No. 3051.

FEBRUARY 18, 1882.

LectureON

DISEASES. OF THE CHEST WALLSREQUIRING

SURGICAL TREATMENT.Delivered at the Hospital at Brompton, Jan. 16th, 1882,

BY JOHN MARSHALL, F.R.S.,PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE AND SENIOR SURGEON

TO THE HOSPITAL, CONSULTING SURGEON TO THEHOSPITAL FOR CONSUMPTION, BROMPTON.

(Reported by HENRY MAUDSLEY, M.B.Lond., and revised by the Lecturer.)

LECTURE I.—PART II.

Now, in none of the preceding cases was there any taintof syphilis, that is to say, of acquired syphilis; for in thelast patient there may have been some congenitally trans-mitted condition of that nature. But if we direct ourattention to cases dependent upon previously acquiredsyphilis, we find them presenting marked peculiarities.Thus they nearly always occur in women, and they show adecided preference to a certain locality-this being thesternum, and especially the upper part of that bone. I amsure that of any twelve instances of syphilitic disease of thechest walls, nine or ten will be in the sternum, and of theseseven or eight at the upper end, in the manubrium, perhapsalso involving the first rib, or even the clavicle. The diseasecommences by a periosteal gumma, which is not necessarilypainful, except at its characteristic after-midnight hour.These gummata are fixed, and at first firm, and when aftera time they soften in the centre, it is by a process of de-generation and death of the deeper parts, associated withsuppuration, not by a purely suppurative process such asoccurs in an acute necrosis or a subacute strumous caries.The superjacent integument reddens, thins, and ulcerateswidely, leaving a large circular opening, not a mere per-foration, as in ordinary caries or necrosis. Sloughs and pusescape, not pus alone ; and instead of the sinuses remainingwith small apertures, or gradually contracting as if disposedto heal, the tendency in these syphilitic cases is towards acontinuous ulcerative proce-s, which spreads out with curvedborders, thus affecting the bones as well as the soft parts.When healed, these syphilitic ulcers leave not mere puckeredindentatinns, but large, ugly, depressed scars, indicative ofloss of substance. The caries of syphilis is distinguished bythe hardness of the eroding bone, quite unlike the soft,easily crushed bone of strumous or tubercular caries. Asalready stated, I would name it hard caries.

1 have lately had under observation two cases of syphiliticdisease (one at University College Hospital, the otherelsewhere) of the upper part of the sternum, almost exactlycorresponding in all particulars. They originated in syphi-litic gummata, which broke down and left circular ulcers,with carious and necrosed bone beneath them. These twocases (7 and 8) occurred in women. I have been disap-pointed in not being able to show one of them here. Athird case (9), recently brought under my notice, was alsopresumably dependent on constitutional syphilis, acquiredduring pregnancy. It was an example of extensive necrosis,with hard caries of the right first rib. There was consider-able swelling, with great tenderness and surrounding painin the suhclavicular and mammary regions ; in the centre ofthis swelling wis a depressed sore, with very induratedtissues around it, yielding an unhealthy discharge, andleading upwards to a cavity beneath the first rib, a largeportion of which was exposed, rough, and hard. Under theinfluence of iodide of potassium, these several conditionshave improved, and the bone appears to have becomecovered. The two fir-t-named cases were completely curedby healing of the ulcers, with, of course, great disfigurement, under full and continued doses of the iodides of putas-sium and of iron.Permit me, now, to make some general observations on the

cases here brought to your notice. It will be noted, first,that with one exception the patients are adults. It has beensaid that caries and necrosis of the ribs are more common in

old than in middle-aged persons ; but this has not been so inmy expoience. With regard to the sex, in my cases thefemales outnumber the males ; but I should be unwilling tosay that this is the rule, excepting in the cafe of syphiliticdisease : it may be accidental. Of more importance is thesituation of the disease. If we exclude the syphilitic cases,ordinary caries or necrosis occurring in the ribs is more fre-quent at the front than at the sides of the chest, and muchmore frequent in the lower than in the upper part. Thereason of this may be that the anterior portions of the lowerribs not being 80 thickly covered with muscles as the upperribs, or the hinder parts of all the ribs, which are so wellpadded by the pectorals, the great serratus, the latissimusdorsi and the spinal muscles, are more affected by pressurefrom the dress or other external agencies, and to wet and coldfrom atmospheric changes. The preference of syphilitic in-flammation for the upper part of the sternum may be due tothis part of the chest being relatively more exposed to cold,especially with the female dress; or it may be partly deter-mined by the fact that all the actions of the upper limb pivotthrough the collar-bone on to the sterno-clavicular articula-tion, and thus throw stress on the upper part of the sternum.The twowomen mentioned above had been domestic servants,and accustomed to lift weights and to scruband wash. The ovalshape, oblique direction, and fixed position of costal abscessesare very characteristic. They are at first rounded, small, andfirm, but as they gradually or quickly enlarge and soften,they always spread along a rib, detaching the periosteumand so causing caries or necrosis. Often at first exceed-

This diagram has been constructed by plotting out thesituation of the costal and sternal abscesses in all thecases mentioned in this lecture. The syphilitic casesare indicated by darker spots.

ingly painful, owing to the stretching of the periosteum,fasciae, and intercostal nerves, the pain diminishes as theperiosteum is separated, as the muscles and fasciae becomethinned and less resistant, and the nerves no longer strained.After a time they may become painless, but usually theygive pain in the act of coughing, or when they are handled.In the case mentioned as having been treated for inter-costal neuralgia., the pain no doubt was of a neuralgic cha-racter, owing to stretching or other implication of the inter-costal nerves. Costal periostitis or osteitis may end inresolution, but this is rare, the subperiosteal exudationbeing very seldom indeed absorbed. The suppurative ter-mination, which is usual, generally ends in more or less ofcaries or necrosis. As a rule, as already mentioned, theacute inflammations lead to necrosis, the subacute or

chronic to caries, or a mixture of caries with necrosis. A

costal or sternal abscess may commence near and extendinto a costo-sternal articulation. If left to open itself, it leavesa narrow sinus, which may discharge for weeks, months, oryears, or even for the rest of the patient’s life ; for manycases are very intractable, owing to the deep position of thecaries or necrosis on the inner surface of the rib.As to the treatment of these cases, it may be said that

any attempt at abortive treatment is almost useless. Theynearly always run their course, and come to an almost uniformconclusion. In spite of the application of iodine, or iodideof lead ointment, or mercurial ointments, or blisters, or

other absorbents or counter-irritants, suppuration almost

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inevitably occurs, owing chiefly to some unfavourable con-current constitutional condition, but also in some measureto the impossihility of keeping the parts sufficiently at rest.We breathe eighteen times in a minute, and the ribs are per-petually disturbed up and down, and therefore twice asmany times in a minute; night and day there is no restfor them; and it is not surprising, therefore, that there shouldbe so little tendency in costal inflammations to resolution andcure. A diseased limb or joint we can, by means of splints,keep absolutely at rest, and thus favour the processes of re-pair ; but not so with the ribs. For a similar reason, estab-lished caries of the ribs is difficult to arrest and cure ; and,in the event of necrosis, the dead bone takes a very longtime, even years, to separate, or before it can be detached,for the necrosis is more or less prone to be progressive.The most judicious treatment is to wait until these costal

abscesses are ripe, and then to open them antiseptically alonga rib, or near its upper border, or in the case of a sternalabscess, vertically along or near the border of the sternum.As a good precaution in sternal abscess, a raspatory ordirector may be used after an incision has been madethrough the skin. The strict antiseptic method is not ahso-lutely necessary; but if the abscesses be large or numerouswe may adopt it. If only of moderate size, they do as wellwith simple antiseptic dressings and perfect drainage. Afteropening them, it is often difficult or impossible to determineat once whether there be caries or necrosis, or both, owingto the deep position of these conditions on the inner surfaceof the rib. The search should be made with a probe bent indifferent curves, and at last it may come upon bone, soft orhard, as the case may be. If the caries be slight, it shouldbe left to itself ; and then free drainage, surgical cleanliness,and the use of antiseptic and stimulating injections, withconstitutional treatment, specially adapted to the case, are ofchief importance. If the caries be extensive, the softenedbone may, after laying open the sinus and separating itswalls with a raspatory, be scraped, or scooped, or gougedaway ; but the removal of carious portions of ribs is not avery successful operation. If, in necrosis, a sequestrum liesloose at the bottom of the sinus, lay this open, and removethe loosened piece or pieces ; but so long as the dead bone i,fixed, it is useless, or, indeed, may be injurious, to attempiits removal by operation. To assist its separation, I hav(more faith in local cleanliness, and local and general meansadapted to improve the vigour of the vital processes, than irany hitherto suggested solvents of the bone. In syphiliti<cases, I have found iodide of starch invaluable as a topicaremedy, more economical, quite as effectual, and muclsafer than iodoform.During the progress of a case of necrosis of a rib, before

the sequestrum has separated, much new bone may bethrown out, especially on the outer surface and margins ofthe rib. Hardly ever does this happen on the inner surfaceof a rib, which, moreover, is more frequently necrosed thanthe outer. This inner surface, indeed, has much less nutri-tive activity and reparative power than the outer surface.Its substance is more compact and less vascular, and itsperiosteal covering is in contact only with the loose sub-pleural connective tissue, whilst the borders and the outersurface have muscular attachments blending directly withtheir periosteal covering. Hence the blood-supply of theseparts of a rib is more assured than that of the inner surface,and they display a greater reparative activity. Even infractured ribs the roughest part of the callus is thrown outon the outer surface and the margins of the bones, and thesmoother part on the inner surface, and for the same reason.This result has been regarded as a special provision for theavoidance of pressure or rubbing against the lung., and nodoubt it is an incidental advantage; but this view furnishesno explanation of the fact. The cause is to be sought in therelatively less abundant blood-supply and lower nutritiveactivity of the deep surfaces of the ribs. Owing to these con-ditions, also, internal necrosis of the ribs commonly lasts formonths or years. Both the ribs and the sternum have beentrephined, or portions of these bones have been removed bygouge, saw, or cutting forceps, in order to reach a deep-seated sequestrum ; and such proceedings are justifiable ifone is sure that the sequestrum is loose. But I wouldadvise great caution in dealing thus with these bones, as itmay lead to serious after-consequences. Fatal pleurisy andpericarditis, and septicaemia have followed such operations.There is also on record a case of fatal peritonitis after anattempt to remove a necrosed xiphoid cartilage. Besides, ifa rib sequestrum be loose, it may probably be quite easily

lifted or tilted out without trephining. As to resection :ofa portion of a rib in its whole thickness, for caries ornecrosis, this also is an operation which must be undertakenwith caution ; for out of thirty-seven cases collected byHeyfelder eight proved fatal.

It is now necessary that I should advert, however briefly,to the New Growths or Tumours of the chest walls. Ex.amples of most of these are on the table before you. Hereare four separate specimens, catalogued as being of medullarycancer, two from the sternum, one from a rib, and another fromthe frontal bone, all from the same patient. They are multipletumours, probably cancerous, but possibly sarcomatous, forthere is no account of their microscopic structure. In thissmaller specimen we find a cancerous nodule just inside thesternum, the result of dissemination of that disease. Here,again, is a large possibly cancerous tumour, which com-menced in the sternum, but has grown forwards throughthat bone, and backwards into the mediastinum, andhas actually invaded the lung. This additional prepara.tion shows an interstitial growth in a rib, apparently asarcoma; and this other, an external periosteal sarcoma ofmelanotic character. In none of these cases would operativeinterference have been justifiable. Some are examples ofgeneralised or diffused disease; and in others the tumourswere so adherent to the under-lying parts that it wouldhave been impossible to remove them completely, which, ayou know, is essential in such cases, without incurring un-warrantable risk.A simple exostosis of the sternum, or of the ribs, is very

rare. Here is an example of a small exostosis situated onthe neck of a rib. It probably gave rise to no symptomsduring life, and from its position it would have been in-accessible to operation. Enchondromas of the ribs or

sternum are now and then met with; but unless the en-largement of this horse’s rib be of that character, I have nomuseum specimen to show you. The hard enchondromatausually grow from a rib, and the softer forms from thesternum ; the latter may become cystic, and the former mayossify, and so become exostoses. The hard enchondromatamay be painful, and, if pedunculated, may be dissected off;if sessile, the diseased portion of the rib may be carefullyresected. The soft enchondromata, usually less painful,may grow to a large size, and hence are serious. It is bettertherefore to remove them early, with a part of the boneto which they are attached; or, at all events, as soon as

they exhibit any rapidity of growth. There is, however,some risk in such operations, for there is no subjacent in-flammatory thickening of the pleura or pericardium, whichin diseases of an inflammatory nature serves to protect theunderlying cavities and organs. Accordingly, wound of thepericardium, and wound of the pleura with prolapse of lung,have occurred in resecting an enchondromatous rib. Never-theless, if the tumour be growing rapidly, the rib had betterbe carefully resected.CASE 7.-In concluding this lecture I am enabled to

bring to your notice a patient sent to me last summer by myfriend Mr. Steil; she is suffering from some form of newgrowth upon the ribs. She is twenty-four years of age andunmarried. Her father is now in a lunatic asylum; hermother is healthy; one sister is said to have died of goitre,and another from a tumour of the head. One brother diedof consumption. The survivors, a brother and sifter, are-

fairly healthy. You will observe that there has been slightrickets, for the sternum and the costal cartilages are ratherprominent, and the ends of the ribs are somewhat enlarged.This enlargement, seen immediately below and to the innerside of the left mamma, is of twelve months’ duration, andwas at first supposed by the patient to he a tumour of thebreast. There is here a firm circumscribed oval swelling,consisting of a smaller upper part, and a larger, prominent,and somewhat softer part below. Seven or eight months sinceI passed a grooved needle into this softer part, but obtainedno serum, no pus, but only a drop of blood. The tumouris really double, consisting of a smaller, hard part attachedto the anterior end of the left fourth rib, and a larger, softerpart connected with the fifth rib very close to the cartilage.They are everywhere excessively tender, and cause gieatpain on coughing, or on exertion of the corresponding arm.These symptoms are due probably to pressure on the inter-costal nerves. I scarcely think thev are hard enough for pureenchondroma, and yet they are of too slow growth for soft

, enchondroma, or for subperiosteal sarcoma. Confirmatory oftheir neoplastic character, I may observe that there seems tor be some obscure and deep-seated growth forming in the left

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mistoid reion ; for the left auricle is being gradually pushedaway from the hea,], an I, as may be seen on looking at thepatient from front or behind, the left ear is now distinctlymore prominent than the right. The space below the lobe ofthe ear, in front of the mastoid process, is fuller than on theoppo-ite side ; and the left condyle of the lower jaw projectsauduh-. There is also pain in this region. Recurring to therib tuno urs, their trntm-nttnust be almost entirely expectant.Their close proximity to the pericardium, taken togetherWith the manifestations of another deep-seated growth at thebasis cranii, preclude any operation, unless it were under-taken to mitigate otherwise uncontrollable suffering, or to

prolong life,-neither of which requirements’ is at presentindicated. Absorbent and alterative treatment of everypossible kind has been without service ; but in some form orother it will be continued.

Clinical LectureON

A CASE OF PNEUMONIA WITHTTPHOID SYMPTOMS.

Delivered at Westminster Hospital,

BY OCTAVIUS STURGES, M.D.,PHYSICIAN TO THE HOSPITAL, AND JOINT LECTURER IN MEDICINE.

GENTLEMEN,-It is commonly said when two conditionsof disease occur in succession that the one which appearslatest is a complication of the other. Pericarditis is a com-

plication of acute rheumatism, bronchitis of gout, pneumoniaof enteric fever. It is obvious, however, that this mode ofexpression is only appropriate where the two affections areof independent origin, and separate in cause as well as in ’,seat. Hence the suitability or otherwise of the word " com- Iplication " as applied to any particular symptom is anelement in diagnosis ; it cannot be determined without a

competent knowledge of the proper features of disease andtheir range of variation. It will sometimes happen thatsymptoms which we are accustomed to see associated, andon that acconnt to refer to a single agency, become ambiguousand difficult of interpretation owing to the anomalous

relationship which they bear to one another. Thus, forinstance, inflammation of the lungs is sometimes associatedwith enteric fever; but the mere fact of conjunction is noproof of any real kindred between the two affections. Itneeds besides that the manner of association should be of acertain kind. A patient of ours illustrates this principle sowell, and at the same time exhibits an aspect of pneumoniaof so much interest and importance, that I cannot do betterthan make him the subject of this afternoon’s lecture.The case is shortly as follows:-A stout, healthy youth of

sixteen, a porter, who had been complaining of slight coldfor some weeks, was seized with shivering on January 1stwhile at his work. He had headache, pleural pain, andcomplete loss of appetite; and on the third day, whenfirst seen, but before admission, his face was flushed, skinhot and pungent, respiration rapid and jerking, with muchpain on inspiration, and very frequent pulse. With aU theaspect of pneumonia, no auscultatory signs of the diseasewere as yet audible. Admitted on the 4th (days of diseasecorresponding with those of the month) ; pul-3e was 132, full,bounding ; respiration 45 ; temperature 105 2&deg; Dulness,tubular breathing, and fine crepitation were now presentover the right chest anteriorly from clavicle nearly to nipple.The tongue was red. moist, and white-furred. Pain in theside still severe. The further progress of the case was

marked plzysically by some extension in the area of lungconsolidation, and generally by restlessness, night delirium,and intense thirst ; the temperature each day up to and in-cluding the sixth, ranging between 104&deg; and 105’2&deg;; thepulse varied between 140 and 125. There was a trace ofalbumen in the uriue. The bowels had been somewhat loosefrom the time of admission; but not until the sixth day didthe patient exhibit signs of enteric fever. This now ap-

peared both in the character of the evaem’ioua and theirincrfa<ed frequency, together with clisteussou of - he abdomen,and some rloW=fut sp;)ts. With this the temperature be,,:;’:nto fall, s r that on the 8th its highest point w-s ’’’eluw lj3;while rhe respiration reached 60. The deli’ium was con-stant and at tunes violent, so that little slet-p BB’’/8 procured.On the evening of the Sth, the diarrhoea suddenly stepped.But it was now plain that the boy was ding. Dulthoccurred on the tenth day from his first seizure, and the fifth orsixth from the first appearance of enteric sympom ; theillness throughout maiutaining the characteri-tics of pneu-monia rather than of typhoid fever. It may be added thatthe fami y hitry afforded no evidence of phthisis or scrofula,and that there was no known source of infection.The leading features of the post-mortern examination,

stated in the same summary way as the symptoms duringlife, were these :-The right lung was uniformly consolidatedin its upper half, red passing into grey, the lung tissue in partsdestroyed. Cuvering the lung was a bulky and consistentlayer of recent lymph; the cavity of the right pleura containedthree or four ounces of clear fluid. The left lung was con-gested merely. On examination of the small intestinesthese presented the characteristic signs of enteric fever in anearly stage, the solitary glands being enlarged, aud Peyer’spatches raised, and at one spot superficially softened. Thelarge intestines were unaffected. The kidneys, heart, spleen,and other organs were natural.Now, the symptoms which were mo3t prominent and the

earliest in this case, both locally and generally, were thoseof pneumonia. The flushed face, the stitch, and the tem-perature were all suggestive of that affection, even beforethe physical signs directly indicated it. It is not until thesixth day, and when the illness had begun to threaten afatal termination, that the signs of enteric fever appear indiarrhoea, abdominal distension, and some doubtful spots.Even then the violent delirium, the pleural pain, and thetime and manner of death resemble pneumonia no3t. Andafter death the doubt as to the relationship of the feverand the lung inflammation is not immediately resolved ; forthere are the signs of simple pleuro-pneumonia along withthe signs of commencing ulceration of the bowel. What wehave to determine, therefore, is this : Have we here simplyenteric fever involving, or, as some would say, com-

plicated with, pneumonia, the pulmonary inflammation beingunusually early and unusually prominent; or have we twodistinct and independent diseases, which happen by chanceto concur in the same individual; or have we, in the thirdplace, a true pleuro-pneumonia of pythogenic origin, andwhich, in consequence of that origin, exhibtts towards itsclose those enteric symptoms which we commonly associatewith the typhoid poison ? I think, and I will try to show,that this last hypothesis is the most tenable.That the two conditions here conjoined are altogether in-

dependent of one another may indeed be true, but it is away out of the difficulty which can only be accepted in thelast resource. It is no new experience to find enteric feverand inflammation of the lungs in company. Assuming,however, the lung condition to be part and parcel of theenteric fever, what requires explanation is this : first, thatthe acute pneumonic symptoms preceded by five or six days sthose of the specific fever ; and next that this pneumonia,thus appearing out of its time, is a lobar pleuro-pneumonia.The question is, Do we find such a pneumonia, as to timeand as to form, among the recognised phenomena of typhoidfever?That pneumonia is amongst the admitted "complications

and seque]se" of enteric fever I have already said. Dr. Mur-chison met with it in 13 per cent. of his ca-es, and Dr. Flintin about 16 per cent. But invariably the pneumonia is subse.quent to the appearance of the enteric symptoms ; and inva-riably it is lobular and not lobar. Dr. l4Zurchison, indeed,remarks that this enteric pneumonia "is usually lobular."I would venture to assert, and upon his own authority, thatit is nearly always both lobular and double, aud that a one-sided lobar pleuro-pneumonia is almost if not altogetherunknown in enteric fever. If to this it be added that thepneumonia in our present case did not so much accompanyas precede the symptoms of enteric fever, no fair review ofthe facts will conclude that the former is a mere "co!npli-cation" of the latter.! What remains, then, but to suppose

1 See Murchison on Fevers, Cases 28 and 29. At p. 94 of the "NaturalHistory of Pneumonia" the question of the character of the pneu-monia which attends typhoid and typhus fever is fully discussed fromthe point of view of statistics.