fifty, affected with scirrhus for two years, was removed by Mr. Lawrence, together with a portion of the subjacent pectoralis major muscle, which had lost its usual healthy appearance. Beneath this muscle was found a gland of stony hardness, which it was deemed prudent not to leave behind. Both patients are for the present doing well.
186
ROYAL MEDICAL &
CHIRURGICAL SOCIETY.
TUESDAY, FEBRUARY 8TH, 1859. SIR CHAS. LOCOCK, BART., M.D., PRESIDENT, IN FIVE CASES OF OVARIAN
THE
CHAIR.
DISEASE,
IN THREE OF WHICH OVARIOTOMY WAS PERFORMED S1:CCESSq FULLY; WITH REMARKS ON THE MEANS OF DI1SZINISHIBO THE MORTALITY AFTER THIS OPERATION. BY T. SPENCER
WELLS, ESQ.,
SURGEON TO THE SAMARITAN HOSPITAL, AND LECTURER ON SQRGERY IN THE 6EOSYEBOE-rLACE SCHOOL OF MEDICINE.
THE author commenced by stating that these were the only in which he had adopted any operative procedure in order to obtain a radical cure of ovarian disease. In the first case, a large cystic tumour, in a single woman twenty-eight years of age, had been situated behind the mtes. tines. An exploratory incision only was made in Dec. 1857, cases
on account of the situation of the inwho was inoculated with it, or the woman attended in labour The incision did not appear to have had any pre- by the surgeon who made the autopsy. judicial influence, the patient dying four months afterwards The author then made some remarks on the means of dimifrom spontaneous rupture of a cyst into the peritoneal cavity. the mortality after the operation. nishing The interest of the case was chiefly in reference to diagnosis, 1. the selection of proper cases only for operation. By showing that, though rarely, the intestines were occasionally 2. By the determination of the stage of the disease in which observed in front of an ovarian tumour ---a fact previously noticed by Piorry, Walshe, and Ballard. The case was also the the operation is most likely to prove successful. 3. By careful preparations to avoid all unnecessary sources of first in which it was proposed to use the ecraseur for the division of the peduncleproposal since successfully adopted by danger. Dr. Attee, of Philadelphia. 4. By the use of anaesthetics to lessen the risk of shock. , In the second case, a multilocular ovarian cyst, in a single 5. By various precautions in the performance of the operawoman twenty-nine years of age, was removed by ovariotomy and by the author, in February, 1858. The principal cyst had careful after-treatment. 6. By been emptied seven times by tapping, and iodine had been inThere were firm and A number of remarks on matters of practical detail were twice. and extensive adhesions, jected the peduncle had been left within the abdominal cavity. Re- made under each of these heads; and the author, before concovery was perfect, the patient having since done a great deal cluding, replied to the objections of those who consider ovarioof hard work as a general servant; and Dr. West, after ex- tomy to be an operation so dangerous to life that it never ought amining her on the 25th of January, 1859, reported the case as to be performed under any circumstances. He urged that a" complete success." The cyst and contents weighed twenty- lithotomy in the adult and ovariotomy are operations singularly six pounds. analogous. The stone in the one case, the tumour in the other, The third case was that of a multilocular ovarian cyst, which may go on for years without causing death; but, setting aside had been tapped three times, in a married woman thirty-eight rare exceptions, the existence is miserable and the end painful in years of age, and was removed by the author in August, 1858. both. If the stone or tumour be removed, a perfect cure may be There were close adhesions of outgrowths from the principal obtained, or death hastened; and it was proved that the mortality oyst to the liver and gall-bladder; but these were separated, after ovariotomy at all ages, and after lithotomy at ages after fourand the patient made a good recovery, leaving the hospital teen, are about the same. After showing that palliative treatthree weeks after the operation. Mr. Ottaway, of Dover, ment and tapping are of little avail, and that injection of iodine saw the patient on the 2nd of February, 1859, and wrote that can only do good in the rare cases of unilocular cyst (its effects she was perfectly well, " in robust health, muscular, and even then being uncertain, sometimes fatal), the author quoted strong." The cyst and contents weighed thirty-one pounds. an eloquent passage from Dr. West’s Lectures, to prove that in The peduncle was secured by ligature, and fixed outside the most of the cases in which the disease is left to its natural terwound. mination, a life of hopeless suffering is ended by a miserable In the fourth case, a pseudo-colloid ovarian tumour, weighing death. He then concluded by stating that some months ago he twenty-one pounds, was removed, after the evacuation of fifty- stood at one of these death-beds in consultation with one of our seven pounds of ascitic fluid. The patient was a married highest authorities on ovarian disease. This gentleman was woman, thirty-three years of age. The operation was per- half convinced by the arguments urged in favour of an operaformed in November, 1858. The great point of interest in the tion ; but he felt the responsibility deeply, and said, "How dare I advise an operation we both know to be so dangerous ?" case was, that a very large vein had been tied, which had given way during the separation of some adhesions, and no bad The author replied, " How dare you leave this poor woman to symptom had followed, the ligature separating on the ninth die without an effort to save her?" And after observing that day. It had been placed laterally on the vein, in such a man- these are the anxious doubts and grave responsibilities ever reo ner that the current of blood was not stopped. The peduncle curring in the life of practitioners of medicine and surgery, he was secured by a metal clamp, and fastened outside the wound. expressed his earnest hope that, by bringing this subject forThe patient made a good recovery, leaving the hospital four ward for discussion at the Royal Medical and Chirurgical Soweeks after the operation; and when heard of through Mr. ciety, something might be done to solve the doubts and lighten Jardine, of Capel, on the 3rd of" February inst., was " getting the responsibility of those who seek for the " influence of stout, and in very good health." authority in matters of opinion." In the fifth case, a pseudo-colloid ovarian tumour, weighing Mr. BAKER BROWN said that as he had devoted much time ten pounds and a half, was removed on the 21st of January and attention, for nearly thirty years, to the study of ovarian last from a single woman thirty-nine years of age. She went disease, he trusted that he might be allowed to make some obon well for twenty-four hours, and then suddenly passed off into servations on the paper which had just been read. He regretted collapse, and died thirty-two hours after operation. Post- its length, because so little time was left for discussing many mortem examination showed large effusion of acrid serum into points of great practical interest; he should, therefore, be only the peritoneal cavity, and superficial exudation of lymph, but able to notice a few parts of the paper. He thought the The peduncle was secured by a clamp outside the author had not sufficiently appreciated the advantages of the no blood. wound, but the clamp had slipped at one spot during the ope- clamp as suggested by Mr. Hutchinson, as in his opinion ration, and it had been also necessary to apply a ligature. The this was one of the greatest improvements yet made for perfectauthor entered at considerable length into an inquiry as to the ing the operation. He could not understand how any vessels exact cause of death in this patient. She had had two grains in the pedicle could have required tying, if a proper clamp had of morphia, in divided doses, within ten hours after the ope- been carefully applied. He thought the author had not felt the ration, and one grain in the succeeding twelve hours, but it importance of preventing the admission of air within the cavity of the peritoneum during the operation; this should be done was not till four hours after the last dose that any bad symptom appeared which could be attributed to opium. There had by two assistants carefully covering the wound with warm wet been no haemorrhage of consequence; so that peritonitis, or the flannels, so as to prevent both the extrusion of the intestines sudden collapse described by Dr. Simpson as sometimes occur- and the admission of the air. The air in the room should be ring after any operation implicating the uterus and its append- warm, not less than 66° to 70° Fahr.; and the same degree of£ ages, were probably, one or both, the chief causes of death. The temperature should be maintained for some days after the opeauthor thought that the danger of peritonitis would be lessened ration, so as to allow the skin to perspire freely. The author if the peritoneal edges of the wound were brought accurately had made one strong recommendation which he (Mr. Brown) together by passing the pins or sutures through them; for if considered seriously objectionable,-namely, that the cut edges any of the surface of the wound were unclosed internally, the of the peritoneum should be caught by the sutures or pins em. pus secreted would pass into the peritoneal cavity. He thought ployed in bringing the edges of the wound together. Now he also that the danger of collapse would be lessened by avoiding as strongly advised all operators to avoid this recommendation ; traction on the uterus; in cases of short peduncle cutting away for he had found, in experiments upon the lower animals, that a portion of the cyst so as to lengthen the peduncle, or even peritonitis immediately followed the use of metallic sutures leaving the stump within the abdomen, rather than exert much when passed through the peritoneum; and as experience traction on the uterus. He also thought it would be better to proved that no necessity existed for this novel mode of £ give morphia in the liquid than in the solid form, the surgeon bringing the edges together, he (Mr. Brown) trusted that then being less dependent on the accuracy of the druggist; it would be found necessary only to apply sutures through and in cases of peritonitis with serous effusion, he would open the aponeurosis of the muscles, carefully avoiding any porthe wound to permit of the escape of serum; as, if absorbed, it tion of the peritoneum, just as the operator for hare-lip caremight poison the patient as readily as it would the surgeon fully avoided the mucous membrane in applying the pins..
nothing more being done testines.
I’ tion;
187
He had found that deep sutures alone were necessary in this operation, and he recommended that the first suture should be applied close to the pedicle, secured by the clamp, and then at every half inch upwards. By this means the chance of air getting into the peritoneal cavity during the process of healing was prevented-a point of great practical importance, as he
as much danger arose from the irritation of the air within the peritoneum as from the sloughing pedicle, when allowed to remain in the pelvic cavity. He (Mr. Brown) observed that the author had not yet felt the importance of giving the patient opium and wine an hour before the operation, yet this was a point of great value, especially when preceded and followed by the free sucking of ice. He differed from the author in recommending the use of opiate suppositories in preference to the administering of opium through the mouth. He (Mr. Brown) believed that if the pure opium of commerce, made into pills direct from the mass, be used, most patients will be able to take opium who would not otherwise bear it; that suppositories were only required in exceptional cases, and then they were of real use. The author had mentioned one case where a band of adhesion extended from the cyst to the liver; these bands were peculiar, and required great care in dividing. Some years since, he (Mr. Brown) operated on a case in St. Mary’s Hospital, where such a band existed, and after consultation with his colleagues, he cut through this band, which appeared to possess no bloodvessels, and yet this patient died two or three days afterwards, with all the symptoms of internal haemorrhage; and on a post-mortem examination it was found that this band possessed two large blood vessels, and from them the blood had flowed which destroyed the patient. In the very next case which he operated on in private practice, the same kind of band was found, and being torn through, no bleeding followed. This led to the conclusion that all adhesions should be torn through, and never cut. The question of adhesions in this disease was one which had led many to consider their existence as opposed to the completion of the operation. He (Mr. Brown) believed, and he was borne out by the great experience of Dr. Clay, that they offered no objection to the operation; indeed, it was doubtful if the peritoneum had not been so thoroughly altered from its normal character as to be less prone to inflammation on that very account. In the second case described by the author, the adhesions were unusually many and strong, and offered such difficulties that most young operators would have been deterred from attempting to break them down; yet this very case did well. On the contrary, had the operation not been completed, there is little doubt she would have died from suppuration and formation of pus within the abdomen. The author alluded to the assistance which he (Mr. Brown) had given in this very operation, and had spoken of his zealous services. He (Mr. Brown) felt very strongly that the words efficient services would have been more appropriately used. Upon the general question of ovariotomy, Mr. Brown felt that a correct diagnosis was of the first and most vital importance. When the nature and character of the case was carefully made out, then the surgeon could decide on the different modes of treatment to be followed, but not till then. Supposing that extirpation was decided on, then the sooner an operation was performed the greater would be the chances of success: in fact, the history of the operation for hernia well illustrated this part of the subject. Formerly that operation was never performed till the patient was in extreme danger and unable to bear the shock; and if the patient did live for twelve hours, the usual black or aperient dose the next morning so irritated the bowel that death rapidly followed. Whereas now, by earlier operation and the use of opium afterwards, these cases were as successful as they were formerly the contrary. In ovariotomy, a careful after-treatment is of as much importance as a correct diagnosis. Mr. Brown said he thought that the author had, on the whole, brought his experience fairly before the Society ; and he (Mr. Brown) only regretted that the length of the paper precluded more discussion, as the question was one of great interest to the profession and the public. Mr. Brown, in conclusion, believed that where no other treatment of a milder form was advisable, we should then give the patient the chance of recovery, if she herself chose to run the risk. Experience proved that females had borne children after extirpation of one ovary, and continued in good health for many years afterwards. Mr. HUTCHINSON exhibited a clamp and a large trocar, which he had previously shown to the members of the Medical Society of London, and a report of which appeared in THE LANCET. Mr. S. WELLS, in reply, stated that in his paper he had spoken favonrablv of the nse nf Mr- Hntfhinson’s clamn.
believed that
atmospheric
188
OBSTETRICAL SOCIETY OF LONDON. WEDNESDAY, FEB. 2ND, 1859. DR. RIGBY, PRESIDENT, (Concluded from
DR. RIGBY
congratulated
the
IN THE
page
CHAIR.
161.)
Society
on
the circumstance
that, at its first meeting, a paper of so much interest and im. portance had been submitted for their consideration. The views propounded by Dr. Tyler Smith were deserving of the
earnest consideration of all obstetricians. He alluded briefly to the statistics of the Dublin Lying-in Hospital, as showing that the mortality to the mother from craniotomy was much greater than when the forceps was employed. He agreed .with the author of the paper in his opinion that the point insisted on by some authorities, of reaching the ear, in order to ascertain the position of the head, in forceps cases, was absurd. To bore the finger up to the ear before applying the forceps was a barbarous practice. The position could be easily ascertained in other ways. He should not like to see the use of the forceps pushed to the extreme advocated by Osiander, a learned but obstinate man, who used forceps with long handles and extra hooks, to enable more than one person to assist in the efforts to extract the child, and who did not publish the results of his cases. The forceps might be used, however, more extensively than was the case at present in this country. In vaginal contractions, producing impediment to delivery, craniotomy was to be condemned, as the author had very properly remarked. Dr. GRANVILLE would remind the author of the paper that the statistics brought forward by him referred chiefly to the results of public practice, and he did not think craniotomy was an operation which was had recourse to with such fre. quency in private practice. He had not performed craniotomy more than a few times, and these were cases of distortion, in which the difficulty only presented itself at the last moment, and when consequently craniotomy was the only resource. The forceps of Asellini was, in his opinion, the best form of the instrument, and he believed that the comparatively infrequent use of the forceps in this country depended on our not having adopted the best form of that instrument. Dr. l4Iu.YgY said, the paper which was before the Society was altogether so new, and contained material which was of so much importance, that the casual objections, which were all that could be made by him, were not likely to be of much
weight. Agreeing with
much that was brought forward by the author of the paper, he differed from him in several important points. There were, in his opinion, cases in which neither turning nor the use of the forceps could be had recourse to, craniotomy being in fact the only resource. Upon the Dublin Lying-in Hospital statistics, referred to by the author, he would make one remark. In that hospital, cases in which the pelvis was deep, funnel-shaped, and masculine, and in which the head was firmly ossified, were very common, and this gave rise to the apparent frequent necessity for craniotomy. Such cases did not present themselves elsewhere, and he did not think the Dublin professors ever performed such an operation unnecessarily. He agreed with the author that it was not necessary to feel the ear in order to apply the forceps. Dr. WALLER would ask, is turning to be regarded as a substitute for craniotomy ? Is it a fact that the head passes more easily through the pelvis when extracted last ? He could not conceive that the dragging the head through a distorted pelvis would be favourable to the life of the child. He had known cases in which the head had been torn off in so doing. Dr. ROGERS considered that the tendency of the paper would be to increase the use of the forceps to a mischievous extent. Dr. TYLER SMITH, in reply, observed that in the cases of abnormal pelvis, which Dr. Murphy had described as being so frequent in the practice of the Dublin Lying-in Hospital, the proper treatment would be the induction of premature labour, and not craniotomy. The child might thus be saved in the majority of such cases, and the mother delivered from the danger of craniotomy. As regards the observations of Dr. Waller, he had no doubt whatever of the superiority of turning to craniotomy in cases of moderate deformity. He referred to cases which he had treated with fellows of the Society in support of this view. No doubt the alternative methods he had recommended, as sufficient to supersede craniotomy, would require increased care and forethought on the part of accoucheurs, but not more, he believed, than could reasonably be given. He felt that the subject was too large for discussion and settlement at a single meeting of the Society; but the questions raised in the paper would go forth to the profession, and receive their due share of attention.
RECORDS.
LIGATURE ON THE SUBCLAVIAN ARTERY. IN lecturing lately on the Subclavian Artery, Mr. Adams, at the London Hospital, made the following observations on the subject of placing a ligature on that vessel ;-" You will perceive in the weekly journals the account of a case of axillary aneurism, in which a ligature was placed around the subclavian artery at St. Thomas’s Hospital. This case appeared to be progressing very satisfactorily for a few days, but I have been informed that the patient has since died of haemorrhage under some violent action of the arm. Now you will find that many cases in which a ligature has been placed around this vessel have terminated fatally from hsemorrbage. We are not much surprised at this, seeing that the impulse of the heart is so great on vessels in such close proximity to this organ as the subclavian ; seeing, also, that the clot which is formed in this vessel after ligature cannot be of much length, owing to the number of branches which spring from this artery so near to the seat of ligature. It has suggested itself to me that in such cases it would be desirable to try the application of the metallic ligature in preference to silk; and the plan I would suggest is this: to place around the subelavian a thin metallic ligature, to draw it moderately tight, and then to cut off the ends, and carefully to bring the parts together, so as to endeavour, by the aid of suitable compresses, to bring about a speedy and complete union of all the structures implicated."
I
IDIOPATHIC ULCERATION OF THE THROAT.
from Dartmouth, sixteen years of age, who has been and for the last three months has suffered from ulceration of the throat, was admitted into Guy’s Hospital, on the 19th of January, under the care of Dr. Wilks. He was in an extremely emaciated condition, and of delicate aspect and constitution. The entire faucial mucous membrane was in a state of ulceration, which originated from no appreciable cause, and has destroyed not only the entire uvula, but also some portion of the pillars of the palate. He has never had syphilis, nor is there any manifestation of disease of the lungs, or other viscera. He works in a paper-mill, and is much exposed to draughts of cold air. This makes the third case of ulcerated throat admitted into Guy’s Hospital within a few months. He is now (Feb. 1st) taking ten-grain doses of chlorate of potass, with ten minims of dilute hydrochloric acid, in an ounce of decoction of cinchona, every six hours; his throat is occasionally touched with the solid nitrate of silver, and he is using a gargle of the chloruret of soda, with evident ad. vantage, as granulations of a healthy character are beginning to spring up. His strength is being supported with four ounces of sherry-wine daily, with beef-tea, &c. There have been isolated cases of this form of sore-throat to be seen at several of our hospitals for some months past, and apparently not depending upon any specific influence. A
LAD
ailing for two years,
EPITHELIOMA OF THE HAND, THE FACE, AND THE LIPS. AT University College Hospital on the 26th January, Mr. PARACENTESIS THORACIS WITH A NEWLYErichsen amputated the left forearm of an elderly man at its INVENTED TROCAR AND CANULA. middle, by the antero-posterior flap operation, for epithelial ON the 3rd February, a man, aged twenty-five years, was cancer of the entire dorsum of the hand. This is the third case admitted, under Dr. Farre’s care, into Luke ward, St. Bartho- of this form of cancer which has occurred in the hospital within, lomew’s Hospital, with extensive effusion into the left pleura, a short period. The first was an instance in which both angles commencing in an attack of pleuritis three weeks before. The of the lip were diseased in a man aged seventy. The second symptoms were very urgent, accompanied with considerable was an enormous ulcerated tumour of the cheek (half the size of dyspnoea; the pulse 120, and the heart displaced towards the ’, a shaddock) in a man of sixty, whose cervical glands were enright side. At nine r.M. paracentesis was performed by Mr. larged, but whose general health, notwithstanding, was good. Coote, who withdrew two pints and a half of thin white pus, a The cause of the disease in each was external injury: the first character of fluid which Dr. Farre suspected to exist before the from smoking a short pipe; the second from a blow on the operation. About the same quantity flowed away through the cheek, received in a scume three years ago, a small tumour bandages and dressings afterwards. This has been followed by forming, which grew and ulcerated; and the third the result of much relief to the patient, who was quiet and easy when last a contused wound thirteen months ago on the hand, which we saw him, on the 5th instant. ulcerated, and assumed the epithelial form of cancer. It is The instrument is the invention of Mr. Thompson, of Wester- denied by some writers that external injury has anything to do ham in Kent, and has been used several times with success in with the appearance of cancer; but Mr. Erichsen thinks it is tapping the abdomen. This was the first occasion of its em- one of the commonest causes in the epithelial form of the disployment on the chest. It consists of a straight trocar and ease, but perhaps not in the true scirrhus and encephaloma. It canula, which are introduced in the usual way ; from the side of would thus seem to be a local disease, and sometimes does not the latter is attached a small gutta-percha tube of some length, return. and when the trocar is partly withdrawn (as far as the opening On the 18th January, Mr. Cock, at Guy’s Hospital, ampuof the tube), it permits the fluid to flow into it, and thus tated the male organ for this disease, an operation which is by escapes without the possibility of air entering the chest. The no means unfrequent, and is generally successful-that is to say,. the patient will be free from a return for several years, proinstrument is a simple and ingenious one. In performing paracentesis, the trocar was entered between vided the glands in the groin are unaffected at the time of rethe sixth and seventh ribs, anterior to the border of the latissi moval. mus dorsi muscle. ’
Medical Societies.
RAPID RECURRENCE OF SCIRRHUS OF THE MAMMA. THE question of greatest interest and importance in the removal of cancerous parts relates to the period of immunity from the disease which the patient may enjoy. This, on the average, would seem to be about two years, but sometimes the disease will recur in a much shorter space of time. At St. Bartholomew’s Hospital on the 5th of February, Mr. Lawrence amputated the left breast of a woman, aged thirty-seven years, for scirrhus, a portion of which had been taken away seven months before. The cicatrix above the nipple was healthy; both, however, were included in an elliptical portion of integument removed with the breast. The disease had implicated some of the axillary glands, which were likewise carefully extirpated. The patient was a stout, apparently healthy, female, with a redundancy of adipose tissue. On the same occasion, the right breast of a corpulent woman, aged fifty, affected with scirrhus for two years, was removed by Mr. Lawrence, together with a portion of the subjacent pectoralis major muscle, which had lost its usual healthy appearance. Beneath this muscle was found a gland of stony hardness, which it was deemed prudent not to leave behind. Both patients are for the present doing well.
186
ROYAL MEDICAL &
CHIRURGICAL SOCIETY.
TUESDAY, FEBRUARY 8TH, 1859. SIR CHAS. LOCOCK, BART., M.D., PRESIDENT, IN FIVE CASES OF OVARIAN
THE
CHAIR.
DISEASE,
IN THREE OF WHICH OVARIOTOMY WAS PERFORMED S1:CCESSq FULLY; WITH REMARKS ON THE MEANS OF DI1SZINISHIBO THE MORTALITY AFTER THIS OPERATION. BY T. SPENCER
WELLS, ESQ.,
SURGEON TO THE SAMARITAN HOSPITAL, AND LECTURER ON SQRGERY IN THE 6EOSYEBOE-rLACE SCHOOL OF MEDICINE.
THE author commenced by stating that these were the only in which he had adopted any operative procedure in order to obtain a radical cure of ovarian disease. In the first case, a large cystic tumour, in a single woman twenty-eight years of age, had been situated behind the mtes. tines. An exploratory incision only was made in Dec. 1857, cases
on account of the situation of the inwho was inoculated with it, or the woman attended in labour The incision did not appear to have had any pre- by the surgeon who made the autopsy. judicial influence, the patient dying four months afterwards The author then made some remarks on the means of dimifrom spontaneous rupture of a cyst into the peritoneal cavity. the mortality after the operation. nishing The interest of the case was chiefly in reference to diagnosis, 1. the selection of proper cases only for operation. By showing that, though rarely, the intestines were occasionally 2. By the determination of the stage of the disease in which observed in front of an ovarian tumour ---a fact previously noticed by Piorry, Walshe, and Ballard. The case was also the the operation is most likely to prove successful. 3. By careful preparations to avoid all unnecessary sources of first in which it was proposed to use the ecraseur for the division of the peduncleproposal since successfully adopted by danger. Dr. Attee, of Philadelphia. 4. By the use of anaesthetics to lessen the risk of shock. , In the second case, a multilocular ovarian cyst, in a single 5. By various precautions in the performance of the operawoman twenty-nine years of age, was removed by ovariotomy and by the author, in February, 1858. The principal cyst had careful after-treatment. 6. By been emptied seven times by tapping, and iodine had been inThere were firm and A number of remarks on matters of practical detail were twice. and extensive adhesions, jected the peduncle had been left within the abdominal cavity. Re- made under each of these heads; and the author, before concovery was perfect, the patient having since done a great deal cluding, replied to the objections of those who consider ovarioof hard work as a general servant; and Dr. West, after ex- tomy to be an operation so dangerous to life that it never ought amining her on the 25th of January, 1859, reported the case as to be performed under any circumstances. He urged that a" complete success." The cyst and contents weighed twenty- lithotomy in the adult and ovariotomy are operations singularly six pounds. analogous. The stone in the one case, the tumour in the other, The third case was that of a multilocular ovarian cyst, which may go on for years without causing death; but, setting aside had been tapped three times, in a married woman thirty-eight rare exceptions, the existence is miserable and the end painful in years of age, and was removed by the author in August, 1858. both. If the stone or tumour be removed, a perfect cure may be There were close adhesions of outgrowths from the principal obtained, or death hastened; and it was proved that the mortality oyst to the liver and gall-bladder; but these were separated, after ovariotomy at all ages, and after lithotomy at ages after fourand the patient made a good recovery, leaving the hospital teen, are about the same. After showing that palliative treatthree weeks after the operation. Mr. Ottaway, of Dover, ment and tapping are of little avail, and that injection of iodine saw the patient on the 2nd of February, 1859, and wrote that can only do good in the rare cases of unilocular cyst (its effects she was perfectly well, " in robust health, muscular, and even then being uncertain, sometimes fatal), the author quoted strong." The cyst and contents weighed thirty-one pounds. an eloquent passage from Dr. West’s Lectures, to prove that in The peduncle was secured by ligature, and fixed outside the most of the cases in which the disease is left to its natural terwound. mination, a life of hopeless suffering is ended by a miserable In the fourth case, a pseudo-colloid ovarian tumour, weighing death. He then concluded by stating that some months ago he twenty-one pounds, was removed, after the evacuation of fifty- stood at one of these death-beds in consultation with one of our seven pounds of ascitic fluid. The patient was a married highest authorities on ovarian disease. This gentleman was woman, thirty-three years of age. The operation was per- half convinced by the arguments urged in favour of an operaformed in November, 1858. The great point of interest in the tion ; but he felt the responsibility deeply, and said, "How dare I advise an operation we both know to be so dangerous ?" case was, that a very large vein had been tied, which had given way during the separation of some adhesions, and no bad The author replied, " How dare you leave this poor woman to symptom had followed, the ligature separating on the ninth die without an effort to save her?" And after observing that day. It had been placed laterally on the vein, in such a man- these are the anxious doubts and grave responsibilities ever reo ner that the current of blood was not stopped. The peduncle curring in the life of practitioners of medicine and surgery, he was secured by a metal clamp, and fastened outside the wound. expressed his earnest hope that, by bringing this subject forThe patient made a good recovery, leaving the hospital four ward for discussion at the Royal Medical and Chirurgical Soweeks after the operation; and when heard of through Mr. ciety, something might be done to solve the doubts and lighten Jardine, of Capel, on the 3rd of" February inst., was " getting the responsibility of those who seek for the " influence of stout, and in very good health." authority in matters of opinion." In the fifth case, a pseudo-colloid ovarian tumour, weighing Mr. BAKER BROWN said that as he had devoted much time ten pounds and a half, was removed on the 21st of January and attention, for nearly thirty years, to the study of ovarian last from a single woman thirty-nine years of age. She went disease, he trusted that he might be allowed to make some obon well for twenty-four hours, and then suddenly passed off into servations on the paper which had just been read. He regretted collapse, and died thirty-two hours after operation. Post- its length, because so little time was left for discussing many mortem examination showed large effusion of acrid serum into points of great practical interest; he should, therefore, be only the peritoneal cavity, and superficial exudation of lymph, but able to notice a few parts of the paper. He thought the The peduncle was secured by a clamp outside the author had not sufficiently appreciated the advantages of the no blood. wound, but the clamp had slipped at one spot during the ope- clamp as suggested by Mr. Hutchinson, as in his opinion ration, and it had been also necessary to apply a ligature. The this was one of the greatest improvements yet made for perfectauthor entered at considerable length into an inquiry as to the ing the operation. He could not understand how any vessels exact cause of death in this patient. She had had two grains in the pedicle could have required tying, if a proper clamp had of morphia, in divided doses, within ten hours after the ope- been carefully applied. He thought the author had not felt the ration, and one grain in the succeeding twelve hours, but it importance of preventing the admission of air within the cavity of the peritoneum during the operation; this should be done was not till four hours after the last dose that any bad symptom appeared which could be attributed to opium. There had by two assistants carefully covering the wound with warm wet been no haemorrhage of consequence; so that peritonitis, or the flannels, so as to prevent both the extrusion of the intestines sudden collapse described by Dr. Simpson as sometimes occur- and the admission of the air. The air in the room should be ring after any operation implicating the uterus and its append- warm, not less than 66° to 70° Fahr.; and the same degree of£ ages, were probably, one or both, the chief causes of death. The temperature should be maintained for some days after the opeauthor thought that the danger of peritonitis would be lessened ration, so as to allow the skin to perspire freely. The author if the peritoneal edges of the wound were brought accurately had made one strong recommendation which he (Mr. Brown) together by passing the pins or sutures through them; for if considered seriously objectionable,-namely, that the cut edges any of the surface of the wound were unclosed internally, the of the peritoneum should be caught by the sutures or pins em. pus secreted would pass into the peritoneal cavity. He thought ployed in bringing the edges of the wound together. Now he also that the danger of collapse would be lessened by avoiding as strongly advised all operators to avoid this recommendation ; traction on the uterus; in cases of short peduncle cutting away for he had found, in experiments upon the lower animals, that a portion of the cyst so as to lengthen the peduncle, or even peritonitis immediately followed the use of metallic sutures leaving the stump within the abdomen, rather than exert much when passed through the peritoneum; and as experience traction on the uterus. He also thought it would be better to proved that no necessity existed for this novel mode of £ give morphia in the liquid than in the solid form, the surgeon bringing the edges together, he (Mr. Brown) trusted that then being less dependent on the accuracy of the druggist; it would be found necessary only to apply sutures through and in cases of peritonitis with serous effusion, he would open the aponeurosis of the muscles, carefully avoiding any porthe wound to permit of the escape of serum; as, if absorbed, it tion of the peritoneum, just as the operator for hare-lip caremight poison the patient as readily as it would the surgeon fully avoided the mucous membrane in applying the pins..
nothing more being done testines.
I’ tion;
187
He had found that deep sutures alone were necessary in this operation, and he recommended that the first suture should be applied close to the pedicle, secured by the clamp, and then at every half inch upwards. By this means the chance of air getting into the peritoneal cavity during the process of healing was prevented-a point of great practical importance, as he
as much danger arose from the irritation of the air within the peritoneum as from the sloughing pedicle, when allowed to remain in the pelvic cavity. He (Mr. Brown) observed that the author had not yet felt the importance of giving the patient opium and wine an hour before the operation, yet this was a point of great value, especially when preceded and followed by the free sucking of ice. He differed from the author in recommending the use of opiate suppositories in preference to the administering of opium through the mouth. He (Mr. Brown) believed that if the pure opium of commerce, made into pills direct from the mass, be used, most patients will be able to take opium who would not otherwise bear it; that suppositories were only required in exceptional cases, and then they were of real use. The author had mentioned one case where a band of adhesion extended from the cyst to the liver; these bands were peculiar, and required great care in dividing. Some years since, he (Mr. Brown) operated on a case in St. Mary’s Hospital, where such a band existed, and after consultation with his colleagues, he cut through this band, which appeared to possess no bloodvessels, and yet this patient died two or three days afterwards, with all the symptoms of internal haemorrhage; and on a post-mortem examination it was found that this band possessed two large blood vessels, and from them the blood had flowed which destroyed the patient. In the very next case which he operated on in private practice, the same kind of band was found, and being torn through, no bleeding followed. This led to the conclusion that all adhesions should be torn through, and never cut. The question of adhesions in this disease was one which had led many to consider their existence as opposed to the completion of the operation. He (Mr. Brown) believed, and he was borne out by the great experience of Dr. Clay, that they offered no objection to the operation; indeed, it was doubtful if the peritoneum had not been so thoroughly altered from its normal character as to be less prone to inflammation on that very account. In the second case described by the author, the adhesions were unusually many and strong, and offered such difficulties that most young operators would have been deterred from attempting to break them down; yet this very case did well. On the contrary, had the operation not been completed, there is little doubt she would have died from suppuration and formation of pus within the abdomen. The author alluded to the assistance which he (Mr. Brown) had given in this very operation, and had spoken of his zealous services. He (Mr. Brown) felt very strongly that the words efficient services would have been more appropriately used. Upon the general question of ovariotomy, Mr. Brown felt that a correct diagnosis was of the first and most vital importance. When the nature and character of the case was carefully made out, then the surgeon could decide on the different modes of treatment to be followed, but not till then. Supposing that extirpation was decided on, then the sooner an operation was performed the greater would be the chances of success: in fact, the history of the operation for hernia well illustrated this part of the subject. Formerly that operation was never performed till the patient was in extreme danger and unable to bear the shock; and if the patient did live for twelve hours, the usual black or aperient dose the next morning so irritated the bowel that death rapidly followed. Whereas now, by earlier operation and the use of opium afterwards, these cases were as successful as they were formerly the contrary. In ovariotomy, a careful after-treatment is of as much importance as a correct diagnosis. Mr. Brown said he thought that the author had, on the whole, brought his experience fairly before the Society ; and he (Mr. Brown) only regretted that the length of the paper precluded more discussion, as the question was one of great interest to the profession and the public. Mr. Brown, in conclusion, believed that where no other treatment of a milder form was advisable, we should then give the patient the chance of recovery, if she herself chose to run the risk. Experience proved that females had borne children after extirpation of one ovary, and continued in good health for many years afterwards. Mr. HUTCHINSON exhibited a clamp and a large trocar, which he had previously shown to the members of the Medical Society of London, and a report of which appeared in THE LANCET. Mr. S. WELLS, in reply, stated that in his paper he had spoken favonrablv of the nse nf Mr- Hntfhinson’s clamn.
believed that
atmospheric
188
OBSTETRICAL SOCIETY OF LONDON. WEDNESDAY, FEB. 2ND, 1859. DR. RIGBY, PRESIDENT, (Concluded from
DR. RIGBY
congratulated
the
IN THE
page
CHAIR.
161.)
Society
on
the circumstance
that, at its first meeting, a paper of so much interest and im. portance had been submitted for their consideration. The views propounded by Dr. Tyler Smith were deserving of the
earnest consideration of all obstetricians. He alluded briefly to the statistics of the Dublin Lying-in Hospital, as showing that the mortality to the mother from craniotomy was much greater than when the forceps was employed. He agreed .with the author of the paper in his opinion that the point insisted on by some authorities, of reaching the ear, in order to ascertain the position of the head, in forceps cases, was absurd. To bore the finger up to the ear before applying the forceps was a barbarous practice. The position could be easily ascertained in other ways. He should not like to see the use of the forceps pushed to the extreme advocated by Osiander, a learned but obstinate man, who used forceps with long handles and extra hooks, to enable more than one person to assist in the efforts to extract the child, and who did not publish the results of his cases. The forceps might be used, however, more extensively than was the case at present in this country. In vaginal contractions, producing impediment to delivery, craniotomy was to be condemned, as the author had very properly remarked. Dr. GRANVILLE would remind the author of the paper that the statistics brought forward by him referred chiefly to the results of public practice, and he did not think craniotomy was an operation which was had recourse to with such fre. quency in private practice. He had not performed craniotomy more than a few times, and these were cases of distortion, in which the difficulty only presented itself at the last moment, and when consequently craniotomy was the only resource. The forceps of Asellini was, in his opinion, the best form of the instrument, and he believed that the comparatively infrequent use of the forceps in this country depended on our not having adopted the best form of that instrument. Dr. l4Iu.YgY said, the paper which was before the Society was altogether so new, and contained material which was of so much importance, that the casual objections, which were all that could be made by him, were not likely to be of much
weight. Agreeing with
much that was brought forward by the author of the paper, he differed from him in several important points. There were, in his opinion, cases in which neither turning nor the use of the forceps could be had recourse to, craniotomy being in fact the only resource. Upon the Dublin Lying-in Hospital statistics, referred to by the author, he would make one remark. In that hospital, cases in which the pelvis was deep, funnel-shaped, and masculine, and in which the head was firmly ossified, were very common, and this gave rise to the apparent frequent necessity for craniotomy. Such cases did not present themselves elsewhere, and he did not think the Dublin professors ever performed such an operation unnecessarily. He agreed with the author that it was not necessary to feel the ear in order to apply the forceps. Dr. WALLER would ask, is turning to be regarded as a substitute for craniotomy ? Is it a fact that the head passes more easily through the pelvis when extracted last ? He could not conceive that the dragging the head through a distorted pelvis would be favourable to the life of the child. He had known cases in which the head had been torn off in so doing. Dr. ROGERS considered that the tendency of the paper would be to increase the use of the forceps to a mischievous extent. Dr. TYLER SMITH, in reply, observed that in the cases of abnormal pelvis, which Dr. Murphy had described as being so frequent in the practice of the Dublin Lying-in Hospital, the proper treatment would be the induction of premature labour, and not craniotomy. The child might thus be saved in the majority of such cases, and the mother delivered from the danger of craniotomy. As regards the observations of Dr. Waller, he had no doubt whatever of the superiority of turning to craniotomy in cases of moderate deformity. He referred to cases which he had treated with fellows of the Society in support of this view. No doubt the alternative methods he had recommended, as sufficient to supersede craniotomy, would require increased care and forethought on the part of accoucheurs, but not more, he believed, than could reasonably be given. He felt that the subject was too large for discussion and settlement at a single meeting of the Society; but the questions raised in the paper would go forth to the profession, and receive their due share of attention.