491 ’I to be sure," he said, "felt some little difficulty in swallow. ing, and thought the food did not go down so well as usually but he had never thought of looking into his throat." N( pain in the part had ever been felt. The above drawings, which are life size, represent the tumour in two conditions. In the first figure it hangs down into the pharynx, resting upon the back part and root of the tongue, and advancing into the mouth. This is its ordinary position, and it appears in this situation when the patient first opens his mouth for an examination. He has the power of throwing it forward by an effort of slight coughing, and it then assumes the appearance repre- sented in the second figure. The tumour.rests upon the dorsum of the tongue, covering its two posterior thirds; it may be freely moved from side toside, and seems as if it would fall out. When carefully examined, the peduncle by which it is attached appears to be continuous with the right pillars of the fauces on the outer side, and with the right portion of the uvula on the inner. Towards the left border of the tumour, the left half of the uvula could be detected by irritating the mucous membrane, when a slight retraction of a very minute ridge was sufficient evidence of the situation of this organ. The entire surface was covered by mucous membrane, the subjacent vessels of which were enlarged and tortuous, giving rise to the impression that the growth itself might be supplied with large blood-vessels. In the absence of Mr. Cock, who deputed Mr. Birkett to attend to the case, the latter punctured the swelling, as he thought, from its elastic nature, that it might arise from an obstructed follicle. But Mr. Birkett was disappointed in this supposi- tion, for he obtained sufficient evidence of the internal struc- ture of the tumour to satisfy himself that the new growth was carcinomatous. A fortnight after admission, Mr. Birkett removed the entire growth by excision, having first passed a ligature through it, so that an assistant might keep it forwards and prevent it, when its peduncle was partially cut through, from falling down upon the epiglottis. Not the slightest haemorrhage of import- ance ensued, and the trifling loss of blood which occurred was easily arrested with cold water. The wound was very trivial, extending along the posterior pillar of the fauces chiefly, and in the site of the uvula. It healed in a few days, and the patient left the hospital ten days after the operation. The man showed himself again four months afterwards, when the pillars of the fauces were found quite perfect; and except the loss of the uvula, in which part there is a slight cicatrix, the region had entirely regained its normal and healthy aspect. Upon examining the morbid structure there could be no doubt but that it was of a carcinomatous nature; and this opinion, derived from mere ocular inspection, was confirmed by observation assisted by the microscope. As an instrument for assisting diagnosis the microscope became available, as stated above, in the first examination. The entire new growth was enveloped by a thin, delicate cyst, seemingly of the sub-mucous cellular tissue. A section exhibited a uniformly smooth, finely mottled, and granular surface; the elements of the tissue were fibres, nucleated bodies, and granular cells. It was of soft consistence, and very easily broken up. A patch of extravasated blood in the centre was, in all probability, caused by transfixing it with the needle and ligature. M. Lebert, in his admirable and recently published work on cancer, (" Traite pratique des Maladies Cancereuses," Paris, 1851,) the best work at present on the subject, writes, at page 421:- " We distinguish two principal forms of cancer of the palate, the most common of which - viz., that of a diffused kind-presents ill-defined limits............The second form is more seldom met with, and is of the encysted kind; of this I have seen two examples. The tumour, in such cases, springs up in the sub-mucous tissue, projects above the velum palati, and is even somewhat moveable. The size is variable, but I have seen it as large as a pigeon’s egg." KING’S COLLEGE HOSPITAL. Two Cases of Vesical Calculus in Boys; Lithotomy ; Recovery. (Under the care of Mr. FERGUSSON.) WE witnessed the lateral operation performed on the same day upon theae two patients, and were much struck by the ease with which Mr. Fergusson removed the small stones with an instru- ment not frequently used for this purpose-viz., the scoop. Among the numerous operations of this kind which we see in the hospitals of this metropolis, we remember a few where, especially from the small ize of the stone, it was very difficult to seize it with the forceps; if in these instances the scoop bad been substituted for the latter instrument, a great deal of trouble and anxiety might perhaps have been saved There is, if we may judge from the promptness with which Mr. Fergusson drew the small calculus from the bladder, much advantage in using the scoop, the only drawback appearing to be, that unless great care be taken, the mucous membrane of the bladder may be somewhat irritated by the scraping action of the scoop. Indeed, calculi of small dimensions are very liable to create much embarrassment to the surgeon. We have recently known two cases of the kind: in one of these the stone could not be found after the neck of the bladder had been laid open, and the calculus was subsequently passed through the wound while the patient lay in bed; and in the other, the stone, which probably is retained in a sacculus of the mucous membrane, could not be dis- covered at all after the incisions had been completed, though it had been felt by the surgeon before the operation. Such a disap- pointment occurred to M. Roux in Paris a few years ago; and we saw the other day a longitudinal stone removed from the urethra by incision in the perinseum, in the case of a little boy, where a complete diagnosis could not be satisfactorily arrived at. The operation had therefore been postponed, and shortly after, the stone became impacted in the urethra, and was removed, as above stated. It is more than probable that at the time the sound was searching for the stone in the b!adder, the former was, if we may judge from its lengthened shape, retained in the ureter. We are obliged to Mr. Wormald for showing us this interesting specimen, the stone having been excised from the perinseum by Mr. Stanley, at St. Bartholomew’s Hospital. It is very likely that the retention of stones in sacculi formed by the herniated mucous membrane, or the calculi being held
Transcript
491
’I to be sure," he said, "felt some little difficulty in swallow.ing, and thought the food did not go down so well as usuallybut he had never thought of looking into his throat." N(pain in the part had ever been felt.
The above drawings, which are life size, represent thetumour in two conditions. In the first figure it hangs downinto the pharynx, resting upon the back part and root of thetongue, and advancing into the mouth. This is its ordinaryposition, and it appears in this situation when the patient firstopens his mouth for an examination.He has the power of throwing it forward by an effort of
slight coughing, and it then assumes the appearance repre-sented in the second figure.The tumour.rests upon the dorsum of the tongue, covering
its two posterior thirds; it may be freely moved from side toside,and seems as if it would fall out. When carefully examined,the peduncle by which it is attached appears to be continuouswith the right pillars of the fauces on the outer side, andwith the right portion of the uvula on the inner. Towardsthe left border of the tumour, the left half of the uvula couldbe detected by irritating the mucous membrane, when a slightretraction of a very minute ridge was sufficient evidence ofthe situation of this organ. The entire surface was coveredby mucous membrane, the subjacent vessels of which wereenlarged and tortuous, giving rise to the impression that thegrowth itself might be supplied with large blood-vessels. Inthe absence of Mr. Cock, who deputed Mr. Birkett to attendto the case, the latter punctured the swelling, as he thought,from its elastic nature, that it might arise from an obstructedfollicle. But Mr. Birkett was disappointed in this supposi-tion, for he obtained sufficient evidence of the internal struc-ture of the tumour to satisfy himself that the new growthwas carcinomatous.A fortnight after admission, Mr. Birkett removed the entire
growth by excision, having first passed a ligature through it,so that an assistant might keep it forwards and prevent it,when its peduncle was partially cut through, from falling downupon the epiglottis. Not the slightest haemorrhage of import-ance ensued, and the trifling loss of blood which occurredwas easily arrested with cold water.The wound was very trivial, extending along the posterior
pillar of the fauces chiefly, and in the site of the uvula. Ithealed in a few days, and the patient left the hospital tendays after the operation.The man showed himself again four months afterwards,
when the pillars of the fauces were found quite perfect; andexcept the loss of the uvula, in which part there is a slightcicatrix, the region had entirely regained its normal andhealthy aspect.Upon examining the morbid structure there could be no
doubt but that it was of a carcinomatous nature; and thisopinion, derived from mere ocular inspection, was confirmedby observation assisted by the microscope. As an instrumentfor assisting diagnosis the microscope became available, asstated above, in the first examination.The entire new growth was enveloped by a thin, delicate
cyst, seemingly of the sub-mucous cellular tissue. A sectionexhibited a uniformly smooth, finely mottled, and granularsurface; the elements of the tissue were fibres, nucleatedbodies, and granular cells. It was of soft consistence, andvery easily broken up. A patch of extravasated blood in thecentre was, in all probability, caused by transfixing it withthe needle and ligature.M. Lebert, in his admirable and recently published work
on cancer, (" Traite pratique des Maladies Cancereuses,"Paris, 1851,) the best work at present on the subject, writes, atpage 421:-
" We distinguish two principal forms of cancer of thepalate, the most common of which - viz., that of adiffused kind-presents ill-defined limits............The secondform is more seldom met with, and is of the encysted kind; ofthis I have seen two examples. The tumour, in such cases,springs up in the sub-mucous tissue, projects above thevelum palati, and is even somewhat moveable. The size isvariable, but I have seen it as large as a pigeon’s egg."
KING’S COLLEGE HOSPITAL.Two Cases of Vesical Calculus in Boys; Lithotomy ; Recovery.
(Under the care of Mr. FERGUSSON.)WE witnessed the lateral operation performed on the same day
upon theae two patients, and were much struck by the ease withwhich Mr. Fergusson removed the small stones with an instru-ment not frequently used for this purpose-viz., the scoop.Among the numerous operations of this kind which we see inthe hospitals of this metropolis, we remember a few where,especially from the small ize of the stone, it was very difficult toseize it with the forceps; if in these instances the scoop bad beensubstituted for the latter instrument, a great deal of trouble andanxiety might perhaps have been saved There is, if we mayjudge from the promptness with which Mr. Fergusson drew thesmall calculus from the bladder, much advantage in using thescoop, the only drawback appearing to be, that unless great carebe taken, the mucous membrane of the bladder may be somewhatirritated by the scraping action of the scoop.
Indeed, calculi of small dimensions are very liable to createmuch embarrassment to the surgeon. We have recently knowntwo cases of the kind: in one of these the stone could not befound after the neck of the bladder had been laid open, and thecalculus was subsequently passed through the wound while thepatient lay in bed; and in the other, the stone, which probably isretained in a sacculus of the mucous membrane, could not be dis-covered at all after the incisions had been completed, though ithad been felt by the surgeon before the operation. Such a disap-pointment occurred to M. Roux in Paris a few years ago; and wesaw the other day a longitudinal stone removed from the urethraby incision in the perinseum, in the case of a little boy, where acomplete diagnosis could not be satisfactorily arrived at. Theoperation had therefore been postponed, and shortly after, thestone became impacted in the urethra, and was removed, as abovestated. It is more than probable that at the time the sound wassearching for the stone in the b!adder, the former was, if we mayjudge from its lengthened shape, retained in the ureter. We areobliged to Mr. Wormald for showing us this interesting specimen,the stone having been excised from the perinseum by Mr.Stanley, at St. Bartholomew’s Hospital.
It is very likely that the retention of stones in sacculi formedby the herniated mucous membrane, or the calculi being held
492
back in the opening of the ureter at the moment they are passinginto the bladder, may sometimes have led the operators them-selves to suppose that they had formed an incorrect diagnosis.The principal facts of Mr. Fergusson’s cases are as follows :-
Edward B-, aged six years, was admitted March 20, 1852,under the care of Mr. Fergusson, with several of the symptomsof vesical calculus. About two years and a half ago, the patient’smother noticed that he experienced pain every time he passed hiswater, and that he was frequently pulling his prepuce; blood wasoften seen in the boy’s urine, and the flow of the latter usedto stop suddenly. These symptoms had continued with more orless intensity ever since, and had caused the patient much dis-tress. Mr. Fergusson readily detected the stone on sounding thechild, and proceeded to perform the lateral operation a weekafter admission.Mr. Fergusson is in the habit of making a free external inci-
sion, and the parts are in such close proximity with youngpatients, that very few strokes of the knife are sufficient after-wards to reach the neck of the bladder and lay it open. Wesuspect that the aperture into this viscus is made at first verysmall, as Mr Fergusson generally appears to dilate it with theleft forefinger before introducing the forceps. This instrument,as stated above, was not used in this instance, as Mr. Fergusson,knowing the calculus to be small, preferred using the scoop, withwhich he succeeded in removing the stone in a very short time.The patient progressed satisfactorily; in about a week the wholeof the urine passed through the urethra, and the boy was dischargedwith a firm perlnseal cicatrix one month after the operation.CASE 2.-John V-, six years of age, was admitted March
14, 1852, under the care of Mr. Fergusson, labouring under thesymptoms of stone in the bladder. The child suffers veryseverely each time he attempts to pass water; micturition iseffected with much straining, the urine being then voided in butvery small quantities, mixed with blood, and containing pus andmucus. The stone was easily detected by sounding, andlithotomy performed immediately after the first patient was re-moved. After the usual incisions, the stone, which was of anoblong shape, and rounded at one end, was removed by the scoop,as in the former case, this instrument being preferred to theforceps for the reasons above stated. From the peculiar figure ofthe calculus, Mr. Fergusson was inclined to think that it hadbeen grasped by the opening of the ureter. The progress of thispatient was marked by a feature which is seldom observed withyoung people: he had, namely, several pretty severe attacks ofhaemorrhage, but the loss of blood was easily controlled byplugging. All went on well with the exception of this, and aboutfive weeks after the operation the patient was discharged in verygood condition.
Being on the subject of haemorrhage after lithotomy, we woulddirect the attention of our readers for a few moments to a methodof operating proposed and performed by Professor Rizzoli, oneof the advantages of which is said to be the non-division of thegreat perinaeal arteries and the prostatic venous plexuses. Theoperation is described in the August number (1851) of theMedico-Chirurgical Review, and is not, as far as we have seen,often performed in this country. The proceedings are describedas followsThe perinseal urethra being well projected out by a very convex
sound, the operator commences his incision of the superficialcoverings, a few lines behind the base of the scrotum, and carriesit to the margin of the anus. Passing the nail of his left thumbor fore-finger under the bulb of the urethra, in order to protectit, he feels for the groove of the sound, and penetrates the anteriorpart of the membranous portion of the urethra with his lithotome,the ligature or torsion being applied to any of the arterialbranches proceeding towards the bulb which, owing to theirabnormal development, may bleed too freely. Having implantedhis bistoury within the origin of the membranous portion, inorder to prevent any injury to the rectum, the surgeon now takesthe sound from the assistant, and, raising the handle to a rightangle with the pubis, enables the instrument to slide under thearch, rendering the membranous portion prominent, and its divi-sion easier, without injuring the rectum. The incision should becarried far enough to scarify the edge of the prostate, as urinaryeffusions into the cellular tissue of the anterior walls of the pelvisare much more likely to occur when it (the incision) is limited tothe membranous portion, and the dilatation of the part by thepassage of large calculi is then more difficult.The incision completed, the operator passes his index finger
into the wound, with the palm or surface upwards, guiding italong the groove of the sound into the bladder, and makingit serve as a conductor for the passage of the forceps. If thesurgeon discover for the first time during the operation thathe has to do with a large calculus, it is better to break itprior to the removal; for which purpose Professor Rizzoli has
contrived an instrument. He believes the advantages of thismethod to be, that neither the bladder, rectum, bulb, vasa
deferentia, the great perinaeat arteries, nor the prostatic venousplexus, are wounded. He has operated upon eight cases
with success; in one of these there were two calculi, oneof which was discharged by an aperture which occurred spon-taneouslv in the nerinseutn.
Talipes Equinus; Tenotomy, Rectification of the Deformity.(Under the care of Mr. PARTRIDGE.)
Mr. Partridge has lately operated upon two brothers whowere each affected with congenital talipes equinus. We need notsay that this variety of club-foot is rarely met with, for it is wellknown thatout of perhaps twenty operations for talipes varus, thereis hardly one for talipes equinus. As to the two brothers present-ing the same congenital defect, may we not suppose that theuterine malposition was owing to some peculiarity of the uterusitself, which has a tendency to produce the same effect atevery gestation? No doubt but that a smaller quantity thanusual of amniotic fluid may have much influence on congenitaldefects of this kind.
C)
I It is no small triumph of modern surgery that talipes shouldnow be so easily remedied; we should, however, mention that itis worth while paying the strictest attention to the manner ofdividing the tendon (which should be delicate and regular), andthe application of the apparatus after tenotomy; for we haveknown cases where the non-observance of these rules caused verytroublesome sloughing, and inflammation of the whole limb.
Seth Y-, aged twelve, was admitted Feb. 3, 1852, underthe care of Mr. Partridge. He is a healthy lad, though thin,and has been much annoyed by the deformity of congenitaltalipes equinus of the left side; he has walked upon the affectedfoot from an early age without assistance. The boy treads onall the toes except the great one, the heel being drawn up so faras to bring the instep almost on a straight line with the leg. Infront the extensor proprius is so contracted that the great toe isdrawn up, and does not come in contact with the ground.Mr. Partridge divided the tendo-Achillis, four days after ad-
mission, and an apparatus, intended to bring the heel downwardsand flatten the foot, was put on a few days afterwards. Pressureon the instep caused a little ulceration in that region, but aboutfive weeks after the operation the patient could put his foot flaton the ground. The improvement kept pace for the next fewweeks, and about three months after the division of the tendon,the boy could walk with comparative ease, very faint traces ofthe deformity being left.The second case refers to a brother of the former patient,
Lewis Y-, aged ten years. The defect was here likewisecongenital, but affecting the right foot, and pretty analogous towhat has been described above, except as to the contracted ex-
tensor, which was not quite so much drawn up. Both patientswere operated on the same day, they progressed pretty well in ananalogous manner, and are now both free from their congenitaldefect.
Reviews and Notices of Books.
On Diseases of the Liver. By GEORGE BUDD, M.D., F.R.S.,Professor of Medicine in King’s College, London, and Fellowof Caius College, Cambridge, pp. 486. London.
IN writing a book on Diseases of the Liver," says Dr. Budd," I shall hardly be accused of having undertaken a needless task.There are no other diseases of such frequent occurrence, whichit is so difficult to discriminate, and for the treatment of whichthe practitioner has so few trustworthy guides. There is, again,no class of diseases at all equal to this in importance, on whichso few treatises have lately been written." Now all this is verytrue, if we make allowance for the small spice of exaggerationwhich will creep into the language of any one who makes hisown estimate of a subject in the investigation of which his facul-ties have been long and successfully absorbed; and even if thesediseases were less important, less obscure, and less difficult totreat than they are, we should be glad to re-welcome in anotheredition, a work, which, by teaching us what is true, will help torid us from the everlasting wearisomeness of hearing that "theliver is out of order," when the poor liver is altogether exemptfrom blame.
Dr. Budd begins with a full analysis of those anatomical andphysiological prinoiples, without the knowledge of which any
