No. 2813.

JULY 28, 1877.

LecturesON

DISEASES OF THE NOSE.Delivered at the London Hospital Medical College,

BY MORELL MACKENZIE, M.D. LOND.,LATELY PHYSICIAN TO THE HOSPITAL.

LECTURE I.(Reported by Dr. GORDON HOLMES.)

GENTLEMEN,-Owing to its accessible situation, and thetroublesome symptoms to which it often gives rise, polypusof the nose was one of the first growths which attracted theattention and employed the pens of the ancient physicians.Nearly five centuries before the Christian era observationhad made such advance that Hippocrates1 was enabled todistinguish, though only empirically, five varieties of thedisease, and to make many valuable suggestions as to theappropriate treatment of different cases. He speaks of allnasal growths under the common name of "fungus" (/lVK1)r;;);but from the manifest resemblance in shape, they were alsogenerally termed " figs" (6ZKOV, ficus) both by Greek andLatin authors.’ The word " polypus," however, came intoearly use among the Romans, and is employed both byCelsus and Galen. Moreover, it may be mentioned that thedisease was popularly confounded with ozaena.3As Gruner4 observes, most of the examples of polypus are

in the vicinity of the natural openings of the body; andMeissner,5 writing in 1820, went so far as to state that suchformations were never found in the heart or great vessels;pathological observations have, however, proved the latterview to be a complete fallacy. No morbid growths, exceptthose situated in the nose, seem to have been known to the

ancients;6 and as late as the beginning of the seventeenthcentury the term 11 polypus" was still wholly restricted tothat formation in the nose, as may be seen from the state-ment of Glandorp,7 that " not every fleshy excrescence is tobe considered a polypus, but that only which occupies thenares.’With respect to the causes of intra-nasal growths,

most of the early writers had generally a vague ideathat they were developed by the inspissation of mucoussupersecretion, the result of a catarrhal condition, or ofan overflowing of the humours of the brain.s No fact,however, was recognised sooner than the quasi- malignantnature of many new formations of the nose,9 as well as therisk of adopting heroic measures for the cure of anything ofa cancerous nature. Thus Hippocrates lays down the rule:"All tumours in which there is an occult tendency to be-come malignant had better not be subjected to active treat-ment, as in such cases the patients quickly perish, whereaswhen left alone they live on for a considerable time." 10As regards the classification of intra-nasal growths, they

presentmany characteristics which enable us to differentiatethem empirically, after the manner of the ancients-viz.,

1 De Mobibna, lib. ii., sect. 33.s Gruner: De Polypis in Cavo Narium Obviis, p. 2. Lipsite, 1825.3 See Horace, Epodon, 12, In Anum Libidinosam.4 On. cit., p. 4.-5 Ub. d. polypen in d. verschiedn. Hohlen d. Menschl. Iiorpers, p. 349.

Leipzig, 1820.13 See Galen, Com. Pharmac., lib. iii.; and Paulus aeg-ineta, lib. iv., cap. 25.7 Tractatus de Polypo, cap. vii. Bremen, 1628. In the following remark-

able sentence Glandorp epitomises the observations and opinions respectingpolypi of the medical writers from Hippocrates to his own time, the variousstatements beiii,- verified by reference to nearly fifty authorities. "Polypusitaque caro est tumida, inseqaalis, membranulatecta, in narium partibuseontra naturam a caustvel iuterna vel externa orta, earum porum nuncunum nuno ambos simul obstruens, polypi piscis carni hand dis,imil:s,modo alba, modo subrubra. vrl mollis vel dura, dolens et nou do]eD-, in-terdum cum hsemorrhagia, non raro etiam sine ea, in principio esigu,,paula’im vero ita accresceus, ut nunc per foramina palati ad fauces de-pendens, nune extn nares propendens, nune in eavitoti duntaxat, perma-Dens, extern as quoque nasi partes tumidas reddens, respirationem inipedtattantum, quo sri niauti ori coguntur dormire aerumque per ipum os cummaxima uifficultate attrabere; insuper et mortem inferens." Cap. ii.

8 Ibid., cap. ix. 9 Ibid.. can. x. 10 Anhorbmi. 38. s. 6.

according to their situation, shape, colour, consistence, orwith respect to their being pedunculated or sessile, smoothor rough on the surface, painful, ulcerated, or covered withvaricose veins, &c.11 In modern times morbid growths aredivided pathologically, according to their composition andmicroscopical structure; and it is also necessary for thera-pputical purposes to separate them again into two greatclasses-viz., benign and malignant. It must, however, beremarked that all tumours of the nares have a great ten-dency to recur after removal, and when they do so recur, theyoccasionally take on malignant action. The same observa-tion holds good with respect to tumours, which, commencingin the nose, attain to such a size as to perforate their bonyenvirons and encroach on other cavities in the vicinity, suchas the cranium and orbit. When malignant disease occursin childhood, it very often originates in the naso- pharyngealcavity, the cranium, or orbit; whilst in adult life typicalcancer rarely commences in the nose-malignant growthsin that situation being usually examples of recurrent sar-comatous, fibroid, or other tumours.l2Mucous Polypus being the typical growth which occurs

in the nose, I propose to treat it first, and with some com-pleteness of detail; leaving the other forms of polypus,which are much rarer to more superficial consideration.Etiology.-The mucous or common polypus of the nose

occurs more frequently than all other intra-nasal growthscombined. It is found chiefly in adults, not often being metwith before the age of puberty, and it is also more commonin males than females. It is doubtless excited by repeatedinflammatory attacks, and the large and sometimesnumerous pendulous growths are but local exaggerations ofa general hypertrophic condition of the pituitary membrane.As, however, polypi do not invariably arise in cases ofchronic nasal catarrh, various writers have searched to findsome other Plement as the immediate determining cause oftheir production. Thus Grunerl3 and Pottl4 attribute theirorigin to such influences as heridity, struma, lues venerea,miasma, suppressed menstruation,l5 &c. Occasionally polypiseem to arise from mechanical irritation, such as may beproduced by foreign bodies, and a case is related in whichthe nucleus of a polypus was formed by a splinter ofwoodJ6

;S’t/M.p<oMM.&mdash;The primary symptoms arising from all nasaltumours in an incipient stage of formation are neither dis-tinctive with respect to the different classes of growths, nor,in fact, distinguishable subjectively from those of chronicrhinitis. The patient suffers from a persistent cold in thehead, with the usual concomitants of discharge, sense offulness, and sometimes slight pain in the nose and frontalregion, together with a partial and variable occlusion ofone or both nostrils. When, however, the polypus, singleor multiform, attains a sufficient size to block up completelythe nasal channel on either side, the sufferer usually be-comes persuaded of the presence of a tumour. As mucous

polypi are generally pedunculated they frequently hangfree in the nasal cavity, and hence give the sensation ofsomething moving backwards and forwards during respira-tion. For the same reason these growths occasionally dis-play a valvular arrangement, and, as the case may be,oppose the ingress or egress of air through the nares, andthey can sometimes be protruded by a voluntary effortthrough the anterior orifice of the nostril. When bothnostrils are obstructed, the patient is of course compelledto breathe both sleeping and waking with the mouth open;the voice acquires a nasal intonation, and the senses ofsmell and taste become more or less vitiated or annulled.Should the growths press backwards into the pharynxdeafness may arise from closure of the outlet of the Eus-tachian tube, whilst lachrymal abscess, epiphora, or

mucocele of the lachrymal sac are the usual results whenthe anterior increase of the polypus leads to compression ofthe nasal duct. All the mechanical symptoms are greatlyaggravated in damp weather, the pathological constitutionof this polypus giving it a hygrometric character, whichrenders it a ready absorbent of moisture; when the baro-

11 See Hippocrates, De Morbis, 1. ii., sect. 33; sTtd Levret-., Observationssur la Cure Radicale de Plusieurs Polypes, &c., p. 209. Paris, 1749.

,2 Spencer Watson, Diseases of the Nose, &c., p. 289. London, 1875.13 Op. cit., p. 21.14 Chirurgical Observations, &c., p. 44. London, 1775.15 Blackburn, London Med. Journ., vol. ii., p. 122,16 Meekrenii Observat. Medico-Chirurgicae; apud Grnner, op. cit.,p. 23.

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meter sinks low the law of osmosis causes a considerableincrease in the size of the growth.With respect to the discharge which accompanies this

class of new formations, it generally consists of a thin,watery mucus; whilst true ozeena is seldom, if ever, present,at least as a consequence. The fluid which comes from thenose is never persistently sanguinolent, although occasionalattacks of epistaxis occur.On rhinoscopic examination the mucous polypus, when

visible, is seen to be a translucent tear- or pear-shapedbody, of a pale-yellow or greenish colour. The surface issmooth and shining, and, when touched lightly with a probe,dimples through its elasticity, and returns at once to itsformer shape. As Grunerl7 remarks, the larger the size towhich they attain, the more they recede from their cha-racteristic pyriform outline, as they are easily moulded bythe unyielding structures which confine them on every side.In some cases the growth cannot be seen at all from thefront, but can easily be viewed by the aid of posteriorrhinoseopy. In other instances an unfavourable anatomicalconfiguration of the parts, or great irritability of thepharynx, may render it impossible to gain any informationfrom the use of the mirror. Under such circumstances wemay explore the posterior nares by passing the fore or littlefinger round the soft palate into either choana. In allcases a probe, straight or curved, should be used, as bythis means we can best ascertain the mobility and exactpoint of attachment of the tumour. These polypi are

usually multiform, and most frequently hang loosely in thenasal cavity, being suspended by a narrow pedicle from theupper or middle turbinated bones. It is thus that gravita-tion, acting on the semi-fluid contents, determines the cha-racteristic shape. These polypi occasionally spring fromthe floor of the nose, where they are generally sessile, but itis almost unknown for them to grow from the septum. Insome instances a single body is found to be attached atseveral different points to the contiguous walls of thenares,18 but no doubt all but one of such rcots are the resultof adhesions contracted during the increase in variousdirections of the polypus. Pressure and friction occurringbetween the sides of the new formation and the mucousmembrane causes slight ulceration, which, as it subsequentlyheals, terminates in the union of the opposed surfaces.Diagnosis.-Anyone who has once seen and examined

a mucous polypus will scarcely be liable afterwards to makea mistake in the diagnosis of such a growth. The softness,elasticity, mobility, and pale translucent appearance, contraststrongly with the hardness, opacity, fixedness, and deeperred colour of other tumours. In addition to this, fibroid,sarcomatous, and malignant formations usually bleed wheneven gently touched. Cartilaginous and osseous growths areso heavy and dense, and offer such a sense of resistance to theprobe, that the practitioner can seldom hesitate for amoment as to their real nature. The probe will also enableus to distinguish the chronic thickening of the mucousmembrane covering the inferior turbinated bone so oftenmet with in scrofulous children from a polypus. In theformer case the absence of any narrow pedicle, the consist-ence, and the gradual blending of the excrescence with thestructures around its base, will eliminate every source oferror. Mr. Spencer Watson19 mentions mucous distensionof the ethmoidal cells as being likely to simulate a mucouspolypus, and illustrates his remarks by the description oftwo specimens in the museum of St. Thomas’s Hospital.Such a tumour, however, is hard and resistant, and onpuncture would yield a discharge of pent-up mucus. The

possibility of the existence of such rare conditions as abscessand blood-tumour of the septum must also be borne inmind.2O It is almost superfluous to caution the intelligentpractitioner against mistaking the deformity caused bydislocation of the septum for a mucous polypus.

Pathology.-It is to growths of this class that the term6&deg; polypus " should be restricted, as they alone, with the ex-ception of occasional examples of fibromata, possess the

pedunculated base, translucent, gelatinous constitution,and ciliary coverings, which render the name so apt.Moreover, although sometimes single, they are most fre-

17 Op. cit., p. 13.18 See a case described by Nessi, fntemcht in d. Wundarz, Bd. ii., p. 42.

Leinzig, 1790. Also ll2eckel: Path. Anat., pp. 301, 311, 313.19 Op. cit., D. 72.so See Mr. Fleming’s remarla on "Blood-tumours and Abscesses of the

Septum" in the Dublin Journal of Medical Science, vol. iv., p. 16.

quently multiple, like the colonies of their prototype. Theexternal investment of these polypi is usually composed ofciliated epithelium, and beneath this outer layer will oftenbe found a number of tortuous bloodvessels. The bulk, orbody, of the growth is generally made up of loose con.nective tissue, the interstices of which are filled up with avarying amount of mucin. The tumour owes its character.istic appearance to this latter constituent, which not un-frequently occupies almost the entire cavity formed by theepithelial covering. Occasionally a large proportion of

glandular tissue enters into the composition of the polypus,and may even predominate to such an extent that theformation appears to consist almost entirely of bypertro-phied muciparous glands. Considerable variation mayindeed be sometimes observed in the minute structure ofthese polypi; and, as Billroth2l points out, they may befound to belong anatomically to any one of four closelyallied classes of growth-viz., pure adenomata, adeno-sarcomata, aedematous sarcomata, or myxo-sarcomata. Itmust not be inferred from this nomenclature that themucous polypus has any similarity in composition with theso-called adenoid vegetations, which are histologicallytotally distinct. It may here be remarked that the intra-nasal growth, commonly known as "sarcoma," is a larda.ceous tumour, sometimes apparently a degenerate stage ofthe mucous polypus, to which it occasionally succeeds whenthe latter proves recurrent and has been frequently removed.It may thus be seen that sarcoma forms the connecting linkbetween the benign and malignant formations.Prognosis.-As Pott22 observes, "The polypus is a com.

plaint which is always troublesome, frequently painful, andsometimes hazardous." The same writer23 remarks, thoughrather indefinitely, that " the kind which springs from theossa spongiosa most frequently grows again" When amucous polypus is carefully evulsed close up to its attach.ments, the chances of its re-formation are not very great.According to my own experience, about one in seven recur.As, however, in the case of recurrent growths there is alwaysa possibility of malignancy, proportionate to the rapiditywith which they increase in size, our prognosis must beguarded until lapse of time has given undeniable proof thatthf patient is absolutely cured of his malady.

Treatment.-As soon as the existence of a polypus hasbeen ascertained, it is advisable at once to effect its re-moval by some means, as delay only renders extirpationmore severe and difficult. In the case of mucous polypi wemay find it advisable or necessary to follow any one or moreof five different courses of treatment-viz., the applicationof drugs, manipulation, galvanic cautery, evulsion, or en-largement of the outlets of the nasal cavity.

1. Application of drugs.-This, as may be supposed, wasone of the primitive methods of getting rid of polypi.24It is, however, of no value except when the growths arevery small and when they can be easily reached by theremedies employed. Small polypi may be painted fre.

quently with strong astringent solutions (Pigmenta,T. H. Ph.), and chloride of zinc or perchloride of iron iswell adapted for this purpose. The author has found thebest results from the use of the latter salt mixed with justsufficient water to form it into a thick paste. Bichromateof potash25 and nitrate of silver have also been tried fre-quently, with more or less success. Mr. Bryant26 thinkshighly of the insuggtion of finely-powdered tannin into theaffected nostril. Rauchfuss’ insufflator is a good instru-ment for making this application. Another remedy of adifferent kind is that introduced by Primus of Baben-

hausen27-namely, the saffronised tincture of opium of thePrussian Pharmacopoeia. If the growth be painted severaltimes a day with this liquid, in about a week or ten days thepolypus, under favourable circumstances, becomes shrivelledup and falls from its attachments.2s

2. Evulsion.-Of all the methods this is by far the readiestand the most generally adopted, although the injudiciousapplication of it has occasionally led to its being decried.29

si Surgical Pathology and Therapeutics, p. 616. Trans. by Dr. Hackley.22 Op. cit., p. 44. 23 ibid, p. 54.24 See Hippocrates, De AQctiombu, sect. 6.25 Sydenham Society’s Year-book, 1863, p. 467. _

26 THE LANCET, Feb., 18i7, p. 235.27 Harteukeil’s Medico-Chirurg. Zeitung. Salzburg, 1821, p. 56.2S See two cases, loc cit.29 See a work by Dzondi, entitled Ergo Polypi Narium nequaquam

Extrahendi. Halre, 1830.

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It has the disadvantage of being often extremely painful,and is commonly supposed to give rise to copious and evendangerous haemorrhage. My own experience, however, con-curs with that of Pvtt,30 as I have never met with caseswhere the treatment gave rise to serious bleeding; on thecontrary, if the haemorrhage did not soon cease sponta-neously, it was immediately subdued by the use of the

ordinary haemostatics.(a) In my opinion, no method of removing mucous

polypi is equal-in simplicity, certainty, and rapidity-to evulsion by means of forceps. This practice, whichseems to have been introduced by Arantius31 towardsthe end of the sixteenth century, has, since that time,found more favour with surgeons than any other measuresfor operating on these tumours. Unfortunately its greatsuccess and facility of execution have often led practitionersto suppose that the proceeding was equally applicable to allintra.nasal growths, wherever situated, and whatever thenature of their attachments. Acting on such premises wefind surgeons increasing the size and leverage of their for-ceps, and adapting them by suitable curves for introductioneither by the nostril or through the mouth, as if no moreconsideration were necessary in the efficient practice of theoperation than to spize every nasal tumour with tenacity,and wrench it away with violence.32 The consequenceswere often deplorable, and we learn from Pott33 that thetearing away of the septum, or the greater part of the

palate bones, was a not infrequent accompaniment of theextraction of polypi by such inconsiderate surgery.The instrument which I have found most generally

useful is a modification of my crushing laryngeal forceps,more slenderly made, and with shanks curved so thatthe handles do not obstruct the operator’s view. A pairof slender forceps, however, with well serrated blades,slightly curved, and not much larger than an ordinarypair of scissors, often answer well. If the growth is ofmoderate size, and a good view of it can be obtainedfrom the front, the nostril may be kept open with ’,Fraenkel’s speculum, and the pedicle easily seized. Thebase of the growth should first be well twisted back-wards and forwards, and then torn out. It is advisable

always to make the twisting of the peduncle the first stepof the extraction, as by this means the deep attachments ofthe tumour are more likely to be torn completely out. Whenthe polypus is situated far back in the nasal channel, thespeculum will be of no service, but we can command thegrowth by passing the forefinger of the left hand roundthe soft palate into the posterior nares. The forceps intro-duced from the front, as before, can then be guided so as toobtain a good grasp of the peduncle, and the rest of theoperation remains as above described. When the polypusis very large, and attached at several different points, itmay be extracted in successive portions, or we may resort tothe expedient devised by Richter,34 of using an instrumentmade somewhat after the pattern of midwifery forceps. Inthis way we can adjust one blade into position, and then in-troduce the second, when both can be looked together and asecure hold taken of the tumour. In rare cases we may evenhave recourse to some of the leviathan forceps forged byThomas WhateJy,35 to which some reference has been madeabove. The structure of a mucous polypus is usually sosoft and tender that it breaks down and tears underthe influence of a very moderate degree of tractionOn this account, the mfthod followed by Dzondi,36 ofdrawing the growth forwards, so as to put the peduncleon the stretch, with one pair of light forceps, and thenwith another pair squeezing and bruising the root of thetumour as close as possible to its attachments until it givesway, is sometimes practicable, although the advantages ofsuch a proceeding are not obvious. The inventor, however,claims for his device that it ensures a perfect freedom fromall danger of recurrence of the growth, as the deep attach-ments of the growth are by this means entirely uprooted.

(b) The evulsion of polypi, by snaring them in a noose ofstring and then employing traction, was no doubt con-

30 Op. cit., p. 53.31 De Tumoribns prater naturam, c. xxi., p. 170. Venetian, 1595.3’-’ See Cases of Two exrrto dinary Polypi removed from the Nose by

tm;o’ Forc&eacute;ps D) 31r. Whatcly, London, 1SU5.:;3 Up. cir., p. 59.. Anrangsgr. d.Wnndarzna!;’k, Ed. i., cap. 21, sect. 601; G6ttiiigen, 1799.

See also Hese, De Po’Ypo Xri’:.m, p. 26; Argent-rati, 1776.3 Op. cit. Jtj Op. cit., p. 14.

6tantly practised at a date anterior to Hippocrates 37 Theinstrument invented by Mr. Hilton is the modern modifica-tion of this rude method, and may often be employed withadvantage. In using this snare the polypus is embraced 8,9near as possible to the base of the pedicle by a lo ’p of wire,which is then drawn home and tightened by means of a cross-piece sliding on the stem of the instrument. Sunicient forceis then applied to tear the growth from its attachments. Thedifficulty consists in getting the loop of wire over the bodyof the tumour and well round the peduncle. This objectmay occasionally be effected by the aid of a small bluntfork, which, being passed into the nostril, can be made todirect, the loop over the thick extremity of the growth.Mr. Durham 38 has used Mr. Hilton’s snare extensivelyat Guy’s Hospital with remarkable success. It does-not occasion much pain or haemorrhage ; the growthin most instances is very completely extracted ; and,of course, after a little practice, the operator becomeshkilful and expeditious in applying the wire. Whenthe polypus is situated near the pharyngpal end of thenasal channel, we may have recourse to the use of Bellocq’scannula, as first suggested in such cases by Waldenburg.39’A stout silk thread should be fastened to the extrt-mity ofthe cannula, and passed into the pharynx in the usual way.One end of the thread being retained in the mouth, thesound is withdrawn. The wire of the snare is then attachedto the string hanging from the nose, and, by means of thestring projecting from the mouth, is drawn to the back ofthe nares behind the polypus and pushed well over its bodywith the assistance of one of the fingers introduced throughthe mouth.

Ansestbetics are often required during these operations,especially in the case of delicate women. The surgeon,however, is in a more advantageous position when he hasto deal with an individual who is able to submit to thetreatment without having recourse to such remedies. Thepatient can, indeed, when the haemorrhage is considerable,render a good deal of assistance to the operator by clearingthe nasal channel and preventing any blood from descend-ing into the air-passages. On the other hand, when thepatient is unconscious threatening suffocation often rendersit necessary to suspend treatment, and take steps to restoreanimation.

3. Galvanic c6tM<efy. - Dr. Thudichum4e has removedpolypi by this means, and although the proceeding is onlypracticable in a limited number of cases, and can nevercome into general use, the invention possesses advantages,and must occasionally prove extremely valuable. Thepolypus is encircled by a wire loop, which is made red-hotby being connected with a galvanic battery, and- the sub-stance of the growth can then be burnt straight through.The operation is attended with little pain, and there is norisk of hsemorrhage, but as the wire can rarely be adjustedto the pedicle of the tumour, and as no traction is madewhich would be likely to draw away the polypus by itsroots, the growth has generally to be removed in slices.Thus, in one of Dr. Thudichum’s cases the wire had to beintroduced forty-five times, and in another thirty-threetimes, bpfore the whole of the formation could be got away.

4. Manipulation -Professor Gross41 has lately revived a,

method of extracting polypi first practised by Morand.4:?One finger is passed into the posterior nares, and anotherinto the nostril in front, when the growth is pushedalternately backwards and forwards so as to exert as muchstrain as possible on the pedicle, which ultimately givesway under the process. As the cases are rare where this

operation could be put into execution, it can only be lookedon as an expedient to which recourse may be had whenaccidental circumstances render its application preferableand facile.

5. Enlargement of the outlets of the nasal cavity. -Cutting operations are very seldom necessary for theextraction of mucous polypi, and Dr. Thudichum’s planof dilating the nostril with laminaria will generally meetthe circumstances of the case where it is necessary to effectany enlargement. In rare instances, however, where thebody of the tumour is unusually large and firm, it may

37 De Affectionibua, sect. 6. 38 Op i it., vol. iv., p. 297.39 Bri- t’e ei.’ies ae, ZI<"-Zul,i&atilde;cbst f. aertze u. Stat sinker, Bd. 2, p. 52,40 Polypus ill the N <’se and Uz.Bna., p. 9. L mud, n, ISbP.41 System of Surgery, vel, ii, p. 342. Philadelphia, 1866,

) 42 Opuscules de Chirurgie, t. ii., p. 196.

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become expedient to amplify the outlets of the nares, eitheranteriorly or posteriorly by the use of the knife. Dieffen-bach’s43 practice of slitting up the al&aelig; to the margins of thenasal bone is a good one, and the parts afterwards heal upso as to leave an almost unnoticeable cicatrix. When it isnecessary to incise both alse the septum must also be divided,and the whole soft portion of the nose can be turned back.Where the growth is situated near the pharynx we mayadopt Dionis’ 44 plan of cutting through the soft palate onthe side affected, and a considerable increase in size of theposterior orifice of the nares is thus gained. The moreserious operations for the removal of intra-nasal growths,which cannot be extracted per vias naturales, will be treatedof in the next section.

ON TWO CASES IN WHICH THE EXTERNALILIAC ARTERY WAS SUCCESSFULLYTIED FOR THE CURE OF ANEURISM:

WITH OBSERVATIONS ON THE FORMATION AND GROWTH OF ASOLID FIBRINOUS TUMOUR IN THE SAC; ALSO, ON THEOCCURRENCE OF THREE ANEURISMS IN THE SAME ARTERY,AND ON THE TREATMENT OF GANGRENE AFTER LIGATURE.

BY OLIVER PEMBERTON, F.R C.S. EDIN.,SURGEON TO THE GENERAL HOSPITAL; AND PROFESSOR OF SURGERY

IN QUEEN’S COLLEGE, BIRMINGHAM.

SiNCE the time (Oct. 4th, 1806) when the external iliacartery was first successfully tied for the cure of an aneurismby George Freer, within the walls of the BirminghamGeneral Hospital, the operation has been so frequently re-peated, and with such happy results, that surgeons havecome to regard the proceeding as par excellence the one

amongst the surgery of the great arteries, if adequatelyperformed, that is attended by the fewest subsequentdisasters. I may certainly add my testimony to the truthof this experience, and I should not venture to solicitattention to the cases I am about to record on this, thewell-worn ground of mere success, did I not feel satisfiedthat unusual, and hitherto unexampled, features of patho-logical interest invest these particular instances of aneu-rismal disease.

CASE 1.&mdash;F. D , aged thirty, a vegetable salesman,unmarried, a fresh healthy-looking man, was admittedunder my care in the hospital, May 8th, 1871. Rathermore than a month ago he felt pain in the left groin, whichhe thought rheumatic. A week after this he noticedpulsation and enlargement, soon followed by pain andnumbness, along the front and inner side of the thigh.When eighteen had syphilis, followed by secondary sym-ptoms of a mild character. Has led an active life, recentlygetting frequently up and down from the step of a highspring cart. Has lived well, and drunk freely of spirits.Beyond rheumatic pains in various limbs has never sufferedillness.From one inch above to three inches below Poupart’s

ligament there extends an aneurismal swelling, somewhatspherical in shape and with its limits well defined. A loud

rasping bruit and vehement distensile pulsation disappearfrom the tumour on the circulation through the externaliliac artery being controlled. The limb is already cedema-tous, and the cutaneous veins are enlarging. The respiratoryand cardiac sounds are natural; the pulse ranging in fre-quency from 90 to 96.Very marked increase from day to day in the amount of

pain, and steady widening of the area of the aneurism,warned me of the risk of delay; and so, on the 17th, ninedays after his admission, under chloroform, I placed a.

hempen ligature on the external iliac artery at the middlepart of its course. There were no difficulties about theoperation beyond those that must always attend this under-taking, and these were lightened by the aid rendered me bymy colleagues. Afterwards the wound infiamed and suppu-

43 Surgical Observations on the Restoration of the Nose and the Removalof Polypi. Translated by T. S. Bashnan. London, 1833. Cours d’Operations de Chirurgie, p. 582.

rated, casting off the ligature on the twenty-first day, andfinally granulated and healed; and on the 1st July he leftthe hospital. During these six weeks the aneurismal swellingslowly consolidated. Pulsation never returned in the sac.

At the same time, the collateral circulation developing surelyand in sufficient degree, the vitality of the parts below wasnever in doubt. On the 31st July there was but little hard-ness to mark the situation of the tumour, whilst a hernialbulging of the scar showed the position of the wound.For nearly two years and a half he remained well and

active, when suddenly he found the seat of the aneurismagain enlarging. He had had no extra exertion, but casuallyfound the condition at the end of a day’s work, and was atonce readmitted, December 3rd, 1873. On examination, Ifound a firm mass, about as large as the closed hand. Itwas without pulsation, sound, or pain, and was unaccom.panied by any oedema of the limb. Absolute rest in bedand some pressure by pad and bandage so reduced the sizeof this that at the end of seven weeks he resumed his occu-pation, wearing a firm support of leather fitted to the swell.ing and attached to a truss he had worn for an inguinalhernia.

I saw little of him until March in the present year, when,desirous of affording the profession an opportunity of com.paring his condition with that of another case that had gonethrough the same proceeding, I carefully inspected him. Ifound the swelling much larger than when I had last seenhim, and the rate of increase more considerable the last fewmonths. It had yet the same characters as at first; wasfree from pulsation and pain, and measured some five inchesin length and breadth by about three in depth. (See figure.)

Without hindrance he had followed his business, and, farewhen resting from an attack of gout for a few days, had inno other way been disabled. I could not prevail on him togive himself again the opportunity by entire rest of dimi-nishing the tumour, and was fain to content myself withapplying a larger and ,better fltting leather pad to its sur-face ; and with this support he is now daily actively em-ployed.

There can, I think, be but little doubt that the tumourin this case is an instance, remarkably clear and distinct, ofthe production within the walls of an " apparently" curedaneurism of deposits of fibrin, continually increasing inamount, always feeling solid, and never giving rise topulsation or sound. If this be so, it follows that the causeswhich led to its production, notwithstanding the history ofthe case subsequently to discharge as " cured," were reallyat work when the blood-current was arrested through thesac by ligature of the main trunk above.