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ST. GEORGE'S, ST. THOMAS'S, AND ST. BARTHOLOMEW'S HOSPITALS.
528 under Mr. Ward, July 31,1849. There existed a large naevus on the left side of the vertebral column, opposite the seventh dorsal vertebra. It was about three inches in length and two in breadth, the long diameter being transverse, the short Vertical. It protruded about a third of an inch from the surface, and extended deeply, so that its base could not be isolated by the fingers, apparently going as far as the ribs. It had existed from birth, and had only slightly increased, the further development being, according to the father’s observation, in the direction of its transverse diameter. After the exhibition of a little castor oil for a day or two, the tumour was strangulated by ligature in a similar manner to the first, an incision of the skin completely round the n2evus having been previously made. The slough separated on the fourth day, when the surface of the wound presented a dark, unhealthy-looking appearance. Prior to its separation, the child had had much constitutional disturbance, cough, and difficulty of breathing. These symptoms still continued, though somewhat mitigated in their severity. In three days, the wound presented generally a healthy granulating surface, interrupted, however, by several dark portions of the naevus, which had not been included in the ligatures, but which were hard and dense. These small portions, during the progress of cicatrization, were kept on a corresponding level with the granulations, by being rubbed freely with nitrate of silver. The wound had healed in about seven weeks after the ligature had been applied, no remnant of the originally diseased structure
existing.
London
Hospital Surgern.
ST. GEORGE’S, ST. THOMAS’S, AND ST. BARTHOLOMEW’S HOSPITALS. Consecutive Amputation.-There are many questions- in surgery on which the most eminent men hold diametricallyopposed opinions; among these, the question whether amputation is to be performed or not, after certain serious injuries, is one of no mean importance. There are, of course, contused and lacerated wounds of so frightful an extent, and compound fractures of so destructive and disorganizing a kind, that no doubt can exist for a moment as to the propriety of removing the limb. (Even here, however, authorities differ as to the precise time of the operation-namely, whether the two shocks are to be sustained rapidly, one upon the other; or whether a certain amount of reaction is to be waited for.) But there are injuries where the bones suffer but little, though the soft parts experience a great degree of contusion and laceration; as, for instance, by the wheels of a vehicle passing over a limb; in these cases, the surgeon will have to pause, and take a variety of circumstances into consideration, before he determines upon the course to be adopted. From scores of cases which have turned out unfavourably, either when amputation was performed or the limb preserved, it will at once appear that to lay down very definite rules would be hardly possible; and when we recollect that two such men as< Sir Astley Cooper and Abernethy, who have given very distinct rules on the subject, differed entirely, we can but be strengthened in the opinion that the conduct of the surgeon must in a great degree be guided by a small number of. principles, and the peculiar circumstances of the case. Restricting our remarks to civil surgery, we would say that the tendency of modern times is against operations, and that attempts are now-a-days made to preserve a limb, when the slightest hope of saving it, without too plainly endangering the patient’s life, can reasonably be harboured; and this: tendency certainly contrasts very greatly with the readiness at lopping off, for which certain of our forefathers, were distinguished. We witnessed, at St. George’s Hospital, on the 1st inst., such a praiseworthy attempt made by Mr. Tatum. His patient was a woman, upwards- of sixty, who had been run over by an omnibus, about the beginning of October, the wheels of which passed over the right forearm. The soft parts were dreadfully lacerated, and the radius fractured,though the elbow-joint escaped. Under these circumstances, Mr. Tatum resolved to make the attempt of saving the- limb. Appropriate medicines were administered, and the sloughing process went on pretty satisfactorily for some time. An abscess, however, formed, which ran up the muscles of the
Remarks.-The treatment of nsevus, when large, by ligature, as usually applied, without great strain on neighbouring structures, and puckering of the surrounding skin, is difficult, and in some instances incapable of being carried out. This difficulty, if not entirely obviated, is considerably lessened by general having recourse to the method described by Mr. Luke, the efficacy of which has also been illustrated in his paper, by reference to several cases in which its application was followed by marked success. The following are his details of the method:" Several needles are to be threaded on a very long and strong ligature, and placed upon it so as to be about twelve or fourteen inches apart. The ligature with the needles on it may be wound round a card, and unwound as it is wanted in the progress of the proceedings. The operator introduces the needle nearest the extremity of the ligature, at a point just beyond the limits of the part to be removed, and having passed it through the integuments, to the opposite side, draws the ligature out sufficiently to leave an end for tying when the needle is cut off. The second needle is then introduced in like manner, about half an inch from where the first is introduced, and brought out at a similar distance from where the first was brought out, and the ligature drawn through also toa sufficient extent to leave an end for tying;" and so on for as many as may- arm. be required. "Having concluded the introduction of the She went on tolerably well until three or four days before, needles, they are to be removed by cutting the ligatures near the operation. Although the sloughs had been separating to the eye, by which proceeding a series of loops of ligatures well, a sudden change occurred, the casting off of mortified are formed, each embracing but a small portion of the mass to parts ceased, the discharge became scanty, an alarming be removed." These loops are then tied so as completely to amount of irritative fever set in, and the ease was taking a strangulate the individual portions of the tumours included by very unfavourable turn. This state of things naturally pointed each loop, and the operation is complete. to the only mode of giving relief-viz,, to remove the source In the details of the first case, it will be observed that a of irritation, which seemed to be too much for the aged constismall pedicle of unremoved structure remained, after the sepa- tution of the patient. She was given alteratives and tonics. ration of the slough, notwithstanding that the individual loops for some days, and the amputation of the arm was resolved were tied as tight as possible. This circumstance pointed out upon. The operation was performed with such care that the the necessity of incising the skin bounding the circumference amount of blood lost was very trifling, a consideration of great of the tumour, in the second case, in order to render the action importance to an aged woman who had already been exposed of the ligature more immediate on the diseased structure. to various sources of debility. Mr. Tatum took off the arm This precaution, though in itself a painful proceeding, appears at the junction of the superior with the middle third of the to detract much from the subsequent constitutional disturb- humerus, by making an anterior and posterior flap. Howsoance, brought about otherwise by the progressive ulceration of ever this case may turn out (the woman was rather weak the highly sensitive integument, by the pressure of the liga- on the 6th), it seems to us that the course pursued in this-inture. It will be observed, also, that in the second case, owing stance was the one dictated both by humanity and sound practo the depth of the tumour, it was impossible to isolate it com. tice. And we hold this opinion in spite of a case which some pletely at its base, so as to bring the whole structure within time age occurred in a Dublin hospital. There the surgeon the direct influence of the threads. Notwithstanding this, a tried to save the leg of a fine young man which had suffered) Cure was effected by the process of inflammation set up during a compound fracture from the crushing of a heavy truck. theseparation of the slough, so that in similar cases afavourable The infiltration of the limb was, however, so rapid, and the termination may be anticipated, provided the part not stran-I, system so quickly poisoned by putrid absorption, that the gulated be within certain limits. patient died a very few days after the accident, leaving the surgeon hardly any time to have recourse to amputation. Ms. HENRY JAMBS JOHNSox.-VVe feel much pleasure in Pyoaemia, as the French call it, is just as much to be dreaded stating that this gentleman, who was formerly one of the sur- with, as without operation; and so much may be learned from geons of St. George’s Hospital, and who left London about the present case, that patients whose limbs we try to save two years since for the continent, in consequence of ill health, should, as this woman was, be closely watched, so that the has returned to London, and resumed his practice, with a com- period when amputation may be of use should not be allowed to, pass by, and the patient be lost. pletely renovated constitution.
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529 Mr. Caesar Hawkins removed, on the same day, a fatty - tumour from the back of a female patient, situated very near the crest of the ilium. This surgeon observed that. it was ofi the usual kind, but rather larger than they are commonly found in-those situations. The third operation consisted in the amputation of a breast from a woman between fifty and sixty, and was performed by Mr. Prescott Hewett. This organ was very large, pendulous, and of a globular form. The tumour had been growing slowly for the last eighteen years, but had increased rapidly within the last five or six months. The breast was taken off by the two usual semicircular incisions; but the solution of continuity was so great, that the dressings had to be very carefully applied, to bring the parts into tolerable Of course the symptoms detailed above put approximation. scirrhus out of the question. Mr. Hewett, by making a section of the tumour, pointed out to the pupils that it was of a sero-cystic kind. The principal cyst had acquired great firmness and density, some were still filled with fluid, and the mass was studded with little pendulous cysts, of the size of nuts, which would probably, with time, have gradually creased in dimensions. Mr. Hewett mentioned that this description of tumour has been closely described by Sir B. Brodie, and we cannot do better than transcribe Sir Benjamin’s own words:— "The sero-cystic tumour does not contaminate either the skin or lymphatic glands; it is not complicated with any responding diseases of the viscera; and all the experience which I have had justifies the conclusion, that if care be taken that no portion of the breast be allowed to remain, we need not be apprehensive of its recurrence. It is undoubtedly not malignant, in the proper acceptation of the term. I, It may go on to inflammation or ulceration, (in this case it did ’, not reach that period in eighteen years,) and the ulcer may spread, and slough, and bleed, but it does not contaminate the constitution. Still I am not prepared to say that it may not, under certain circumstances, and in peculiar constitutions, assume a. malignant character, this being no more than may happen to almost any morbid growth." (Lectures Illustrative of Various Subjects in Pathology and Surgery.) The latter remark of this quotation is borne out by a case which Mr. Hewett mentioned in concluding his demonstration. He said that " Mr. Csesar Hawkins had operated upon a similar tumour five or six years ago, and that it has now returned under a malignant
I
fibrous
in-
Mr. Simon, at St. Thomas’s Hospital, on the Here, however, the existing cause was very appa-
operated upon by
3rd inst.
the bursse of both limbs had suffered from habitual The patient was a woman between fifty and sixty. One of the tumours had been growing a twelvemonth, the other somewhat less, and they had attained the size of a hen’s egg. Mr. Simon has had other cases of the same description, where the tumours had attained a much larger size; this surgeon removed two a short time ago from the same region, in a female patient, who had allowed them to attain a pretty large dimension; these were likewise of a fibro-cystic character. Chloroform in Mr. Dixon’s case had avery powerful and lasting effect on the patient, and we had here an opportunity of witnessing how long sensibility can be blunted by this agent. Sutures were applied to the wound full half an hour after the operation, and the patient seemed hardly to feel the usually very painful passage of the needle through the tissues. We were sorry at being prevented from attending a microscopical demonstration of these tumours, which Mr. Simon gave to his
rent,
as
kneeling. -
pupils.
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On Saturday last, November 10, Mr. Stanley brought before the pupils of St. Bartholomew’s Hospital, assembled in the theatre, a patient who had lost the whole of his lower jaw by necrosis. The man, who looked about five or six and twenty, had been six months in the hospital, and traced the affection of the jaw to the effects of the vapours of phosphorus, to which his trade of a lucifer-match maker had exposed him. The whole body of the lower maxilla, with one of the condyles, were exhibited, and presented several necrosed fragments, in which the original shape of the bone could easily be recognised. Mr. Stanley mentioned that the condyle, which was wanting to complete the necrosed jaw, had very probably been .absorbed. The patient’s appearance did not at first sight betoken such considerable osseous loss, and the usual contour of the face was tolerably preserved. This small amount of deformity was accounted for by the eminent surgeon under whose care he had been, by the thickening of the tissues in contact with the jaw, and an abundant fibrinous deposit which Nature had thrown out, in her endeavour to repair the loss of bone which the patient had suffered. New bone, however, is never thrown out in this form of necrosis. Mastication, in this instance, is carried on tolerably well; the food must be reduced into small fragments, which the patient prepares further by pressing them strongly against the roof of the mouth with his tongue. The function of nutrition We mentioned in the week before last a case of cancer of seems to be going on tolerably well with this patient, for he the dorsum of the hand which Mr.’Fergusson removed in the looks in pretty good health. It may, then, be inferred, that theatre of King’s College; we saw, on the 3rd inst., by the this imperfect preparation of the alimentary bolus proves kindness of Mr. Dixon, of St. Thomas’s Hospital, a case which sufficient for the digestive functions. The painful feelings bears some analogy with Mr. Fergusson’s, though it was of excited by the sight of this new victim of our vaunted imolder standing, involved a greater part of the hand, was far provements in various branches of manufacture were greatly gone in the ulcerative stage, and required amputation of the mitigated by the announcement Mr. Stanley subsequently forearm. The case runs as follows:made, regarding the prophylaxis of these dreadful affections. G. Wiz, aged sixty-five, had followed the occupation of a Workmen in lucifer-match manufactories have now a chance sailor until the age of thirty, when he was disabled by an in- of escaping the baneful effects of the evolution of phosphorous jury to the left thumb, requiring the removal of both pha- acid, by placing saucers filled with oil of turpentine about langes. His general health has always been good, and his their workrooms. As oil of turpentine is a solvent of phosappearance is that of a hearty man of fifty-five. He had been phorus, it is expected that it will absorb the vapours which burnt on the back of the left hand when an infant, and about do so much mischief. This precaution is taken at a large ten years ago a pimple appeared in the middle of the cicatrix, lucifer-match manufactory in the neighbourhood of the and soon became an open sore. This spread very slowly, London Hospital, and the very best results are expected from until the beginning of this summer, when it rapidly increased, it. This case, so very interesting and instructive in itself, was and on his admission into the hospital, Oct. 30, it occupied all rendered peculiarly valuable in being brought forward by the back of the hand, from its inner border to the second the distinguished author of the recently published treatise on metacarpal bone, and from near the bend of the wrist to the "Diseases of the Bones;" and we were sorry that the time distal ends of the first phalanges of the middle, ring, and little and place did not allow Mr. Stanley to enter fully into the fingers. The surface of the sore was foul and sloughy, except different questions which such a case will naturally give towards the wrist, where it presented a red, warty appear- rise to; for instance, as to whether the fumes act priance, with raised, everted edges. The secretion was abun- marily on the periosteum, or whether the jaw is secondant, and most foetid. There was no glandular enlargement darily affected, as a consequence of the contamination of at the bend of the elbow or in the armpit. Amputation the system. This question, which is left unsettled in the through the forearm was performed on the 3rd of November work just alluded to, appears of some importance; for if it by Mr. Dixon. We-need not point out how forcibly the two were made tolerably clear that the constitution is affected cases of cancer of the hand, which we have mentioned, point first, the poison might be counteracted by throwing approto the advantages of early operation. priate chemical agents into the blood. Indeed, we should be Mr. Samuel Cooper, in his "First Lines," treating ofthe affec- much inclined, from the analogy offered by the effects of tions of bursae mucosse, says, that he had, in 1839, an oppor- mercury, to think that the vapours act but secondarily on the tunity of removing a tumour formed in the bursa, lying be- jaw, though it would appear that the system must be in a tween the ligamentum patellae and the fascia. It was of the peculiar condition to become affected. The two cases mensize of an orange, and everywhere solid, excepting a small tioned in the last number of THE LANCET, by Mr. Henry central point, at which there were a few cells filled with Taylor, of Nottingham, will prove very valuable to those who synovial fluid. We are not told of the exciting cause of the may investigate this subject in all its bearings; for here we swelling, nor how long the tumour took to attain its size; but have two men, who were employed for a considerable time at it is very probable that the case was pretty similar to one the manufactory before they experienced any ill effects ;
cor-If
form."
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530 the communication of Messrs. Busk and Marshall, and D];ff. Griffiths and Jenner, clearly show that the investigation, from its peculiar nature, was as new to them as it was to Mr. Brittan, Dr. Budd, and myself; and it is but fair that these gentlemen should give proofs of the superior accuracy and completeness of their observations over ours, before they are entitled to implicit belief. Now, the accuracy of my colleagues and myself has been so repeatedly questioned in this Report,. that I feel that it is but due to ourselves to show that the statements contained in the Report are by no means unassailable in this respect. I think I shall be able to prove, in the following analysis of the Report, that it contains some conclu-sions, founded upon incomplete observations, as well as otherswhich are strikingly at variance with one another. The Report commences by detailing the results of several experiments, performed with a view of detecting " annularbodies" in the air. The experiments thus performed were seven in number, and were attended with purely negative results. But when I mention that Mr. Brittan, although he has. met with some failures, has obtained positive results in at least an equal number of cases to the above, and that he has submitted them to some of the first microscopists in London, it will at once be evident that his testimony is of more valuethan any of a purely negative character, whether deduced from,. examinations of condensed atmosphere, or from" cobwebs," and: washed from the broken glass of windows." boast. Had the experimenters succeeded in discovering anything identical with the " annular bodies" in the atmosphere of unON THE USE OF CHLOROFORM. infected places, the Report would have been justified in at the conclusion that these bodies have nothing to arriving CALEB Uckfield. BY RADFORD, ESQ., F.R.C.S., do with cholera. Hitherto, however, nothing of the kind hasTHE case, in your last number, of the death of a man in St. been detected except in infected localities. The same may Thomas’s Hospital, illustrates the great susceptibility there is be said of the seventeen negative experiments which were with some individuals to be influenced by chloroform-in made upon drinking-water. But it must be also recollected,. short, that a dose which in one instance is quite inoperative, that many of these experiments were performed upon water-in another is fatal. some time after the cholera had left the districts from which Shortly after chloroform came into use, I gave ten minims it was taken. The next part of the Report is occupied with observations, boy sprinkling on a handkerchief, and applying over the face of a tall, athletic woman, about thirty; in half a minute she upon the microscopic bodies found in cholera dejections, and was completely under its influence; I opened her mouth and commences as follows : -" We next proceed to show how extracted a molar tooth. The insensibility continuing, she was various are the bodies which have been confounded together opposite a window, and cold water thrown in her face; under the terms annular bodies (Mr. Brittan), cholera cellar placed in a few minutes she revived, but complained of feeling very (Mr. Swayne), and cholera fungi (Dr. Budd)." This remark is illustrated by references to a drawing contained in the Re-faint; a little stimulant soon relieved this. In another case, thirty minims were sufficient to make a port, in which the objects seen by us have been most cruelly man wholly insensible, while I amputated his thigh; and in a misrepresented. In answer to this, it may be replied that a" third instance, twenty minims rendered painless the excision very cursory examination of our respective publications will. of an inch of the median nerve above the wrist; but more than at once show that Mr. Brittan, Dr. Budd, and myself, are iIlf two drachms of the chloroform produced only a very partial the main agreed as to the most usual form of these bodies... effect in a healthy woman who wished to take it for extrac- The varieties of description are not more than would be tion of a tooth. The whole of these persons took the drug likely to occur when each person follows out a different line from the same supply, and in a few days of each other; the of investigation. In proof of this, I may refer to the Report,. and point out " how various are the bodies which have been strength of the chloroform, therefore, would be uniform. Since there seems no means of knowing who will be easily confounded with" the cholera cells viz., the spiral and, affected, and who will require a full dose, the only safe plan is annular tissues from " cabbages, potatoes, and onions, the to begin with a very small one. withered style of wheat-grain and portions of cane in sugarOf the persons I have named, the woman who took but ten (Mr. Marshall), chalk mixture (Dr. Griffiths), and the detached minims was remarkable for her strength and determination; nuclei of epithelium, (" ourselves,") with the smaller bodies;. the man whose limb was removed was fifty-six years of age, and the " rust, smut, and bunt of grain" (Mr. Marshall); "the and was exhausted a good deal by knee-joint disease. The urido segetum or bunt," (Mr. Busk); the " contents of bran other man was seventy years of age, and suffered from neur- cells" and "altered starch grains" (Mr. Busk); and fatty bodies (Mr. Marshall), with the larger bodies. algia, extending from the finger to the axilla. In the Report, the cholera bodies are divided into fourNovember, 1849. classes, the first three of which are found in the evacuations.These are:-1. "Things which enclose a free area, and which OBSERVATIONS ON THE 2. " Globular or oval cells." 3. Bodies are often broken." REPORT OF THE COLLEGE OF PHYSICIANS having apparently the form of discs with thick rounded edges and centres of indistinct structure." The Report then pro-RELATIVE TO THE ORGANIC BODIES DISCOVERED IN THE ceeds to deal with each of these bodies separately. It treats EVACUATIONS OF CHOLERA PATIENTS. of, 1, "the rings," which, "when closely examined, are seen BY J. G. SWAYNE, M.D. Lond. to be of different kinds, some perfectly continuous in theirLECTURER ON MIDWIFERY AT THE BRISTOL MEDICAL SCHOOL. entire circle, others formed by.a curled fibre, some round,some oval, others lozenge-shaped." From this vague descripI IT is but fair and right that the profession, before tion, and the still more vague plate accompanying it, it would the conclusions contained in the recent Report of the College really appear doubtful whether those who drew up this Report of Physicians upon the bodies in cholera discharges, should had actually seen the bodies in question. Mr. Brittan and be perfectly satisfied as to the accuracy of the premises myself have examined specimens from more than sixty eases, from which these conclusions are drawn. The Report, and can distinctly state that we have never seen any of these it should be remembered, does not represent the collec- smaller bodies which were either " formed by a curled fibre" tive wisdom of the College of Physicians, but is based merely or " lozenge-shaped." However this may be, we are told that " these bodies haveupon the observations of three or four individuals whose conclusions are placed in opposition to those of the two or three been traced to their true source" by Mr. Marshall, who finds: persons who first described these peculiar bodies. The ques- that they are formed by the curled fibres of vegetables of diftion, also, is not one which can be settled by authority, nor is ferent kinds, which have been mentioned above. But this it one upon which experience has been brought to bear; for explanation by Mr. Marshall would hardly account for the
whilst in one the upper, and in the other the lower jaw, suffered necrosis. These men were " dippers;" and it is but fair to suppose that the hand would havebeen the first to suffer, had the effect been direct. It must, however, be confessed, that the fact of the upper maxilla being affected, in Case 1, militates against the following passage, which we find at p. 75 of Mr. Stanley’s excellent treatise: " Against the opinion that the phosphoric vapour acts merely as a local excitant, the objection has been urged, that it produces no effect on the periosteum of the bones of the nasal passages through which the vapour is directly inhaled." That these cases should not be classed among ordinary necrosis of bones is sufficiently obvious, the entire absence of the least attempt at the regeneration of bone being the most characteristic differential feature. Nor could this regeneration well take place, as, to use Mr. Stanley’s words, (p. 76,) " there is herea total want of the essential conditions for the reproduction of bone-namely, inflammation in healthy structures, with health in the general system." The grey, pumice-stone-like, newly-formed osseous substance, found by Dr. Heyfelder on the outer surface of the bone which he extracted in similar cases, likewise portionsasofMr. points, Stanley remarks, to an affection distinct from the usual death of bone. We sincerely hope that the etiology of these affections will fix the attention of the many able investigators in surgical science of which this country can _____________
-
adopting
existing.
London
Hospital Surgern.
ST. GEORGE’S, ST. THOMAS’S, AND ST. BARTHOLOMEW’S HOSPITALS. Consecutive Amputation.-There are many questions- in surgery on which the most eminent men hold diametricallyopposed opinions; among these, the question whether amputation is to be performed or not, after certain serious injuries, is one of no mean importance. There are, of course, contused and lacerated wounds of so frightful an extent, and compound fractures of so destructive and disorganizing a kind, that no doubt can exist for a moment as to the propriety of removing the limb. (Even here, however, authorities differ as to the precise time of the operation-namely, whether the two shocks are to be sustained rapidly, one upon the other; or whether a certain amount of reaction is to be waited for.) But there are injuries where the bones suffer but little, though the soft parts experience a great degree of contusion and laceration; as, for instance, by the wheels of a vehicle passing over a limb; in these cases, the surgeon will have to pause, and take a variety of circumstances into consideration, before he determines upon the course to be adopted. From scores of cases which have turned out unfavourably, either when amputation was performed or the limb preserved, it will at once appear that to lay down very definite rules would be hardly possible; and when we recollect that two such men as< Sir Astley Cooper and Abernethy, who have given very distinct rules on the subject, differed entirely, we can but be strengthened in the opinion that the conduct of the surgeon must in a great degree be guided by a small number of. principles, and the peculiar circumstances of the case. Restricting our remarks to civil surgery, we would say that the tendency of modern times is against operations, and that attempts are now-a-days made to preserve a limb, when the slightest hope of saving it, without too plainly endangering the patient’s life, can reasonably be harboured; and this: tendency certainly contrasts very greatly with the readiness at lopping off, for which certain of our forefathers, were distinguished. We witnessed, at St. George’s Hospital, on the 1st inst., such a praiseworthy attempt made by Mr. Tatum. His patient was a woman, upwards- of sixty, who had been run over by an omnibus, about the beginning of October, the wheels of which passed over the right forearm. The soft parts were dreadfully lacerated, and the radius fractured,though the elbow-joint escaped. Under these circumstances, Mr. Tatum resolved to make the attempt of saving the- limb. Appropriate medicines were administered, and the sloughing process went on pretty satisfactorily for some time. An abscess, however, formed, which ran up the muscles of the
Remarks.-The treatment of nsevus, when large, by ligature, as usually applied, without great strain on neighbouring structures, and puckering of the surrounding skin, is difficult, and in some instances incapable of being carried out. This difficulty, if not entirely obviated, is considerably lessened by general having recourse to the method described by Mr. Luke, the efficacy of which has also been illustrated in his paper, by reference to several cases in which its application was followed by marked success. The following are his details of the method:" Several needles are to be threaded on a very long and strong ligature, and placed upon it so as to be about twelve or fourteen inches apart. The ligature with the needles on it may be wound round a card, and unwound as it is wanted in the progress of the proceedings. The operator introduces the needle nearest the extremity of the ligature, at a point just beyond the limits of the part to be removed, and having passed it through the integuments, to the opposite side, draws the ligature out sufficiently to leave an end for tying when the needle is cut off. The second needle is then introduced in like manner, about half an inch from where the first is introduced, and brought out at a similar distance from where the first was brought out, and the ligature drawn through also toa sufficient extent to leave an end for tying;" and so on for as many as may- arm. be required. "Having concluded the introduction of the She went on tolerably well until three or four days before, needles, they are to be removed by cutting the ligatures near the operation. Although the sloughs had been separating to the eye, by which proceeding a series of loops of ligatures well, a sudden change occurred, the casting off of mortified are formed, each embracing but a small portion of the mass to parts ceased, the discharge became scanty, an alarming be removed." These loops are then tied so as completely to amount of irritative fever set in, and the ease was taking a strangulate the individual portions of the tumours included by very unfavourable turn. This state of things naturally pointed each loop, and the operation is complete. to the only mode of giving relief-viz,, to remove the source In the details of the first case, it will be observed that a of irritation, which seemed to be too much for the aged constismall pedicle of unremoved structure remained, after the sepa- tution of the patient. She was given alteratives and tonics. ration of the slough, notwithstanding that the individual loops for some days, and the amputation of the arm was resolved were tied as tight as possible. This circumstance pointed out upon. The operation was performed with such care that the the necessity of incising the skin bounding the circumference amount of blood lost was very trifling, a consideration of great of the tumour, in the second case, in order to render the action importance to an aged woman who had already been exposed of the ligature more immediate on the diseased structure. to various sources of debility. Mr. Tatum took off the arm This precaution, though in itself a painful proceeding, appears at the junction of the superior with the middle third of the to detract much from the subsequent constitutional disturb- humerus, by making an anterior and posterior flap. Howsoance, brought about otherwise by the progressive ulceration of ever this case may turn out (the woman was rather weak the highly sensitive integument, by the pressure of the liga- on the 6th), it seems to us that the course pursued in this-inture. It will be observed, also, that in the second case, owing stance was the one dictated both by humanity and sound practo the depth of the tumour, it was impossible to isolate it com. tice. And we hold this opinion in spite of a case which some pletely at its base, so as to bring the whole structure within time age occurred in a Dublin hospital. There the surgeon the direct influence of the threads. Notwithstanding this, a tried to save the leg of a fine young man which had suffered) Cure was effected by the process of inflammation set up during a compound fracture from the crushing of a heavy truck. theseparation of the slough, so that in similar cases afavourable The infiltration of the limb was, however, so rapid, and the termination may be anticipated, provided the part not stran-I, system so quickly poisoned by putrid absorption, that the gulated be within certain limits. patient died a very few days after the accident, leaving the surgeon hardly any time to have recourse to amputation. Ms. HENRY JAMBS JOHNSox.-VVe feel much pleasure in Pyoaemia, as the French call it, is just as much to be dreaded stating that this gentleman, who was formerly one of the sur- with, as without operation; and so much may be learned from geons of St. George’s Hospital, and who left London about the present case, that patients whose limbs we try to save two years since for the continent, in consequence of ill health, should, as this woman was, be closely watched, so that the has returned to London, and resumed his practice, with a com- period when amputation may be of use should not be allowed to, pass by, and the patient be lost. pletely renovated constitution.
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529 Mr. Caesar Hawkins removed, on the same day, a fatty - tumour from the back of a female patient, situated very near the crest of the ilium. This surgeon observed that. it was ofi the usual kind, but rather larger than they are commonly found in-those situations. The third operation consisted in the amputation of a breast from a woman between fifty and sixty, and was performed by Mr. Prescott Hewett. This organ was very large, pendulous, and of a globular form. The tumour had been growing slowly for the last eighteen years, but had increased rapidly within the last five or six months. The breast was taken off by the two usual semicircular incisions; but the solution of continuity was so great, that the dressings had to be very carefully applied, to bring the parts into tolerable Of course the symptoms detailed above put approximation. scirrhus out of the question. Mr. Hewett, by making a section of the tumour, pointed out to the pupils that it was of a sero-cystic kind. The principal cyst had acquired great firmness and density, some were still filled with fluid, and the mass was studded with little pendulous cysts, of the size of nuts, which would probably, with time, have gradually creased in dimensions. Mr. Hewett mentioned that this description of tumour has been closely described by Sir B. Brodie, and we cannot do better than transcribe Sir Benjamin’s own words:— "The sero-cystic tumour does not contaminate either the skin or lymphatic glands; it is not complicated with any responding diseases of the viscera; and all the experience which I have had justifies the conclusion, that if care be taken that no portion of the breast be allowed to remain, we need not be apprehensive of its recurrence. It is undoubtedly not malignant, in the proper acceptation of the term. I, It may go on to inflammation or ulceration, (in this case it did ’, not reach that period in eighteen years,) and the ulcer may spread, and slough, and bleed, but it does not contaminate the constitution. Still I am not prepared to say that it may not, under certain circumstances, and in peculiar constitutions, assume a. malignant character, this being no more than may happen to almost any morbid growth." (Lectures Illustrative of Various Subjects in Pathology and Surgery.) The latter remark of this quotation is borne out by a case which Mr. Hewett mentioned in concluding his demonstration. He said that " Mr. Csesar Hawkins had operated upon a similar tumour five or six years ago, and that it has now returned under a malignant
I
fibrous
in-
Mr. Simon, at St. Thomas’s Hospital, on the Here, however, the existing cause was very appa-
operated upon by
3rd inst.
the bursse of both limbs had suffered from habitual The patient was a woman between fifty and sixty. One of the tumours had been growing a twelvemonth, the other somewhat less, and they had attained the size of a hen’s egg. Mr. Simon has had other cases of the same description, where the tumours had attained a much larger size; this surgeon removed two a short time ago from the same region, in a female patient, who had allowed them to attain a pretty large dimension; these were likewise of a fibro-cystic character. Chloroform in Mr. Dixon’s case had avery powerful and lasting effect on the patient, and we had here an opportunity of witnessing how long sensibility can be blunted by this agent. Sutures were applied to the wound full half an hour after the operation, and the patient seemed hardly to feel the usually very painful passage of the needle through the tissues. We were sorry at being prevented from attending a microscopical demonstration of these tumours, which Mr. Simon gave to his
rent,
as
kneeling. -
pupils.
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On Saturday last, November 10, Mr. Stanley brought before the pupils of St. Bartholomew’s Hospital, assembled in the theatre, a patient who had lost the whole of his lower jaw by necrosis. The man, who looked about five or six and twenty, had been six months in the hospital, and traced the affection of the jaw to the effects of the vapours of phosphorus, to which his trade of a lucifer-match maker had exposed him. The whole body of the lower maxilla, with one of the condyles, were exhibited, and presented several necrosed fragments, in which the original shape of the bone could easily be recognised. Mr. Stanley mentioned that the condyle, which was wanting to complete the necrosed jaw, had very probably been .absorbed. The patient’s appearance did not at first sight betoken such considerable osseous loss, and the usual contour of the face was tolerably preserved. This small amount of deformity was accounted for by the eminent surgeon under whose care he had been, by the thickening of the tissues in contact with the jaw, and an abundant fibrinous deposit which Nature had thrown out, in her endeavour to repair the loss of bone which the patient had suffered. New bone, however, is never thrown out in this form of necrosis. Mastication, in this instance, is carried on tolerably well; the food must be reduced into small fragments, which the patient prepares further by pressing them strongly against the roof of the mouth with his tongue. The function of nutrition We mentioned in the week before last a case of cancer of seems to be going on tolerably well with this patient, for he the dorsum of the hand which Mr.’Fergusson removed in the looks in pretty good health. It may, then, be inferred, that theatre of King’s College; we saw, on the 3rd inst., by the this imperfect preparation of the alimentary bolus proves kindness of Mr. Dixon, of St. Thomas’s Hospital, a case which sufficient for the digestive functions. The painful feelings bears some analogy with Mr. Fergusson’s, though it was of excited by the sight of this new victim of our vaunted imolder standing, involved a greater part of the hand, was far provements in various branches of manufacture were greatly gone in the ulcerative stage, and required amputation of the mitigated by the announcement Mr. Stanley subsequently forearm. The case runs as follows:made, regarding the prophylaxis of these dreadful affections. G. Wiz, aged sixty-five, had followed the occupation of a Workmen in lucifer-match manufactories have now a chance sailor until the age of thirty, when he was disabled by an in- of escaping the baneful effects of the evolution of phosphorous jury to the left thumb, requiring the removal of both pha- acid, by placing saucers filled with oil of turpentine about langes. His general health has always been good, and his their workrooms. As oil of turpentine is a solvent of phosappearance is that of a hearty man of fifty-five. He had been phorus, it is expected that it will absorb the vapours which burnt on the back of the left hand when an infant, and about do so much mischief. This precaution is taken at a large ten years ago a pimple appeared in the middle of the cicatrix, lucifer-match manufactory in the neighbourhood of the and soon became an open sore. This spread very slowly, London Hospital, and the very best results are expected from until the beginning of this summer, when it rapidly increased, it. This case, so very interesting and instructive in itself, was and on his admission into the hospital, Oct. 30, it occupied all rendered peculiarly valuable in being brought forward by the back of the hand, from its inner border to the second the distinguished author of the recently published treatise on metacarpal bone, and from near the bend of the wrist to the "Diseases of the Bones;" and we were sorry that the time distal ends of the first phalanges of the middle, ring, and little and place did not allow Mr. Stanley to enter fully into the fingers. The surface of the sore was foul and sloughy, except different questions which such a case will naturally give towards the wrist, where it presented a red, warty appear- rise to; for instance, as to whether the fumes act priance, with raised, everted edges. The secretion was abun- marily on the periosteum, or whether the jaw is secondant, and most foetid. There was no glandular enlargement darily affected, as a consequence of the contamination of at the bend of the elbow or in the armpit. Amputation the system. This question, which is left unsettled in the through the forearm was performed on the 3rd of November work just alluded to, appears of some importance; for if it by Mr. Dixon. We-need not point out how forcibly the two were made tolerably clear that the constitution is affected cases of cancer of the hand, which we have mentioned, point first, the poison might be counteracted by throwing approto the advantages of early operation. priate chemical agents into the blood. Indeed, we should be Mr. Samuel Cooper, in his "First Lines," treating ofthe affec- much inclined, from the analogy offered by the effects of tions of bursae mucosse, says, that he had, in 1839, an oppor- mercury, to think that the vapours act but secondarily on the tunity of removing a tumour formed in the bursa, lying be- jaw, though it would appear that the system must be in a tween the ligamentum patellae and the fascia. It was of the peculiar condition to become affected. The two cases mensize of an orange, and everywhere solid, excepting a small tioned in the last number of THE LANCET, by Mr. Henry central point, at which there were a few cells filled with Taylor, of Nottingham, will prove very valuable to those who synovial fluid. We are not told of the exciting cause of the may investigate this subject in all its bearings; for here we swelling, nor how long the tumour took to attain its size; but have two men, who were employed for a considerable time at it is very probable that the case was pretty similar to one the manufactory before they experienced any ill effects ;
cor-If
form."
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530 the communication of Messrs. Busk and Marshall, and D];ff. Griffiths and Jenner, clearly show that the investigation, from its peculiar nature, was as new to them as it was to Mr. Brittan, Dr. Budd, and myself; and it is but fair that these gentlemen should give proofs of the superior accuracy and completeness of their observations over ours, before they are entitled to implicit belief. Now, the accuracy of my colleagues and myself has been so repeatedly questioned in this Report,. that I feel that it is but due to ourselves to show that the statements contained in the Report are by no means unassailable in this respect. I think I shall be able to prove, in the following analysis of the Report, that it contains some conclu-sions, founded upon incomplete observations, as well as otherswhich are strikingly at variance with one another. The Report commences by detailing the results of several experiments, performed with a view of detecting " annularbodies" in the air. The experiments thus performed were seven in number, and were attended with purely negative results. But when I mention that Mr. Brittan, although he has. met with some failures, has obtained positive results in at least an equal number of cases to the above, and that he has submitted them to some of the first microscopists in London, it will at once be evident that his testimony is of more valuethan any of a purely negative character, whether deduced from,. examinations of condensed atmosphere, or from" cobwebs," and: washed from the broken glass of windows." boast. Had the experimenters succeeded in discovering anything identical with the " annular bodies" in the atmosphere of unON THE USE OF CHLOROFORM. infected places, the Report would have been justified in at the conclusion that these bodies have nothing to arriving CALEB Uckfield. BY RADFORD, ESQ., F.R.C.S., do with cholera. Hitherto, however, nothing of the kind hasTHE case, in your last number, of the death of a man in St. been detected except in infected localities. The same may Thomas’s Hospital, illustrates the great susceptibility there is be said of the seventeen negative experiments which were with some individuals to be influenced by chloroform-in made upon drinking-water. But it must be also recollected,. short, that a dose which in one instance is quite inoperative, that many of these experiments were performed upon water-in another is fatal. some time after the cholera had left the districts from which Shortly after chloroform came into use, I gave ten minims it was taken. The next part of the Report is occupied with observations, boy sprinkling on a handkerchief, and applying over the face of a tall, athletic woman, about thirty; in half a minute she upon the microscopic bodies found in cholera dejections, and was completely under its influence; I opened her mouth and commences as follows : -" We next proceed to show how extracted a molar tooth. The insensibility continuing, she was various are the bodies which have been confounded together opposite a window, and cold water thrown in her face; under the terms annular bodies (Mr. Brittan), cholera cellar placed in a few minutes she revived, but complained of feeling very (Mr. Swayne), and cholera fungi (Dr. Budd)." This remark is illustrated by references to a drawing contained in the Re-faint; a little stimulant soon relieved this. In another case, thirty minims were sufficient to make a port, in which the objects seen by us have been most cruelly man wholly insensible, while I amputated his thigh; and in a misrepresented. In answer to this, it may be replied that a" third instance, twenty minims rendered painless the excision very cursory examination of our respective publications will. of an inch of the median nerve above the wrist; but more than at once show that Mr. Brittan, Dr. Budd, and myself, are iIlf two drachms of the chloroform produced only a very partial the main agreed as to the most usual form of these bodies... effect in a healthy woman who wished to take it for extrac- The varieties of description are not more than would be tion of a tooth. The whole of these persons took the drug likely to occur when each person follows out a different line from the same supply, and in a few days of each other; the of investigation. In proof of this, I may refer to the Report,. and point out " how various are the bodies which have been strength of the chloroform, therefore, would be uniform. Since there seems no means of knowing who will be easily confounded with" the cholera cells viz., the spiral and, affected, and who will require a full dose, the only safe plan is annular tissues from " cabbages, potatoes, and onions, the to begin with a very small one. withered style of wheat-grain and portions of cane in sugarOf the persons I have named, the woman who took but ten (Mr. Marshall), chalk mixture (Dr. Griffiths), and the detached minims was remarkable for her strength and determination; nuclei of epithelium, (" ourselves,") with the smaller bodies;. the man whose limb was removed was fifty-six years of age, and the " rust, smut, and bunt of grain" (Mr. Marshall); "the and was exhausted a good deal by knee-joint disease. The urido segetum or bunt," (Mr. Busk); the " contents of bran other man was seventy years of age, and suffered from neur- cells" and "altered starch grains" (Mr. Busk); and fatty bodies (Mr. Marshall), with the larger bodies. algia, extending from the finger to the axilla. In the Report, the cholera bodies are divided into fourNovember, 1849. classes, the first three of which are found in the evacuations.These are:-1. "Things which enclose a free area, and which OBSERVATIONS ON THE 2. " Globular or oval cells." 3. Bodies are often broken." REPORT OF THE COLLEGE OF PHYSICIANS having apparently the form of discs with thick rounded edges and centres of indistinct structure." The Report then pro-RELATIVE TO THE ORGANIC BODIES DISCOVERED IN THE ceeds to deal with each of these bodies separately. It treats EVACUATIONS OF CHOLERA PATIENTS. of, 1, "the rings," which, "when closely examined, are seen BY J. G. SWAYNE, M.D. Lond. to be of different kinds, some perfectly continuous in theirLECTURER ON MIDWIFERY AT THE BRISTOL MEDICAL SCHOOL. entire circle, others formed by.a curled fibre, some round,some oval, others lozenge-shaped." From this vague descripI IT is but fair and right that the profession, before tion, and the still more vague plate accompanying it, it would the conclusions contained in the recent Report of the College really appear doubtful whether those who drew up this Report of Physicians upon the bodies in cholera discharges, should had actually seen the bodies in question. Mr. Brittan and be perfectly satisfied as to the accuracy of the premises myself have examined specimens from more than sixty eases, from which these conclusions are drawn. The Report, and can distinctly state that we have never seen any of these it should be remembered, does not represent the collec- smaller bodies which were either " formed by a curled fibre" tive wisdom of the College of Physicians, but is based merely or " lozenge-shaped." However this may be, we are told that " these bodies haveupon the observations of three or four individuals whose conclusions are placed in opposition to those of the two or three been traced to their true source" by Mr. Marshall, who finds: persons who first described these peculiar bodies. The ques- that they are formed by the curled fibres of vegetables of diftion, also, is not one which can be settled by authority, nor is ferent kinds, which have been mentioned above. But this it one upon which experience has been brought to bear; for explanation by Mr. Marshall would hardly account for the
whilst in one the upper, and in the other the lower jaw, suffered necrosis. These men were " dippers;" and it is but fair to suppose that the hand would havebeen the first to suffer, had the effect been direct. It must, however, be confessed, that the fact of the upper maxilla being affected, in Case 1, militates against the following passage, which we find at p. 75 of Mr. Stanley’s excellent treatise: " Against the opinion that the phosphoric vapour acts merely as a local excitant, the objection has been urged, that it produces no effect on the periosteum of the bones of the nasal passages through which the vapour is directly inhaled." That these cases should not be classed among ordinary necrosis of bones is sufficiently obvious, the entire absence of the least attempt at the regeneration of bone being the most characteristic differential feature. Nor could this regeneration well take place, as, to use Mr. Stanley’s words, (p. 76,) " there is herea total want of the essential conditions for the reproduction of bone-namely, inflammation in healthy structures, with health in the general system." The grey, pumice-stone-like, newly-formed osseous substance, found by Dr. Heyfelder on the outer surface of the bone which he extracted in similar cases, likewise portionsasofMr. points, Stanley remarks, to an affection distinct from the usual death of bone. We sincerely hope that the etiology of these affections will fix the attention of the many able investigators in surgical science of which this country can _____________
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adopting